Journal of Medical Society, RIMS Imphal - Regional Institute of ...

ISSN 0972-4958JOURNALOFMEDICALSOCIETYRegional Institute of Medical Sciences,ImphalJMS 2011, VOL No. 25 Issue 2Website: http://medicalsociety.rims.edu.inThis journal is indexed in EXCERPTA MEDICA, DATABASES, ELSEVIER, Armsterdam

Journal of Medical SocietyVolume 25 Number 2 May 20111 EditorialPostgraduate medical education : competency-based resident trainingDr. S. Thingbaijam,ORIGINAL ARTICLES4 Guillain-Barre syndrome in adult population of Tripura : A prospective studyArindam Datta, Avik Chakraborty, C.Ray Barman, Dr. Th. Premchand Singh10 A study of clinical antiplatelet drugs resistance in atherosclerotic vascular disease.M. Ratankumar Singh, Th. Bhimo Singh, Th. Sachin Deba Singh, Th. Brojendro Singh, K. Ghanachandra14 Prediction of outcome using Mannheim Peritonitis Index in patients of Secondary PeritonitisRosemary Vumkhoching, Ningombam Jitendra, Ng Javan, T.Arunkumar , Chetan Maibam19 Study of colour doppler velocimetry in intra-uterine growth retardationLalkhrawsthangi K, Y. Ajitkumar, Ratana Usham, Ng. Indrakumar, W. Jatishwor, Ch. Manglem24 Open interlocking nailing of fractures of the distal third of shaft of femur – A prospective study.A. Mahendra Singh, Joseph L. Chongthu, Sanjib Waikhom, Santosh Reang,29 Variation of serum zinc level in psoriasisCh.Bimola Devi, S.Jibankumar, Th. Nandakishore, S.Sunil, L.Rupachandra, S.Kunjeshwori Devi37 A study of Tobacco use and patterns of consumption in a rural area of ManipurJ. Ado, H. Sanayaima Devi, P. Romola, Y. Manihar Singh,41 A study of serum adenosine deaminase (ada)And CD 4count in hiv infected patientsSuchitra Chongtham, M. Amuba Singh, W. Gyaneshwor Singh, Ng. Brajachand Singh46 A Study on Electrogastrography (EGG)Punyabati O, Len Awor Luikham50 Response Pattern Of Wisc-iii Uk Among The Students Of A Private And A Government School In Manipur.Mihir Kumar Thounaojam, M.Akshay Kumar Singh, N.Heramani Singh.54 Comparison of Intubating Conditions of Succinylcholine, Vecuronium and Rocuronium in patientsundergoing elective surgery- A study.N. Ratan Singh, Tingonglei Thangluai, Laithangbam PKS, T. Hemjit Singh, L. Chaoba Singh, R K Shanti Devi59 Pattern of Psychiatric Admission in a Regional Medical Institute ofNorth-East India: A 3-year Retrospective StudyNelson L, Sameeta Ng, Lenin RK, Gojendra S, Heramani N64 Chronic Low Back Pain and Its Correlation with Life Stress and DepressionSameeta Ng, Ak. Joy Singh, Debina L, Th. Khelendro Singh67 A retrospective study of 22 consecutive cases of ocular injuries due to Airsoft gun pellets during aone-year period.Ng. Sangeeta Devi, R.K. Bhabanisana, R.K. Vidyarani, Kh. Kaminibabu Singh, H. Beema71 A Clinicopathological Study On Solitary Thyroid Nodules.S. Thingbaijam, Nicola C. Lyngdoh, R K Bedajit, N.Y. Savizo, Anirudh Mazumder Th. Ibohal76 Malignant transformation of Sino-nasal inverted papilloma: Our experience in RIMS Imphal.Lyngdoh N, Ori J, S.Thingbaijam, R.K. Bedajit80 Laparoscopic Tubal ligation: a comparison between inj saline and inj lignocaine sprayed on thefallopian tube in relieving painN. Jitendra Singh, L. Chaoba Singh, Th. Nonibala Devi, Th. Bidhumukhi Devi, Ch. Manglem Singh84 INVISALIGN: Is it the epitome of orthodontics?Angela Laithangbam, Waikhom Robindro SinghShort Cases88 A case report of Guillain-Barre Syndrome in pregnancyK.Pratima Devi, S. Randhoni Devi, L. Bimolchandra Singh91 Superficial cervical plexus block for total thyroidectomyL. Chaoba Singh, O. Priyokumar Singh, N. Ratan Singh, N. Jitendra Singh93 Gorham’s Disease of Humerus: A case Report.Sanjib Waikhom, I. Ibomcha Singh, T. Umesh, P. Punyabati95 Thrombocytopenic purpura with extrapulmonary tuberculosisTh. Brojendro Singh, Th. Bhimo Singh, N. Biplab, Lalbiakdiki99 Herpes zoster in a healthy adult: Report of a case with oro-cutaneous presentationsNg. Sangeeta, W. Robindro Singh, O.Brajachand Singh102 Multiple Anomalies in the Lower Limb—A Case ReportIrungbam Deven Singh, Th. Naranbabu Singh, ,Y. Ibochouba Singh, M. Matum Singh104 Accidental subdural block in spinal anesthesia – A reportN.Ratan Singh, Laithangbam PKS, L.Chaoba Singh, R.K Shanti Devi107 Roberts - SC phocomelia syndrome – a case reportCh.Shyamsunder Singh, Jayanta K. Poddar, L.Ranbir Singh, A.Meina SinghThe Editors are not responsible for the opinions expressed by authors in the Journal.

GUEST EDITORIALPostgraduate medical education : competency-based residenttrainingIn India, residency training programmeneeds a serious insight and an overallevolution. It has been continuing without anychange for quite a long time. Medical educationin the United States has evolved over thecourse of the last century. The last steps inthe evolution of medical education iscompetency - based resident trainingparadigm, an result of the AccreditationCouncil for Graduate Medical Education(ACGME) Outcomes Project. In February1999, the ACGMe endorsed the OutcomesProject which was funded by the Robert woodJohnson Foundation and designed to focus oneducational outcomes 1 . This project eventuallyled to foundamental changes in the waysresidents are educated.The first major activtity of theOutcomes Project was the development of thesix general competencies for residencytraining 2 . For the purposes of accuracy, thedescription of the ACGME generalcompetencies used is that approved by theACGME 3 . The six general competencies are1. Patient care2. Medical knowledge3. Practice-based learning andimprovement4. Interpersonal and communicationskills5. Professionalism6. Systems-based practicePatient careDr. S. ThingbaijamDepartment of ENT, RIMS, ImphalEditor, JMSResidents must provide patient carethat is compassionate, appropriate, andeffective for the treatment of health problemsand the promotion of health. Residents areexpected to• Communicate effectively anddemonstrate caring and respectfulbehaviors when interacting withpatients and their families.• Gather essential and accurateinformation about their patients• Make informed decisions aboutdiagnostic and therapeuticinterventions based on patientinformation and preferences, up-todatescientific evidence, and clinicaljudgment• Develop and carry out patientmanagement plans• Counsel and educate patients andtheir families• Use information technology tosupport patient care decisions andpatient educationJMS * Vol 25 * No. 2 * May, 2011 1

GUEST EDITORIAL• Perform competently all medical andinvasive procedures consideredessential for the area of practice.• Provide health care services aimedat preventing health problems ormaintaining health• Work with health care professionals,Practice-based learning andimprovementResidents must investigate and evaluatetheir patient care practices, appraise andassimilate scientific evidence, and improve theirpatient care practices. Residents are expectedto• Analyze practice experience andperform practice-basedimprovement activities using asystematic methodology• Locate, appraise, and assimilateevidence from scientific studiesrelated to their patients’ healthproblems• Obtain and use information abouttheir own population of patients andthe larger population from which theirpatients are drawn• Apply knowledge of study designsand statistical methods to theappraisal of clinical studies and otherinformation on diagnostic andtherapeutic effectiveness.• Use information technology tomanage information, access on-linemedical information, and supporttheir own education• Facilitate the learning of students andother health care professionalsInterpersonal and communication skillsResidents must demonstrateinterpersonal and communication skills that2result in effective information exchange andteaming with patients, their patients families,and professional associates. Residents areexpected to• Create and sustain a therapeutic andethically sound relationship withpatients• Use effective listening skills and elicitand provide information usingeffective nonverbal, explanatory,questioning, and writing skills• Work effectively with others as amember or leader of a health careteam or other professional group.ProfessionalismResidents must demonstrate acommitment to performing professionalresponsibilities, adherence to ethicalprinciples, and sensitivity to a diverse patientpopulation. Residents are expected todemonstrate• Respect, compassion, and integrity;a responsiveness to the needs ofpatients and society thatsupercedes self-interest;accountability to patients, society,and the profession; and acommitment to excellence andongoing professional development• Commitment to ethical principlespertaining to provision or withholdingof clinical care, confidentiality ofpatient information, informedconsent, and business practices• Sensitivity and responsiveness topatients’ culture, age, gender, anddisabilitiesSystem-based practiceResidents must demonstrate anawareness of and responsiveness to thelarger context and system of health care andJMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEthe ability to effectively call on systemresources to provide care that is of optimalvalue. Residents are expected to• Understand how their patient careand other professional practicesaffect other health careprofessionals, the health careorganization, and the larger societyand how these elements of thesystem affect their own practice• Know how types of medical practiceand delivery systems differ from oneanother, including methods ofcontrolling health care costs andallocating resources• Practice cost-effective health careand resource allocation that does notcompromise quality of care• Advocate for quality patient care andassist patients in dealing with systemcomplexities• Know how to partner with health caremanagers and health care providersto assess, coordinate, and Improvehealth care and know how theseactivities can affect systemperformanceAt first glance, the efforts required totransform residency programs as suggestedby the ACGME Outcomes appearedmonumental, but most programs have beenable to modify existing didactic and clinicalexperience to align with the generalcompetencies required by the ACGME 4,5 .The resident education programmeneeds a serious concern in India urgently. Sofar, in India no such projects are in sight. Weneed a competency-based resident educationprogramme as early as possible so as toproduce, competent, ethical and profficientmedical graduates.References1) Joyner BD. An historical review of graduatemedical education and a protocol ofaccreditation Council for Medical Educationcompliance, J Urol 2004;179:34-92) Accreditation Council on Graduate MedicalEducation. Available at: http://w w w. a c g m e . o r g / o u t c o m e / p r o j e c t /OPintrorevl_7-05.ppt-12. Accessed May, 2011.outcome/comp/compFull.asp. Accessed May,2011.4) Dyre PL. Strauss RW, Rinnert S. Systemsbasedpractice: the sixth core competency,Acad Emerg Med 2002;9:1270-7.5) Hobgood CO, Riviello KJ,Jouriles N, et al.Assessment of communication andinterpersonal skills competencies, Aead EmergMed 2002;9:1305-9.3) Accreditation Council on Graduate MedicalEducation. Available at : www.acgme.org/JMS * Vol 25 * No. 2 * May, 2011 3

