ISSN - 0971 - 9903 THE JOURNAL OF MAHATMA GANDHI INSTITUTE OF MEDICAL SCIENCES Volume 14, Number (i) March 2009 EDITORIAL I Redesigning Self ! OP Gupta WORLD HEALTH DAY THEME, 2009 v “ Save Lives - Make Hospitals Safe In Emergencies” S Anwar & B S Garg REVIEW ARTICLE 1 Migraine : A Review A Saxena, OP Gupta 7 Evaluation And Management Of The Patient With Esophageal Varices. J Jain 12 Gastroesophageal Reflux In Children A Taksande, KY Vilhekar 17 Face To Face With Nontuberculous Mycobacteria At Sevagram DK Mendiratta, P Narang, R Narang ORIGINAL ARTICLE 22 Effect Of Physiological Factors On Soleus H-Refles In Normal Human Subjects B Ghugare, R Singh, AP Jain 26 Assessment Of Functional Capacity In Elderly Population By Elderly Mobility Scale In Wardha (District) Maharashtra India SD Ganvir, SS Ganvir 38 Suicides In Elderly Age-Group In Wardha Region Of Maharashtra In A Period Of Five Years, From 1st January 2001 To 31st December 2005. PN Murkey, BH Tirpude, VG Pawar, KS Singh. CASE REPORT 43 Inability To Start Hemodialysis After A Smooth Dual Lumen Hemodialysis Catheter Insertion Procedure : A Case Report S Kumar, AP Jain 45 GENETIC STUDY - A HELPING HAND FOR CLINICAL DIAGNOSIS AM Tarnekar, JE Waghmare, P Bokariya, IV Ingole, AK Pal 49 I Want My Father Back - Child’s Destiny. BH Tripude, PN Murkey, VG Pawar, S Shende, A Keche, KS Singh 52 Dislocation Of First Metatarsal Phalangeal Joint : A Case Report A Kumar, C Rathod, CM Badole, KR Patond DRUG UPDATE 54 RENIN BLOCKERS - A Newer Therapy In Regulating Hypertension B Taksande, S Yelwatkar, UN Jajoo BOOK REVIEW 57 Utopia Is Now Promised By Science! Book - Future Human Evolution : Eugenics In Twenty First Century Anupama G. OBITUARY 61 Dr Michael Ellis Debakey NOBEL PRIZE IN PHYSIOLOGY OR MEDICINE 25 Year 2008 62 Year 1909 POEM 63 The Liberation Dr OP Gupta 64 Abstracts of The Papers Presented in The National and International Conferences Held During The Year 2008 91 Instruction To Authors
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ISSN - 0971 - 9903
THEJOURNAL OFMAHATMA GANDHI INSTITUTEOF MEDICAL SCIENCES
Volume 14, Number (i) March 2009
EDITORIAL
I Redesigning Self !OP Gupta
WORLD HEALTH DAY THEME, 2009
v “ Save Lives - Make Hospitals Safe In Emergencies”S Anwar & B S Garg
REVIEW ARTICLE
1 Migraine : A ReviewA Saxena, OP Gupta
7 Evaluation And Management Of The PatientWith Esophageal Varices.J Jain
12 Gastroesophageal Reflux In ChildrenA Taksande, KY Vilhekar
17 Face To Face With NontuberculousMycobacteria At SevagramDK Mendiratta, P Narang, R Narang
ORIGINAL ARTICLE
22 Effect Of Physiological Factors On SoleusH-Refles In Normal Human SubjectsB Ghugare, R Singh, AP Jain
26 Assessment Of Functional Capacity InElderly Population By Elderly Mobility Scale InWardha (District) Maharashtra IndiaSD Ganvir, SS Ganvir
38 Suicides In Elderly Age-Group In Wardha RegionOf Maharashtra In A Period Of Five Years,From 1st January 2001 To 31st December 2005.PN Murkey, BH Tirpude, VG Pawar, KS Singh.
CASE REPORT
43 Inability To Start Hemodialysis AfterA Smooth Dual Lumen HemodialysisCatheter Insertion Procedure : A Case ReportS Kumar, AP Jain
45 GENETIC STUDY - A HELPING HAND FORCLINICAL DIAGNOSISAM Tarnekar, JE Waghmare, P Bokariya,IV Ingole, AK Pal
49 I Want My Father Back - Child’s Destiny.BH Tripude, PN Murkey, VG Pawar,S Shende, A Keche, KS Singh
52 Dislocation Of First MetatarsalPhalangeal Joint : A Case ReportA Kumar, C Rathod, CM Badole, KR Patond
DRUG UPDATE
54 RENIN BLOCKERS - A Newer Therapy InRegulating HypertensionB Taksande, S Yelwatkar, UN Jajoo
BOOK REVIEW
57 Utopia Is Now Promised By Science!Book - Future Human Evolution : EugenicsIn Twenty First CenturyAnupama G.
OBITUARY
61 Dr Michael Ellis Debakey
NOBEL PRIZE IN PHYSIOLOGY OR MEDICINE
25 Year 200862 Year 1909
P O E M
63 The LiberationDr OP Gupta
64 Abstracts of The Papers Presented in TheNational and International ConferencesHeld During The Year 2008
91 Instruction To Authors
THE JOURNAL OF
MAHATMA GANDHI INSTITUTEOF MEDICAL SCIENCES
Vol. 14, No. 1, 2009
CHIEF PATRONSHRI DHIRU S MEHTA
PATRON
Dr P NARANG
Dr S CHHABRA
ASSOCIATE EDITORSDr A P Jain Dr P Chaturvedi
Dr B S Garg Dr S P Kalantri
Dr D K Mendiratta Dr M V R Reddy
ASSISTANT EDITORDr R Joshi
EDITORIAL ADVISORY BOARDDr B S Chaubey, (Nagpur) Dr G M Taori, (Nagpur)
Dr M Kothari, (Mumbai) Dr A B Vaidya, (Mumbai)
Dr N N Wig,(Chandigarh ) Dr J L Gupta, (New Delhi)
Dr K K Aggarwal,(New Delhi) Dr Robert A Ollar, (U.S.A.)
Dr Madhukar Pai, (U.S.A.) Dr Sunil Gupta, (Nagpur)
Dr Anil Narang (Chandigarh) Dr P S Shankar (Gulbarg)
Dr J Anbalagan (Pondichery) Dr M G Pillai (Bombay)
EDITORIAL CORRESPONDENCEThe Editor,JOURNAL OF MGIMSDepartment of Medicine,M.G.Institute of Medical Sciences, SEVAGRAM 442102 (MS)Tel : (07152) 284341 to 55 Extn : 327 - Ext. : 23, Fax : (07152) 284333E-mail : [email protected] Web Site : www.mgims.ac.inPrinted published & distributed by Dr OP Gupta for Mahatma Gandhi Institute of Medical Sciences, Sevagram 442102.
MGIMS FACULTYDr S Pande Dr K V Desikan
Dr R Narang Dr B C Harinath
Dr R K Gupta Dr N Gangane
Dr B H Tirpude Dr P B Behere
Dr A K Shukla Dr Ramji Singh
Dr A T Tayade Dr V Vyas
Dr P S Nagpure Dr R S Naik
Dr K R Patond Dr Dilip Gupta
Dr K Vilhekar Dr S Kar
Dr I Ingole
EDITOR IN CHIEFDr O P Gupta
REDESIGNING SELF!
Editorial
We celebrated bicentenary of Charles Robert Darwin (1809-1882) on 12th Feb 2009. Darwin’s
“On the Origin of Species by Means of Natural Selection” in late 19th century revolutionized the
whole concept of the origin of life. The theory of evolution put forth by him convinced people at that
time. Most people thought Drawinian science is a universal solvent that can sort out most recalcitrant
problems of the society, consciousness, politics, literature and more, they mislead them, writes Steve Jones
in an essay.
According to Darwin’s concepts, initially there was spontaneous generation of life by chance
from inanimate matter into unicellular form and through adaptation, conflict and environmental
influences it evolved in different species, including the present day man. Though in his own time
other scientist criticized and refuted his theories. Darwin himself acknowledged that only by making
a supreme effort of imagination to think about the vast stretches of time in which tiny changes in form
can take place. In moral terms, he accepted that ‘ homosapiens was something more—“of all the differences
between man and animals, the moral sense or conscience is by far the most important” (Steve Jones)
‘ Dr Hargovind Khorana and colleagues were awarded Noble prize for discovering the genetic
code-the DNA which is regarded as master molecule of life. The genes containing DNA molecules have
the growth plan and are capable of replicating and sustaining the growth of a creature. So are we
our genes? Or the proteins generated from DNA via RNA? Life is a mystery and for time immemorial
search is on to find the final answer.
Thus the ‘genes’ promote their self replication.Genes use individuals to make more genes.
When genes adopt the bodies it becomes their principal mode of transport. Every part of us is either
an adaptation or by-product of adaptation. Why we live, suffer or die is basic question! Answer is provided
again in the genetic concept—we live because by working together, the genes can build bigger and
better adaptation then they can by going alone. We suffer because our adaptations are designed to
promote not health or happiness but gene replication. And we die because we are built not to last but
J MGIMS, March 2009, Vol 14, No (i), i - iii
i
to be replaced by new gene-replicating machines. Thus the genes are potentially immortal, while the
vehicle they create—us—are not. (Helena Cronin, Oliver Curry)
It reminds me of shloka from Shrimadbhagvatgeeta —-
The embodied soul casts away old and takes up new bodies as a man changes worn out
raiment for new, thus it uses the body as vechicle for its own transport The soul is indestructible,
and immortal. However it remains debatable whether the genes per say can be equated with that of
the soul.
The completion of human genome project by Francis Collins and Craig Venter in 1995 has
given rise to new ideology, and new thinking —Eugenics- “liberal vision for the improvement in the state of
all humankind”. In view of Dr glad, it is opening up new opportunities for the enhancement of both
the physical and mental conditions of human species. Here is an attempt to examine Darwinism
critically. Hansen NE et al write,”Common understanding of the naturalness of natural selection
appears to be fundamentally disconnected from the daily lived experience of the human species.
Impairment and disability are not commonly understood as natural variations in human biology but
as biology having gone wrong”.
The eugenic practices are on going since long. Sir Francis Galton (1883), Darwin’s cousin
coined the word eugenic in his book “Inquiries into Human faculties”. Individual efforts are already
in full swing, like sterilization or vasectomies for population control, permitted selective abortions on
health ground, one child norms of China.“How can we best protect the interest of still unborn generation?”
is the recent thinking. A close ended question is asked ‘do people have the right to give birth to babies
who in all probability will grow up feeble minded or who are likely to suffer from devastating genetic
illnesses? Or Do we not want our next generation to be genius and physically fit. And here is the crux of
the matter that is the ‘use and abuse of the eugenics. The eugenicists then ask that forced sterilization
J MGIMS, March 2009, Vol 14, No (i), i - iii
ii
Editorial
of persons with genetically predetermined low IQ and major genetic illnesses should be reinstituted.
And many more such radical suggestions are put forth by them like, curbing reproductive rights of
criminals, insane, feeble minded & paupars, not to discourage female feticide, reducing age of
pregnancy, allowing polygynae, asexual in-vitro fertilization etc which are likely to be unpopular, and
unacceptable socially and morally (please read the book review’ on ‘Future Human Evolution’ in this
issue). This is so called the overall efforts to ‘redesign self’. It may be labeled as barbaric, inhumane, mad
idea or materialistic reductionism etc by the moralists. The society and the moralists react strongly to
oppose such proposals at the initial stages, but a time comes when their slogans lose the sharpness and
they themselves become insensitive to such issue, and the things like euthanasia are legalized and
later misused.
“We know what we are, but not what we may be”
HAMLET
Darwin wrote “man in distant future will be far more creative than he now is”. Life is
developed by primarily natural and sexual selection. Life was material and consciousness an
epiphenomenon. (Athar Yawar) The modern science has provided an apparently secure way for human
being to excel themselves. Though essence of excellence is material and not spiritual. All the human
behaviors, emotions, and morality could be explained by ultimately self-centered urge to survive and
reproduce. The era of evolution of species, or specifically homosapiens by genetic (artificial) selection
rather than natural selection is on the anvil.
Dr. O P GUPTA
1. Lancet, Darwin’s gifts, December ‘2008
2. Future of Human Evolution, John Glad (2006)
Hermitage publishers
J MGIMS, March 2009, Vol 14, No (i), i - iii
iii
Editorial
" SAVE LIVES - MAKE HOSPITALS SAFE IN EMERGENCIES "
World Health Day Theme, 2009
SANAM ANWAR* & B S GARG**
* Associate Professor, ** Professor and Head,Address for correspondence : Dr. Sanam Anwar, Dept. ofCommunity Medicine, MGIMS, Sevagram, Wardha,MH-442102. Email : [email protected]
The World Health Day is one of WHO's
most visible opportunities to raise awareness in
global health priorities. On 7 April 2009, the
World Health Organization will mark World
Health Day (WHD), the theme of which being
"SAVE LIVES - MAKE HOSPITALS SAFE IN
EMERGENCIES." This theme underscores the
critical importance of ensuring health facilities
are built safely, possess the resilience to withstand
various crises and can deliver services in any
emergency scenario.
The health centres, staff and other health
care providers in the area are critical life-lines
for vulnerable people in disasters - treating
injuries, preventing illnesses and caring for
people's health needs. They are cornerstones for
primary health care in communities - meeting
everyday needs, such as safe childbirth services,
immunizations and chronic disease care that must
continue in emergencies. Often, already fragile
health systems are unable to keep functioning
through a disaster, with immediate and future
public health consequences. Many people are left
even without emergency care during and after
disasters when hospitals and health facilities fail
to perform.
Global Context
Globally, natural hazards and disasters
are set to increase. Increased frequency of hazards
such as floods, droughts and cyclones, are
worsening the impacts on lives and livelihoods.
Hundreds of hospitals and health facilities are
destroyed or damaged every year by disasters. The
number of people at risk has been growing by
70-80 million per year. According to global
statistics, Asia is the continent exposed to the
most hazards, and has the highest numbers
of people vulnerable to hazards, due to both
physical and socio-economic factors. The World
Disaster Report 2006 highlighted the discouraging
fact that around 58% of the total number of
people killed in natural disasters during the
decade 1996-2005 was from the Asia region.
In December 2004, the Tsunami in the
Indian Ocean destroyed 61% of the health facilities
in Banda Aceh, Indonesia. In August, 2007
within two minutes, the city of Pisco, Peru lost
97% of its hospital beds to an 8.0 magnitude
earthquake. In the October 2005 earthquake in
Pakistan, 50% of the health facilities in affected
areas were completely destroyed.
In this context, the importance of disaster
risk reduction and preparedness requires great
emphasis. The trend towards a focus on this area
began with the International Decade for Natural
Disaster Reduction (IDNDR) in 1990. At the
closure of the decade, the International Strategy
for Disaster Reduction (ISDR) was approved by
the United Nations General Assembly (UNGA)
in 1999 to coordinate action for disaster risk
reduction worldwide.
Hyogo Framework for Action 2005-2015 (HFA)
Less than one month after the tsunami,
at the January 2005 World conference on Disaster
J MGIMS, March 2009, Vol 14, No (i), v - x
v
Reduction, 168 nations endorsed the Hyogo
Framework for Action 2005-2015 (HFA). Among
other challenges, the HFA calls on countries to
"Integrate disaster risk reduction planning into
the health sector; promote the goal of HOSPITALS
SAFE FROM DISASTERS by ensuring that all
new hospitals are built with a level of resilience
that strengthens their capacity to remain func-
tional in disaster situations and implement
mitigation measures to reinforce existing health
facilities, particularly those providing primary
health care.
Later in 2005, disaster health professionals
primarily from SEAR countries took initial steps
towards filling the identified gaps and improving
the level of disaster preparedness region-wise by
developing benchmarks against which to measure
progress. One benchmark (Benchmark 11) calls
for health facilities to be built or modified to
withstand expected risks posed by natural
hazards. Issues to be ensured are :
multi-sectorality : there is a need for the
health system to include and engage
lawmakers and regulation enforcers,
especially for building codes, engineers
and architects ;
expansion beyond hospitals to include other
critical facilities such as blood banks and
laboratories is imperative; and,
hazards and risk assessment-based planning
for hospitals is essential so that plans remain
appropriate and stay within available
resources
Regional Context
The 11 member countries of WHO's
South-East Asia Region are highly vulnerable to
disasters. The diagram shows the situation in the
region.
(Source: The World Disasters Report 2006)
There are countless examples of health infra-
structure-from sophisticated hospitals to small
but vital health centres-that have suffered this
fate. A few are below:
2001, Gujarat (India) Earthquake
3812 health facilities were destroyed during
the earthquake. There was total collapse of
the health infrastructure in Kutch district,
which was the worst affected. Most difficulties
encountered during the response phase in
the Kutch district were due to the collapse
of the health infrastructure. The cost of
reconstruction for the health sector alone
was estimated at US$ 60 million.