ORIGINAL ARTICLEGuillain-Barre syndrome in adultpopulation of Tripura : A prospective study1Arindam Datta, 1 Avik Chakraborty, 2 C.Ray Barman, 3 Dr. Th. Premchand SinghAbstractObjective: Guillain-Barré syndrome is aneponym for a heterogeneous group ofimmune mediated peripheral neuropathies.The aim of this study is to diagnose Guillain-Barré syndrome in patients presenting withacute flaccid paralysis and to identify thesubtypes of Guillain-Barré syndrome in theadult population of Tripura, their ethnicvariation and presence of seasonaloccurrence. Patients and Method: Tenpatients presenting with acute flaccidparalysis who fulfilled the diagnostic criteriaof Guillain-Barré syndrome as defined byAsbury and Cornblath admitted in TMC andDr. BRAM Teaching Hospital, Agartala, Tripura.during the 3 years period from 1 st April,2007to 30 th April,2010 comprised the material forthis study. Electrophysiological study wasdone to diagnose the subtypes of Guillain-Barré syndrome by observing prolongation ofdistal latencies, a delay in F waves, slowingof nerve conduction or conduction block andmeasurement of compounded muscle actionpotential (CMAP). Results: Ten patients ofGuillain-Barré syndrome, 6 males and 4females were diagnosed from the patientspresenting with acute flaccid paralysis. The1. Assistant professor, Department of Medicine, 2.Assistant professor, Department of Paediatrics, TMC&DR.BRAM Teaching Hospital, Agartala, Tripura, 3.Professor of Medicine, Regional Institute of MedicalSciences, Imphal, Manipur.Correspondence authorDr. Th. Premchand Singh, Professor of Medicine,Regional Institute of Medical Sciences, Imphal,Manipur4youngest was of 17 years and the oldest wasof 55 years of age with mean age of 30.9years. 80 percent of the patients e.g., 8 of the10 patients belonged to tribal community andthe remainder 2(20%) were Bengalis. Out ofthe 8 tribal patients, 6 (75%) were males and2(25%) females. All the 2 Bengali patientswere females(100%). Upper respiratory tractinfections was the antecedent factor in 8 outof the 10 patients (80%) and the rest 2(20%)had gastro intestinal tract infection. Acutemotor axonal neuropathy (AMAN)wasdiagnosed in 6 patients (60%), 3 patients(30%) were of mixed variety (axonalpredominant) Guillain-Barré syndrome andone patient(10%) had acute motor sensoryaxonal neuropathy (AMSAN).Key words: Guillain-Barré Syndrome, Acutemotor axonal neuropathy (AMAN), Acute motorsensory axonal neuropathy(AMSAN)IntroductionGuillain-Barré syndrome covers a set ofclinical syndromes manifested as idiopathicperipheral neuropathy affecting motor, sensoryand autonomic nerves and spinal rootscausing acute or subacute, progressive motorweakness in more than one limb 1,2 . Guillain-Barré syndrome has been considered to beprimarily a demyelinating disease which issynonymous with acute inflammatorydemyelinating polyradiculoneuropathy (AIDP).Fisher described in 1956 a syndromecharacterised by the triad of ataxia, areflexia,and ophthalmoplegia coined as Fishersyndrome 3 which is recognised as a clinicalJMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEvariant of Guillain-Barré syndrome. Theconcept of axonal Guillain-Barré syndromewas first raised by Feasby et al, 4 who foundearly axonal degeneration of motor andsensory fibres in five patients with clinicallydefined Guillain-Barré syndrome. This patternof Guillain-Barré syndrome, termed acutemotor-sensory axonal neuropathy (AMSAN),is usually associated with a worse prognosisthan demyelinating Guillain-Barré syndrome.Studies in northern China identified anotherform of axonal Guillain-Barré syndrome,termed acute motor axonal neuropathy(AMAN) 5,6 . Guillain-Barré syndrome is believedto result from autoimmune humoral- and cellmediatedresponses to a recent infection orany of a long list of medical problems. Itsrelation to antecedent infections and theidentification of various antigangliosideantibodies suggest that molecular mimicrymay serve as a possible mechanism 7,8 . Thetriggering events are most frequentlynonspecific or ‘’flu-like’’upper respiratoryinfections, gastrointestinal illnesses andvaccinations 9,10 Organisms which areidentified as causative factor are C.jejuni,Herpes virus, EB virus ,CMV andMycoplasma pneumonia 11 .The prevalence of subtypes of Guillain-Barrésyndrome varies in different countries. Theincidence of Guillain-Barré syndrome is 1.2-3per 100,000 inhabitants in United Statesmaking Guillain-Barré syndrome the mostcommon cause of acute flaccidparalysis 12.13 .Acute inflammatory demyelinatingpolyradiculoneuropathy (AIDP) accounts for90% of all cases Guillain-Barré syndrome inEurope, North America, whereas acute motoraxonal neuropathy (AMAN) and acute motorsensory axonal neuropathy (AMSAN) occurmainly in China, Japan and Mexico 14 . M-fishersyndrome has been reported to be commonin Mexico and Singapore 1,15,16 .There has been no study of this syndrome inthe state of Tripura yet. The purpose of thisstudy is to diagnose Guillain-Barré syndromein patients presenting with acute flaccidparalysis and to identify the subtypes ofGuillain-Barré syndrome in the adult populationof Tripura, ethnic variation and presence ofseasonal occurrence.Patients and Methods:The study was carried out in the Departmentof Medicine, TMC and Dr. BRAM TeachingHospital, Agartala, Tripura from 1 st October2007 to 30 th April 2010. During the studyperiod of 3 years, 10 patients of Guillain-Barrésyndrome were diagnosed among the patientsadmitted with acute flaccid paralysis. Clinicaldata were collected from each patientincluding duration of the illness, extension ofweakness, involvement of bowel and bladderand antecedent illness. Past history of anytrauma, diabetes mellitus, hypertension,collagen disease and family historysuggestive of myopathy, neuropathy werenoted. The patients were subjected tothorough clinical examination, includinggeneral physical and systemic examinationsespecially of central nervous system. Signsof meningeal irritation and deformity of skeletalsystem were also recorded. All the patientswere subjected to lumbar puncture andcerebrospinal fluid (CSF) analysis.The diagnosis of Guillain-Barré syndrome wasmade by the criteria defined by Asbury andCornblath 17 . Electrophysiological study wasdone for all the patients to diagnose thesubtypes of Guillain-Barré syndrome byobserving prolongation of distal latencies, adelay in F waves, slowing of nerve conductionor conduction block and measurement ofcompounded muscle action potential(CMAP) 18 .Patients were classified as having acuteinflammatory demyelinating polyradiculoneuropathy(AIDP) when there was evidencethat conduction was slowed or blockedproximally or distally according to criteria ofAlbers et al. 19 . The presence of axonaldegeneration in association with acuteinflammatorydemyelinatingpolyradiculoneuropathy was inferred whenthere was either additional electromyographicevidence of denervation (fibrillations or positivesharp waves). Patients were classified ashaving either acute motor axonal neuropathyor acute motor and sensory axonal neuropathyif there was electromyographic evidence ofJMS * Vol 25 * No. 2 * May, 2011 5

ORIGINAL ARTICLEaxonal degeneration together with a reductionof more than 50 percent of the lower limit ofthe amplitudes of compound muscle actionpotentials (CMAPs) or sensory nerve actionpotentials (SNAPs) in the presence of normalmotor conduction velocities, distal motorlatencies, and minimum F-wave latencies (20) .ResultsIn the study period of three years from 1 stOctober 2007 to 30 th 010, 10 patients werediagnosed with Guillain-Barré syndrome ofwhich 6 (60%) were males and 4 (40%)females. The youngest was of 17 years andthe oldest was of 55 years of age with meanage of 30.9 years. It was observed that themaximum of the patients were in the age groupof 21 to 30 years (40%). Figure 1 shows thesex and age distribution of the patients.Figure 1Out of the 10 patients diagnosed with Guillain-Barré syndrome, 9 (90%) patients presentedin winter months (Oct to Jan) and only I(10%)of them presented in hotter months of theyear(April).Upper respiratory tract infections was theantecedent event in 8 out of the 10 patients(80%) and the rest 2(20%) had gastrointestinal tract infection. Gastrointestinalinfections was seen to precede 2 of the 6acute motor axonal neuropathy (AMAN)cases.People belonging to the tribal communitypredominates among the patients withGuillain-Barré syndrome comprising 80 %of the patients e.g., 8 of the 10 patients andthe remaining 2(20%) were Bengalis. Out ofthe 8 tribal patients, 6 (75%) were males and2(25%) females. All the 2 Bengali patientswere females(100%) as shown in Figure 2.Figure 2All the patients reported within 7 to 14 days oftheir illness. 8(80%) of them presented withsudden weakness of all four limbs and 2(20%) had involvement of lower limbs only.4(40%) of them presented with tingling andnumbness of lower limbs and one (10%)had some sensory deficit on clinicalexamination as well as in electrophysiologicalstudy.Figure 3 shows that all the patients werefound to have hypotonia , areflexia andreduced muscle power that differed in upperand lower limbs in each individual. Musclepower varied from 0/5 to 2/5 grades in thelower limbs and 3/5 to 5/5 grades in the upperlimbs when involved. No patient had boweland bladder involvement. One patient (10%)presented with mild respiratoryembarrassment. All the patients (100%) hadtypical albumino cytological dissociation incerebrospinal fluid (CSF) analysis. AverageClinical presentations in GBSPercentage of patients of GBSFigure 36JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEcerebrospinal fluid (CSF) cell count was 7.1cells/cumm and all were lymphocytes. Theaverage CSF protein was 157.8mg%. Therewas no AFB or malignant cell in any of theCSF samples.Table 1 : Electrophysiological findings and subtypesof GBSElectrophysiological No. Of Type %FindingscasesDecreased NCV only 00 Demyelination 00%Decreased CMAPs 06 AMAN 60%Combined decreasedMixed demyelinationNCV and 03 andDecreased CMAPs Axonal type 30%Combined decreasedSNAPs 01 AMSAN 10%And decreased CMAPsThe electrophysiological study shown in Table1 revealed the types of Guillain-Barrésyndrome depending on the characteristicfindings. 6(60%) patients mainly showeddecreased compound muscle actionpotentials (CMAPs) with normal nerveconduction velocity with no involvement ofsensory nerves, thus indicating the diagnosisof acute motor axonal neuropathy (AMAN).Another 3(30%) patients showed decreasedcompound muscle action potentials (CMAPs)as well as slightly reduced motor nerveconduction velocity ,thus indicating thediagnosis of mixed variety (axonalpredominant) Guillain-Barré syndrome. Thelast one patient (10%) showed absent lowerlimb sensory nerve action potentials (SNAPs)as well as absent lower limb compoundmuscle action potentials (CMAPs) with absentF-waves, thus giving the diagnosis of acutemotor sensory axonal neuropathy (AMSAN) .The patient presented with respiratoryembarrassment was treated with intravenousImmunoglobulin. The other remaining 9patients were treated with I/VMethylprednisolone (1gm/day) for 5 days. Allof them showed improvement within 2(two)weeks of hospital stay after which they weredischarged and on our follow up no onereported any deterioration till date.DISCUSSIONThe study showed a male predominance of1.5:1(6 males and 4 females) which agreeswith other studies (13,17) . Maximum number ofour patients belong to the age group of 21years to 30 years (40%) with mean age of30.9 years. Arami and his colleagues alsoobserved a mean age of 34.43 years in thestudy of Guillain-Barré syndrome in Iran (21) .Ng et al in their study in Singapore found theirpatients’ mean age to be 42.3 years with arange of 21 to 81 years and opined thatGuillain-Barré syndrome in Asian populationoccurs in younger populations (16) . Dowlinget al (22) and Schonberger et al (23) reported anearly peak among 15-30 years almost similarto our study age group , and showed bimodaldistribution with another peak in older agegroup. However Rocha and her colleagues(24)could not find any bimodal distribution ofthe disease in their study.We observed more patients, 9 (90%) patientsin winter months (90%) whereas most of thestudies reported maximum of their cases insummer (15,17,25) . This may be due to differentpreceding events. Guillain-Barré syndrome isthe protypic “postinfectious” disease withabout two thirds of patients with an antecedentinfection. Respiratory tract infection being themain antecedent infection (80%) in our studyis usually seen in winter months followed bygastro intestinal infection(20%). Ng et al alsoobserved respiratory tract infections the mostcommon preceding event followed bynonspecific fever with chills (16) . Many workersreported gastro intestinal infection as the mainantecedent cause of which C. Jejuni was morecommonly associated (15,20,23,24) .Patients who had respiratory tractinfection(80%) as antecedent event in ourstudy presented with different subtypes ofGuillain-Barré syndrome e.g., 3 of them(37.5%) had mixed type, 1 (12.5%) had acutemotor sensory axonal neuropathy (AMSAN)and rest 4(50%) purely acute motor axonalneuropathy (AMAN) type . 2 patients (20%)who had gastrointestinal tract infectionpresented with purely axonal subtype ofGuillain-Barré syndrome.Guillain-Barré syndrome was diagnosedmore among the tribal population ascompared to the Bengali population(4:1) inour study. Ng et al observed a preponderanceJMS * Vol 25 * No. 2 * May, 2011 7