Earthquakes and Tsunami of 26 December
2004
The earthquake and tsunami of 26 December
2004 was a watershed event for countries in
WHO's South-East Asia Region. Never before
had one single event affected such a large
number of countries so severely.
Aceh province (Indonesia) Indian Ocean
Tsunami
It damaged 61% of health facilities and
killed nearly a third of the area's midwives,
a major loss for women's health.
Figure I
J MGIMS, March 2009, Vol 14, No (i), v - x
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“ Save Lives - Make Hospitals Safe In Emergencies “ World Health Day Theme, 2009
Maldives
One regular hospital and 20 health
centers were destroyed. As many as 5000
people had to be evacuated from 13 is-
lands.
Sri Lanka
92 health facilities were destroyed. This
included 35 hospitals.
India
7 district hospitals, 13 primary health
centers and 80 sub-centers were damaged
in the southern Indian States of Tamil
Nadu, Andhra Pradesh, Kerala, the
Union Territory of Pondicherry and the
Andaman and Nicobar Islands.
2005 December, Jammu & Kashmir (India)
Earthquake
38 health facilities in the Kashmir were
completely damaged and 14 were partially
damaged. One such case is the Uri Hospital
in the Baramulla district, which serves a
population of 130,000 was totally destroyed.
Patients were shifted to buildings which
were under construction and those who were
in a position to be carried, were taken to the
temporary health care outlets set up by the
Directorate of Health Services.
2006 March, Bantul district (Indonesia)
Earthquake
One of the six hospitals in the district was
destroyed. This led to overcrowding in the
surrounding hospitals. Bantul was worst hit
by the earthquake.
2007 February, Indonesia Floods
49 health facilities were damaged by the flood
waters.
2008 May, China earthquake
More than 11 000 medical institutions were
damaged in China's Wenchuan earthquake
in May 2008, forcing tens of thousands of
people to seek treatment elsewhere.
Current conflicts in Ethiopia and Gaza are
interrupting primary health services, such
as immunizations.
Why focus on health facilities safe from
disasters?
Health facilities and health services are
the community's lifeline in normal times, but
especially so in times of crisis. It is the main
location for providing care for the injured and,
in many cases, a point for delivery of relief goods.
It is also the point where information on missing
people can be collected. Damage to the health
system can include the loss of services, human
resources and damage to health-related infra-
structure. This can create gaps in service
provision following the disaster and lead to
secondary disasters. Public health infrastructure
losses include damaged hospitals, drug stores,
cold rooms, preventive health care offices, health
staff accommodation facilities, district health
offices, vehicles, and medical equipment in
hospitals, stores, clinics. Disasters create an
intensive demand for health services. In addition
to treating disaster victims, hospitals must
quickly resume treatment of everyday emergencies
and routine care.
Hospitals provide a great social value to
communities and an essential sense of security.
Hospitals represent an enormous investment for
any country. In some regions of the world, the cost
of running hospitals consumes approximately
70% of the budget of the ministries of health; in
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vii
S Anwar & B S Garg
remote areas and in small island nations,
frequently there is only one facility of this type;
losing this hospital represents a 100% loss.
Destruction or loss of functionality poses a major
economic burden. Direct economic losses involve
more than the structure; the value of non-structural
elements can be higher than the structure itself.
USD 350 million was the estimated amount for
projects and programmes to rebuild health
facilities in Aceh post tsunami; USD 60 million
to rebuild health facilities after the Gujarat
earthquake of 2001.
Certain factors put hospitals and health
facilities at risk during disaster :
Buildings: The location, design specifications
and resilience of the material used, all
contribute to a hospital's ability to withstand
natural hazards.
Patients : Damage to hospitals multiplies
patient vulnerability and increase in numbers.
Hospital beds : Increase in demands for
emergency care.
Health Workforce : The loss or unavailability
at the time of disaster, hiring outside personnel
to sustain response capacity - add to the over-
all economic burden.
Equipments : Damage to non-structural
elements can cost 80% of the total costs.
Basic lifelines and services : Electrical power,
water and sanitation, waste management and
disposal can affect the entire health facility.
Civil conflicts have also made it difficult for
health facilities to cope with a sudden influx of
injured people. In these situations, the problem
is usually not the physical or structural integrity
of a hospital or clinic, but understaffing, the lack
of access to supplies and essential utilities.
During mass demonstrations in Nepal in 2006,
WHO-led hospital assessments revealed that the
main problem was understaffing and the lack of
access to "lifelines" (eg. power, gas).
Several initiatives have been started to
reduce a health facility's risk of destruction in
an emergency. However, it is important to know
what we mean by safe health facilities.
Safe health facilities
The term 'safe health facilities' encom-
passes all health facilities - large or small, urban
or rural, complex or primary care centres. A
health facility can be classified as safe when three
aspects are in place :
Physical integrity - in accordance with the
hazards in its environment, allowing the
facility to remain intact and not collapse in
disasters, killing or injuring patients and staff;
Continued functionality - Installed capacities,
so that it will continue to function, providing
critical services and absorb extra needs when
there is an emergency
Contingency plans and a well-trained health
workforce that is ready and able to deal with
the health consequences of emergencies.
How to keep safe health facilities
The processes leading to the HFA represent
a significant change from the way disasters have
been dealt with in the past. Whereas previous
strategies were focused on emergency management,
humanitarian response and relief measures,
today there is strong recognition that risk and
vulnerability reduction are key in reducing the
negative impacts of hazards, and thus essential
to the achievement of sustainable development.
J MGIMS, March 2009, Vol 14, No (i), v - x
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“ Save Lives - Make Hospitals Safe In Emergencies “ World Health Day Theme, 2009
Well-built or retrofitted hospitals have
remained functioning following disasters.
The health sector has excellent examples of
and substantial accumulated experience
contributing to in safe health facilities.
The knowledge exists to assess vulnerability
and reduce risk in health facilities. The cost
of protection is much less when included in
the design stage. Vulnerability assessments
for structural and non-structural aspects of
hospitals in Nepal was done with the goal to
keep hospitals in the Kathmandu Valley
physically intact and functioning in the
scenario of an earthquake. The work to keep
health facilities safe also entails training and
planning. The key technical issues that must
be addressed are hazard assessment, site
evaluation, appropriate conceptual design,
competent analysis, complete pre-construction
detailing, quality control during construction
and planned maintenance. Several countries
are working to keep hospitals safe, improving
preparedness to protect lives.
In Mexico, trained evaluators have
diagnosed the safety of 200 health
facilities, identifying which facilities
need improvements.
Multi-functional facilities for health,
education and agriculture were built in
Bangladesh to aid relief after cyclones
and floods - which saved thousands of
lives after Cyclone Sidr in 2007.
In Japan, Pakistan and Peru, health facilities
are now built to withstand earthquakes.
After the Gujarat earthquake in 2001, all
health facilities were rebuilt to interna-
tional standards to make this critical
infrastructure disaster resilient.
Activities to address the problem
The UN International Strategy for
Disaster Reduction (UN/ISDR) and the World
Health Organization (WHO) are partnering with
governments, international and regional organi-
zations, non-governmental organizations and
individuals worldwide to raise awareness about
how and why we must redouble efforts to protect
health facilities and ensure they can function
during and in the aftermath of disasters. The
theme of the World Disaster Reduction Campaign
2008-09 is HOSPITALS SAFE FROM DISAS-
TERS: REDUCE RISK, PROTECT HEALTH
FACILITIES, SAVE LIVES. The campaign is
implemented with support from the Global
Facility for Disaster Reduction and Recovery
(GFDRR) of the World Bank. The campaign's
objectives are :
Contribute to structural resilience of health
facilities.
Help hospital services continue to function
in the aftermath of emergencies and disasters
Assist health institutions to improve risk and
emergency management capability
Involve health professionals in identifying
and reducing risk.
Take steps to incorporate these priorities into
national development plans.
The campaign urges all those responsible
such as decision makers, politicians, architects,
engineers, public health professionals, development
banks and donors to come forward with required
policies, legislation, technical guidance and
public awareness to make hospitals and health
facilities safe from disasters.
A regional Consultation on keeping
Health Facilities Safe from Disasters was held
in New Delhi in April 2008. It recommended
the following key action points :
J MGIMS, March 2009, Vol 14, No (i), v - x
ix
S Anwar & B S Garg
Establish safe hospitals committees
Ensure new health facilities are safe at
planning and design stage
Conduct contingency planning and training
for existing health facilities
Obtain political and donor commitment
through advocacy.
The theme of World Health Day, 2009
"SAVE LIVES. MAKE HOSPITALS SAFE
IN EMERGENCIES" is an opportunity for
advocacy. This year on World Health Day WHO
and international partners will underscore the
importance of investing in health infrastructure
that can withstand hazards and serve people in
immediate need. They will also urge health
facilities to implement systems to respond to
internal emergencies, such as fires, and ensure
the continuity of care. Events around the world
will highlight successes, advocate for safe facility
design and construction, and build momentum
for widespread emergency preparedness - to save
lives and improve global health. In summary with
current knowledge, existing resources, and a
strong political commitment, it is possible to
stop disasters and reduce risk in the health
sector. Everyday problems in providing routine
health services can be looked for. However, in
large-scale emergencies, the backbone of lifesaving
health services must be preserved.
References :
1. Hospitals safe from disasters. World Disaster
Reduction Campaign, 2008-2009 (ISDR, WHO).
2008.[Online]. [Cited 2009 February 20].
Available from: http://www.unisdr.org/eng/
public aware/world camp/2008-2009/pdf/
wdrc-2008-2009-information-kit.pdf
2. Emergency and Humanitarian Action: FOCUS
(WHO) 2008. [Online]. [Cited 2009 February 20].
Available from: http://www.searo.who.int/
LinkFiles/Hospitals_Safe_from_Disasters_
EHAFOCUSnew30.pdf
3. Safe hospitals, a collective responsibility, a Global
measure of Disaster Reduction (PAHO, WHO)
2005. [Online]. [Cited 2009 February 20].
Available from: http://www.paho.org/english/dd/
ped/SafeHospitalsBooklet.pdf
4. World Health Day 2009: Save lives, make hospitals
safe in emergencies. [Online]. [Cited 2009
February 20]. Available from: http://
www.searo.who.int/worldhealthday2009/
World_Health_day.htm
5. Hospitals safe from disasters. World health day
2009. [Online]. [Cited 2009 February 20].
Available from: http://www.safehospitals.info/
J MGIMS, March 2009, Vol 14, No (i), v - x
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“ Save Lives - Make Hospitals Safe In Emergencies “ World Health Day Theme, 2009
MIGRAINE : A REVIEW
A SAXENA*, OP GUPTA**
**Professor, *Sr. Lecturer, Add. for correspondence :Dr Amrish Saxena, Deptt. of Medicine, MGIMS,Sewagram. Email : [email protected]
Headache is the commonest problem,
men have been enduring since the time immemorial.
Migraine, one of the more troubling cause of
headache, afflicts approximately 15% of women
and 6% of men, No age is immune but it generally
starts in younger generation.
Migraine is a markedly disabling condition,
and exerts a significant burden on the sufferer
in terms of pain, suffering and imparied quality
of life. This results in a large economic burden
on society, both in therms of direct medical costs
of care and indirect costs due to lost work time
and working at reduced productivity. It is a
common clinincal disorder that continues to
be underrecognised, underdiagnosed and
undertreated.
Migraine is a heterogeneous condition,
with headache attacks varying in frequency,
duration, symptomatology and associated
disability, both between sufferers and between
attacks in the same individual. It can be defined
as a benign and recurring syndrome of headache,
nausea, vomiting, tenderness around the face
and scalp and/or symptoms of neurologic
dysfunction in varying admixtures. It is a
neurovascular event the occurs in people with a
genetically susceptible sensitive nervous system.
Migraine is a complex disorder with polygenic
inheritance and a strong environmental
component.
Migraine Historical timeline :
Date Event
400 BC Hippocrates states that headaches
are derived from “humors” (fluidsor vapors) circulating in the body,
illness resulted from imbalances of
natural elements.
200 AD Galen introduces the term
“migraine”, which is derived from
the Greek world hemicrania.
1598 Charles Le Pois described premonitory
symptoms and migraine with aura
for the first time.
1938 Graham and Wolff demonstrate the
efficacy of ergotamine in aborting
migraine by constricting cerebralblood vessels.
1943 Stoll and Hoffman synthesize DHE
(dihydroergotamine).
1945 Horton, Peters, and Blumenthal use
DHE to treat acute migraine at the
Mayo clinic.
1976 Propranolol is reported to be
efficacious in migraine prevention.
1991 Pat Humphrey reports the efficacy
of Sumatriptan in aborting acute
migraine in human volunteers.
1993 Sumatriptan is first triptan to beFDA approved and marketed.
2002 Valproic acid is FDA approved for
migraine prevention.
2004 Topiramate is FDA approved for
migraine prevention.
Review Article
J MGIMS, March 2009, Vol 14, No (i), 1 - 6
1
Pathogenesis :
It was widely held for many years that
the headache phase of migrainous attacks was
caused by extracranial vasodilatation and that
the neurologic symptoms were produced by
intracranial vasoconstriction (i.e., the “vascular”
hypothesis of migraine).
Migraine is now considered to be a
neurovascualr disorder because its pathology
involves important interactions between the
cerebral nerves and blood vessels. A simple
clinical definition of migraine is “a referred
pain from duramater and blood vessels” It is a
clinical syndrome of self-limited neurogenic
inflammation. The concept of neurogenic
inflammation(NI), referring to both vasodilatation
and increased vascular permeability is mediated
by the peripheral release of neuropeptides such
as substance P(SP), neurokinin A(NKA),
endothelin-3 (ET-3), and calcitonin gene-related
peptide (CGRP).
The release of tachykinins and endothelin
-3(ET-3) from trigeminal neurons induces
dural vascular permeability and vasodilatation
via activation of tachykinin receptor (1 (Tacr 1)
and endothelin receptor type B (Ednrb) on
endothelial cells. Endothelial cell receptor
stimulation results in cellular contraction, leading
to plasma protein extravasation (PPE), which is
the most recognized physiological hallmark of
neurologic inflammation (NI), and NO-induced
vasodilatation. By contrast, the release of calcitonin
gene-related peptide (CGRP) from trigeminal
neurons- also a key physiological commponent
of NI- does not affect vascular permeability but
does induce neurogenic vasodilatation (NV) via
the direct, (Endothelium independent) relaxation
of vascular smooth muscle.
Fig - Mechanism of migrain. Migraine is probably
triggered through hypothalamic or cortical mechanisms.
Trigeminal innervation of pain sensitive intracranial
structures, dura mater, and blood vessels provides pain
input through trigeminal ganglion to trigeminal nucleus.
The nucleus extends from medulla to C2 (accounting for
commonly reported neck pain with migraine) and sends
fibres to thalamus. 5-Hydroxytryptamine receptors on
blood vessel (5-HT 1B) and neurone (5-HT1D) mediate
vasoconstriction and presynaptic inhibition, thus
antagonising vasodilator effects of calcitonin gene
related peptide. Peripheral transmission in blocked by
sumatriptan and ergotamine, while central transmission
is also blocked by zolmitriptan7.
Current theories propose that
(1) In genetically predisposed individuals
migraine-specific triggers promote
meningeal nociceptor activation, dilation of
meningial blood vessels and the activation
of trigeminovascular system.
(2) Sensitization of cells in the trigeminal nucleus
caudalis in the medulla (a pain-processing
center for the head and face region) results
in the release of vasoactive neuropeptides,
including substnace P and calcitonin gene-
related peptide,
(3) These peptide neurotransmitters induce a
J MGIMS, March 2009, Vol 14, No (i), 1 - 6
2
Migraine : A review
Natural remidies for Migraine :
Recently, some good studies have
demonstrated the effectiveness of the herb
Butterbur (Petasites hybridus) in preventing
migraines. Another herb, Feverfew (Tanacetum
Parthenium), is also wodely used and some
studies have shown it to be safe and possibly
effective for migraine prevention.
A variety of other CAM (complimentary
& alternative medicine) techniques are not bolstered
by solid scientific data, but they may be perceived
to be of benefit to patients. A few techniques
commonly practiced for headache relief include
body work (eg, chiropractic, massage), creative arts
survival in cirrhosis. Gastroenterology 1997; 113(5) :
1632-9
4. Laine L, Cook D. Endoscopic ligation compared
with sclerotherapy for treatment of esophageal
variceal bleeding: a meta-analysis. Ann Intern Med
1995;123(4):280-7
5. Luketic VA, Sanyal AJ. Esophageal varices. II.
Transjugular intrahepatic portosystemic shunt
and surgical therapy. GI Clin North Am 2000; 29(2):
387-421.
J MGIMS, March 2009, Vol 14, No (i), 7 - 11
11
Jain J
GASTROESOPHAGEAL REFLUX IN CHILDREN
A TAKSANDE*, KY VILHEKAR**
* Senior Lecturer, ** Professor,Address for Correspondence : Dr. Amar M Taksande, Dept.of Pediatrics, MGIMS, Sevagram, Wardha, MS-442102E mail : [email protected]
Introductions :
Gastroesophageal reflux (GER) is the
common esophageal disorder and occurs when
stomach contents reflux into the esophagus
during a meal. Lower esophageal sphincter (LES)
at the bottom of the esophagus opens and closes
to allow food to enter the stomach. Reflux can
occur when the LES opens, allowing stomach
contents and acid to come back up into the
esophagus1. Transient LES relaxation (TLESR)
is the major primary mechanism allowing refluxe
to occur. A vagovagal reflux, composed of afferent
mechanoreceptor in the proximal stomach, a
brainstem pattern generators, and efferent in
the LES, regulates TLESR. Gastric distension
is the main stimulus for TLESR. There is a high
prevalence of GER in children with chronic
cough and asthma2.
GER is classified as follows :
Functional GER : patients have no underyling
predisposing factors. Growth and development
are normal, and treatment is typically not
necessary.
Pathogenic GER or Gastroesophageal reflux
disease(GERD) : Patients frequently experience
complications, including strictures, malnu-
trition, respiratory disorders, esophagitis,
bleeding, and changes in the normal epithelial
lining of the lower esophagus. Patients
require careful evaluation and treatment2,3.
Secondary GER : A case in which an underlying
condition predisposes to GER. Examples
include hiatal hernia and gastric outlet
obstruction.
Risk Factors: 4,5.
Anatomic factors that predispose to GER
include.
The angle of His (made by the esophagus
and the axis of the stomach) is obtuse
in newborns but decreases as infants
develop. This ensures a more effective
barrier against GER.
The presence of a hiatal hernia displaces
the LES into the thoracic cavity. The lower
intrathoracic presure may facilitate GER.
Resistance to gastric outflow raises
intragastric pressure and leads to reflux
and vomiting. Examples: gastroparesis,
gastric outlet obstruction, and pyloric
stenosis.
Other factors that predispose individuals to
GER include :
Medications 9eg. Valium Theophylline)
Smoking
Poor dietary habits (eg. overeating, eating
late at night, assuming a supine position
shortly after eating)
Food allergies
Certain foods (eg. greasy, highly acidic)
Short Review
J MGIMS, March 2009, Vol 14, No (i), 12 - 15
12
Disorders of motility (postulated to
potentially cause reflux)
Antral dysmotility
Delayed gastric emptying
TLESR, accounting for 94% of reflux
episodes in children and adults.
Physiologic factors : Reflux is also facilitated
when an increase in intra-abdominal pressure
exists, but, the presence of a chronically lax
sphincter and a functional decrease in
sphincter tone determine the occurrence
of GER2.
Clinical Manifestation :
Infant reflux become symptomatic
during the first few month of life, peaking at
about 4 month and resolving in most by 12
month and nearly all by 24 months. Symptoms
in older children tend to be chronic, waxing
and waning, but completely resolving in more
than half, resembling adult pattern6.
When refluxed material rapidly returns
to the stomach, it does not harm the esophagus.
However, in some children, the stomach contents
remain in the esophagus and damage the
esophageal lining. In other children, the stomach
contents go up to the mouth and are swallowed
again. When the refluxed material passes into
the back of the mouth or enters the airways, the
child may have a raspy voice, or a chronic cough.
Other symptoms include7,8.
Recurrent pneumonia
Wheezing
Difficult or painful swallowing
Vomiting
Sore throat
Weight loss
Heartburn (in older children)
Investigation9,10,11.
Upper endoscopy, which involves the
direct visulization of the esophagus, stomach,
and a portion of the small intestines. Biopsies
can be obtained at the time of endoscopy to
determine whether there is inflammation due
to GERD or whether there are other problems
such as allergic esophagitis that are causing the
symptoms.
Contrast (usually barium) radiographic study of
the esophagus and upper GIT.
Esophageal pH probe monitoring : A thin, light
wire with an acid sensor at its tip is inserted
through the nose into the lower part of the
esophagus. This probe detects and records the
amount of stomach acid coming back up into
the esophagus and indicates whether acid is in
the esophagus when the child has symptoms such
as crying, coughing, or arching her back.
Radionucleotide scintography using technetium
may demonstrate aspiration and delayed gastric
emptying when these are suspected.
Esophageal manometry permits evaluation for
dysmotility.
Esophagography : In more seven cases, diagnosis
is made by barium esophagography under
fluoroscopic control. Strictures can be
demonstrated by esophagography.
MANGEMENT :
Medical Care11,12.
Functional GER - Reassurance is the only
treatment needed
Conservative measures:
Sleeping on the left side has been shown
to drastically reduce nighttime reflux
episodes in patients
J MGIMS, March 2009, Vol 14, No (i), 12 - 15
13
Taksande A, Vilhekar KY
Upright positioning after feeding
Mild, uncomplicated cases: the prone
position with thickening of feeds with
cereal and burping after feeds is beneficial.
More severe cases : prone position in
addition to elevating the head of the bed
to 300 is recommended.
Providing small, frequent feeds thickened
with cereal.
Older children benefit from bland diet,
small, frequent feeds, and proper eating
habits.
The goals of medical therapy are to
decrease acid secretion and to increase gastric
emptying2,12.
Antacids :
- Rapid & transient relief of symptoms
- Acid neutralisation
Histamine 2 receptor antagonists:
- First line drugs for mild to moderate GER
- Ranitidine, Cimetidine, Famotidine
Proton Pump Inhibitors (PPIs): A second
class of medications often used to reduce
stomach acid is PPI, which block the production
of stomach acid. This class of drugs block
the hydrogen-potassium ATPase channels in
gastric acid secretion.
- Omeprazole & Lansoprazole
Prokinetic agents : These agents make the
LES close tighter so stomach acid cannot
reflux into the esophagus.
- Metoclopramide (dopamine 2 & 5HT 3
antagonist)
- Bethanecol (cholinergic agonist)
- erythromycin (motilin receptor agonist)
- Indcrease LES pressure, improve gastric
emptying & esophageal clearance
Surgery13:
Goal : Re-establish the antireflux barrier
without creating obstruction to the food
bolus.
Nissen Fundoplication : The stomach is
wrapped and sutured 3600 around the distal
esophagus.
Disadvantage : More episodes of dysphagia
and gas bloat than a partial wrap.
Complications of GERD2 :
Strictures occur in mid to distal esophagus.
Patients present with dysphagia to solid meals
and vomiting of nondigested foods.
Barrett esophagus occurs when goblet cell
metaplasia occurs.
Risk of adenocarcinoma is increased 30-40
times.
Failure to thrive because of caloric deficit.
Key Points :
GER disease includes all consequences of
reflux of acid or other irritants from the
stomach into the esophagus.
GER is common in infants, but most
children grow out of it.
GER may cause vomiting, coughing, hoarseness,
or painful swallowing.
Treatment depends on the child’s symptoms
and age and may incoude changes in eating
habits and taking medications. Surgery may
be an option.
References :
1. Monnier P, Ollyo JB, Fontolliet C. Epidemiology
and Natural History of Reflux esophagitis. Semin
Laparosc Surg. 1995, 2: 2-9.
J MGIMS, March 2009, Vol 14, No (i), 12 - 15
14
Gastroesophageal reflux in children
2. Orenstein S, Peters J, Khan S, Youssef N, Hussain
SZ. Gastroesophageal Reflex disease. In: Behrman
RE, Kliegman RM, Jenson HB, editors. Nelson
Texibook of Pediatrics. 17th ed. Philadelphia: WB
Saunders, 2000; p. 1222-25.
3. Spechler SJ. Epidemiology and natural history
of gastro-esophageal reflux disease. Digestion.
1992; 51 Suppl 1: 24-9.
4. DeVault KR, Castell DO. Updated guidelines
for the diagnosis and treatment of gastrosophageal
reflux disease. The Practice Parameters Commit-
tee of the American College of Gastroenterolog.
Am J Gastroenterol. 1999: 94 (6): 1434-42.
5. Orenstein SR. Esophageal disorder in infant
and children. Current opinion in Pediatrics 1993;
5: 580-89.
6. Fernando HC, Schauer PR, Rosenblatt M, et al.
Quality of life after antireflux surgery compared
with nonoperative management for servere
gastroesophageal reflux disease. J Am Coll Surg.
Jan 2002; 194(1): 23-7.
7. Bremner RM, Bremner CG, DeMeester TR.
Gastroesophageal reflux: the use of pH monitoring.
Curr Probl Surg. Jun 1995; 32(6): 429-558.
8. Harding SM, Richter JE, Guzzo MR, et al Asthma
and Gastroesophageal reflux: acid suppressive
therapy improves asthma outcome. Am J Med. Apr
1996; 100(4): 395-405.
9. McCallum RW, Berkowitz DM, Lerner E. Gastric
emptying in patinets with Gastroesophageal reflux.
Gastroenterology. Feb 1981; 80(2): 285-91.
10. Vigneri S, Termini R, Leandro G, et al. A
comparison of five maintenance therapies for
reflux esophagitis. N Engl J Med. Oct 26 1995;
333(17): 1106-10.
11. Porro GB, Pace F, Peracchia A, et al. Short-term
treatment of refractory reflux esophagitis with
different doses of omeprazole or ranitidine. J
Clin Gastroenterol. Oct 1992; 15(3): 192-8.
12. Patti MG, Arcerito M, Feo CV, et al. An analysis
of operations for gastroesophageal reflux disease:
identifying the important technical elements. Arch
Surg. Jun 1998; 133(6): 600-6; discussion 606-7.
13. Abbas A, Deschamps C, Cassivi SD, et al. (2004).
“The role of laparoscopic fundoplication in
Barrett’s esophagus”. Annals of Thoracic Surgery
77(2): 393-396.
J MGIMS, March 2009, Vol 14, No (i), 12 - 15
15
Taksande A, Vilhekar KY
FACE TO FACE WITH NONTUBERCULOUS
MYCOBACTERIA AT SEVAGRAM
DK MENDIRATTA *, P NARANG **, R NARANG ***
*Professor & Head., ** Director Professor & SecretaryKHS, *** Professor, Deptt. of Microbiology, MGIMS,Sevagram. Corresponding author : Dr Deepak KMendiratta, Prof & Head , Dept of Microbiology,MGIMS, Sevagram. Email:[email protected]
The non-tuberculous mycobacteria
(NTM), also known as atypical mycobacteria or
mycobacteria other than M. tuberculosis (MOTT)
have been recognized since Koch's time but being
opportunists they did not gain as much importance
as M. tuberculosis. Today, however, the recovery of
NTM from patient's specimens, where they can
cause infections called "other mycobacteriosis" 1
and from environmental sources is of concern
to microbiologists, epidemiologists and physicians.
There is a gradually shift in the focus from AFB
with rough, tough and buff colonies to AFB with
smooth and pigmented colonies , some of which
may be rapid growers. NTM infections are more
common in developed countries but have also
been documented in developing countries of
Latin America, Africa, and Asia2,3,4,5,6. Many a
times the NTM are found circulating in blood
(mycobacteremia) and this has lead to disseminated
infections. Among disseminated NTM infections,
most are caused by mycobacteria belonging to
Mycobacterium avium complex (MAC) and are
known as Disseminated MAC (DMAC). DMAC
infection decreases survival and worsens the
quality of life. DMAC was rare before the advent
of acquired immunodeficiency syndrome (AIDS)
and a steady rise has been observed after increase
in cases with AIDS. Between 1985 and 1990
DMAC occurred in 16% of AIDS patients at
Grady Memorial Hospital, Atlanta7. It was estimated
that most AIDS patients would develop DMAC
infection if they survive long enough to become
severely immunocompromised8. However, highly
active anti retro viral therapy (HAART) changed
the scenario and among patients in John
Hopkins cohort with advanced HIV disease, the
proportion developing DMAC had fallen from
16% before 1996 to 4% after 1996, and the rate
observed in 2004 was less than 1%9.
Clinically in AIDS patients it is not possible
to differentiate between M tuberculosis and other
mycobacteriosis. M tuberculosis causes majority of
pulmonary infections and the risk is largely
increased if the CD4 count falls below 300cell/
cumm10. In some cases disseminated infections
are also found11,12. NTM, on the other hand, may
colonize the gut or respiratory tract of HIV patients
but once the CD4 counts fall <100 cells/cumm,
they start multiplying rapidly, enter the blood
stream and cause disseminated infections. Patient
may succumb to these infections if not treated
in time. Horsburg in 1994 stated that persons
with HIV infection are like open culture plates
and AIDS related immunosuppression is the
single most important risk factor associated with
disseminated NTM infection especially MAC.
Laboratory support is a must to diagnose
these conditions and the clinical samples for
detection of various NTM species are blood,
Review Article
J MGIMS, March 2009, Vol 14, No (i), 16 - 21
16
sputum, stool and other extra-pulmonary specimens.
Smear examination and isolation of Mycobacteria
are two important steps in laboratory diagnosis
of such infections. Only smear examination, as
recommended by RNTCP, may not be sufficient
in such conditions, especially in HIV/AIDS
patients, as NTM which are important organisms
causing disease in such cases need to be
differentiated from M. tuberculosis by culture,
since the treatment of the two differs.
Isolation of Mycobacteria from clinical
specimens other than blood is performed
routinely in many of the laboratories these days
using Egg based media, BACTEC media &
system, MGIT 960, BACTEC 9000MB system and
BacT/ALERT MB. Blood samples which need
special treatment and media are not routinely
cultured. However, since NTM cause bacteremia,
blood may be the only sample from where we can
isolate such organisms. Likewise, in some of the
TB patients with advanced HIV disease blood
may be the only sample yielding M. tuberculosis13.
The radiometric BACTEC 13A blood culture
bottle (Bectec Dickinson Diagnostic Instrument
System) or Isolator lysis centrifugation system
(E.I. Du Pont, de Nemours, Wilmington, Del) is
recommended for blood culture.
Lowenstein Jenson medium routinely
used for isolation of M. tuberculosis supports
growth of NTM from specimens other than blood,
but utilization of paraffin wax as sole carbon
source for growth by NTM and the inability of
Mycobacterium tuberculosis to do so, in a basal salt
media is a useful and often forgotten fact. The
paraffin system is a biphasic system which consists
of a liquid (Czapek Broth) phase and solid
(paraffin wax coated slide) phase. Non-motile
organisms such as Nocardia and NTM are carried
by Brownian movement to the paraffin wax, sole
carbon source. When these organisms attach to
the paraffin wax acting as sole carbon source
they begin to grow, since they now have all the
essential components for their growth cycle. When
positive, in situ growth is seen on the paraffin
slide and it appears as distinct points or spots
on the paraffin wax surface. One can also often
see the presence of a heavy growth at the meniscus
of the broth/slide. In some instances the heavy
growth can even display pigmentation. The
beauty of this system is that few pathogens
(NTM, Nocardia, Psuedomonas & C.tropicalis) can
grow in such a system and the growth of NTM
can not only be confirmed by Z N stain and
observed under the microscope in situ but also
used for molecular studies. Moreover, even the
least experienced member of a laboratory can
obtain quality results with this method. The system
could be made selective for NTM by adding
a cocktail of antibiotics like Polymyxin B,
Amphotericin B, Naladixic acid, Trimethoprim
and Azlocillin to the medium. This system has
been standardized and successfully used for
isolation of NTM from stool, sputum, blood
and environment as also speciation and drug
susceptibility testing in our laboratory14,15,16,17.
Identification of NTM species is important
as, not only does the treatment variy between the
species but geographical location may also be a
risk factor for certain species. Speciation is usually
done using conventional phenotypic and newer
genotypic methods. By conventional methods ie
rate & temperature of growth, pigmentation,
niacin & catalase (quantitative and qualitative)
production, tellurite and nitrate reduction,
tween-80, arylsulphatase & urea hydrolysis, TCH
sensitivity, growth on MacConkey agar, sodium
chloride tolerance etc, the identification of
mycobacterial strain requires 2 to 4 weeks for
J MGIMS, March 2009, Vol 14, No (i), 16 - 21
17
Mendiratta DK, Narang P, Narang R
morphological and biochemical tests, in addition
to 4-6 weeks required for primary isolation.
Newer methods which include analysis of fatty
acids by chromatography, hybridization with gene
probe, gene amplification followed by restriction
analysis ( hsp65: heat shock protein, 16S rDNA,
ITS : internal transcribed spacer 16S-23S rDNA,
RNA polymerase beta sub unit: rpoB), LiPA
Mycobacteria( line probe assay) and gene
amplification analysis by sequencing are very
rapid and reduce the turn around time remarkably.