ORIGINAL ARTICLEof Chinese (58%) followed by Malay (26%) intheir study of Guillain-Barré syndrome inSingapore (16) . The cause of this ethnicdifference is not known however the poorsocio -economic status of the tribals mayexplain in an increased incidence of infectiousdiseases and consequent Guillain-Barrésyndrome .In the present study 8(80%) of the patientswith Guillain-Barré syndrome, presented withinvolvement of all the four limbs,2(20%)patients had only paraparesis, and4(40%) of them presented with paraesthesiawhich agrees with the finding of Ng et al (16) .Acute motor axonal neuropathy (AMAN) typewas seen in the maximum of 6 (60%) of ourpatients, mixed demyelination and axonal typein 3 patients (30%) and acute motor sensoryaxonal neuropathy (AMSAN) type in 1patient(10%). This finding correlates with theobservations of other studies from China,Mexico and Bangladesh (17,21,22) . Kalita et alhowever reported acute inflammatorydemyelinating polyradiculoneuropathy (AIDP)in 86.3%, acute motor axonal neuropathy(AMAN) in 7.8% and acute motor sensoryaxonal neuropathy (AMSAN) in 5.9% of theirstudy of 51 patients (26) . Arami et al alsoobserved a majority of 33% patients had acuteinflammatory demyelinating polyradiculoneuropathy(AIDP),9% patients acutemotor axonal neuropathy (AMAN) type and 5%patients acute motor sensory axonalneuropathy (AMSAN) in their study of GuillainBarre syndrome in Iran (21) . Acute inflammatorydemyelinating polyradiculoneuropathy (AIDP)accounts for 90% of cases in Europe, NorthAmerica and the other developedcountries (27) .ConclusionOur study shows that Guillain-Barré syndromeis found in the population of Tripura thoughrare. Males and young adults are mostlyaffected. Among the different ethnic groupsof people, the tribal community are moreprone to develop the disease. It may bepostulated that the poorer socio economicstatus of the tribal population with subsequentincreased incidence of infectious diseasesmay result in augmented risk of developingGuillain-Barré syndrome . Upper respiratorytract infections was the common antecedentfactor followed by gastro intestinal tractinfection Out of the 4 subtypes of Guillain-Barré syndrome, acute motor axonalneuropathy (AMAN)was the commonestfollowed by the mixed variety (axonalpredominant).References1. Griffin JW, Li CY, Ho TW, et al. Guillain-Barrésyndrome in northern China. The spectrum ofneuropathological changes in clinically definedcases. Brain 1995;118:577-595.2. Hartung HP, Pollard JD, Harvey GK, Toyka KV.Immunopathogenesis and treatment of theGuillain-Barré syndrome. Muscle Nerve1995;18:137-153.3. Fisher M. An unusual variant of acute idiopathicpolyneuritis (syndrome of ophthalmoplegia,ataxia, and areflexia). N Engl J Med1956;255:57–65.84. Feasby TE, Gilbert JJ, Brown WF, Bolton CF,Hahn AF, Koopman WF, Zochodne DW. Anacute axonal form of Guillain-Barrépolyneuropathy. Brain 1986;109:1115–1126.5. McKhann GM, Cornblath DR, Griffin JW, HoTW, Li CY, Jiang Z, et al. Acute motor axonalneuropathy: a frequent cause of acute flaccidparalysis in China. Ann Neurol 1993; 33:333–42.6. Ho TW, Mishu B, Li CY, Gao CY, CornblathDR, Griffin JW, et al. Guillain-Barré syndromein northern China. Relationship toCampylobacter jejuni infection and antiglycolipidantibodies. Brain 1995;118:597–605.JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLE7. Kimoto K, Koga M, Odaka M, et al. Relationshipof bacterial strains to clinical syndromes ofC a m p y l o b a c t e r - a s s o c i a t e dneuropathies. Neurology. 2006;67(10):1837-1843.8. Geleijns K, Roos A, Houwing-Duistermaat JJ,et al. Mannose-binding lectin contributes to theseverity of Guillain-Barre syndrome. J Immunol.2006;177(6):4211-6217.9. Alter M. The epidemiology of Guillain-Barrésyndrome. Ann Neurol 1990;27(Suppl):S7-S12..10. Lasky T, Terracciano GJ, Magder L, Kioski CL,Ballesteros M, Nash D, Clark S, Haber P,Stolley PD, Schonberger B, Chen RT. The Guillain-Barré syndrome and the 1992-1993 and 1993-1994 influenza vaccines. N Engl J Med1998;339:1797-180211. Winer JB, Hughes RAC, Anderson MJ, JonesDM, Kangro H, Watkins RP. A prospective studyof acute idiopathic neuropathy. II. antecedentevents. J Neurol Neurosurg Psychiatry1988;51:613-618.12. Van Koningsveld R, Van Doorn PA. Steroids inthe Guillain-Barré syndrome: is there atherapeutic window?. Neurologia.2005;20(2):53-57.13. Alshekhlee A, Hussain Z, Sultan B, KatirjiB. Guillain-Barré syndrome: incidence andmortality rates in US hospitals. Neurology.2008;70(18):1608-1613.14. McKhann GM, Cornblath DR, Griffin JW, HoTW, Li CY, Jiang Z. Acute motor axonalneuropathy: a frequent cause of acute flaccidparalysis in China. Ann Neurol. 1993;33(4):333-342.15. Nachamkin I, Barbosha PA, Ung H et al. Patternsof Guillain-Barré syndrome in children: Resultsfrom a Mexican population .Neurology.69:1665-1671.16. Ng YS, Lo YL and Lim PAC. Characteristicsand acute rehabilitation of Guillain-Barrésyndrome in Singapore. Ann Acad MedSingapore 2004; 33: 314-31917. Asbury AK, Cornblath DR. Assessment ofcurrent diagnostic criteria for Guillain-Barrésyndrome. Ann. Neurol.1990.27:521 – 524.18 Winer JB. Guillain-Barré syndrome. MolPathol. Dec 2001;54(6):381-385.19. Albers JW, Donofrio PD, McGonagle TR.Sequential electrodiagnostic abnormalities inacute inflammatory demyelinatingpolyradiculopathy. Muscle Nerve 1985; 8: 528-53920. Rees JH, Soudani SE, Gregson NA, HugesRAC. Campylobacter jejuni infection andGuillain- Barre syndrome. N Engl JMed.1995.333:1374-137921. Arami MA, Yazdchi M, Khandaghi R.Epidemiology and characteristics of Guillain-Barré syndrome in the northwest of Iran. AnnSaudi Med 2006; 26: 22 -2722. Dowling PC, Menonna JP,Cook SD. Guillain-Barré syndrome in greater New York – NewJersey. JAMA.1977.238(4 ):317-318.23. Schonberger LB, Hurwitz ES, Katona P, HolmanRC, Bregman DJ . Guillain-Barré syndrome :its epidemiology and association with influenzavaccination. Ann. Neurol.1981.9:31-38.24. Rocha MSG, Brucki SMD , Carvalho AAdeS,Lima UWP. Epidemiologic features of Guillain-Barré syndrome in Sao Paulo, Brazil. Arq.Neuro- Psiquiatr. 2004.62(1): 33-3725. Islam Z, Jacobs BC, Van Belkum A, MohammadQD, Islam MB, Herbrink P, Diordista S, LubySP, Talukder K A, Endtz H P. Axonal variant ofGuillain-Barré syndrome associated withcampylobacter infection in Bangladesh.Neurology.74:581-587.26. Kalita J, Misra U, Das M. Neurophysiologicalcriteria in the diagnosis of different clinical typesof Guillain-Barré syndrome. J Neurol NeurosurgPsychiatry 2008; 79: 289-2 9327. Alsheklee A, Hussain Z, Sultan B, Katirji B.Guillain-Barré syndrome: incidence andmortality rates in US hospitals. Neurology 2008;70(18): 1608-1613JMS * Vol 25 * No. 2 * May, 2011 9

ORIGINAL ARTICLEA study of clinical antiplatelet drugs resistance in atherosclerotic vasculardisease.1M. Ratankumar Singh, 2 Th. Bhimo Singh, 3 Th. Sachin Deba Singh, 4 Th. Brojendro Singh, 5 K. GhanachandraAbstractObjective – To study treatment failure in spiteof giving antiplatelet agents in patients ofatherosclerotic vascular disease attendingRegional Institute of Medical SciencesHospital, Imphal. Methods – The study wasconducted prospectively in patients ofatherosclerotic vascular disease (coronaryartery disease and thrombotic cerebral stroke)admitted in Medicine ward from January 2005to December 2006, who experiencedrecurrent vascular events (acute coronarysyndrome, ACS, and/or thrombotic stroke ortransient ischemic attack, TIA), despite oralantiplatelet agent therapy for >7 days withaspirin, clopidogrel or both at dose of 75mgdaily. Results – out of a total 593atherosclerotic vascular events admitted, 85patients (14.33%) had recurrent vascularevents. Out of these, 48 patients (8.09%) hadprevious CAD, 44 (7.42%) of them came withACS while 4 patients (0.67%) had thromboticstroke. Out of 37 patients (6.24%) who had1. Senior Resident, Department Of Medicine,Jawaharlal Nehru Institute Of Medical Sciences,Imphal, 2. Prof. Of Medicine Rims, Imphal. 3. AssociateProf. Of Cardiology, Regional Institute Of MedicalSciences, Imphal, 4. Asst. Prof., of Medicine RegionalInstitute Of Medical Sciences, Imphal 5. Associate Prof.Of Medicine, Jawaharlal Nehru Institute Of MedicalSciences, ImphalAddress For Correspondance:-Dr. M. Ratankumar Singh, Senior Resident,Department Of Medicine, Jawaharlal Nehru InstituteOf Medical Sciences, Imphalprevious thrombotic stroke, 34 (5.73%) camewith recurrent thrombotic stroke (all in differentvascular territory), 1 (0.17%) had TIA and 2(.34%) had ACS. Conclusion: As with alldrugs, treatment failure (antiplatelet drugsresistance) is quite common and recurrentvascular events still continue despite effectivedrug therapy.Key words:Aspirin resistance, Clopidogrel resistance,acute coronary syndrome, stroke.Introduction:Aspirin and the thienopyridine clopiodogrel areantiplatelet agents that display goodantithrombotic activity. In the past few years,the concept of ‘Aspirin Resistance’ and“Clopidogrel Resistance” has been largelyemphasized in the medical literature. Theterm “Aspirin Resistance” has been used todescribe a number of different phenomena,including the inability of aspirin to accomplishthe following : (1) to protect the individual fromthrombotic complications, (2) to cause aprolongation of the bleeding time; (3) to reducethromboxane (TXO 2) production; or (4) toproduce an antiplatelet effect on one or morein vitro tests of platelet function. 1 ‘Clopidogrelresistance’ on the other hand is probablymostly caused by inefficient metabolism of theprodrug clopidogrel to its major metbabolite. 2We conducted this short term hospital basedstudy to see the frequency of clinical drugresistance in our local Manipuri population.10JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEMaterials And Methods:This hospital based study was carried out inthe Department of Medicine, Regional Instituteof Medical Sciences Hospital, Manipur, in theperiod between January 2005 to December2006 (24 months). A total of 593 patients whohad atherosclerotic vascular events (acutecoronary syndrome, ACS, or thromboticstroke) were evaluated. All of them were givenantiplatelet drugs (aspirin and/or clopidogrel)after confirming the diagnosis, or werereceiving these drugs before admission.Clinical antiplatelet drugs resistance wasdiagnosed based on patients experiencingacute recurrent vascular events (ACS, orstroke or TIA) despite ongoing drug therapywith aspirin and/or clopidorgrel at dose of75mg daily for at least 7 days. ACS wasdiagnosed based on history, physicalexamination, and confirmed by ECG andcardiac enzymes. Cerebral events were alsodiagnosed based on history, physicalexamination and CT scan of brain.Patients were also evaluated for concurrentrisk factors and drug intake including statins.Results:Out of 593 patients screened. 284 (47.89%)received aspirin and 276 patients receivedclopidogrel (46.54%), while 33 (5.56%)patients received both drugs. 85 patients(14.33%) fulfilled our criteria of clinicalantiplatelet drug resistance. The period ofrecurrence ranged from 8 days to 180 days(mean 131.01 ± 23 days).Table I : Patients characteristics.Total number = 593ClinicalRespondersClinical DrugResistanceNUMBER 508 (85.67%) 85 (14.33%)AGE RANGE (in years) 38-67 (Mean 41-64 (Mean54.02±0.4) 55.01±0.7)Male:Female ratio 51.08:48.02 52.01:47.99Diabetics 251 (49.41%) 41 (48.24%)Hypertension 201 (39.57%) 34 (40%)Obesity (BMI>30) 238 (46.85%) 40 (47.06%)Sedentary Activity 311 (61.22%) 52 (61.20%)Self perceived stress 112 (22.05%) 18 (21.20%)Alcohol consumption 123 (24.21%) 21 (24.71%)Smoking 95 (18.70%) 15 (17.65%)Dyslipedemia on atorvastatin 131 (25.79%) 22 (25.88%)Table I shows the characteristics of bothgroups of patients. In all parameters studied,it was found that, most parameters weresimilar.Thirty three patients (38.83%) received aspirinat dose of 75mg daily and 42 (49.41%)received clopidogrel at same dose. Tenpatients (11.96%) received both drugs.Table II Types and percentage of recurrent vascular events.Previous vascular event Drug 20 (3.39%) Recurrent eventAspirin 20 (3.39%) ACS 18 (3.04%),Stroke 2 (0.34%)Coronary artery disease48 patient (8.00%) Clopidogrel 22 (3.71%) ACS 20 (3.39%),48 patients (8.09%) Stroke 2 (0.34%)Combination 6 (1.01%) ACS 0, Stroke 0Aspirin 15 (2.53%) ACS 0, Stroke 15(2.53%)Thrombotic stroke Clopidogrel 20 (3.39%) ACS 2 (0.34%), stroke37 patients (6.24%) 18 (3.04%)Combination 2 (0.34%) ACS 0, Stroke 2(0.34%)Table II shows the type and percentage ofrecurrent vascular events. ACS was the mostcommon recurrent event, seen in 44 (7.42%)patients, while 4 patients (0.67%) hadthrombotic stroke.In those 37 patients who have a recurrentcerebrovasacular event, 32 (5.73%) hadrecurrent thrombotic stroke in a differentvascular territory and 1 (0.17%) had TIA. Twopatients (0.34%) had ACS as presentation.Recurrence of events was seen with bothaspirin, clopidogrel and combination [20(3.39%), 22 (3.9%), 6 (1.01%) and 15 (2.53%),20 (3.33%), 2 (0.34%), in previous coronaryartery disease, and thrombotic stroke groupsrespectively].Again, a total of 152 patients (25.63%) wereon Atorvastatin at 10-20mg daily fordyslipedemia. Atorvastatin treatment durationranged from 18 to 150 days (Mean 76.0615days) Among these, 22 patients (3.17%) hadrecurrent vascular events. Out of these 22patients, 18 (81.82%) were on clopidogrel,either alone or in combination with aspirin and4 patients (18.18%) were on aspirin.JMS * Vol 25 * No. 2 * May, 2011 11

ORIGINAL ARTICLEDiscussion:Aspirin and the thienopyridine clopidogrel areinhibitors of platelet aggregation that displaygood antithrombotic activity. They are used inthe long term prevention of cardiovascular andcerebrovascular events. However despiteregular use of aspirin, it has been found that asubstantial proportion of patients suffer breakthrough events. Eikelboom et al. hadestimated that one in eight (12.5%) patientssuffer from recurrence of a vascular eventwithin 2 years, despite regular daily aspirin. 3Again Grundmann et al. 4 found that aspirin nonresponder status was seen in 34% of patientswith recurrent cerebral ischemic events,despite regular use of aspirin for more than60 months. In our study, acute coronary eventand thrombotic stroke were seen in 3.04% and2.8% respectively among aspirin users withcombined aspirin resistance of 5.91% whichis less than the other studies. This may bebecause of our relatively shorter term study(duration of only two years).Clopidogrel is a prodrug, which needs to bemetabolized by the liver to an activemetabolite, through the hepatic cytochromeP450 pathway. 5 Lesser known than aspirinresistance, but certainly better characterisedis ‘Clopidogrel resistance’. Lau et al 6 hadpublished that 50% of their patients were eitherclopidorgel nonresponders or low responders.This high percentage is observed when thedegree of inhibition of platelet aggregationinduced by ATP was measured. In our studywe had a low incidence of clopidogrel (7.10%)resistance. This may be because wemeasured only clinical events.What is significant in our study is highincidence of recurrent events in patients whoreceived both clopidogrel and atorvastatincompared to aspirin and atorvastatin receivers(81.82 vs 18.18%). This is similar to otherstudies, which have suggested thatconcurrent treatment with lipohilic statins thatare substrates of CYP3A4 (e.g. atrorvastatinand simvastatin) may interfere with theinhibitory effects of Clopidogrel on plateletfunction. 7 In the study by Lau et al 8 ,atorvastation, but not pravastatin, attenuatedthe antiplatelet effect of clopidogrel in a dosedependent manner.With combination treatment (aspirin +clopidogrel) the perecentage of recurrentevent is 1.35%. There is not much data inliterature about frequency of recurrent eventsin those with this combination treatment.Conclusion:‘Clinical’ antiplatelet drug resistance is quitefrequent. As we see in our daily practice,treatment failure is a common phenomenonoccurring with all drugs (e.g. lipid lowering oranti hypertensive drugs). Given themultifactoral nature of atherothrombosis andthe possibility that platelet – mediatedthrombosis may not be responsible for allvascular events, it is not surprising that only afraction of all vascular complications can beprevented by any single mode of preventivestrategy.References:1. Patron C. Aspirin resistance: definition,mechanisms and clinical results. J ThromHaemost 2003;1:1710-1713.2. Muller I, Besta F, Schulz C, et al. Prevalenceof clopidogrel non responders among patientswith stable angina pectoris scheduled forelective coronary stent placement. ThromHaemost 2003;89:793-787.3. Eikelbloom JW, Hankey GJ. Aspirin resistance:a new independent predictor of vascularevents? J Am Coll Cardiol 2003, 41:966-968.124. Grundmann K, Jaschonek K, Kleine B,Dichgans J, Topaka H. Aspirin non-responderstatus in patients with recurrent cerebralischemic attacks. J Neurol 2003; 250: 63-66.5. Cazenave J-P, Gachet C. Pharmacology ofticlopididne and clopidorgrel. In : Gresele P,Page C, Fuster V, Vermylen J, eds. Plateletsin Thrombotic and non thrombotic disorders.Cambridge: Cambridge University Press; 2002:929-939.6. Lau WC, Gurbel PA, Watkins PB, Neer CJ,Hopp AS, Carville DGM, Gayer KE, Tait AR,JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEBates ER. Contribution of hepatic cytochromeP450 3A4 metabolic activity to the phenomenonof clopidogrel resistance. Circulation. 2004;109: 166-171.7. Neubauer H, Gunesdogan B, Hanefeld C, etal. Lipophilic statins interfere with the inhibitoryeffects of clopidogrel on platelet function; a flowcytometry study. Eur Heart J 2003; 24: 1744-1749.Lau WC, Was Kell LA, Watkins PB, et al.Atrovastatin reduces the ability of clopidogrelto inhibit platelet aggregation: a new drug-druginteraction. Circulation 2003; 107: 32-37.JMS * Vol 25 * No. 2 * May, 2011 13