Kox et al18 for the first time used 16s rDNA based
gene amplification assay directly on clinical
samples containing mycobacteria. These new
alternative methods have limited the role of
conventional identification methods.
Speciation of mycobacteria using phenotypic
methods is still widely used in many of the
laboratories in the developing countries19 since
the genotypic methods are costly and not easily
available. The reference laboratories such as
Central JALMA Institute for Leprosy and other
Mycobacterial Diseases, Agra; Tuberculosis
Research Centre, Chennai (TRC); Centers for
Disease Control and Prevention, Atlanta, USA
(CDC) and National Mycobacteria Research
Laboratory, Bilthoven, The Netherlands are some
of the reference centers which help in identifying
the mycobacterial isolates by genotypic methods
to species level and beyond.
The mechanism of resistance in NTM
are quite distinct from M. tuberculosis and
mechanisms like permeability at cell wall and
efflux pumps appear to be more important than
targets like rpoB in M tuberculosis. Usual mutations
seen in M. tuberculosis are not frequently seen in
resistant NTM. Generally NTM are resistant to
low concentrations of various anti-tuberculous
drugs. The drugs to which NTM usually respond
and are modestly effective in controlling bacteremia
are macrolides (clarithromycin, azithromycin),
ethambutol, clofazimine and rifamycins (especially
rifabutin). However, the only antimicrobial agents
for which correlation between in-vitro susceptibility
test and clinical response has been demonstrated
in controlled clinical trials are macrolides
(Azithromycin & Clarithromycin) and that too
in MAC only. Drug susceptibility testing of the
mycobacterial isolate is an important aspect for
guiding the treatment. However, till recently
there were no approved guidelines for drug
susceptibility testing of mycobacteria, especially
NTM. In the year 2003, Clinical and Laboratory
Standards Institute (CLSI)20 published approved
standards for Mycobacteria, Nocardiae and other
aerobic Actinomycetes.
NTM are ubiquitous and majority are
present in the environment surrounding the
patient. AIDS patients may acquire infection
with multiple NTM species or multiple strains
of the same species21. It is thus important to type
mycobacterial strains if we wish to find the
relatedness of multiple isolates from a single patient.
If environmental samples from surroundings of
the patient suffering from NTM disease are
screened for NTM and the same species are
isolated from clinical and environmental samples,
typing of these isolates helps us to know if the
same strain has caused infection in such
patients22. A number of phenotypic techniques
viz. biotyping, antibiogram typing, serotyping,
multilocus enzyme electrophoresis (MEE) have
been used in the past. However, since in all these
methods measurement relies upon gene expression
which can be influenced by cultural conditions
their typeability, reproducibility and discrimination
may vary. Newer typing methods are based on
the analysis of DNA (and thus are unaffected by
J MGIMS, March 2009, Vol 14, No (i), 16 - 21
18
Face To Face With Nontuberculous Mycobacteria At Sevagram
environmental conditions) and include plasmid
typing, restriction fragment length polymorphism
(RFLP), analysis of chromosomal DNA of rRNA
genes, rRNA spacer sequencing and large restriction
fragment (LRF) involving pulsed field gel
electrophoresis (PFGE).
In the department of Microbiology at
Mahatma Gandhi Institute of Medical Sciences,
Sevagram studies on NTM were initiated way
back in 1988 , when an ICMR sponsored project
to estimate the prevalence of pulmonary TB in
Wardha was underway in the early eighties.
Lowenstein Jensen medium was used for isolation
of mycobacteria and species were identified using
phenotypic methods - morphology and biochemical
reactions. A total 14 tests were performed and
150 NTM belonging to 16 species were recovered,
in addition to the principal pathogen , MTB.
HIV testing was not performed during this field
house to house survey14.
Later, during 1997-1998, we standardized
the paraffin slide culture (PSC) technique for
isolation, identification and drug susceptibility
testing of NTM15. Fifteen known species of NTM
along with Nocardia asteroides (positive control)
and M. tuberculosis H37Rv (negative control) were
used for this standardization. This PSC technique
was later used to isolate NTM from stool and
sputum samples of HIV seropositive subjects. Six
NTM species (4 MAC and 2 M. fortuitum) were
isolated from 80 stool samples and three NTM
species (2 MAC and one unspeciated) were isolated
from 42 sputum samples. Biochemical reactions
using PSC technique was used to speciate the
NTM. Drug susceptibility testing was performed
by MIC using PSC, LJ and Microtitre plates.
PSC results were comparable with that done on
LJ & Microtitre plates. The MAC isolates were
uniformly sensitive to Azithromycin and variably
sensitive to first line anti-TB drugs16. In another
study blood samples from 77 HIV seropositive
subjects were subjected to culture for mycobacteria
using BACTEC 13A medium followed by
subcultures on PSC and LJ medium. A total of 6
NTM isolates were recovered including 3 MAC
and 3 M. simiae6. In our initial studies on NTM
and HIV, CD4 counts were not performed and
thus the information of patients' HIV disease
status was not known and also that all the clinical
samples were not processed for the recruited
subjects.
A comprehensive study was undertaken
in 2005-0717 where in all the possible clinical
samples viz. blood, stool, sputum and other
extrapulmonary specimens were processed for
mycobacteria. CD4 counts were performed as
part of the protocol. A number of mycobacterial
species viz. M. tuberculosis, M. avium, M. simiae,
M. vaccae and M. wolinskyi were isolated. In two
patients, same species of NTM, M. avium in one
case and M. simiae in another, was isolated from
both blood and stool samples. In this study,
environmental viz. soil and water were also
processed for NTM using PSC technique. These
samples were collected from the environment of
patients with NTM disease. A large number of
species of NTM viz. MAC, M. fortuitum, M.
chelonae, M. abscessus, M. flavescens, M. phlei, and
M. thermoresistibile were isolated from such
samples. Drug susceptibility testing was performed
using MIC in microtitre plates and BACTEC
460TB system. Variable patterns of susceptibility
were obtained, the clinical isolates being more
resistant as compared to environmental isolates.
The clinical and environmental isolates of M.
avium were typed using PCR designed to amplify
DNA segments located between the insertion
sequences IS1245 and IS1311. Only two clinical
J MGIMS, March 2009, Vol 14, No (i), 16 - 21
19
Mendiratta DK, Narang P, Narang R
isolates from the same patient matched.
The NTM isolates obtained during
2005-07 were speciated using morphology and
biochemical reactions in our laboratory and
further confirmed using advanced techniques in
reference laboratories, by HPLC in CDC Atlanta,
InnoLiPA in Bilthoven the Netherlands, and
PCR-PRA & Gene Sequencing in National
JALMA Institute for Leprosy and other
Mycobacterial Diseases in Agra. The main
problematic NTM species showing discrepant
results was the M. simiae.
To conclude, NTM have started appearing
as important pathogens along with M. tuberculosis,
at least in AIDS patients. Paraffin slide culture
technique can be used as a selective medium for
NTM along with the routine LJ medium. The
laboratories can use phenotypic speciation
methods, which are available in most Medical
College laboratories and significant isolates from
important clinical samples may be sent to NRL
for confirmation. As per CLSI, MIC using
microtitre plate is acceptable method for drug
susceptibility testing of NTM.
Acknowledgement : The exhaustive work on NTM
has been possible due to contributions by Dr
Rahul Narang, Dr G M S Siddique, Dr Sangeeta
Dey, Dr Debashish Roy, Dr S Bhatacharya, Mr D
U Ingle, Mr Sunil Tiwari, Mr Sandeep Taksande
and Mr Siddharth Mendiratta)
References :
1. Anon (1989) Editor's note. Am Rev Respir Dis
140: 561
2. Grant AD, Djomand G, De Cock KM (1997)
Natural history and spectrum of disease in adults
with HIV/AIDS in Africa. AIDS 11(suppl B):
S43-S54.
3. McDonald LC, Archibald LK, Rheanpumikankit
S, et al (1999) Unrecognised Mycobacterium
tuberculosis bacteraemia among hospital inpatients
in less developed countries. Lancet 354:1159-1163.
4. Mohar A, Romo J, Salido F, et al (1992) The
spectrum of clinical and pathological manifesta-
tions of AIDS in a consecutive series of autopsied
patients in Mexico. AIDS 6:467-473.
5. Murillo J and Castro KG (1994) HIV infection
and AIDS in Latin America. Epidemiologic
features and clinical manifestations. Infect Dis Clin
North Am. 8(1):1-11.
6. Narang P, Narang R, Mendiratta DK, Roy D,
Deotale V, M. A. Yakrus, Sean T, and Kale V (2005)
Isolation of Mycobacterium avium complex and M.
simiae from blood of AIDS patients from Sevagram,
Maharashtra. Indian J Tuberc 52:21-26.
7. Joseph O, Falkinham,III (1996) Epidemiology of
Infection by Nontuberculous Mycobacteria Clin
Microbiol Rev 9(2);177-215
8. Bucher HC, Griffith LE, Guyatt GH, et al (1999)
Isoniazid prophylaxis for tuberculosis in HIV
infection: a meta-analysis of randomized controlled
trials. AIDS 13:501-507
9. Karakousis P C, Moore R D and Chasson R (2004)
Mycobacterium avium complex in patients with HIV
infection disease. Lancet 14:557-65.
10. Kumarswamy N,.Snigdha V, Timothy P (2005)
Clinical profile of HIV in India.Ind J Med Res
121: 377-394
11. David ST, Mukundan U, Brahmadathan KN and
John TJ (2004) Detecting mycobacteraemia for
diagnosing tuberculosis. Indian J Med Res
119(6):259-66.
12. Deodhar L (1999) Mycobacteraemia in AIDS
patients report of 2 cases. Ind J. Med. Microbiol
17 (4): 196-197.
13. Shafer RW, Goldberg R, Sierra M, Glatt AE (1989)
Frequency of Mycobacterium tuberculosis
bacteremia in patients with tuberculosis in an
Area endemic for AIDS. Am Rev Respir Dis 140;
I51I-1513.
J MGIMS, March 2009, Vol 14, No (i), 16 - 21
20
Face To Face With Nontuberculous Mycobacteria At Sevagram
The study was conducted at Mahatma Gandhi Institute of Medical Sciences (MGIMS),
Sevagram from 1st January 2001 upto 31st December 2005 i.e. 5 years on 99 cases of elderly suicide
which were received from in and around the district Wardha, Maharashtra. Cases included
victims greater than or equal to 50 years of age. Data was analyzed with regard to the age, sex,
methods of suicide, place of suicide, cause of suicide and time of the year components. There were
71 male (72%) and 28 female (28%) victims. The age range of the suicide victims was 50 to 85 years.
Commonest age group involved in our study was 50 - 59 years (n=47, 47.47%) in both sexes.
Poisoning (n= 62, 63%) was the most common method of suicide, followed by burning (n=27, 27 %)
and drowning (n=6, 6%). Maximum numbers of suicides were seen in the rainy and winter season
(n=54, 55%). Financial problem (n = 53, 53.5%) was the most common reason behind the suicide.
Key Words : Suicide, poisoning, burning, chronic illness.
Original Article
INTRODUCTION :
Aging is a natural phenomenon which is
inevitable to everyone. In the recent years, there
has been a considerable increase in the relative
or absolute numbers of the elderly people which
is due to decline in the fertility rates combined
with increase in life expectancy of people
achieved through medical interventions.1 In the
year 2002, there were an estimated 605 million
old persons in the world of which 400 millions
were living in the low income countries. It is
expected that by the year 2025, the number of
elderly people will rise to more than 1.2 billion,
with about 840 million of these living in low-income
countries. As per SRS estimates for the year 2003,
7.2 percent of total population were above the
age of 60 years.2
For most older people, their life is a time of
fulfillment, satisfaction with life's accomplishments.
For some older adults, however, later life is a time
of physical pain, psychological distress, and
dissatisfaction with present, and, perhaps, past
aspects of life. They feel hopeless about making
changes to improve their lives. Suicide is one of
the possible outcome. Life events commonly
associated with elderly suicide are: the death of
a loved one, physical illness, uncontrollable pain,
fear of dying a prolonged death that damages
family members emotionally and economically,
social isolation, lack of care from children and
loneliness and financial problems due to job
loss or retirement. The widowed, divorced, and
recently bereaved are at high risk. Others at high
* Associate Professor, ** Professor & Head, *** PostGraduate Students, Address for Correspondence :Dr.P.N.Murkey, Associate Professor, Dept. of FMT,MGIMS, Sevagram. E-mail : [email protected]
J MGIMS, March 2009, Vol 14, No (i), 38 - 42
38
risk include depressed individuals and those
who abuse alcohol or drugs.3
In America, each year more than 6,300
older adults take their own lives, which means
nearly 18 older Americans kill themselves each
day. Although they comprise only 12 percent of
the U.S. population, people age 65 and older
accounted for 16 percent of suicide deaths in
2004.4 In India the rate of suicide among the
elderly in the year 2005 was 8.2 % (Male 5.8%, and
Female 2.4%) of the total suicides. According to
NCRB India report 2005, nearly 42.8% of the
elder age group committed suicide due to illness.5
In the present article, we have attempted
to study the incidences, patterns and modes of
suicides in the elderly persons brought for
medico-legal autopsy to MGIMS, Sevagram.
MATERIAL AND METHODS :
The Mahatma Gandhi Institute of Medical
Sciences (MGIMS), Sevagram, is one of the pioneer
rural based hospital in the country which was
established with the motive of providing the basic
medical needs to the rural population of India.
As in any other government medical hospitals,
here too the medico-legal autopsies are conducted
which covers the whole of Wardha district
(mainly) and also other nearby districts. We went
through all cases of elderly deaths on which
postmortems were done at MGIMS, Sevagram
(age of victim being 50 years and above, as
compared to 60 years and above in other studies)
over a period of 5 years, from 1st January 2001 to
31st December 2005. A total of 1306 autopsies were
done during this period, out of which 230 cases
were of elderly subjects (50 years and above). Out
of these 230 elderly autopsies, 99 cases were of
suicides, which constitutes about 7.58 % of all
the total autopsied cases which were done in the
above mentioned period of 5 years. The detailed
analysis of these cases was based on the medical
records and the evaluation of autopsy reports.
DISCUSSION :
In our study, out of total 1306 autopsy
cases, 312 cases were of suicides, which constitutes
about 23.89 % of all the autopsy cases. Out of
these 312 cases, 99 cases were in the elder age
group (50 years and above) which amounts to
31.73% of all the suicide cases.
In our study from 2001 to 2005, there
were almost an equal numbers of suicides in
each year with slight variation in the figures with
maximum incidence in 2002 (n=24) and minimum
incidence in 2004 (n=16). Kua et al, in a study
describing the trends of elderly suicide rates of
Chinese, Malays and Indians in Singapore from
1991 to 2000 reported that the suicide rates for
the elderly showed a decline, especially in elderly
Chinese.6
As for the pattern of age and sex wise dis-
tribution of suicide, Pritchard in a study of
changing patterns of suicide in the Western
World, examined changes in suicide rates between
1974 and 1992 in twenty-two countries. He found
a decrease in rate of suicide in 65-74 years olds of
both sexes in most countries and increases in
suicide rates in the population aged 75 years
and older, again in both sexes, but with a male
preponderance.7 But in our study, there is a
decrease in the rate of suicide with increasing
age with the commonest age group involved
was 50-59 years (n = 47, 47.47%) followed by the
age-group 60 - 69 years (n=31, 31.32%) and 70-79
years (n=15, 15.15%). Minimum cases of elderly
suicides were found in the age-group of 80-89
years (n=6, 6.06%). There is male preponderance
in all the age-groups except in the last one where
females are dominating. The highest rate of
J MGIMS, March 2009, Vol 14, No (i), 38 - 42
39
Murkey PN, & et al.
elderly suicides in the age-group of 50-59 years
with male preponderance in our study may be
explained by the fact that there is high rate of
suicides among the farmers in the region of
Maharashtra.
Poisoning was the most common cause
of death (n=62, 62.6%) followed by burn injuries
(n=27, 27.3%). In cases of poisoning, the male :
female is 5.2 :1 whereas in cases of burns, females
predominated males with a male : female of 1:2.
Next to burn injuries the cause of death was
drowning which formed about 6.1% (n=6) with
male : female ratio of 1:5, followed by hanging
(n=2, M:F = 1:1)and railway cutting (n=2, both
males). Therefore, it was concluded that among
males poisoning was the most common cause of
death whereas among females burning was the
commonest mode of suicide. In a similar study
of 10 years (from 1996 - 2005) by C. Behera et al
at AIIMS, they found that hanging was the most
common cause of death which is quite different
from our study.1 This highlights the basic
difference of mode of suicide in rural and
urban areas where poisoning was most common
method in rural areas due to easy availability of
poisons (mostly pesticides and insecticides) in
each home of rural areas. Studies from most of
the western countries revealed firearms as the
most common method of suicide 8 which is quite
contradictory in our scenario where there was
not a single such case.