ORIGINAL ARTICLEPrediction of outcome using Mannheim Peritonitis Index in patients ofSecondary Peritonitis1Rosemary Vumkhoching, 2 Ningombam Jitendra, 3 Ng Javan, 4 T.Arunkumar , 5 Chetan MaibamAbstract:- To study the causes of Secondaryperitonitis and assess the severity of thecases using the Mannheim Peritonitis Index(MPI) and predict the outcome of thepatients.Materials and methods:A study of110 consecutive cases of SecondaryPeritonitis admitted in General Surgery wardsof the Regional Institute of Medical Sciences,Imphal from May 2007 to April 2009 whounderwent exploratory laparotomy was doneand analyzed using the Mannheim PeritonitisIndex(MPI). Statistical analysis was done byusing Student t test, Anova test,Pearson’scorrelation and Chi Square test.Conclusion:-Higher values of MPI were observed in thosepatients with a longer hospital stay.Correlations of MPI with hospital stay issignificant when Pearson’s Correlation isapplied. In this study if MPI value is less than21, the mortality rate is 0%, while the mortalityrate is 5.5% when the MPI is in the range of21-29. However, when MPI is more than 29,the mortality rate increased to 25%.Key words. Peritonitis, Mannheim PeritonitisIndex (MPI)Introduction:-Peritonitis is inflammation ofthe peritoneum and peritoneal cavity and ismost commonly due to localized or1.Surgeon, Department of Surgery JNIMS,PorompatImphal2.Associate Professor, Department of SurgeryJNIMS,Porompat Imphal 3.Assistant Professor,Department of Surgery JNIMS,Porompat Imphal4.Professor, 5. Registrar, Dept. of Surgery,RIMS,Imphal.Corresponding author :Dr. N. Jitendra, Associate Prof. Dept. of Surgery JNIMS,Porompat, Imphal14generalized infection. Bacterial peritonitis canbe classified into Primary, Secondary andTertiary peritonitis 1 . Primary peritonitis isusually defined as diffuse bacterial infectionof the peritoneal cavity occurring without lossof integrity of the digestive tract and involvesusually one single pathogen. Secondaryperitonitis is most commonly caused byperforation or anastomotic disruption of thedigestive tract, and in about 80% respondswell to timely surgical intervention combinedwith appropriate antimicrobial therapy.Frequent causes of Secondary bacterialperitonitis include perforated peptic ulcerdisease, acute perforated appendicitis,perforated colonic diverticulum, jejunal andileal perforations 2 . Tertiary peritonitis occurseither due to failure of the host inflammatoryresponse or due to super infection, when thepatient’s body protective mechanisms areunable to contain the infection because ofimpaired host defense or overwhelminginfection a tertiary peritonitis developscharacterized by poor recovery fromsecondary peritonitis despite appropriatesurgical and antimicrobial treatment. There ispresence of occult infections with positivecultures of fungi and gram negative bacteriawith low pathogenecity and impaired hostdefence. Most common pathogens are E-coli,Klebsiella pneumonae, Bacteroides fragilis,Staphylococcus aureus and Pseudomonas.Gram +ve cocci are common ingastroduodenal perforations. Pseudomonasare frequently seen in small bowelperforations, whereas E-coli is thecommonest organism in appendicular andcolonic perforations 3 .JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEDespite a better understanding ofpathophysiology, advances in diagnosis,surgery, antimicrobial therapy, intensive careand support, peritonitis remains a potentiallyfatal affliction. The contamination of peritonealcavity thus can lead to a cascade of infections,sepsis and multisystem organ failure anddeath, if not treated in a timely manner 4 .During the last few decades, scoring systemssuch as the APACHE II and the MannheimPeritonitis Index (MPI) have been used topredict outcome in patients with Secondaryperitonitis 3 .The Mannheim Peritonitis Index (MPI) wasdeveloped by Wacha, Linder and others 5 andwas published in 1937. The MPI takes intoaccount age, gender, organ failure, cancer,duration of peritonitis, involvement of colon andextent of spread and character of peritonealfluid. The score was originally developed bydiscriminate analysis of data from 1253patients with peritonitis. It appears to be morepractical than other scoring systems such asAPACHE II. Eight risk factors of prognosticrelevance are entered into the index with aweighting, according to the predictive power.The scoring of MPI is in the range of 0-47. Fora score of upto 15, the mortality rate is zero(0). Between 15-21 the mortality rate is 6%and for a score of 29 or above the mortalityrate is > 50 % 6 .The Mannheim Peritonitis Index (MPI) is oneof the easiest to apply because it comprisessimple clinical parameters. So determinationof risk is readily available during the initialoperation. A high score will alert the clinicianfor extra vigilance and extraordinarymeasures. So it can be concluded that theMPI provides an easy and reliable means ofrisk evaluation and classification for patientsof peritonitis 7 .Materials And MethodsThis study is carried out in the Department ofGeneral Surgery, Regional Institute of MedicalSciences Hospital, Imphal. The materials ofthis study are 110 consecutive cases ofSecondary peritonitis admitted in GeneralSurgery wards from May 2007 to April 2009who underwent exploratory laparotomy.A performa for all the cases is maintained.This includes detailed history of the patientincluding age, sex, signs and symptoms alongwith a variety of information such as:i. Pain - time of onset, mode of onset, siteand character of pain.ii.iii.iv.Vomiting - frequency, contents ofvomitus is noted.Bowel & micturition habits.Distension - duration & progress.In addition personal and family history of thepatients is recorded. A thorough physicalexamination is done with special emphasison the abdomen, including inspection,palpation, percussion and auscultation.Laboratory investigations like routine bloodexamination, routine urine examination, kidneyfunction tests, ECG, x-ray chest and abdomenerect and if required liver function test,ultrasonography of the abdomen andcomputerised axial tomography scan ofabdomen are done.After confirmation of diagnosis of peritonitiseither clinically or through radiologicalinvestigations, patients underwent exploratorylaparotomy. Dates of operation, type ofoperation, nature of peritoneal fluid, presenceor absence of malignancy clinically arerecorded. Scoring is done according to theMannheim Peritonitis Index shown below: -MANNHEIM PERITONITIS INDEX (MPI)Sl. Risk Factor Weighting if present(i) Age> 50 years 5(ii) Female Sex 5(iii) Organ Failure* 7(iv) Malignancy 4(v) Preoperative duration 4Of peritonitis > 24 hrs(vi) Origin of infection not colonic 4(vii) Diffuse generalized peritonitis 6(viii)ExudateClear 0Cloudy, purulent 6Faecal 12JMS * Vol 25 * No. 2 * May, 2011 15

ORIGINAL ARTICLEDefinitions of Organ failureKidney Creatinine level > 177 mol/1Urea level > 167 mmol/1Oliguria < 20ml/hLung P aO 2< 50mmHgP aCO 2> 50 mmHgShock (definition according to Shoemaker)-hypodynamic or hyperdynamic.Intestinal obstruction (only if profound) -Paralysis > 24h or complet mechanical ileusThe scoring of MPI is in the range of 0 - 47.Patients are grouped under three categoriesbased on disease severity.a. Those with MPI less than 21b. Between 21 and 29c. Greater than 29Post-operative events like recovery,haemorrhage, wound infection, fistula, lungcomplication, hospital stay in days,reoperation and mortality if any are recorded.Follow up of these patients are done and theirwell-being noted.ResultsIn this study, 110 consecutive cases ofsecondary peritonitis were studied. 43.6%cases were due to duodenal perforation,24.5% due to ileal perforation. Appendicularperforation constituted 16.4%, jejunal 5.5% andgastric and colonic perforation comprised of4.5% each.TABLE 1. : Causes of secondary peritonitisCauses Frequency PercentDuodenal perforation 48 43.6Ileal perforation 27 24.5Appendicular perforation 18 16.4Jejunal perforation 6 5.5Gastric perforation 5 4.5Colonic perforation 5 4.5Meckel’s perforation 1 9Total 110 100.0There was no post-operative complicationsin 65.5% of the cases while 23.6% had minorcomplications and 5.5% had majorcomplication with a mortality rate of5.5%(Table 1).TABLE 3.Correlation of MPI with hospital stayMPI ValueHospital StayPearson 1.000 .911*CorrelationSig. (2-tailed) .045N .110Pearson .191* 1.0001CorrelationSig. (2-tailed) .046N .110 10.000*Correlation is significant at the 0.05 level (2-tailed)Mean Standard DeviationMPI- 22.07 +/- 5.834Hosp. Stay- 13.42 +/- 9.504MPI value range from 10 to 43 mean being 22.07 and standard deviation being 5.834 (Table 2).TABLE 2. : MPI Value—DescriptivesN Mean Std. Std. 95% confidence Minimum MaximumDeviation Error Interval for MeanLower UpperBound BoundDuodenal perforation 48 21.23 5.050 .729 19.76 22.70 13 37Ileal perforation 27 23.41 6.338 1.220 20.90 25.91 12 43Appendicular perforation 18 20.00 5.770 1.360 17.13 22.87 10 30Jejunal perforation 6 24.17 8.998 3.673 14.72 33.61 16 34Gastric perforation 5 27.40 3.050 1.364 23.61 31.19 25 32Large Colonic perforation 5 23.00 5.523 2.470 16.14 29.86 17 31Meckel’s perforation 1 20.00Total 110 22.07 5.834 .556 20.97 23.18 10 43*One case of Meckel’s perforation excludedDf-5 F-2.028 p Value 0.81*16JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEWhen MPI is correlated with hospital stay byusing Pearson’s correlation, it is found to besignificant. The higher the MPI value, thelonger is the hospital stay (Table 3).MPI ValueBetweenANOVA TESTSum of Df Mean Square F Sig.SquaresGroups 1119.057 2 559.529 23.112 .000WithinGroups 2590.361 107 24.209Total 3790.418 109MPI value when correlated with outcome ofcases, those with no complications have amean value of 20.07 while those withcomplications have a mean value of 24.69.Patients who died have a mean MPI value of32.17. Using Anova test this is found to behighly significant (Table 4).Table 5. shows comparison of behavior ofeach risk factor of MPI in three intervalsstudied.Patients with MPI values less than 21 haveno mortality, while there was 5.5% mortalityrate in 21-29 MPI group. In the MPI group morethan 29, mortality rate was 25% (Table 6).Table5: - Comparison of behavior of each risk factor of MPIin three intervals studied.Risk factor 29points(58/110) (36/110) (16/110)Age >50 years 8 23 12Age /= 24hours 50 35 16Time < 24 hours 8 1 0Non colonic origin 56 34 14Colonic origin 2 2 2Generalized peritonitis 52 36 16Localized peritonitis 6 0 0Clear peritoneal fluid 7 0 0Purulent peritoneal fluid 50 34 9Feculent peritoneal fluid 1 2 7Table6: - Mortality in relation to MPI valueMPI Mortality Male Female Total no. of pts.< 21 0 (0.0%) 0 0 5821-29 2 (5.5% ) 2 0 36>29 4 ( 25% ) 3 1 16DiscussionDuodenal ulcer had the highest incidence (43.6%)followed by Ileal perforation (24.5%), Appendicularperforation (18%), Jejunal (6%), Gastric and Colonicperforation 4.5% each. This finding is comparableto a number of studies done previously. 4,8Complications are found to be commoner in thosepatients having MPI value greater than 21. Mortalityis higher when MPI is more than 29. In this study,it is found that the longer the hospital stay the higheris the MPI value.TABLE 4.MPI Value in relation to outcome of patients95% Conficenceinterval for MeanN Mean Std. Std. Minimum MaximumDeviation Deviation Lower UpperBoundBoundNo Complication 72 20.07 4.542 .535 19.00 21.14 10 34Complication 32 24.69 5.343 .944 22.76 26.61 16 33Death 6 32.17 6.940 2.833 24.88 39.45 25 43Total 110 22.7 5.834 .556 20.97 23.18 10 43JMS * Vol 25 * No. 2 * May, 2011 17

ORIGINAL ARTICLEIn this study, out of 110 patients, 58 had MPI valueless than 21, 36 patients (21-29), 16 patients (>29).Males outnumbered the females. Presence of organfailure in 2 patients in MPI range 21-29 and 9patients in MPI more than 29 group. Malignancy isfound in two patients in both these groups. Therewas neither organ failure nor malignancy amongstpatients with MPI less than 21.The scoring of MPI is in the range 0-47. For a scoreof upto 15,mortality is 0, whereas for 15-21 themortality rate is 6% and that of a score of 29 orabove the mortality rate is more than 50%. 5 In thisstudy mean MPI value of less than 21 had nocomplications. In analyzing, MPI of patients withcomplications, the mean MPI is found to be 24.69.For those patients who expired, the mean MPI valueis 32.17.ConclusionThe Mannheim Peritonitis Index (MPI) is an usefuland simple index which can be effectively used inprediction of outcome of patients of SecondaryPeritonitis.References1. Mulari K, Leppaniemi A. Severe secondaryperitonitis following Gastrointestinal tractperforation. Scandinavian Journal of Surgery2004; 93 : 204-208.2. Simmen HP, Heinzelmann M and Largiader F :Peritonitis, Dig Surgery ; 13 : 381 - 383, 1996.3. W ittmann DH, Schein M, Condon RE :Management of secondary peritonitis, Ann Surg;224 : 10-18,1996.4. Sanjoy Gupta and Robin Kaushik : PeritonitisThe Eastern experience, World Journal ofEmergency Surgery ; 1 : 13, 2006.5. Wacha H, Linder MM, Feldmann V, Wesch G,Gundalach E, and Stefensand RA : MannheimPeritonitis Index - Prediction of risk of deathfrom peritonitis. Construction of a statistic andvalidation of an empirically based index,Theoretical Surgery ; 1 : 169 - 177, 1987.6. Linder MM, Wacha H, Feldmann V, Wesch G,Streifensand RA and Gund lach E : TheMannheim Peritonitis Index. An instrument forthe intraoperative prognosis of peritonitis, Chirug; 58 : 84 - 92, 1987.7. Dalal S, Garg P. Nityasha and Sharma R :Prediction of outcome using MannheimPeritonitis Index in Patients of Peritonitis, TheIndian Practitioner; 59 : 515 - 518 , 2006.8. Khan S, Khan IU, Aslam S and Haque A:Retrospective analysis of abdominal surgeriesat Nepalgunj medical college, Nepal: 2 yrsexperience ; Kathmandu Univ Med J; 2 : 336-343, 2004.18JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEStudy of colour doppler velocimetry in intra-uterine growth retardation1Lalkhrawsthangi K, 2 Y. Ajitkumar Singh, 3 Ratana Usham, 4 Ng. Indrakumar Singh, 5 W. Jatishwor Singh6Ch. Manglem SinghAbstractObjectives: To study the Doppler velocimetryof foetal aorta (FA), umbilical artery (UA) andmiddle cerebral artery (MCA) in Intra-uterinegrowth retardation (IUGR) and to detect thosefoetuses at risk. Methods: Doppler velocitywaveform of foetal MCA, UA and FA werestudied using pulsed Doppler ultrasound in100 pregnant women with diagnosed IUGRfoetus. The results were analyzed to assessthe risks of foetal outcome. Results: The resultof this study showed that umbilical artery S/Dratio is the most sensitive (68.1%) parameterin predicting the perinatal morbidity. Thehighest specificity and positive predictive value(PPV) of predicting neonatal morbidity frommiddle cerebral artery pulsatility index are 92%and 88.4% respectively. The different ratiosexamined showed a uniformly highersensitivity in the prediction of the perinataloutcome when compared to the study ofindividual vessels. Conclusion: T h i sstudy showed that Doppler velocimetry offershigher accuracy in diagnosing IUGR and itsassociated complications. This is the mostimportant diagnostic method in detecting1. Post graduate trainee, 2. Registrar, Obstetrics andGynaecology Department, RIMS. 3. Asst. Prof.4. Professor, Obstetrics and GynaecologyDepartment, JNIMS, Porompat, Imphal. 5. AssociateProfessor and Head, Radiodiagnosis Department,RIMS. 6. Professor and Head, Obstetrics andGynaecology Department, RIMS.Corresponding author:Dr. Y. Ajitkumar Singh, Department of Obstetrics andGynaecology, Regional Institute of MedicalSciences, Imphal, Manipur.pregnancy complicated by IUGR besidespredicting adverse perinatal outcome.Key words: Doppler velocimetry, Intrauterinegrowth retardation (IUGR), Foetuses at risk,adverse perinatal outcome.IntroductionThe foetus has been described as a perfectparasite and its growth in utero is a functionof both soil and seed. Ideally, an appropriatehormonal and endocrine milieu for both motherand the foetus enables optimal foetal growth. 1IUGR is associated with an increased risk ofperinatal mortality, morbidity and impairmentin the neurodevelopment. The correctdetection of the compromised IUGR foetus toallow timely intervention is a main objective ofantenatal care. 2 These IUGR babies have fourto five times increased risk of perinatal andneonatal morbidity and mortality. Thus, it isvery important to diagnose such cases andmanage them accordingly in time. 3The global incidence of IUGR varies from 3to10%.In India the average incidence is about11%, 4 and approximately 1.5 million perinataldeaths occur every year despite variousmeasures taken to reduce its incidence. 5Perinatal mortality is 8 to 10 times higher forIUGR foetuses and morbidity is noted in 50 to75% of the affected surviving infants. 6The most important diagnostic method fordetection of pregnancy complicated by IUGRis Doppler flow velocimetry. Analysis ofplacento-foetal circulation could assess thefetal wellbeing and optimal timing of delivery.JMS * Vol 25 * No. 2 * May, 2011 19

ORIGINAL ARTICLEFoetal outcome was studied under major andAnd it also acts as a tool for prediction of1992). 8 Neonatal deaths 10(10%)adverse perinatal outcome.Materials and MethodsOne hundred pregnant women with diagnosedIUGR foetuses attending the Department ofObstetrics and Gynaecology were referred toDepartment of Radiodiagnosis, Regionalminor adverse outcomes. The major adverseoutcomes were perinatal deaths - includingintrauterine and early neonatal deathswhereas the minor outcomes includedCaesarean delivery for foetal distress, Apgarscore 3 and 2.6 inor ultrasonography foetal biometry andumbilical and uterine arteries respectively wereultrasound parameters. IUGR were diagnosedconsidered abnormal. Absent end diastolicas estimated foetal weight less than 10 thvelocity (AEDV), reversed end diastolicpercentile of gestational age. The findings at velocity (REDV) and persistent early diastolicthe time of first examination were taken into notch in uterine artery were consideredconsideration. Repetitive Doppler studies abnormal. An increased in diastolic flow inwere performed whenever required. Doppler foetal MCA suggested “brain sparing effect”velocity waveform analysis of foetal MCA, UAand FA located in the standard plane with themother in a recumbent position during foetalinactivity and apnea were obtained usingpulsed Doppler ultrasound (LOGIQ 700-GEMedical systems, Waukesha, Winsconsin)with 3.5 MHz curvilinear probe with a highpass filter.seen in asymmetric IUGR.ResultsThe mean maternal age of the study populationwas 24.7 years. It has been observed that themajority of the pregnant women weremultipara comprising 59% as compared to41% primipara. Besides spontaneous vaginaldelivery, 13% and 21% had undergone theDoppler study was considered abnormalinduced labour and Caesarean sectionwhen:respectively. The main indication for1. S/D ratio, Resistance and Pulsatility indexof Middle Cerebral artery 2SD and Umbilical artery >2SDfor the gestational age according to the Maternal characteristics No. of patients (n=100) (%)standard reference values; Umbilical artery RIreference was according to Kurmanavicius JParityPrimipara 41(41%)et al (1997). 7 Multipara 59(59%)The reference value of umbilicalPregnancy complicationartery PI, descending abdominal aorta PI, Intrauterine growth restriction 83(83%)cerebro umbilical ratio were according to the Pre-eclampsia and IUGR 17(17%)findings of Gramellini D et al (1992) 8 and MCA DeliverySpontaneous vaginal delivery 66(66%)PI ratio was according to Mari G and DeterInduced 13(13%)RL (1992). 9 Chauhan R et al (2002) reference Caesarean section 21(21%)values were taken for Umbilical artery S/Dratio. 10Indication for Caesarean sectionFoetal distress 16(16%)Severe pre-eclampsia 2(2%)2. The ratio examined were considered Others 3(3%)Perinatal outcomeabnormal when S/D of MCA/UA

ORIGINAL ARTICLETable 2. Characteristic outcome of pregnancy of studypopulation (n=100)Pregnancy outcomeLive birth 93Term 64Preterm 29Average birth weight (gram) 2270 gmBirth Weight (gram)>2500 111500-2500 611000-1500 23

ORIGINAL ARTICLEstudy. Perinatal outcome was poor withumbilical artery pulsatility with five deaths (3IUD and 2 NND). Four babies requiredCaesarean section and three were admittedinto NICU for more than ten days.Thirteen patients had absent/reversedumbilical artery diastolic flow. All showedsignificant ‘brain sparing effect’ (Pl MCA

ORIGINAL ARTICLEReferences1. Devi PK, Khrishna MK and Bhaskar RK:Antenatal care, Post Graduate Obstetrics andGynecology, Orient Longman, New Delhi1986; 3 rd ed., 219-232.2. Lakhkar BN, Rajagopal KV and GourisankarPT: Doppler Prediction of Adverse PerinatalOutcome in PIH and IUGR, Ind J Radiol Imag2006; 16(1): 109-116.3. Nidhi K, Usha M and Satbir S: Role of ColourDoppler in IUGR Foetuses, Obs. and Gynae.Today 2001; VI (2): 84-87.4. Bhattacharya N, Mukhopadhyay G, BiswasS, Saha SP and Ghosh D: IUGR - the role ofamino-acid supplementation, J. Obstet.Gynecol. Ind.2004; 54(3): 243-245.5. Sahar RK and Soni RK: Perinatal mortality inRural Punjab – a population based study, J.Trop. Pediatr.2000; 46: 43-45.6. Lockwood CJ and Weiner S: Assessment offetal growth, Clin. Perinatol.1986; 13: 3-35.7. Kurmanavicius J, Florio I and Wisser J:Reference resistance indices of the umbilical,fetal middle cerebral and uterine arteries at24-42 weeks of gestation, Ultrasound inObstetrics and Gynecology1997; 23(7): 1908-15.8. Gramellini D, Folli MC, Rahoni P, Vadora Eand Medialdi A: Cerebral-umbilical Dopplerratio was predicts of adverse perinataloutcome, Obstet. Gynecol.1992; 79(3): 416-420.9. Mari G and Deter RL: Middle cerebral arteryflow velocity waveforms in normal and smallfor gestation age fetuses, American Journalof Obstetrics and Gynecology 1992; 166:1262-1270.10. Chauhan R and Samiksha T: Role of Dopplerstudy in high risk pregnancy, Journal ofObstetrics and Gynecology of India 2002;52(3): 112-117.11. OTT WJ: Comparison of the non-stress testwith the evaluation of centralization of bloodflow for prediction of neonatal compromise,Ultrasound in Obstetrics and Gynecology1999; 14: 38-41.12. New Ballard: Score, Expanded to includeextremely premature infants, J. Pediatir.1991,119: 417.13. Fong KW, Ohlsson A, Hanah Me and KingdomJ: Prediction of perinatal outcome in fetusessuspected to have Intrauterine GrowthRestriction - Doppler US Study of FetalCerebral, Renal, and Umbilical Arteries,Radiology 1999; 213: 681-689.JMS * Vol 25 * No. 2 * May, 2011 23