The highest number of suicides in the
elderly age groups was recorded in autumn and
winter (55%, n=54) followed by the rainy season
(28%, n=28) and spring and summer season (17%,
n=17) which is quite different from the findings
observed in the studies from eastern part of India
by S. Mohanty et al9 and from Northern India by
c.Behera et al1 where maximum cases were
recorded in the rainy season. Most of the suicides
occurred indoors (n=87, 88%), which is consistent
with the findings observed by S.Mohanty et al9
and c.Behera et al1.
The specific types of events most
pertinent to suicide in later life differ from
those of younger victims. Interpersonal discord,
financial and job problems, legal difficulties and
disputed romance etc. are more typical of suicides
in young and middle adulthood, whereas physical
illness and other losses including family
economical losses are the most common stressors
in older adults who end their own lives.
As per the findings of our study, financial
problem was the foremost reason behind the
high rates of suicide among the elders which
constituted 53.5 % (n=53) of the total cases. This
may be due to the below-poverty-line economy
of the poor rural populations combined with
high indebt from high-interest-money lenders.
This is followed by other family and personal
problems (n=26, 26.3 %) and chronic illness (n=11,
11.1%). This is quite contradictory to the findings
of most of the studies. Dorpat et al (1968)10 in a
study stated that physical illness directly contributed
to suicide in almost 70% of victims over 60 years
of age. Margda waern et al11in their study
mentioned that physical illness is a common
antecedent to suicide in elderly people, with
prevalent figures varying widely from 34% to
94% and higher risk factors in men than in
women. In 9.1% cases (n=9) the causes were unknown,
but here conditions like social isolation and
loneliness are important factors to be considered
(Barraclough 197112).
CONCLUSION :
Suicide is rarely, if ever, caused by any
single event or reason. Rather it results from
J MGIMS, March 2009, Vol 14, No (i), 38 - 42
40
Suicides In Elderly Age-Group In Wardha Region Of MH In A Period Of Five Years, From 1st Jan. 2001 To 31st Dec. 2005.
many factors working in combination which
produce feelings of hopelessness and depression.
Elder suicide is usually associated with depression
and factors causing depression e.g. chronic illness,
physical impairment, unrelieved pain, financial
stress, loss and grief, social isolation and alcoholism
commonly include anatomic variation of the internal
jugular vein in relation to the carotid artery,
stenosis, total occlusion, and nonocclusive thrombus
formation. The hemodialysis catheter had not
followed the expected course of the right subclavian
vein into the right jugular vein that crosses the
midline to join the right brachiocephalic vein
to form the superior vena cava. The catheter had
most likely entered a tributary of the right
subclavian vein i.e. right external jugular vein,
(fig-2) which explains why there was free flow
of blood by syringe aspiration during catheter
insertion, but not by the blood pump of the
hemodialysis machine that generated a suction
force to execute a flow rate of 200 mL/min. Such
complication may happen in patients who had
previous catheter insertions. The external
jugular vein varies in size, bearing an inverse
proportion to the other veins of the neck. It is
provided with two pairs of valves, the lower pair
being placed at its entrance into the subclavian
vein, the upper in most cases about 4 cm. above
the clavicle.
To circumvent these problems, direct
real-time ultrasound guidance for the insertion
of temporary hemodialysis catheter has greatly
enhanced the safety and success rates of this
procedure,3 which is commonly performed by
the practicing nephrologist, intensivist, and
radiologist in major hospitals worldwide. However
at this centre we are doing blindly because of lack
of resources without any much complication and
inconvenience. Indeed, sonography does not
allow the operator to follow the course of the
guidewire and catheter beyond the subclavian
vein or internal jugular vein. So in addition to
an ultrasound survey, venography performed
during catheter insertion may detect unexpected,
clinically significant anatomical abnormalities or
variations of the central veins.
References -1. Lin BS, Kong CW, Tarng DC, Huang TP, Tang
GJ. Anatomical variation of the internal jugularvein and its impact on temporary haemodialysisvascular access : An ultrasonographic survey inuraemic patients. Nephrol Dial Transplant. 1998;13:134-138.
2. M.Moini, M.R.Rasouli, M.M.Kenari, H.R.Mahmoodi : Non-cuffed dual lumen cathetersin the external jugular veins versus other centralveins for hemodialysis patients. Saudi J KidneyDis Transpl 2009; 20:44-8.
3. Oguzkurt L, Tercan F, Kara G, Torun D, KizilkilicO, Yildirim T. US-guided placement of temporaryinternal jugular vein catheters: Immediatetechnical success and complications in normal andhigh-risk patients. Eur J Radiol. 2005;55:125-129.
Fig-2 : Major vein and their tributries(taken from internet)
J MGIMS, March 2009, Vol 14, No (i), 43 - 44
44
Inability to start hemodialysis after a smooth dual lumen hemodialysis catheter insertion procedure : a case report
GENETIC STUDY - A HELPING HAND FOR CLINICAL DIAGNOSIS
AM TARNEKAR *, JE WAGHMARE **, P BOKARIYA ***, IV INGOLE ****, AK PAL *****
ABSTRACT
Genetic disorders have diverse modes of presentation. Some present with obvious features
and have strong clinical suspicion in order to make a clinical diagnosis. Many other genetic disorders
remain masked till a specific genetic test such as karyotype analysis or molecular analysis (FISH,
PCR) is carried out. Some routinely encountered genetic disorders such as Klinefelter's syndrome,
Turner's syndrome and Down's syndrome may present in a variant form. In such cases there is very
little clinical suspicion for a genetic disorder and diagnosis is entirely based on karyotype analysis.
Importance of genetic study in conditions of poor reproductive outcome, bad obstetric history
(BOH) and inheritance of Down's syndrome is highlighted.
Key words : karyotype, mosaicism, genetic counseling.
Case Report
*Associate Prof., ** Senior Lecturer, *** Lecturer,**** Prof. & Head *****Prof. (Cytogenetics) &corresponding author. Human cytogenetics unit, Dept.of Anatomy, MGIMS, Sevagram.
INTRODUCTION
With better control of infectious and
nutritional diseases more number of genetic
disorders are emerging1. People in general are
largely unaware of genetic disorders. Different
genetic disorders present in diverse manner and
manifest at different ages. Problems related to
fertility manifest much later than bodily deformities
(congenital anomalies) that manifest in neonatal
period. Many others manifest in adulthood or
may not reveal at all till a triggering signal is
received. Regardless of age of presentation, all
such conditions can however be identified at a
quite early age if specific genetic tests are applied
whenever clinically suspected.
Diagnosis of some of the genetic disorders
can be presumptively made on the basis of
presentation, signs and symptoms [e.g. Klinefelter's
syndrome, Down syndrome & Turner's syndrome].
However in many others a genetic test such as
Karyotype of peripheral blood lymphocytes or
molecular genetic tests such as PCR (polymerase
chain reaction) and FISH (fluorescent in situ
hybridization) are required to identify and
localise the abnormality. Most of the new world
diseases such as cancer, diabetes, hyperlipidaemia
etc have a genetic predisposition. This necessitates
carrying out a susceptibility test (e.g. human
leucocytic antigen 'HLA' typing) for the timely
diagnosis and proper management of such
conditions.
We have analysed some of the routinely
referred subjects to cytogenetics unit and categorized
some such cases where a clinical clue to point a
genetic abnormality was lacking. It reveals the
importance of carrying out Karyotype analysis
and subsequent genetic counseling for the
comprehensive management of such conditions.
Scenario 1 : An infertile married couple
is referred. No abnormality found in female
partner. Husband was azoospermic and found
J MGIMS, March 2009, Vol 14, No (i), 45 - 48
45
to have deletion of Y chromosome (46,XYq-); OR
mosaic of Klinefelter's syndrome (46,XY /
47,XXY) OR some other structural abnormalities
of 'Y' chromosome.
Fig 3 : Karyotype of the child with translocatedDown syndrome: Karyotype: 46,XY,t(14;21)
Scenario 4 : a couple presents with a child
who was born after series of pregnancy losses.
His parents want to rule out any genetic disorder
in child. Karyotype of the child reveals
traslocated type of Down's syndrome.
DISCUSSION :
The case scenarios suggest the modes
of presentation of some genetic disorders. The
existing myths about disease causation can be
removed by proper counseling and the scientific
background of such conditions be explained to
the family members in order to regain the peace
of the family.
In scenario 1, gentleman did not know
that he might have an abnormality till seminal
analysis and karyotype was performed. Mosaics
of Klinefelter's syndrome may not be azoospermic
and some sperms or round spermatids may be
obtained by MESA (micro epididymal sperm
aspiration) or TESA (Testicular sperm extraction)
for invitro fertilization (IVF) such as ICSI (intra
cytoplasmic sperm injection)2. Such persons have
chromosomally imbalanced gametes that may
lead to birth of an abnormal child. It is therefore
most undesirable for such couples to try their
Fig 1 : Karyotype of an azoospermic individual :karyotype 46,XYq-
Scenario 2 : Another infertile married
couple, male partner found normal, female
partner has mosaic pattern of Turner's syndrome
(45,X0 / 46,XX or 47,XXX / 45,X0) OR other
structural abnormalities of an 'X' chromosome.
Scenario 3 : A childless couple with history
of several pregnancy losses (bad obstetric history
'BOH'). Karyotype reveals autosomal structural
abnormality e.g. 46, XY, t(6;13) (p24; q21) in male
OR 46, XX, t(9;15)] in female partner.
Fig 2 : G banded Karyotype of male partner ofa couple with BOH: 46, XY, t(6;13)(p24;q21)
J MGIMS, March 2009, Vol 14, No (i), 45 - 48
46
Genetic Study - A Helping Hand For Clinical Diagnosis
luck with assisted reproductive techniques
(ARTs), the ideal option is adoption. It is quite
unfortunate on part of lady when we here about
husband's second marriage, separation of the
couple or continued harassment of the lady3 by
family members in such circumstances.
In scenario 2, a lady in whom onset of
menses (menarche) occurs as usual, secondary
sex characters are developed, clinical examination
may not reveal any abnormality but the lady is
infertile due to a constitutional chromosomal
abnormality - 'X' chromosomal abnormality
[structural or numerical] such as mosaic
Turner's syndrome and fragile 'X' syndrome4. 'X'
mosaicisms cause premature ovarian failure
(POF) or polycystic ovary syndrome (PCOS) ren-
dering a lady primarily or secondarily infertile5.
In conditions of reciprocal balanced
autosomal translocations [scenario 3] phenotypic
abnormalities may not be there. However the
particular structural abnormality of autosomes
leads to improper segregation of chromosomes6
during gametogenesis rendering the gametes
chromosomally imbalanced and therefore
pregnancy either does not occur or results in
miscarriage (BOH)7.
The occurrence of abnormal karyotype
as 'translocated Down' in child [scenario 4] was
the result of inheritance of Robertsonian
translocation from one of the parents, which
happens in 3-4% cases of Down's syndrome8. In
such cases usual phenotypic features of Down's
syndrome are lacking so there is no clinical
suspicion. Though such children might lead an
apparently normal life as their parents do, but
their reproductive outcome will be poor. 'Trisomic'
Down's syndrome, which is the usual form of the
syndrome, occurs de novo and is never inherited.
Karyotype analysis is a basic investigative
tool for diagnosis of a genetic disorder. The
drastic features of genetic disorders are hereby
summarised for a proper and ethical approach
towards their management.
Genetic disorders may arise either de
novo or familial, so they are not always predictable;
only by genetic tools they can be identified; they
provide no option for treatment, any attempt of
treatment or further investigation will be
wastage of resources.
Pre marital counseling is must when a
genetic disorder is suspected in families of
marriageable candidates9. If already married,
child should be planned only after proper
genetic counseling. If an expert advice is seeked
when already pregnant, pre natal diagnosis is a
measure to rule out birth of baby with congenital
anomaly10.
On realizing that there is no treatment
option left, people might raise doubts about
feasibility of carrying out a genetic test. It can
clearly be stated that to have a safe future
generation genetic study should be carried out
today.
Acknowledgements : Authors gratefully acknowledge
the technical assistance of MR V P Kavinesan
and Mr. Satish Shingare.
REFERENCES :
1. Verma IC. The challenge of genetic disorders
in India : Molecular genetics and gene therapy.
The New Frontier. In Proceedings of First Annual
Ranbaxy Science Foundations Symposium, New
Delhi 1994: 11-20.
2. Lanfranco F, Kamischke A, Zitzmann M and
Nieschlag E. Klinefelter's syndrome. Lancet 2004;
364: 273-283.
J MGIMS, March 2009, Vol 14, No (i), 45 - 48
47
Tarnekar AM & et al
3. Phadke SR. and Agarwal SS. Adverse effects of
genetic counseling on women carriers of disease:
The Indian perspective. The National Medical
Journal of India 2001; 14, (1).
4. Pal A K, Waghmare JE, Tarnekar A, Rawlani S
and Ingole I. Genetic aspects of human infertility.
Perspectives in Cytology and Genetics (Eds. Giri
AK, Ghosh PD and Mukherjee A; AICCG
publication) 2007; 13: 106-114
5. Anasti JN. Premature ovarian failure: an update.
Fertility and Sterility 1998; 70: 1-15.
6. Sadler TW. Gametogenesis: conversion of germ
cells into male and female gametes. In Langman's
Medical Embryology (Lippincott Williams and
Wilkins Publ.), 10th Edition : 2008 : 11- 29.
7. Chandley AC, Edmond P, Christie S, Gowans L,
Fletcher J, Frackiewicz A and Newton M.
Cytogenetics and infertility in man. I. Karyotype
and seminal analysis. Results of a five year survey
of men attending a sub fertility clinic. Annals of
Human Genetics 1975; 39: 231-252.
8. Hamerton JL, Cowie VA, Gianneli F, Briggs SM,
Polani PE. Differential transmission of Down's
syndrome (Mongolism) through male and female
translocation carriers. The Lancet 1961 (ii): 956-958
9. Abdel MN, Zaki MS and Hammad SA. Premarital
genetic investigations: effect of genetic counseling.
East Mediterr. Health J. 2000; 6 (94):652-60.
10. Jackson LG. Prenatal genetic counseling. Primary
care Dec 1976; 3(4): 701-16.
J MGIMS, March 2009, Vol 14, No (i), 45 - 48
48
Genetic Study - A Helping Hand For Clinical Diagnosis
I WANT MY FATHER BACK - CHILD’S DESTINY.
BH TRIPUDE *, PN MURKEY **, VG PAWAR ***, S SHENDE ***, A KECHE ***, KS SINGH ***
ABSTRACT
A 50 years / male, rural farmer in Wardha district, Vidarbha region of Maharashtra,
cultivated cotton on his eight acres (3.2 heactares) of land, and the returns were good until a
couple of years ago. On August 11, 2007, he had consumed some unknown poison in his farm and
admitted in Kasturba Hospital, Sewagram and died during treatment. As the body comes to the
postmortem examination the children’s were crying agonizingly and shouting as “majhe baba mala
parat daya”. On postmortem examination, a visceral examination indicated the presence of a
pesticide. He had apparently taken the step as he is unable to face the local bankers and
moneylenders who had loaned him money. Two successive failed monsoons, coupled with the
non-payment of dues by an apathetic State Government, left him with barely enough to feed his
family and repay a debt of Rs. 50,000. It is a situation that thousands of farmers in the cotton belt
of Maharashtra are familiar with, and increasingly they are reaching for the pesticide can as a way
out of the misery. As this is one of the case filed as farmer suicide from the institute.
Key words - Poison, Pesticide, Cultivation.
Case Report
Introduction -
Rig Veda mentions laws and regulations
regarding poisoning. Poisoning is prevalent in
all over the world since ancient times. Meera was
killed by giving “Charanamrit” by king Rana.
Cleopatra committed suicide by inducing snake
bite by her own. Nepolean Bonaparte of France
was killed by slow arsenic poisoning. Ala-Uddin
Khilagi and General Romel were also killed by
poison. Greece and Rome also practiced medical
laws and ethics regarding poisoning since 600
B.C.
Today the social scenario has changed the
face of poisoning. India being an agricultural
country, uses insecticides very commonly to pro-
tect the crops, fruits and vegetables from insects.
There is no check on the supply, sale and uses of
the insecticides; hence incidence of poisoning
cases is increasing rapidly. Instructions about the
use of the insecticides regarding concentration
and protective measures are not followed by the
users as the instructions written in very small
letters by manufacturers are Toxic substances are
mostly manufactured in developed countries and
banned in their own countries, but they are to
the developing countries.
Case Report :
The following information was brought
from the inquest made by the police, case paper
study and relatives.
A 50 yrs. old male, was brought by police
constable, in the casualty of KHS, Sevgram on
11/08/07 at night, with the history of consumption
of insecticides in his farm as he is unable to face
the local bankers and moneylenders who had
loaned him money.
* Prof. & Head, ** Associate Professor, *** PostGraduate Students, Dept. of Forensic Medicine &Toxicology, MGIMS, Sevagram
J MGIMS, March 2009, Vol 14, No (i), 49 - 53
49
Then he was referred to medicine ICU
for further treatment but he died during the
treatment. Postmortem was done on 12/08/07.
Postmortem Examination -
General Examination -
The body was averagely built and
nourished, height of 5”6’, was wrapped with
white cotton bed sheet.
On external examination, face was
congested, both eyes were open, pupils were
dilated, lips shows blusih purple colour, tongue
within the oral cavity, no bite marks on tongue,
subconjunctival hemorrhages present in both
eyes, no oozing from mouth, nostrils, ears
neigher any evidence of dribbling of saliva
present. Finger nails were bluish purple in colour.
No injuries to external genitalia seen but evidence
of purging of the stool as well as semen present.
No sign of decomposition seen postmortem
lividity was present and fixed on the back. Rigor
mortis well developed all over the body.
Internal Examiantion -
Head
The scalp was opened, no injuries under
the scalp were seen. The skull and meninges
appeared normal, brain matter edematous and
small petechial hemorrhages seen on cut section
of the brain. No pus or excessive cerebrospinal
fluid was noted, Circle of Willis and other vessels
were normal.
Respiratory system -
1) Walls, ribs, cartilages- No injuries fracture
of the ribs, cartilages, pleura were intact and
adherent to both sides of thoracic cavity.
2) Airway - The larynx appears normal, trachea
and major bronchi contained minute
haemorrhages, mucosa appears slightly
hyperemic.
3) Parenchyma and lungs- both lungs were
congested and collapsed, minute haemorrhages
were present on the surface. On cut section,
both lungs were congested and show minute
pin point petechial haemorrhages severaly
and kerosene like smell present.
Cardiovascular system -
1) Heart- The pericardium was empty and intact.
The heart was normal in size and shape and
weighs about 230 gms. both the chambers
were filled with fluid blood, no evidence of
infarction, no thickening of cusps of valves,
no hypertrophy seen. Coronary arteries were
patent.
2) Arteries - Aorta show mild atherosclerotic
changes.
Alimentary syswtem -
Esophagus was normal, mucosa congested, no ul-
cers seen. All organs in situ. No free fluid in the
peritoneal cavity.
Stomach contaiins greenish colour fluid about
700 cc. with kerosene like smell to the contents.
Mucosa shows multiple haemorrhagic spots.
Food particles like rice and dal were partially
digested.
Liver and gall bladder - was of normal appearance,
on cut section, pale and easily friable and weighted
has to accept its selective disappearance from the
planet!
The book is a detailed account of history
and post- World War II Renaissance of eugenic
movement and insists that success of the movement
is the only hope of ever sustainable life on mother
planet. The Eugenics (Greek-eu 'well'+genes 'born')
is a branch of genetics dealing with improvement
of a population by controlled breeding to increase
the occurrence of desirable and inheritable
characteristics. All animal and plant breeders
know its utility very well, while practicing it in
human race suffered a near lethal blow by racial
killings and Nazi holocaust in early part of
twentieth century. Revival of interest in this
direction is evident from the number of books
written on the topic in recent years and worldwide
scientific deliberation going on. Out of total
3200 books listed on 'online computer library
center/OCLC/Worldcat', 473 are published
within last five years apart from innumerable
online discussions.
Author makes it clear in the beginning
itself that it is not the therapeutic eugenics he
is proposing, for eugenics to prevent genetic
diseases by pre- and post marital counseling,
antenatal diagnosis and selective abortion of
affected fetus is already more or less accepted by
most of us except few religious groups. It is the
new socio-political aspect of reproductive eugenic
movement which has been pondered over in the
book. Molecular biologists as prophets of this
new religion of genetics have following basic
concepts -
1. In the role of a species on earth, we behaved
in utter indisciplined way, in fact just like a
malignant disease - freeing ourselves from
regulatory constraints of natural selection
and limitations of natural resources. Our
invasive development started to wreak havoc
not only on our fellow species and on the
J MGIMS, March 2009, Vol 14, No (i), 57 - 60
57
host we parasitize- the planet but now also
endangering our own survival.
2. Evolutionary selection process which created
the human species on earth is almost stopped
by development of civilization, science in
general and Medicine in particular. Almost
everyone who is born, however genetically
weak he/she is, lives full life today thanks to
power of medical sciences. As a result, natural
selection by differential mortality is replaced
largely by differential fertility patterns of
communities.
3. Moreover fertility is decreasing fast in high
IQ individuals and groups (procreation is not
their ambition) while it is still high in low IQ
groups, world wide. This dysgenic phenomenon
is leading to deterioration of quality of human
life as a race. Not only we stopped evolution
on earth, we are going backwards in
evolutionary chain. This can be evidenced by
less and less numbers of masterminds and
geniuses with every passing generation.
4. Different ethnic populations on the earth are
not one Homo sapiens, the myth purposefully
woven by egalitarians, but are different species
with separate gene map of their own and so
their IQ, abilities and capabilities
5. Almost all physical, mental, behavioral, moral
and social characteristics are determined by
genes and are inheritable. 'Nurture' has trivial
role in defining the personality, unlike the
popular thinking. The author is troubled that
we continue to apply moral criteria of behavior
in spite of knowing that we are about to
decipher behavioral patterns scientifically,
after mapping of human genome.
6. Humanity is defined not as only the currently
living population, but as the total number of
people who will potentially ever live on earth.
Since the unborn constitute a vastly greater
potential population than do currently
living, their rights prevail (though in present
political - social sphere future generations
represent a zero political constituency).
Emboldened by recent mapping of human
genome, new breakthroughs in biotechnology,
animal cloning and stem cell research, Glad with
other proponents of eugenics predicts that areas
of health and behavior up till viewed through a
moral prism are going to be explained by genes
in a few years time. "The genie of enlightenment
can not be squeezed back into the bottle of
ignorance" whoever tries to do it now. They propose
that we should start working for artificial selection
of fertility by joining hands with genetics to make
human race evolving further and this time also
to save ecology of the mother planet. "Eugenics
views itself as the fourth leg of the chair of
civilization, the other three being a thrifty
expenditure of natural resources, mitigation of
environmental pollution and maintenance of a
human population not exceeding the planet's
carrying capacity." Eugenicists believe that "while
our social conduct, like that of all other animal
species, is necessarily centered around the mating
ritual, our perception of this process is governed
by a myriad of camouflaging taboos and fetishes.
The gap between reality and fantasy could not
be more crass." The goals advised by the author
for twenty first century are
A. to reduce fertility of low IQ groups from
each ethnic community by
1. curbing their reproductive rights, along with
criminals, insane, feebleminded and paupers
2. removal of or severe constraints on help
provided to welfare mothers
J MGIMS, March 2009, Vol 14, No (i), 57 - 60
58
Utopia is now promised by science! Book - Future Human Evolution : Eugenics in twenty first century
3. not to discourage female feticide in countries
with increasing population and thus
reducing number of reproducing females
B. to increase high IQ groups fertility in each
ethnic community by
1. reducing the age of first pregnancy in the
females of these groups so they can bear more
children
2. polygynae /artificial insemination to make
best use of high quality sperms
3. asexual procreation by low IQ females using
high quality ova and sperms fertilized in vitro
4. asexual cloning of high IQ individuals
It is evident that the first and foremost
prerequisite to achieve these goals is to release
sex from its procreative duty and also from
number of myths encasing it. The speed at which
we are depleting the natural resources for our
mainly dysgenic and huge species, makes it very
clear that sooner or later we are bound to agree
to above proposals or accept our inevitable
extinction from the face of the earth.
But are we ready to consider the eugenic
movement our saviour? It is hard to accept the
following notions in the first place that :
1. Different ethnic communities are separate
species. Few like Jews are genetically privi-
leged than others. Moreover gene mapping
can answer all our questions regarding
biodiversity in human race.
2. IQ can be the sole criteria to decide the
worth, progeny and fate of an individual on
the earth.
3. Not only physical but behavioral and social
negative traits as violent behavior, criminal
attitudes, cruelty, consumerism, addictions,
even marriage and divorce are not correctable
as determined by nature and not nurture.
4. Success stories of breeding of health animals/
plants which did not take any socio-politico-
cultural issues in to consideration, suffice to
proceed for human breeding program
5. We have to surrender our beliefs in all other
socio-political movements if want to achieve
equality.
6. The basis of morals, emotions and relationships
can be entirely different in next era.
Even if we try to believe that the goal of
an advanced human species working in harmony
with nature is achievable through eugenics,
innumerable questions still remain -
1. Advantages of eugenic practices will take at
least ten generations to surface if we start
action from the current reproducing popu-
lation (which is impossible as we just started
to explore genome, to use it we have to go a
long way) but abuse of eugenics is already very
well known to us in form of racial hatred,
Nazi holocaust and forced sterilizations. We
have to be absolutely ruthless and honest just
as nature, if we play god. Our history doesn't
assure us regarding this quality in us. How can
we trust the purity of intentions of eugenicists
and the politicians guiding them, this time?
2. Even if we trust them, who will decide which
characteristic is desirable up to what extent?
The world is not black and white; it has
innumerable shades of grey in between which
are angelic but intolerable to others.
3. According to Glad we must be dispassionate
(towards loss of reproductive freedom to
current population, morals) when talking
of scholarly discussion over eugenics! Perhaps
he forgot that being passionate must also
be a genetically determined trait in us which
can not be changed.
J MGIMS, March 2009, Vol 14, No (i), 57 - 60
59
John Glad
4. In an all highly intelligent society who will
do the manual labor, need for which will
always be there? It means the future
generations will have lord-slave system
again or else, have to live with robots.
5. If low IQ persons are more involved in crime
then what do we label all white collar scams
and scandals? Perhaps eugenics does not
count them in criminal activities.
6. Can we afford the total collapse of judiciary
in an already threatened world? The new
system would not lay responsibility on the
individuals for their own criminal acts and
crimes will no more be punishable. Concept
of Marriage will be irrelevant; and so also
the concept of adultery and incest as children
of same biological parents (who will be very
few selected individuals) but different legal
parents may make couples. Though all these
complications may look unreal or perverse in
present socio-cultural setting, this in fact is
the future being written for us by eugenic
movement
7. It is the fact that people prefer their own
biological children at any cost. Reproductive
rights of a couple will no more be a personal
property in the new regime. Author himself
expressed fear of inability to pass this hurdle.
Moreover the love and natural bond formed
between a biological child and parents is
necessary for psychosocial development of
the child. Perhaps emotional security is also
considered here inherited! Which government
will risk its viability by this intrusion into
personal sphere when the promise of every
government is to give as much as freedom is
possible to its citizens?
8. Will concern over issues of reducing male :
female ratio and woman's rights to career and
development be absurd forever? The high IQ
females will be forced to enter the reproductive
pool at early age and thus the personal
freedom partially obtained just in last
century through a long feminist movement
to will be snatched away again.
9. Even if we are different genetically, we are
extremely intimately related species and if
reproductive rights of one community are
favored over other owing to genetic superiority,
will it not reflect into even more intense
intergroup conflicts than today?
Eugenics is proposing that there will be
no more stories of miracle from dust to sky; no
more families; no more interethnic marriages.
Or it is just another type of 'fantasies plucked
from the air' as J Bauer, a Viennese physician once
said about Nazi concept of race. Some of these
questions are addressed by Glad in the book very
intelligently but without satisfactory answers. A
book for rights of future generations and for that
of the earth is indeed a holy mission but as he
indicates, both of these clients have no say in the
matter and present population have to be forced
only, to act in such direction questioning its
feasibility.
If still you are ready to buy the idea, you
are welcome to dream once again of the Eugenic
Utopia.
By
DR. ANUPAMA GProfessor Dept., of PathologyMGIMS, Sevagram
J MGIMS, March 2009, Vol 14, No (i), 57 - 60
60
Utopia is now promised by science! Book - Future Human Evolution : Eugenics in twenty first century
DR MICHAEL ELLIS DEBAKEY
(Sept’ 1908-July 2008)
Obituary
“Dr Debakey, a pioneering surgeon whose
carrier spanned 70 years, was one of the creator of
cardiovascular surgery. His death has brought to
an end almost a century of tireless work for
improvement of surgical treatment of major
cardiovascular disorders.” writes The Iris Medical
Times.
Dr Michael Debakey was born on 7th Sept
1908 at Lake Charles, Louisiana to Lebanese
immigrant parents. Interestingly, his father had a
Farmacy and his mother taught him to sew and knit
which resulted in his joining the medical school
and developing the surgical skills. He completed
his medical degree from Tulane University in
New Orleans. Later he continued his studies at the
University of Strassbourg in France and University
of Heidelberg in Germany.
In that era “there was virtually nothing you
could do to a patient of heart disease, If a patient
came with heart attack it was up to God” so said
Dr Debakey. He developed a roller pump which
subsequently became an important component of
heart-lung machine necessary today for any open-
heart surgery. The development of bypass surgery
for coronary heart disease made a medical history.
In 1953 for the first time he used a dacron graft for
blood vessel replacement allowing the repair of
Aortic Aneurysm. He with Dr Denton Cooley was
the first to introduced cardiac transplant in USA in
1968, after the very first transplant carried out by
Dr Christian bernard in South Africaq in 1967.
He developed the artifical heart for the patients
waiting for cardiac transplant. His innovations have
helped developing several newer surgical instru-
ments and surgical techniques Hundreds of heart
surgeons trained by him are working around the
world. He was totally dedicated to his work and his
patients without any
discrimication. He has been
tirelessly working almost 12
hours a day, performed
1000 operations per year
totalling about 60000. He continued to operate
till the age of 90 years. He remained active and
have been moving for delivering lectures and
attending conferences. He has over 1300 published
medical articles besides several chapters, and
books on surgery and medicine “The living heart”
is one of his best sellar publication.
He worked in army during second world
war initially as captain. Later he was made director
of surgical consultants division at Office of the
Surgeon General in Europe. His innovative mind
helped here also in developing ‘Mobile Surgical
Hospital. He has been medical advisor to five
presidents of United States of America. This
political support resulted in creation of Medicare
Health Insurance Scheme. In such a long carrier
he received innumerable awards. The few prominent
ones are President Medal for Freedom (1969 given
by President Lyndon Johnson), National Medal for
Science (1987, given by President Ronal Regan) and
the latest Cogressional Gold Medal (2008, given by
President George W Bush).
In leisure time he liked shooting and fishing.
He was Episcopalian by faith. In 2006 he had
himself undergone an aortic surgery. He passed
away at the age of 99 year on 11th July 2008. He has
improved the human conditions and touched the
life of generations to come. The medical world will
always remain indebted to him.
(Sources- Net reports of Irish medical times, the telegraph
and Houston Chronicle)
J MGIMS, March 2009, Vol 14, No (i), 61
61
THE NOBEL PRIZE IN PHYSIOLOGY OR MEDICINE 1909
EMIL THEODOR KOCHER
(August 25, 1841 - July 27, 1917)
Emil Theodor Kocher was a Swissphysician, medical researcher, and Nobel laureatefor his work in the physiology, pathology andsurgery of the thyroid.
Theodor Kocher was born on August 25,1841, at Berne Switzerland. His father, was a Chief-Engineer. He studied in Zurich, Berlin, London andVienna, and obtained his medical doctorate in Bernein 1865. His teachers of surgery were Demme, Lucke,Billroth, and Langenbeck. In 1872, he succeededGeorg Albert Lucke as Ordinary Professor ofSurgery and Director of the University SurgicalClinic at the Inselspital in Berne.
In 1883 Kocher announced his discoveryof a cretinoid pattern in patients after total excisionof the thyroid gland, when a portion of the glandwas left intact, however, there were only transitorysigns of the pathological pattern.
When Kocher began his surgical activitiesthe transition from the septic to the antiseptictreatment of wounds, works on the antiseptictreatment of wounds with weak chlorine solutions,Kocher was one of the first to go over to pureasepsis processes he sought to advance.
He published works on a number ofsubjects other than the thyroid gland includinghemostasis, antiseptic treatments, surgical infectiousdiseases, on gunshot wounds, acute osteomyelitis,the theory of strangulated hernia, and abdominalsurgery. His new ideas on the thyroid gland wereinitially controversial but his successful treatmentof goiter with a steadily decreasing mortality ratesoon won him recognition and the Nobel prize. Theprize money he received, he donated to his Universitythe sum of 200,000 Swiss francs which helped himto establish the ‘Kocher Institute’ in Berne.