ORIGINAL ARTICLEOpen interlocking nailing of fractures of the distal third of shaft of femur –A prospective study.1A. Mahendra Singh, 2 Joseph L. Chongthu, 3 Sanjib Waikhom, 2 Santosh Reang,Summary:Aims: To study the outcome of openinterlocking nailing of the fractures of the distalthird of shaft of femur in terms of fractureunion, anatomical alignment, earlymobilisation and weight bearing and earlyfunctional return of the limb. Methods:Patients with femoral shaft fractures of thedistal third were managed with openinterlocking nailing. Serial follow upassessment for radiological and clinical unionwas done. Patients were monitored for union,limb functions and complications. Results:Thirty patients (m=25, f=5) with a mean ageof 28.73 ± 9.40 years were operated. Theywere followed up for a period of two years.Outcome was excellent in twenty five andgood in five patients. Major complicationsencountered were single case of broken nail,broken screws and delayed union.Conclusion: Open interlocking nailing withminimal soft tissue traumatisation, reamingand static fixation is a safe procedure for distalthird femoral shaft fractures. With an excellentfunctional outcome, early clinical andradiological union, it can be done on a routinebasis with a minimum of complications.Key words: interlocking, open nailing, distalthird, infra isthmal, dynamisation.1. Professor, 2. Post Graduate Trainee, 3. Assistant Professor,Department of Orthopaedics, RIMS, Imphal, Manipur India.Corresponding Author :Prof. A. Mahendra Singh, Department of Orthopaedics, Regional Insituteof Medical Sciences, Imphal – 796004, Manipur, India.Email: drmahendrarambam@yahoo.comIntroduction:Fractures of the femoral shafts have an agerelated and gender-related bimodaldistribution and occur most frequently inyoung men after high-energy trauma and inelderly women after a low-energy fall. 1 It isdefined as one involving the shaft from thelevel of the lesser trochanter to the flare of thecondyles or the level of the adductor tubercle. 2Classification is based on the anatomiclocation, fracture morphology, degree ofcomminution or combinations thereof.Winquist and colleagues have classified thefractures of the distal third of the shaft of femurinto: Distal transverse, distal oblique and distalcomminuted. 3Fractures of the distal third of femoral shaftare usually treated with open reduction andinternal fixation (ORIF), either by nailing orplating. K-nailing is not suitable in suchfractures as the medullary canal widens atthis level. Interlocked nailing gives better resultthan plating and is presently considered thegold standard method of surgical treatmentfor these fractures. 4 Most reports on suchmanagement are closed nailing and reportson open interlocked nailing are very few.Closed nailing in our set up is not suitablesince operations are delayed due to varioustechnical problems. We have undertaken thepresent study to see the effect of openinterlocking nailing of these fractures in termsof fracture union, anatomical alignment, earlymobilisation and weight bearing and earlyfunctional return of the limb.24JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEMaterials and Methods:After due approval from our Institution ethicscommittee, adult patients with fresh fracturesof the distal third of shaft of femur wereadmitted in the department of Orthopaedicsfrom the hospital Emergency Services andOut Patient Deparment (OPD) betweenAugust 2008 and September 2010. Writteninformed consent was taken from all patients.Patients with pathological fractures,polytrauma, open fractures type II (Gustillo-Anderson) and above, supracondylarinvolvement, associated morbid medicalconditions and those lost to follow up wereexcluded from the study.Relevent detailed history, clinical examinationand findings were recorded for all patients.Routine investigations for fractureassessment and perioperative fitness weredone. Fractures were classified according tothe Winquist Hansen classification 5 as seenfrom the radiological film (fig. 1 A,B). Openfractures were thoroughly debrided and wereoperated upon after proper wound healing.Limb was maintained in Thomas splint withtraction till operation. The required nail sizeand length was measured by a combinationof the radiological and direct method. 5,6Operative technique:All patients were operated by the same teamof surgeons under C-arm IITV monitoringunder spinal anaesthesia in supine positionon a fracture table. Entry site over the pyriformfossa was approached through a lateralincision and skin was dissected in layers tillthe fossa was exposed which was thenpunctured with a curved diamond awl. Guidewire was introduced through this opening totraverse the medullary cavity over the facturesite. Open reduction was done by a lateralapproach of the thigh over the site of fracture.The guide wire was then passed over thefracture site and its position in the lower endof the femur checked with IITVThe medullary canal was reamed over theguidewire to 1mm larger than the diameter ofthe nail to be inserted. The nail was insertedmanually over the guidewire by gently rotatingthe nail in small arc. The final nail position wasconfirmed by IITV. Locking of the distalfragment was done by using one or two fullythreaded locking screws using the free handtechnique followed by proximal locking forcomminuted fractures through the nail jig withone or two screws. Skin was closed over anegative suction drain and sterile dressingsapplied.The operated limb was kept elevated with boththe hip and knee partially flexed. Parenteralthird generation cephalosporin was given for2 days and sutures removed on tenth day.Active and passive movements of the limbwas started and continued from immediatepost operative day. Full weight bearingcommenced when callus appears on X-rayfilm. For unstable fractures, non weightbearing walking was allowed from drainremoval but full weight bearing was allowedonly when callus was corticalised.Patients were followed up once in three weeksfor the first twelve (12) weeks after surgery;once a month for the next three (3) monthsand then every three (3) months for a periodof one year. Radiological assessment 7 ofunion (fig. 1C) and functional limbassessment 8 was done in each visit. Finalresults (fig. 2) were grouped into fourcategories at the end of the study period.Legends:Figure 1: Showing X-rays of: (A) Transverse fracture. (B):Oblique fracture. (C): United fracture with implants in situ.JMS * Vol 25 * No. 2 * May, 2011 25

ORIGINAL ARTICLETable 3: Showing time parameters.Parameters Open Fractures Closed Fractures Combined MeanOperating time - - 60-210 138±41.9Time(Minutes)to operation 12-18 (15.00 ±3.00) 3-15 (7.00 ±3.44) 3-18 7.80 ±4.14(days)Duration of 25-35 (29.00 ± 5.29) 15-28 (18.14 ± 3.44) 15-35 19.23 ± 4.85hospitalisation (days)Clinical union(weeks) - - 9-32 13.60 ± 4.38Radiological union - - 20-40 25.73 ± 5.13(weeks)Figure 2: Showing outcome: (A) Equal limb length, normalknees. (B): Full knee extension and full weight bearing. (C):Full range of hip and knee flexion.ResultsThirty patients (m:f=5:1) were operated (table1). The mean age was 28.73 ± 9.40 yrs (18-58 yrs). The most common cause of injurywas road traffic accidents. Details of fracturesare shown in table 2. Nailing with 9 mm nailswas done in twenty one patients and 10 mmnails in nine patients. All patients weresubjected to static fixation with variablenumber of proximal and distal locking screws.Associated injuries were seen in 9 (30%)TABLES.Table 1: Showing age-sex distribution of patients.Age group (in years) Male Female Total Percentage(% )18-20 5 1 6 2021-30 15 3 18 6031-40 3 - 3 1041-50 1 1 2 6.6751-60 1 - 1 3.33Total 25 5 30 100.00Table 2: Showing fracture characteristics.Fracture characters No. of patients Percentage (%) [n=30]Closed 27 90Open (type I) 3 10Oblique 21 70Transverse 9 30Right 18 60Left 12 40RTA 24 80Falls 6 2026Table 4: Showing major complications and final result.Parameters No. Of patients Percentage (%)Complications Delayed union 1 7patients. Details of operating time,hospitalisation and time to union is shown intable 3. Implants were safely removed in 6patients. Complications and final result isshown in table 4.Discussion:Broken screws 1 7Broken nail 1 7Limb shortening 4 13.33Quadriceps wasting 4 13.33Result Excellent 25 83.33Good 5 16.67The age group predominance, mean age,male to female ratio, high incidence of closedfractures, fracture pattern and associatedinjuries in our study is comparable to otherstudies. 4,9,10,11,12,13,14 Road traffic accidents(RTA) accounted for 80% and fall from heightaccounted for 20% of injuries, similar toreports by other authors. 11,12,14 The right femurwas involved in 18 (60%) patients and leftfemur in 12 (40%) patients.. Mold BR et al 15reported 70% right sided involvement.The mean time to operation was 7.80 ± 4.14days (3 – 18 days) for all patients. Hajek PDet al 10 operated within 1 and a half day of injurywhile Knut S et al 14 operated 76% of theirpatients on day 1 after injury. Del pino JMO etal 16 operated at a mean of 7 days from injury(2-14 days). The delay in our patients wasmostly due to lack of operating time availableto the surgeons as a result of which closedreduction was a problem thereby necessitatingJMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEthe open method of reduction. Meena RC etal 17 reported on 62 open interlocking nailingin 108 femoral shaft fractures with an outcomecomparable to closed nailing. The meanoperating time of 138 ± 41.9 minutes (60-210mins) was nearly identical to reports by HajekPD et al 10 (140, 99-225 min). The operationsthat took longer time were those where weencountered problems with reduction anddistal locking.All patients were subjected to static fixationwith variable number of proximal and distallocking screws. Knut S et al 14 had similarlyperformed static locking in all their patients(25 patients). We did not encounter anysignificant difference in the outcome whennumber of distal screws is taken intoconsideration. Considering the technicaldifficulty of distal locking and the possibleprolongation of the operating time, we are ofthe opinion that in fractures where thegeometry permits an adequate and stablereduction, distal locking with a single lockingscrew is sufficient and an additional lockingscrew adds no further benefit.The use of smaller size nail is possibly due tothe anthropologic profile of the populationunder study. Dawanki LL 18 reported nearidentical results in similar study population(9mm nail in 86.67%) whereas westernliterature quotes larger sized nails. 10,14 Bloodtransfusion was given to 21 patients withoutany clinical evidence of transfusion relatedreactions. Hajek PD et al 10 reported anaverage blood loss of 525 ml (200-1000 ml).Mean hospitalisation days in our patients werelonger possibly because of the delay in timeto operation. Del pino JMO et al 16 reported anaverage post operative hospitalisation of 14days (4-45 days). Dynamisation and bonegrafting was done at 24 weeks in one case ofdelayed union which subsequently unitedsatisfactorily. Satisfactory outcome ofdynamisation or bone grafting are alsoreported by other authors. 10,11 Wesupplemented bone grafting to ensure unionand to avoid further intervention in thisparticular patient.Mean time to clinical union of 13.60 ± 4.38weeks (9 -32) is comparable to other reports10,15,19Time to complete radiological union was25.73 ± 5.13 weeks (20 - 40), a little longerthan other authors. 13,14,19 Intraoperativedifficulties were; difficult reduction in 3 patientsand difficulty with distal locking in 8 patients.No other intra-operative, immediate postoperative complications and infections wereseen. Delayed complications encounteredand their outcome were comparable to otherstudies. 11,14,19,20,21Twenty five patients (83.33%) had excellentoutcome and five patients (16.67%) had goodoutcome in the final result as assessed bymodified Sanders criteria. 8 Knut S et al 14reported excellent outcome in 56% and goodoutcome in 20% of their patients while Chichuan W et al 11 reported excellent or goodoutcome in 78.57% of their patients. This highincidence of excellent outcome in our seriesmay be due to small sample size, strictinclusion criteria and proper adherence ofpatients to the follow up protocol. Assessmentof patient’s compliance to the rehabilitationprotocol for early return of joints and limbfunctions is of paramount importance. Whenpatients are motivated to actively participatein such activities the outcome should bepositive provided our fixation is stable.Conclusion:Interlocking nail acts as an intramedullary loadsharing device, stabilising fracture fragmentsand ensuring early bony union. Stressshielding is minimal and the nail systemproduces a rigid nail-bone fixation withoutelastic impingement which preventsmalrotation or shortening. Early return of jointfunctions and weight bearing is easily achievedconcurrent with fracture healing. OpenJMS * Vol 25 * No. 2 * May, 2011 27

ORIGINAL ARTICLEinterlocking nailing with minimal soft tissuetraumatisation, reaming and static fixation isa safe procedure for distal third femoral shaftfractures. Patients do well and activeparticipation of the treating surgeon in theirrehabilitative care has a positive impact on thepatient’s adherence to such activities. With anexcellent functional outcome, early clinical andradiological union, it can be done on a routinebasis with a minimum of complications.References:1. Koval KJ, Zuckerman JD. Handbook offractures. 3rd ed. Philadelphia: LippincottWilliams & Wilkins; 2006.2. Johnson KD. Femoral shaft fractures. In:Browner, Jupiter L, Trafton, editors. Skeletaltrauma - fractures dislocations injuries. 2nd ed.Philadelphia: W B Saunders; 1992. p. 1525-1541.3. Winquist RA, Hansen ST, Clawson DK. ClosedIntramedullary Nailing of Femoral Fractures: Areport of five hundred and twenty cases. J BoneJoint Surg Am 1984; 66:529-39.4. Wiss DA, Brien WW, Stetson WB. Interlockednailing for treatment of segmental fractures of thefemur. J Bone Joint Surg Am 1990; 72:724-8.5. Sisk TD. Fracture of lower extremity. In:Crenshaw AH, editor. Campbell’s operativeorthopaedics. 7th ed. New Delhi: JaypeeBrothers; 1989. p. 1680-1718.6. Weller S, Hantsch D. Medullary nailing ofFemur and Tibia. In: Allgower M, editor. Manualof internal fixation. 3rd ed. New York: Springer-Verlag; 1990. p. 291-364.7. Schmit KP. Evaluation of fracture healing andits disturbances. In: Maatz R, Lents W, ArensW, Beck H, editors. Intramedullary nailing andother intramedullary Osteosynthesis. 15th ed.Philadelphia: WB Saunders; 1986. p. 51-61.8. Sander R, Koval KJ, Dispasquale T, Heisfet,Franklin M. Retrograde reamed femoral nailing.J Orthop Trauma 1993; 7:293-302.9. Richards RR, Waddell JP, Sullivan TR,Ashworth MA, Rorabeck CH. Infra-Isthmalfractures of the femur: A review of 82 cases. JTrauma 1984; 24:735-41.10. Hajek PD, Bicknell HR, Bronson WE, AlbrightJA, Saha S. The Use of One Compared withTwo Distal Screws in the Treatment of FemoralShaft Fractures with Interlocking IntramedullaryNailing. J Bone Joint Surg Am 1993; 75:519-25.11. Chi-Chuan W, Chun-Hsiung S. Interlocking nailingof distal femoral fractures: 28 patients followed for1-2 years. Acta Orthop Scand 1991; 62:342-45.12. Papagiannopoulos G, Clement DA. Treatmentof fractures of the distal third of the femur: Aprospective trial of the derby intramedullary nail.J Bone Joint Surg Br 1987; 69:67-70.13. Brooker AF, Brumback RJ. Brooker-wills nailsin treatment of infra-isthmal injuries of thefemur. J Trauma 1988; 28:688-91.14. Knut S, Antti A, Arne E. The Grosse-Kempfnail for distal femoral fractures: 2-year followupof 25 cases. Acta Orthopaedica 1990;61:512-6.15. Mold BR, Watson JT. Retrograde intramedullarynailing without reaming of fractures of thefemoral shaft in multiple injures patients. J BoneJoint Surg Am 1993; 77:1520-8.16. Del pino JMO, Tomas LPJA Beltran GJ, ArrietaPJC. Treatment of complex fractures of femur:Our experience with the Brooker-Wills nail.Spanish Journal of Surgery Osteoarticular 1996;31:289-92.17. Meena RC, Kundnani V, Hussain Z. Fracture ofthe shaft of the femur: close vs open interlockingnailing. Indian J Orthop 2006; 40:243-6.18. Dawanki LL. A study of the efficacy of openinterlocking nails in adult femoral shaft fractures[thesis]. Imphal: Manipur University; 2001.19. Thoresan BO, Alho A, Ekeland A, Stromsoe K,Folleras G, Haukebo A. Interlockingintramedullary nailing in femoral shaft fractures.A report of forty eight cases. J Bone Joint SurgAm 1985; 67:1313-20.20. Kempf I, Grosse A, Beck G. Closed LockedIntramedullary Nailing: Its application tocomminuted fractures of the femur. J Bone JointSurg Am 1985; 67:709-20.21. Finsen V, Harnes OB, Nesse O, Benum P.Muscle function after plated and nailed femoralshaft fractures. Injury 1993; 24:531-3.28JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEVariation of serum zinc level in psoriasis1Ch.Bimola Devi, 1 S.Jibankumar Singh , 2 Th. Nandakishore, 1 S.Sunil Singh, 3 L.Rupachandra Singh,4S.Kunjeshwori DeviAbstractObjective: To develop a convenient andstandardized enzymatic (apocarbonicanhydrase) method of serum zincdetermination and to study the relationshipbetween serum zinc level and psoriasis.Methods: 100 confirmed cases of psoriasisaged 1-78 years attending the Department ofDermatology, RIMS Hospital, Imphal and 50healthy volunteers were recruited and theirserum zinc levels were determined. Zincdetermination was performed by using astandardized enzymatic method of carbonicanhydrase apoprotein reactivation with p-nitrophenyl acetate as the substrate andabsorption measured spectrophotometricallyat 405nm. Results: Out of 100 patients,37(37%) were males and 63(63%) werefemales. Male to female ratio was 1:1.7. Ofcontrol 20(40%) were males and 30(60%)were females. The mean ages of patientsand control was 39.1±17.71years and33.38±15.08years respectively. Most of thepsoriasis patients were in the third and fourthdecades of life and 35(35%) were in the agegroup 30-44years. The most common clinicalphenotype was chronic plaque typepsoriasis(64%) followed by guttate (13%),1. Research scholar 3. Professor 4. AssociateProfessor, Dept. of Biochemistry, Manipur University,Canchipur, Imphal 2. Assistant Professor, Dept. ofDermatology, Regional Institute of Medical Sciences,ImphalCorresponding author:Dr.S.Kunjeshwori Devi , Dept. of Biochemistry,Manipur University, Canchipur, Imphal-795003, Indiapalmoplantar (10%), pustular (7%) and scalp(6%).The extent of psoriasis was mildinvolving less than 5% body surface area(BSA) in 43%, moderate (5-10%BSA) in 26%and severe (>10% BSA) in 31% of thecases.The mean serum zinc level (µmol/L)in psoriasis patients and control were 12.40 ±3.81(range: 7.49 – 22.40) and 15.80 ±3.86(range: 8.74–23.53) respectively. Thedifference was statistically significant (p=0.004). There was no significant correlationof serum zinc level with either duration ofdisease (p=0.770) or extent (p= 0.780).However there was significant difference inserum zinc levels with disease activity (p=0.0037). Serum zinc levels showed anincreasing trend when the disease becameless active.Conclusion: Serum zinc level is reduced inpsoriasis. There is no variation in serum zinclevels with relation to disease duration andseverity. However serum zinc level showsincreasing trend with disease remission.Serum zinc estimation by enzymatic assayusing carbonic anhydrase was found to beconvenient , reliable and sensitive. Themethod could be adopted for serum zincdetermination in relevant clinical conditions .Keywords: Psoriasis, serum zinc, enzymaticzinc assay, carbonic anhydraseIntroductionPsoriasis is a chronic, common inflammatoryand proliferative disease of the skincharacterized by sharply demarcated dull red,scaly papules and plaques distributed mainlyJMS * Vol 25 * No. 2 * May, 2011 29