His Chirugische Operationslehre (Theoryon surgical operations) reached six editionsand was translated into most modern languages. Itdescribed many operations, mostly in abdominalsurgery and the surgery of joints. His book
Erkrankungen derSchilddruse ( Diseasesof the thyroid gland )discussed the etiology,symptology and treatmentof goitres.
Kocher was an honorary member ofnumerous academies and medical scoeities, e.g. theGerman Surgical Society. An Honorary Fellow ofthe Royal College of Surgeons; Honorary Member ofthe Royal Society of Sciences, Uppasala; HonoraryMember of the American Surgical Society; theNew York Academy of Medicine & the College ofPhysicians, Philadelphia; the Imperial MilitaryMedical Academy, the Royal Medical Society ofVienna; Royal Medico-Surgical Society, London;He was a Corresponding member of the SurgicalSociety of Paris, Brussels : Belgiam Academy ofMedicine; the German Society of Neurologists andof the Hufeland Society of Berlin; Honorary M.D.of the Free University of Brussels.
In 1902 he was President of the GermanSociety of Surgeons in Berlin and President of theFirst International Surgical Congress, 1905, in Brussels.
A number of instruments and surgicaltechniques (for example, the Kocher manoeuvre)are named after him, as well as the Kocher-Debre-Semelaigne syndrome, Kocher zonde Spoon-shapedprobe for goitre operations, Kocher’s arced incisionOblique incision for opening the knee joint.,Kocher’s incision II Tranverse incision over glandulathyreoidea in the neck for thyroidectomies, Kocher’ssign Eyelid phenomenon in hyperthyreosis andBasedow’s disease, Kocher’s syndrome Splenomegalywith or without lymphocytosis and lymphadenopathyin thyrotoxicosis etc.
Kocher married Marie Witchi (1851-1921).They had three sons, the eldest of whom, Albert(1872-1941) became Assistant Professor of Surgeryand gave his father considerable help in his work.Theodor Kocher died at Berne on July 27, 1917.
J MGIMS, March 2009, Vol 14, No (i), 62
62Source - Noble prize.org
THE LIBERATION
Poem
Representative of the summit of creation,
The man,
Utopia remains his dreams, his imagination
Possessing consciousness, the supramental ability,
Prays and crave for immortality !!
About to slip in another world
Away from the wearying regimen of __
Pokes, prods, and pinches__
Endured since diagnosed as Acute leukemia
Curly haired
Cherub faced, reserved
Prone to one word answer
Behind his shy exterior
Lurked a creative spirit
Endowed with the capacity to endure
In the material universe, ever unsure
Eventide follow even the brightest day
Like the epilogue of life’s romance in a way
Plunging in to gloomy incertitude
‘Death’! No terror but the life’s prelude
Inevitably inseparable, intertwined
An evolutionary march for the new one, it reminds
No thanatophobia,
But a feeling of liberation from bondages
Carried on through the ages
Dr OP GUPTA
J MGIMS, March 2009, Vol 14, No (i), 63
63
A N A T O M Y
1. EFFECT OF CELLPHONE ON DEVELOPING
LENS OF CHICK EMBRYO. IV Ingole, JE Waghmare,
P Bokariya, BR Sonatakke, Tapti Das. 56 NATCON of
ASI, BHU Varanasi, Dec 27-29, 2008.
Magnitude of the problem of exposure to
Cellphone radiation is self evident from a vast number of
mobile phone users where the whole atmosphere gets
charged with the radiation acting as an environmental
pollutant. The radiation emitted by the Cellphone has been
incriminated to adversely affect the biological tissues. The
embryonic tissues are the most sensitive as the processes of
division and differentiation of the cells are crucial to its
development and are most sensitive to any type of insult at
this stage. Various effects on the developing visual system
have been reported as a result of exposure to cellphone
radiation case of congenital cataract have been frequently
reported as a result of prenatal exposure to certain teratogens.
None theless the reports of the adverse effects of radiation
emitted by cellphone on the developing lens have been
contradictory. The present study is aimed at investigating
direct effect if any on the developing lens. Fertile hen eggs
were incubated in 2 batches. Each batch comprised 18 eggs.
Out of 18 eggs, 9 eggs were incubated in a standard egg
incubator without giving any exposure to radiation and
treated as control. Remaining 9 eggs were incubated in a
special incubator exposing them to radiation from
cellphone. Total exposure of 4 hours duration was given to
the experimental group of both the batches. One batch was
sacrificed at the completion of 4 days and the other at the
completion of 6 days. Embryos were procesed for histological
examination. 5 micron thick sections were cut and stained
with H & E. The lens epithelial cells from experimental
groups showed increased number of mitotic figures in the
form of metaphase and anaphase as compared to that of
controls. This points towards increased proliferation of
cells which may be compensatory phenomenon in response
to increased destruction of cells.
2. NEED OF GENETIC COUNSELING IN
INFERTILE COUPLES. DOES A GENDER BIAS
EXIST?. AM Tarnekar, JE Waghmare, IV Ingole &
AK Pal. 56th NATCON of ASI, BHU Varanasi, Dec
27-29, 2008.
It is a social stigma to be carrier of a disorder and
infertility is a lifelong suffering. It is a globally accepted
fact that both the partners be investigated simultaneously if
a couple is infertile. In India, especially, it is seen that women
have to undergo traumatic experiences of investigations
first. Unfortunately medical men too sometimes neglect
this issue and do not ask for examination of male subjects
simultaneously. Genetic counseling is essential at the very
beginning of the management of infertility. Karyotype
analysis is the most basic of the genetic tests and is usually
employed as a screening test in infertility. The best policy
from our point of view is to have a pre marital counseling
done by a geneticist. Or else prenatal diagnosis be done if
a couple wishes to got for assisted methods of reproduction.
Measures can also be taken to identify genetic abnormality
in the foetus in order to prevent the birth of an abnormal
child if clinically suspected. When it is evident that a couple
can not conceive the best way out is to adopt a child.
On interrogation with the infertile subjects
referred for Karyotype analysis, some facts revealed pointing
to a possible gender bias in management of infertile couples.
Some scenario that we have identified as the most common
prevaling situations in India, causing unnecessary delay in
investigations, wastage of money & manpower and ultimately
some untoward consequences to the extent of separation of
couple or remarriage, will be presented.
3. NEED OF MORE CAPABLE TECHNICIANS TO
SUIT THE ANATOMY DEPARTMENT. Pradeep
Bokariya, Ruchi Kotheri, S Rawlani, AM Tarnekar, S
Kakde, IV Ingole. 56th NATCON of ASI, BHU
Varanasi, Dec 27-29, 2008.
Most of the diploma courses after XII (like DMLT,
BMLT) make a candidate suitable for working in Pathology
labs but not in Anatomy Dept. These courses do not provide
the candidates with the appropriate knowledge of embalming,
museum up keeping, organ identification. Most of them
are unaware with basic know how of Anatomy.
Considering paucity of suitable candidates for
Anatomy Department, there should be a provision of
Diploma course in Anatomy after XII.
Some recommendations for the same are as follows -
1) Such a course should be conducted in a Medical College.
2) It can be for duration of 9-12 months.
3) Evaluation at the end of term should be more practical
based.
4) The course can be named as “DALT - Diploma in
Anatomy lab Technology”
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
64
ABSTRACTS OF THE PAPERS PRESENTED IN THE NATIONAL ANDINTERNATIONAL CONFERENCES HELD DURING THE YEAR 2008
Few bottlenecks are also there in implementing
such a course but they can be overlooked considering the
benefit of the department of Anatomy.
4. DERMATOGLYPHIC STUDY OF
SCHIZOPHRENIC PATIENTS - A CASE
CONTROL STUDY. BR Sontakke, IV Ingole, PB
Behere, SS Rawlani, AM Tarnekar, JE Waghmare.
56th NATCON of ASI, BHU Varanasi, Dec 27-29, 2008.
Dermatoglyphics is a scientific study of epidermal
ridges and their configuration on volar aspect of hands,
fingers, feet and toes. Eighty (80) clinically diagnosed
patients of schizophrenia (48 males & 32 females) were
selected from out patient department of Psychiatry and
compared them with 76 (44 males and 32 females) healthy
controls. Palm and finger prints were taken by ink method.
Both qualitative and quantitative analysis of finger tip,
palmar pattern and atd angle was done. We found statistically
significant increased total whorl composite, total arches
and tur palmar pattern at hypothenar area in male
schizophrenics as compared to male controls.
5. A HISTOLOGICAL STUDY OF THE EFFECT
OF MONOSODIUM GLUTAMATE IN LIVER OF
ALBINO MICE. T Das Bhattacharjee, AM Tarnekar,
IV Ingole. 56th NATCON of ASI, BHU Varanasi,
Dec 27-29, 2008.
Monosodium glutamate popularly known as
Azinomoto is used as flavouring agent in Chinese cuisines.
It is responsible for creating the fifth basic type of taste
sensation ‘Umami taste’ in brain. Receptors for Umami
taste sensation are found in Chorda tympani as well as
Glossopharyngeal nerve. It is powerful neurotransmitter -
both excitatory and inhibitory. MSG is reported to cause
damage in brain and reduced reproductive function in
adults. Present study was carried out with 25 albino mice
after exposing the animals to MSG (2mg/g body weight
subcutaneous injection) in neonatal period. Total 5 injections
were given at the interval of 48 hours starting 48 hours
after birth. Animals were sacrificed 75 days after birth and
liver was isolated and processed for histological study.
Histological findings were compared with same number
of control animals. The findings will be discussed.
6. VARIANT ARTERIAL PATTERN IN UPPER
LIMB WITH PERSISTANT MEDIAN ARTERY. AD
Kannamwar, AM Tarnekar, SJ Kakde, T Das, P
Bokariya, IV Ingole. 56th NATCON of ASI, BHU
Varanasi, Dec 27-29, 2008.
During the routine dissection of the right and left
upper limbs of a middle aged male cadaver, we encountered
mixed vascular pattern. We observed variant arterial
pattern in arm, forearm and hand which was present
bilaterally but not exactly similar.Most striking feature
was persistence of median artery which had significant
contribution in formation of superficial palmar arch
bilaterally. Details of this case along with its embryological
basis and clinical significance will be presented in conference.
POSTER PRESENTATIONS :
1. ANTHROPOMETRIC STUDY OF FEMUR IN
CENTRAL INDIAN POPULATION. Pradeep
Bokariya, S Rawlani, JE Waghmare, A Kannamwar,
IV Ingole. 56th NATCON of ASI, BHU Varanasi,
Dec 27-29.
Anthropometric provides scientific method and
technique for taking various measurements in different
geographic regions and races. The femur itself is a complex
anatomic unit so anthropometric study was devised on the
same. In the present study 106 (58 right and 48 left) intact
adult femora were obtained from the bone bank of Anatomy
department of MGIMS, Sevagram. For this purpose a sliding
caliper, osteometric board, tapeline and gonometer were
used.
The study was aimed at determining measurements
for obtaining platymeric index, robusticity index and
foraminal index for both right and left femur. The details
of data obtained with relevant review of literature will be
discussed.
2. EVALUATION OF SAFETY OF ASPARTAME
AS A FOOD ADDITIVE BY EXPERIMENTATION
OF NEONATAL SWISS - ALBINO MICE. SJ Kakde,
AM Tarnekr, A Kannamwar, SS Rawlani and IV Ingole.
56th NATCON of ASI, BHU Varanasi, Dec 27-29, 2008.
Aspartame is used in many baby products like baby
food, vitamin solutions etc. Present study was conducted
in Department of Anatomy at MGIMS, Sevagram with 30
control and 30 experimental neonatal Swiss-albino mice.
Aspartame was injected intra peritoneally at a strength of
100 microgm per gm body wt into experimental mice at an
interval of 48 hours for 6 doses starting from 72 hours of
life. Control group received same amount of normal saline
with same dose schedule. Animals were kept in cages and
were fed with standard rat feed free from aspartame with
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
65
cool drinking water ad libitum under ideal conditions. Body
weights were taken at birth and at 28th day of life. Body weights
were reduced in exposed group compared to controls.
Significant number of exposed animal had seizures during
experiment and subsequently death in few. Mortality rate
was significantly high in experimental group as compared
to control group. Details with be presented.
3. BILATERAL ABSENCE OF EXTENSOR
INDICIS MUSCLE - A CASE REPORT. SJ Kakde,
AM Tarnekar, A Kannamwar, JE Waghmare, P Bokariya,
IV Ingole. 56th NATCON of ASI, BHU Varanasi,
Dec 27-29, 2008.
During routine dissection in a middle aged male
cadaver we found absence of Extensor indicis muscle
bilaterally. There was no scar mark or external deformity
over forearm. Literature suggests it as a rare variation in
the form of congenital absence of extensors of forearm.
It is reported to be associated with polyneuropathy.
Reconstructive interventions of hand require knowledge
of such variations. Details of this case with its ontogeny
and clinical significance will be presented.
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
66
COMMUNITY MEDICINE
PAPER PRESENTED IN XVII WORLD CONGRESS
OF EPIDEMIOLOGY AT PORTO ALEGRE, RS Brazil :
20-24 September 2008
1. PERCEPTIONS AND HEALTH CARE SEEKING
ABOUT NEWBORN DANGER SIGNS AMONG
MOTHERS OF RURAL WARDHA. Dongre AR,
Deshmukh PR, Garg BS.
Abstract : Objectives : The objectives of the present study
were to know mothers' knowledge and explore their
perceptions about newborn danger signs and health care
seeking behaviors.
Material and Methods : In December 2003, a cross-sectional
study was undertaken in three of the 27 Primary Health
Centres of Wardha district; namely Anji, Gaul and Talegaon
with a population of 88187. Out of 1322 such mothers, 1160
mothers in the area were interviewed by house-to-house
visits. Data was entered and analyzed in SPSS 12.0.1. In
order to explore mothers' perception of danger signs and
actions taken, a triangulation of formative research methods
like chapatti diagram and Focus Group Discussion (FGD)
was undertaken. The analysis of free list and pile sort
data obtained was undertaken using Anthropac 4.98.1/X
software.
Results : About 67.2 % mothers knew at least one newborn
danger sign. Majority of mothers (87.4%) responded that
the sick child should be immediately taken to the doctor
but only 41.8% of such sick newborns got treatment either
from government hospital (21.8%) or from private hospital
(20%) and 46.1% of sick babies received no treatment. The
reasons for not taking actions even in presence of danger
signs/symptoms were ignorance of parents, lack of money,
faith in supernatural causes, non availability of transport,
home remedy, non availability of doctor and responsible
person not at home. For almost all the danger signs/
symptoms supernatural causes were suspected and remedy
was sought from traditional faith healer (vaidu) followed
by doctor of Primary Health Centre and private doctor.
Conclusions : The present study found gap between mothers'
knowledge and their health seeking behavior for sick newborn
and explored their deep perceptions, constraints and
various traditional treatments. Comprehensive intervention
strategies are required to change behaviour of caregivers
along with improvement in capacity of Government health
care services and National Health Programs to ensure
newborn survival in rural area.
2. EFFECT OF USE OF SOCIALLY MARKETED
FAUCET FITTED EARTHEN VESSEL / SODIUM
HYPOCHLORITE SOLUTION ON DIARRHEA
PREVENTION AT HOUSEHOLD LEVEL IN
RURAL INDIA. Dongre AR, Deshmukh PR, Garg BS.
Abstract : Objective : To evaluate the effect of socially
marketed faucet fitted to earthen vessel/sodium hypochlorite
solution on diarrhea prevention at rural household level
as a social intervention for diarrhea prevention under
'Community Led Initiatives for Child Survival (CLICS)
program.
Methods : Unmatched case-control study was carried out in
10 villages of Primary Health Centre, Anji, located in rural
central India. During the study period, 144 households used
either faucet fitted earthen vessel to store drinking water
or used sodium hypochlorite solution (SH) for keeping
drinking water safe. These served as case households for
the present study. 213 neighborhood control households
from same locality who used neither of the methods were
also selected.
Results : Odds ratio for households who used faucets fitted
to earthen vessel was 0.49 (95% CI= 0.25 - 0.95). Odds ratio
for households who used sodium hypochlorite solution
was 0.55 (95% CI= 0.31 - 0.98). Use of these methods by
the community, would prevent about 27 percent and 22
percent cases of the diarrhea (Population attributable risk
proportion = 0.25 by faucets fitted to earthen vessels and
0.22 by use of sodium hypochlorite solution) respectively.
Conclusion : To ensure safe drinking water at household
level, the effective and cheap methods like fitting faucet
to traditionally used earthen vessel and/or use of sodium
hypochlorite solution must be promoted through
community participation at household level for cost and
culture sensitive rural people in India.