ORIGINAL ARTICLEon extensor aspects of the extremities, trunkand scalp. Its prevalence in the generalpopulation is 0.5 to 2.5% worldwide and 0.44to 2.8% in India 1 . Abnormal keratinocyteproliferation, differentiation and infiltration ofinflammatory components into the skincharacterise the pathology. Psoriasis is amultifactorial disease, generally believed to bea T-cell mediated disorder in whichenvironmental factors precipitate the diseasein a genetically predisposed individual 2 .However other mechanisms might beinvolved. The involvement of antioxidantenzyme systems in the regulation ofkeratinocyte proliferation has been reported 3 .Recently, psoriasis has also been postulatedto be due to imbalance in oxidant/antioxidantsystem of the skin 4 . Zinc is as an essentialtrace metal involved in virtually all aspects ofmetabolism by acting as a metal moiety ofmore than 300 metalloenzymes. It also playsan important role in the maintenance ofnormal immune functions. Besides, zinc isalso considered an important antioxidant inskin playing a vital role in the protection againstfree radical damage 5 . The role of traceminerals in the aetiopathogenesis of psoriasishas been investigated by a few workers only6,7. Previous studies regarding the relationshipbetween the serum zinc status and psoriasishave revealed conflicting results. 8,9,10,11 . Thereare only very few studies from India on thisaspect also 7,8,12,13 . Moreover, the methodadopted for serum zinc determination havebeen mainly atomic absorptionspectrophotometry. A new enzymatic methodof semi automated measurement of serumzinc has been described 14 . In view of theconflicting data of serum zinc level in psoriasispatients as well as paucity of such studyparticularly from the north-eastern part ofIndia, we took up the present study todetermine variation in serum zinc level inpsoriasis patient population in Manipur by astandardized and specific enzymatic methodbased on carbonic anhydrase apoproteinreactivation by zinc ion.Materials and MethodsChemicals: Zinc standard: Zinc standardsolution [Zn(NO 3) 2in HNO 3] were purchasedfrom Merck, Germany (Catalogue No.30119806); Commercially available purifiedbovine erythrocyte carbonic anhydrase[lyophilized powder] was from SigmaChemical Co., USA (Product No. C3934]; 4-Nitrophenyl acetate (MW 181.1) was fromSigma Chemical Co., USA (Product No.N8130); Pyridine 2, 6-dicarboxylic acid (MW167.12) was from Merck, Germany (ProductNo. 800614); All other biochemicals andchemicals used in the investigation were ofanalytical grade. Purified deionized waterused in the investigation was obtained througha water purification system TKA Smart2PureUV/UF (Germany).Solutions and buffers:Substrate solution (6.0 mM p-nitrophenylacetate): 13.8 mg p-nitrophenyl acetate wasdissolved in 1.5 mL of acetone and volumemade up to 12.5 mL by adding deionized water.Suspension buffer: 0.2 M phosphate buffer pH7.4Enzyme (Bovine Carbonic anhydrase)solution: 10 mg of CA was dissolved in 2 mLof the suspension buffer.Assay buffer : 0.5 M phosphate buffer pH 7.5Standard zinc solution: The concentration ofZn 2+ in the standard zinc solution wasdetermined by Flame Atomic AbsorptionSpectrometer Model Perkin Elmer 3110 in theSophisticated Analytical Instrument Facility(SAIF), North-Eastern Hill University, Shillong.Carbonic anhydrase assay: CA was assayedby spectrophotometrically monitoring theesterolytic formation of p-nitrophenol (ª 405=1.75x10 4 M -1 cm -1 ) in an assay mixtureconstituted by mixing appropriately dilutedenzyme sample with 0.8mM p-nitrophenylacetate as the substrate in 0.5 M phosphatebuffer pH 7.5 at 30°C. The reaction wasstarted with the addition of substrate. After thelapse of 15s of the substrate addition,absorbance at 405 nm was noted for every30s. The absorbance increase due to slowautocatalytic cleavage of the substrate wasalways deducted to obtain the net enzymaticabsorbance increase. The unit of the enzymeactivity was defined as the amount of CAwhich catalyzed the formation of one ìmole ofJMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEp-nitrophenol in one minute under theexperimental conditions. Protein wasdetermined by the method of Lowry et al. 15using crystalline bovine serum albumin as thestandard. The specific activity of CA wasfound to be 1.05 units/mg protein under thestandard assay conditions.Preparation of apocarbonic anhydrase:Apocarbonic anhydrase (apo-CA) wasprepared by a modification of the method ofErel and Avci (2002) 14 by dissolving thecommercial bovine erythrocyte carbonicanhydrase (30 mg) in 3 mL of suspensionbuffer (0.2 M phosphate buffer pH 7.4) anddialysed against the same buffer containing0.15 M pyridine 2,6-dicarboxylic acid (chelator)for 12 h at 4°C. The external chelator solutionwas then replaced by ice-cold deionized waterand dialysis was continued for 8 h with twosolvent changes.Finally, the external solvent was replaced withthe suspension buffer and dialysis wascontinued for 4 h more .Re-activation of apocarbonic anhydrase: Theapo-CA was re-activated by adding increasingconcentration of external Zn 2+ to standardassay mixture used for Carbonic anhydraseassay above. The activity restored to apo-CAwas assayed by spectrophotometricallymonitoring the formation of p-nitrophenol (ª 405= 1.75x10 4 M -1 cm -1 ) in an assay mixtureconstituted by mixing an appropriate amountof apo-CA, externally added Zn 2+ at differentdesignated concentrations, and p-nitrophenylacetate as the substrate at 0.8 mM in 0.5 Mphosphate buffer pH 7.5 at 30°C. The reactionwas started with the addition of substrate aftera lapse of 45 s of the mixing of apo-CA withZn 2+ . After the lapse of 15 s of the substrateaddition, absorbance at 405 nm was notedfor every minute. The absorbance increasedue to slow autocatalytic cleavage of thesubstrate was always deducted to obtain thenet enzymatic absorbance increase.Determination of activity restored to apo-CAat each designated Zn 2+ concentration wasrepeated thrice and each experimental valuewas obtained by averaging the threecorresponding rates of net absorbancechange.Analysis of the apo-CA reactivation data andcalculation of Zn 2+ concentration: The data ofactivity restored to the apo-CA as a functionof Zn 2+ concentration in the standard assaymixture determined in Re-activation of apo-CA above were analyzed kinetically and theresulting rate equation was used to calculatethe unknown Zn 2+ concentrationcorresponding to the experimentallydetermined activity restored to the apoenzymeon addition of the sample.Psoriasis patients: Patients attending theDepartment of Dermatology, Regional Instituteof Medical Sciences Hospital, Imphal, duringthe period January 2007 to December 2009were recruited. The diagnosis of psoriasispatients and assessment of other clinicalparameters were carried out by a qualifieddermatologist in the medical institute. Adetailed cutaneous and systemic examinationwas done in all patients and patients with otherskin disorders or systemic diseases wereexcluded from the study group. Psoriasis wasgraded clinically by assessing the bodysurface area involved: mild (10%), and lesion wiseconsideration of erythema, induration andscaling. One hundred psoriasis patients(n=100) were taken as the study cases.Control individuals: The control groupcomprised of healthy volunteers (n = 50)having neither signiûcant medical illness norunder medications for at least 3-monthsduration at the time of blood collection.Ethical issues: Ethical approval for collectingblood samples of psoriasis patients andcontrols was obtained from the ResearchEthical Committee of Regional Institute ofMedical Sciences Hospital, Imphal. Thepatients/guardians and normal individualswere thoroughly informed and their writtenconsents were taken before taking the bloodsamples.Sample collection and storage: Fastingvenous blood (3 mL) was collected from eachpatient /control in special sterile tube(AcCuvet). Blood was allowed to clot at roomtemperature for about 15 min and thencentrifuged at 1500g for 20 min to separatethe serum. The supernatant serum wasJMS * Vol 25 * No. 2 * May, 2011 31