PAPER PRESENTED IN INTERNATIONAL
CONFERENCE OF THE NETWORK - TOWARDS
UNITY FOR HEALTH AT BAGOTA: 27th September 2008
- 2nd October 2008
1. FORMATIVE EXPLORATION OF STUDENTS'
PERCEPTION ABOUT COMMUNITY MEDICINE
TEACHING AT MAHATMA GANDHI INSTITUTE
OF MEDICAL SCIENCES, SEWAGRAM, INDIA.
Garg BS, Dongre AR, Deshmukh PR.
Abstract: Objective : The objectives of the present formative
research were to explore medical undergraduates' study
problems and their perceived effective teaching approaches
in currently practiced teaching framework of Community
Medicine.
Methods : The present formative research was undertaken
at Dr. Sushila Nayar School of Public Health incorporating
Department of Community Medicine, MGIMS, Sewagram.
The respondents were 17 (26.5%) conveniently selected
final year exam appearing medical undergraduates from
2004 regular batch of 64 students. A triangulation of
qualitative research methods like structured free listing
and pile sort exercise and semi structured Focus Group
Discussion (FGD) were used. A two dimensional scaling
and hierarchical clustering analysis was completed with the
pile sort data. The data was analyzed by using software
Anthropac.
Results : The medical undergraduates could understand
the subject matter and learn skilled based topics like
IMNCI, PHC, Cold chain system, Immunization and Health
education, Dietary survey and Survey methods in community
based camp approaches. Students found it difficult to
comprehend the core of subject from scattered lecture
series over long time especially using lengthy OHP/LCD
presentations. The major problems encountered in studying
Community Medicine were difficulty in understanding con-
cepts of Biostatistics, confusions due to apparently similar
text in National Health Programs, concepts of Epidemiology,
difficult to recall subject, understanding Health planning
and Management and problems due to vast syllabus.
Conclusions : Students perceived community based camp
approach of teaching as a best method to understand the
subject, which is an integration of task oriented assignments,
integration of social sciences within medical domain and
active community involvement. The community based
camp approach can be scaled up as a best Community
Medicine teaching approach. Lectures and Clinics need
to be more interactive and problem based.
2. AN APPROACH TO MONITOR AND INITIATE
COMMUNITY LED ACTIONS FOR ANTENATAL
CARE IN RURAL INDIA - A PILOT STUDY. Garg
BS, Dongre AR, Deshmukh PR.
Abstract : Background & Objective : Utilization of antenatal
care in rural India is far from universal. It requires monitoring
and identification of specific needs at field levels for timely
corrective actions. To pilot test the triangulation of rapid
quantitative (Lot Quality Assurance Sampling) and qualitative
(Focus Group Discussion) monitoring tools for timely and
locally relevant information for decision making and
facilitating participatory community actions for ensuring
antenatal care in a community based program.
Methods : The present study was undertaken in surrounding
23 villages of Kasturba Rural Health Training Centre
(KRHTC), Anji, which is also a field practice area of
Mahatma Gandhi Institute of Medical Science (MGIMS),
Sewagram. The monthly monitoring and action system of
the study was based on the rapid quantitative monitoring
tool (Lot Quality Assurance Sampling, LQAS) to find out
poor performing supervision areas and overall antenatal
service coverage and the qualitative methods (Focus group
discussions (FGDs), and free listing) for exploring ongoing
operational constraints in the processes for timely decision
making at program and community level. A trained
program supervisor paid house visit to 95 randomly
selected pregnant women from 5 supervision areas by
using pre-designed and pre-tested questionnaire. For
poor performing indicators, semi structured FGDs and
free listing exercise were undertaken to identify unmet
service needs and reasons for its poor performance.
Results : Over three months period, the overall antenatal
registration improved from 253 (67%) to 327 (86.7%). The
proportion of pregnant mothers reporting farm work as
their current occupation, declined from 41.1% to 31.6%.
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
67
Registration of pregnancy within 12 weeks improved from
24.2% to 29.5%. The consumption of 100 IFA tablets
during pregnancy also improved from 6.9% to 16.4%. There
was significant improvement in awareness regarding
pregnancy danger signs and symptoms.
Interpretation & Conclusion : To summarize, the present
field based monitoring and action approach constructively
identified the reasons for failures and directed specific
collective actions to achieve targets.
PAPER PRESENTED IN 9TH SOUTH EAST ASIA
REGIONAL SCIENTIFIC MEETING OF
INTERNATIONAL EPIDEMIOLOGICAL
ASSOCIATION AT DHAKA : 9-12 February 2008
1. CORRELATES OF OVERWEIGHT/OBESITY
AMONG SCHOOL GOING CHILDREN OF
WARDHA CITY. Bharati DR, Deshmukh PR, Garg BS.
Abstract: Background & objectives : Overweight and obesity
are important determinants of health leading to adverse
metabolic changes and increases risk of non-communicable
diseases. Following the increase in adult obesity, the
proportion of children and adolescents who are overweight
and obese has also been increasing. To halt the epidemic,
it is important to understand the epidemiology. Hence,
the present study was undertaken to study the magnitude
of overweight/obesity and its correlates among school
going children of Wardha city in central India.
Methods : The cross-sectional study was carried out in all
the 31 middle-schools (5th to 7th standard) and high-schools
(8th to 10th standard) of Wardha city. Probability proportionate
to size of population technique (PPS) was used to decide
the number of children to be studied from each school,
each class and then each section of the class. Systematic
random sampling technique was used to select the children
from each section. Pre-designed and pre-tested questionnaire
was used to elicit the information on family characteristics
and individual characteristics. Height and weight was
measured and BMI was calculated. Overweight and obesity
was assessed by BMI for age using CDC 2000 reference.
Student who had BMI for age =85th and < 95th percentile
of reference population were classified as overweight and
BMI for age = 95th percentile of reference population were
classified as obese. Data was analyzed by using epi_info
2002 v 3.3 and SPSS 12.0.1.
Results : In the present study, overweight and obesity was
found to be 3.1% (95% CI: 2.5%-3.8%) and 1.2% (95% CI:
0.8%-1.8%) respectively; together constitute 4.3% (95% CI:
3.6%-5.2%) for overweight/obesity. Final model of the
multivariate logistic regression showed that the important
correlated of overweight/obesity were urban residence, joint
family, father and/or mother involved in service/business,
English medium school and child playing outdoor games
for less than 30 minutes.
Interpretation & conclusion : The magnitude of overweight/
obesity among school going children of Wardha city was
found to be 4.3%. Family characteristics play important role
in predisposing the children to overweight/obesity and
hence the interventions need to be directed towards the
families.
2. THE EFFECT OF COMMUNITY BASED
HEALTH EDUCATION INTERVENTION ON
MANAGEMENT OF MENSTRUAL HYGIENE
AMONG RURAL INDIAN ADOLESCENT GIRLS.
Dongre AR, Deshmukh PR, Garg BS
Abstract : Objective : To study the effect of a community-based
health education intervention on awareness and behavior
change of rural adolescent girls regarding their management
of menstrual hygiene.
Material & Methods : A participatory-action study was
undertaken in Primary Health Centres in 23 villages in
Anji in Wardha district of Maharashtra state. Study
subjects were unmarried rural adolescent girls (12-19years).
We conducted a needs assessment for health messages with
this target audience, using a triangulated research design
of quantitative (survey) and qualitative (Focus Group
Discussion) methods. Program for Appropriate Technology
for Health (PATH) guidelines were used to develop a
pre-tested, hand made flip book containing need based
key messages about the management of menstrual
hygiene.The messages were delivered at monthly meetings
of village based groups of adolescent girls, called Kishori
Panchayat.After three years, the effect of messages was
assessed using a combination of quantitative (survey) and
qualitative(Trend Analysis) methods.
Results : After three years, significantly more adolescent
girls (55%) were aware of menstruation before its initiation
compared with base line(33%).The practice of using
readymade pads increased significantly from 5% to 25%
and re-use of cloth declined from 85% to57%. The trend
analysis showed that adolescent girls perceived a positive
change in their behavior and level of awareness.
Conclusion : The present community health education
intervention strategy could bring significant changes in the
awareness and behavior of rural adolescent girls regarding
management of their menstrual hygiene.
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
68
PAPER PRESENTED IN 26 TH ANNUAL
CONFERENCE INDIAN SOCIETY FOR MEDICAL
STATISTICS AT NAINITAL : 7-9 Nov. 2008.
1. NEONATAL MORTALITY DIFFERENTIALS
IN RURAL AREAS IN CENTRAL INDIA,
DISTRICT WARDHA MAHARASHTRA. Bharambe
MS, Gupta SS, Deshmukh PR, Garg BS.
Abstract : Neonatal mortality is a very important component
of the Infant mortality, which contributes almost 50% of
the total infant mortality. The neonatal mortality is mostly
affected by endogenous causes and partly by the antenatal
care and the availability of obstetrics and neonatal care
services. These determinants of neonatal mortality are
largely depends upon national health policy and the
availability and utilization of the health care services. In
the present paper and attempt has been made to compare
the neonatal mortality as is achieved by the use of usual
health services and a specific model claimed to reduce
the neonatal mortality by around 25%.
The material used for the study has been taken
from the data about neonatal mortality collected from the
PHCs and the two large research projects supported by
USAID and Government of India in rural areas of districts
Wardha and Yeotmal of the Vidharbha region of
Maharashtra State. The study is based on 6207 neonates;
comprised of 3143 subjects from Government of India (ICMR)
project claiming 25% improvement in the neonatal mortality
and 3064 neonates from the CLICS study, the study period
is from July 2006 to June 2008, and the data has been
collected on the parameters of the child, mother, socio-
economic variables and the health services parted in the
two schemes. The neonates delivered outside the study
area have been excluded from the analysis.
The factor analysis has been done to study the
multi-collinearity in the maternal parameters viz. age,
parity, weight, education, caste/religion etc. Two principal
components comprising of i) age, parity and weight, and ii)
education, caste/religion etc. have been extracted, contributing
more than 70% of the variation of these variables.
The very young and mothers of age 30+ years,
and the primi-mothers and of parity more than 4 along
with no education were associated with the higher neonatal
mortality. The neonatal mortality decreased with increasing
baby weight, however, showing a reverse trend after the
birth weight more than 4 kg.
PAPER PRESENTED IN 52 ND NATIONAL
CONFERENCE OF INDIAN PUBLIC HEALTH
ASSOCIATION AT MAMC, New Delhi : 7-9 March 2008
1. EPIDEMIOLOGICAL CORRELATES OF
NUTRITIONAL ANEMIA AMONG CHILDREN
(6-36 MONTHS) IN RURAL WARDHA. Sinha N,
Deshmukh PR, Garg BS.
Abstract : Background and objectives : Nutritional anemia
is associated with impaired performance on a range of
mental and physical functions in children along with
increased morbidity. Iron supplementation at a later age
may not reverse the adverse effects. National Nutritional
Anemia Control Program was launched in India in 1970
failed to make any impact. The present study was undertaken
to find out prevalence of anemia and its correlates in rural
Wardha in children 6-35 months.
Methods : 772 children between 6-35 months were studied
for anemia by cluster sampling method. The hemoglobin
was estimated in the child by "Filter Paper Cyanmethemo-
globin method". Pre-designed and pre-tested questionnaire
was used to collect data on socio-demographic and other
variables. Data was analyzed by SPSS 12.0.1.
Results : Mean hemoglobin level was 98.5±12.9 gm/L.
Prevalence of anemia was 80.3%. Only 1.3% children had
severe anemia (hemoglobin < 70 gm/L). The univariate
analysis showed that anemia is significantly associated with
age of the child, education of mother and father, occupation
of father, socio-economic status, birth order and nutritional
status as measured by weight for age. The final model
suggested that only educational status of the mother,
occupation of the father, birth order and nutritional status
of the child were significantly associated with anemia.
Interpretation & conclusion : For short term impact,
appropriate nutritional interventions remain the only
operational intervention as only the nutritional status
(weight for age) is modifiable factor. But for long term
sustained impact, policy makers need to focus on improving
maternal education and reducing family size.
2. NUTRITIONAL STATUS AND AGE AT
MENARCHE IN ADOLESCENT GIRLS IN AN
URBAN SCHOOL OF WARDHA. D.G. Dambhare,
M.S. Bharambe, S.S. Gupta, B.S. Garg.
Research Question : What is the relationship between age at
menarche and nutritional status? Objectives : 1. To access
the nutritional status of adolescent girls. 2. To determine
the association between age at menarche and nutritional
status. Study Design : Cross sectional study. Setting : Kamla
Nehru School, Wardha. Participants : All 360 female students
in the age group 10-19 years studying in high school.
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
69
Results : The mean age was 13.76 years (SD. 2.35). The mean
age at menarche in those who had attained menarche was
15.45 years (SD. 1.75). Menarche was attained by 51.94% of
the adolescents. A statistically significant relation between
menarcheal age and socioeconomic class is found
(P<0.0001). The overall level of malnutrition was very high
84.44%. However, in 10-14 years age group malnutrition
was significantly high 70.06% compared to 29.83% in 15-19
years age group (p <0.001). Among the adolescent of age
group 10-14 years, 28.94% attained menarche compared
to 95.2% adolescent of 15-19 years age (p <0.001). The
difference between the mean BMI of those girls who had
attained menarche 17.15 compared to those who had not
attained menarche 14.83 was statistically significant (p<
0.001). Conclusion : In this study, the adolescents from the
upper social class were attained menarche earlier than
those whose belong to lower social class. The rate of under
nutrition amongst adolescent girls was very high 84.44%.
The nutritional status was associated with age at menarche.
The higher the nutritional status, the lower is the age at
menarche.
3. MORBIDITY STATUS OF UNDER THREE
CHILDREN IN RURAL WARDHA. Thaware Preeti,
Deshmukh PR, Garg BS.
Background and Objective : Pre-school children, especially
under three children constitute the most vulnerable segment
of any community. Their morbidity status is a sensitive
indicator of community health.. Hence the present study
was undertaken with the following objective:
Objective : To assess the morbidity status of under three
children in villages under field practice area of Department
of Community-Medicine, M.G.I.M.S, Sewagram.
Materials & Methods : A cross-sectional study was conducted
in 3 PHC areas of Wardha District; namely Anji, Talegaon
and Gaul. 30-cluster sampling technique was used for
selection of study subjects. 33 respondents from each
cluster [11 from each of (0-11) months, (12-23) months, and
(24-35)month's age group] were selected for study purpose.
Thus, total 990 children were studied. Basic information
was collected by using a pre-designed and pre-tested
questionnaire. Data was entered and analyzed by using
epi_info 6.0
Results : In the study area; more then 50% children are in
the morbid condition. There is no difference in the morbid
status among male and female children in under three
children. According to the socioeconomic condition, the
children from low socioeconomic status are more morbid
then the children in high or middle socioeconomic status
family. There is considerable less morbidity in the children
in open group. Whereas almost no variation in morbidity
status in the children of other cast.i.e they are more morbid.
More morbidity is present in under weight and anemic
children (56%,54% respectively).The children with muac of
12.5 are more more morbid (55%) as compare to other
group The children with the parents of higher education
are less morbid.
Conclusion and Recommendation : Widespread prevalence
of morbidity among under three children and highlight a
need for a integrated approach towards improving the
child health by increasing the education,socio-economic
status of parents, at the same time nutritional status of
the children in this area.
4. ROLE OF VILLAGE COORDINATION
COMMITTEE (VCC) IN DECENTRALIZED
HEALTH CARE. Datta SS, Garg BS.
Research Question : To assess the effectiveness of Village
Coordination Committee (VCC) in decentralized health
care delivery in rural area. Objectives: 1. To develop and
test Institutional Maturity Index (IMI) for the VCC. 2. To
assess the effectiveness of VCC with emphasis on various
dimensions of health interventions. Study Design: Process
documentation vis. a vis. quasi experimental study. Setting:
Villages of three PHC areas: Anji, Gaul and Talegaon in
Wardha district of Maharashtra state. Participants: 64 VCCs
formed in these villages of atleast one year old. Results:
The IMI for the VCC was developed in a participatory man-
ner including various activities of VCC specially those
which are vital for sustainability. The IMI already devel-
oped by Aga Khan Rural Support Program (AKRSP) at
Gujarat was utilized as reference. Gradation of all VCCs
has been done using the IMI scoring mechanism and each
VCC promises of heading towards ownership of village
level activities. All VCC have village health plan in place
and majority has prepared their sustainability plan. The
average IMI score of the VCCs is 58 out of 100. Once any
VCC achieves score of 80 out of 100 and reaches a five star
VCC status, will also achieve ownership of health activities
at village level. Conclusions: The VCC has synergy with
'Village Health and Sanitation Committee' in NRHM and
the experience gained in the process will have long term
repercussion in the implementation of NRHM and at the
same time can guide into assessing maturity of these
Medicine, MGIMS, Sevagram (MS) 442102Ref: ManuscriptTitled __________________________by ____________ and _____________
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