ORIGINAL ARTICLEtransferred to a separate sterile vial and keptat -20°C in the deep freezer till the analysis.Analysis for serum zinc level: The frozen serumwas first thawed and mixed with equal volumeof 5%(v/v) TCA to precipitate serum proteins.The resulting suspension was centrifuged at1500g for 30 min to collect the supernatant asthe serum zinc sample. An aliquot (0.01 mL)of the serum zinc sample was analyzed for itszinc concentration by the standardized andspecific enzymatic method based on the apo-CA reactivation described above.Statistical analyses: All the clinical data wereanalysed using Statistical Package for theSocial Sciences, SPSS, version 16.0 (SPSSInc). The Student’s t-test and ANOVA wereused wherever applicable. The normal rangeof serum zinc level is 11-22 µmol/L.ResultsThe enzyme sample was found to behomogeneous on SDS-PAGE and hencesuitable for application in serum zincdetermination based on the kinetic analysisof re-activation of its correspondingapoenzyme by addition of external Zn 2+ in theotherwise standard assay mixture. The apo-CA prepared was found to be 100%- Zn 2+ -freeas evidenced by its complete inactivity underthe standard assay conditions. It was alsofound to be fully stable for at least 2 monthsunder refrigeration and suitable for use as areagent for day to day zinc determination inserum samples. The apo-CA was fully reactivatedby addition of increasingconcentration of externally added Zn 2+ in theotherwise standard assay mixture. The resultsof Zn 2+ -dependent restoration of activity to theapo-CA is shown in Fig.1.Fig.1: Re-activation of apocarbonic anhydrase (apo-CA) by externally added Zn 2+ . (A) Activity restored toapo-CA (0.43 mg/mL in test) at increasing [Zn 2+ ]externally added in the otherwise standard assaymixture in Carbonic anhydrase assay under Materialsand Methods. Each experimental point was anaverage of three measurements at each [Zn 2+ ]. (B)Corresponding Lineweaver-Burk (double reciprocal)plot of the [Zn 2+ ]-dependent restoration of activity toapo-CA.The re-activation could be analyzed in termsof a hyperbolic kinetics shown in Fig.1(A)corresponding to the Michaelis-Menten rateequation,V = (V max[Zn 2+ ]) / (K m+ [Zn 2+ ])where V = activity restored to apo-CA (definedÄAbs at 405 nm/6 min) under the standardconditions of activity assay, V max= maximalactivity restored to apo-CA under saturating[Zn 2+ ], and K m= Michaelis-Menten rate constantfor the re-activation of the apoenzyme. Theexhibition of hyperbolic restoration of activityto the apoenzyme was confirmed by linearityin the Lineweaver-Burk plot of the [Zn 2+ ]-Table 1. Demographic profile of psoriasis patients and controlNo. of patients No. of control(%); n=100 (%); n=50Age(yr)Mean± SD; Range 39.17± 17.71;1-78 33.38 ± 15.08;7-72SexMale 37(37) 20(40)Female 63(63) 30(60)ReligionHindu 84(84) 36(72)Muslims 5(5) 5(10)Christians 11(11) 9(18)ResidenceRural 36(36) 20(40)Urban 64(64) 30(60)Socio-economic statusLow 39(39) 20(40)Middle 53(53) 24(48)High 8(8) 6(12)32JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLETable 2. Clinical profile of psoriasis patientsCharacteristics1. Initial site of involvementNo. of patients (n=100)Scalp 14Trunk 17Extensors 38Hands and Feet 13Palms and Soles 182. Clinical type of psoriasisScalp 6Plaque 64Guttate 13Palmo-plantar 10Pustular 73. Duration of disease at presentation< 1 year 381 – 5 years 35>5 years 274. Extent of body surface area (BSA) involvementMild (< 5% 43Moderate (5-10%) 26Severe (>10%) 31Table 3. Descriptive data of serum zinc level in psoriasispatients and controlsCases(n=100)RangeControls(n=50)Rangep-valueSerum zinc(µmol/L) 12.40±3.81* 7.49-22.40 15.80±3.86* 8.74 - 23.53 0.004***Values are expressed in terms of Mean±SD**p < 0.05 (significant)Table 4. Serum zinc concentration in psoriasis patients inrelation to duration, body surface area and disease activityCharacteristics n=100 [Zn 2+ ] µmol/LDuration of diseaseMean±SD Range p-value< 1 year 38 13.09±3.98 8.97-18.81 – 5 years 35 12.07±3.84 7.49-22.40>5 years 27 12.86 ±4.26 8.6-22.1Extent of Body surface area (BSA) involvementMild (< 5% ) 43 12.76±3.58 8.86-22.1Moderate (5-10%) 26 11.63±5.00 8.60-22.40Severe (>10%) 31 12.48±3.02 8.20-16.47Activity of disease0.7700.780Active 30* 11.59± 2.70 8.2-16.47 0.0037Remission 30* 16.09 ± 3.85 11.87-21.40*Thirty psoriasis patients were assessed for variation of serum zinclevel in relation to disease activity.dependent re-activation data shown inFig.1(B). From this double-reciprocal plot, theV maxand K mwere found out to be 0.625 ÄAbsat 405 nm/6 min and 0.128 ìM respectively,and these kinetic values were used forcalculating the Zn 2+ levels using the above rateequation in a serum samples taken either frompsoriasis patients or normal individuals.Demographic profile of the psoriasis patientsand controls involved in the presentinvestigation is given in Table 1. Male to femaleratio was 1:1.7. The difference in the meanages of patients and controls was statisticallynot significant (p=0.1448) which denotes thatthey were comparable. Most of the patientswere in the third or fourth decade of life ofwhich maximum cases 35(35%) were in theage group 30-44years. Children accounted for6% of the cases. Clinical data of psoriasis isshown in Table 2.The body part mostcommonly involved by psoriasis at the onsetof disease was extensors (38%) followed bypalms and soles (18%) and scalp (14%) . Onethird (31%) of the psoriasis patients hadextensive body involvement. Present studydid not reveal facial, nail and mucosalinvolvement. The most common (64%) clinicalphenotype was chronic plaque type psoriasis(psoriasis vulgaris), followed by guttate (13%),palmoplantar (10%), pustular (7%) and scalp(6%) respectively. We did not find arthropathicand erythrodermic forms of psoriasis in thepresent investigation. Table 3 gives thecomparative analysis of serum zinc levelsbetween psoriatic patients and control group.The serum zinc levels in the psoriasis patientswere significantly lower (p < 0.05). Theanalytical data of serum zinc level in varioussub-categories of psoriasis patients are givenin Table 4. There was no significant change inthe serum zinc level in psoriatics on the basisof their duration of disease or extent of BSAinvolvement. However, analysis done on 30patients to study the variation in serum zinclevel between active and inactive phases ofpsoriasis revealed highly significant difference(‘paired’ t- test, p=0.0037).DiscussionTrace metals like zinc and copper have longbeen believed to play important roles inimmunological and inflammatory reactions.Psoriasis being a chronic inflammatorycondition of skin, investigations to clarify therelationship of zinc alone or zinc and copperJMS * Vol 25 * No. 2 * May, 2011 33

ORIGINAL ARTICLEtogether with psoriasis has been carried outby many workers. However analyses of thesefindings have revealed contradictory results.Withers et al. 16 , Portnoy and Molokhia 17 , Hinkset al. 6 , Tasaki et al. 18 and Kreft et al. 11 reportedno change in the serum zinc levels inpsoriasis patients. On the other handVoorhees et al. 19 , Tsambaos and Orfanos 20 ,Bruske and Salfeld 9 and Butnaru et al. 21have found elevated serum zinc levels in theirstudies. In the present study the mean serumzinc level in the psoriasis patients was12.40±3.81 while in the controls it was15.80±3.86. These results indicate that serumzinc levels in psoriasis patients were reducedsignificantly (p< 0.05) as compared to thoseof normal individuals. This is consistent withthe findings of previous studies of Greavesand Boyde 22 , Greaves 23, 24 , Donadini et al. 25and Saxena et al. 8Various explanations have been provided toaccount for the conflicting serum zinc levelsin psoriasis. One possible reason could bethe failure to consider body surface areainvolvement in psoriasis 6 . Depression ofserum zinc level with increasing areas ofpsoriatic involvement in one way could beaccounted by increased secondary zinc lossthrough exfoliation which is normally 306-612nmol/day. Greaves and Boyde 22 reportedsignificant lowering of the plasma zincconcentration in patients with extensivepsoriasis. McMillan and Rowe 10 found plasmazinc level in psoriasis was not statisticallydifferent significantly compared to normallevel but those with extensive involvement hadlower levels than those with minimalinvolvement. In a recent Indian study byNigam 13 , patients with more than 20% BSAinvolvement showed a significantly decreased(p < 0.01) serum zinc concentration than thosewith less than 20% BSA involvement. Howeverthe present study could not substantiate theseresults as there was no difference in serumzinc concentration with extent of BSAinvolvement. Tsambaos and Orfanos 20 alsofound no correlation between elevated zinclevel and extent of psoriatic skin involvement.One limitation of the present investigationis the study of a single element (zinc)variation. Study of serum Zn/Cu ratios may34serve a better diagnostic value than simplemeasurement of Zn or Cu values in psoriasisas both elements are metaboliccompetitors 12 . Zinc plays an essential role inthe normal keratinization process of animalskin along with copper 26 . Zinc also has aprotective effect on keratinocyte activationmarkers like ICAM-I and TNF-á secretionstimulated by IFN-ã 27 . Keratinocyte proliferationand development of psoriasis may also beclosely related with alterations in the oxidant/antioxidant enzyme systems 3,4 of the skin inwhich zinc plays a pivotal role 5 . Zinc alsoinduces upregulation of TNF-á induced protein3(A 20) mRNA which decreases nuclear factorkappa B (NF-êB) activation resulting indecreased generation of inflammatorycytokines 28 .Thus zinc could be intricatelyrelated to psoriasis in many ways.Determination of zinc concentrations inbiologic specimens though usually performedby atomic absorption spectrophotometry(AAS) has disadvantage because of highinstrument cost and complicated techniqueto prevent its widespread use.Metalloenzymes show selectivity, specificityand sensitivity for metal elements which aretheir cofactors. Among metalloenzymes CAprovides a big advantage for analyticalsensitivity because it has a high turn overnumber for its substrates. Morever it ispreferable to alkaline phosphatase andaminopeptidase for zinc determination asadopted by Donangelo and Chang 29 becausemore than one zinc atom is required toreactivate alkaline phosphatase andaminopeptidase enzymes from the zinc freestate 14 . The heat denaturation method ofserum proteins utilised by Demir et al. 30 tomeasure zinc concentration has unacceptableprecision values and is impractical for routineusage in clinical laboratories. The interferenceeffect of other metals create the main problemin colorimetric zinc measurement methods 31 .Zinc determination performed by using astandardized enzymatic method of carbonicanhydrase apoprotein reactivation with p-nitrophenyl acetate as the substrate andabsorption measured spectrophotometricallyat 405nm in the present study was sensitiveand reliable.JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEConclusionSerum zinc level is reduced in psoriasis.There is no variation in serum zinc level withrelation to disease duration and severity.However, serum zinc level shows increasingtrend in the remission phase compared toactive stage of the disease. Furtherinvestigations including copper in addition tozinc with a larger sample size would be helpfulto validate the findings of the present study.Evaluation of clinical response in psoriasispatients after oral zinc therapy will further helpelucidate the relationship of zinc with psoriasisin the light of present knowledge. Serum zincestimation by the enzymatic assay usingcarbonic anhydrase was found to be relativelycheap, easy and convenient. This methodcould be utilised for serum zinc determinationin other clinical conditions also.AcknowledgmentsThe authors are grateful to Dr. Paul Dkhar,Scientific Officer, Sophisticated AnalyticalInstrument Facility (SAIF), North-Eastern HillUniversity, Shillong , for technical support.References1. Dogra S, Yadav S. Psoriasis in India:Prevalence and pattern. Indian J DermatolVenereol Leprol 2010;76: 595-6012. Griffiths CE, Barker JN. Pathogenesis andclinical features of psoriasis. Lancet 2007; 370:263-71.3. Grashin RA, Antonov VG, Karpishchenko AI,KhaÄ-rutdinov VR. The free radical oxidationand antioxidant defense systems as indicatorsof the activity of keratinocytic proliferation inpsoriasis . Klin Lab Diagn 2010 Jan ;(1):18-244. Yildirum M, Inaloz HS, Baysal V, Delibas N.The role of oxidants and antioxidants inpsoriasis. J Eur Acad Dermatol Venereol 2003; 17(1): 34-365. Rostan EF, Holly VD, Madey DL and Pinnel SR. Evidence supporting zinc as an importantantioxidant for skin. Int J Dermatol 2002; 41:606- 6116. Hinks J, Young S, Clayton B. Trace elementstatus in eczema and psoriasis. Clin ExpDermatol 1987;12: 93–977. Basavaraj KH, Darshan MS, Shanmugavelu P,Rashmi R, Mhatre AY, Dhanabal SP, Rao KSJ.Study on the levels of trace elements in mildand severe psoriasis. Clinica Chimica Acta2009; 405: 66-708.8. Saxena N, Sharma RP, Singh VS. A study ofserum zinc and copper levels in psoriasis.Indian J Dermatol Venereol Leprol1990;56:216-8.9. Bruske K, Salfeld K. Zinc and its status insome dermatologic diseases- a statisticalAssessment. Z Hautkr 1987; 62 : 125- 31.10. McMillan E M, Rowe D. Plasma zinc inpsoriasis: relation to surface area involvement.Br J Dermatol 1983 ; 108 (3): 301-5.11. Kreft B, Wohlrab J, Fischer M, Uhlig H,Skolziger R, Marsch WC. Analysis of seruminc level in patients with atopic dermatitis,psoriasis vulgaris and in probands with healthyskin. Hautarzt 2000 Dec; 51 (12): 931-4.12. Bhatnagar M, Bapna A, Khare AK. Serumproteins, trace metals and phosphatases inpsoriasis. Indian J Dermatol Venereol Leprol1994;60:18-21.13. Nigam PK. Serum zinc and copper levels andCu: Zn ratio in psoriasis. Indian J DermatolVenereol Leprol 2005 May-Jun; 71(3):205-6.14 Erel O and Avci S. Semi-automated enzymaticmeasurement of serum zinc concentration.Clin Biochem 2002 ; 35: 41–47.15. Lowry OH, Rosebrough NJ, Farr AL, RandallRJ. J Biol Chem;193:265-275, 1951.16. Withers AF, Baker H, Musa M, Dormandy TL.Plasma- zinc in psoriasis. Lancet 1968Aug 3;2(7562): 278.17. Portnoy B, Molokhia MM. Zinc and copper inpsoriasis. Br J Dermatol 1972; 86:205.JMS * Vol 25 * No. 2 * May, 2011 35

ORIGINAL ARTICLE18. Tasaki M, Hanada K, Hashimoto I. Analysesof serum copper and zinc levels andcopper/zinc ratios in skin diseases. JDermatol 1993 Jan; 20(1):21-4.19. Voorhees JJ, Chakrabarti SG , Botero F,Miedler L, Harrell ER, Zinc Therapy andDistribution in Psoriasis. Arch Dermatol 1969;100(6): 669-673.20. Tsambaos D , Orfanos C.E. Zinc distributiondisorders in psoriasis. Arch Dermatol Research1977Jul; 259(1): 97-100.21. Butnaru C, Pascu M, Mircea C, Agoroaei L,Solovastru L, Vaþa D, Butnaru E,PetrescuZ. Serum zinc and copper levels insome dermatological diseases. RevMed Chir Soc Med Na Iasi. 2008 Jan-Mar;112(1): 253-7.22. Greaves MW, Boyde TRC. Plasma zincconcentrations in patients with psoriasis,other dermatoses, and venous leg ulcerations.Lancet 1967; 2:1019-20.23. Greaves MW. Zinc in psoriasis. Lancet 1970;1:1295.24. Greaves MW. Zinc and copper in psoriasis. BrJ Dermatol 1971;84:178.25. Donadini A, Pazzaglia A, Desirello G, MinoiaC, Colli M. Plasma levels of Zn, Cu andNi in healthy controls and in psoriasis patients.Possible correlations with vitamins. ActaVitaminol Enzymol 1980; 2(1-2): 9 -16.26. Day C, McCollum EV. Effect of acute dietaryzinc deficiency in rat. Proc Exp Biol Med 1940; 45: 282-7.27. Gueniche A, Viac J, Lizard G ,Charveron M.Protective effect of zinc on keratinocyteactivation markers induced by interferon ornickel. Acta Derm Venereol 1995Jan; 75(1):19-23.28. Prasad AS. Clinical, immunological,antinflammatory and antioxidant roles of zinc.Exp Gerontol 2008 May; 43 (5): 370-729. Donangelo CM, Chang GW. An enzymaticassay for available zinc in plasma and serum.Clin Chim Acta 1981;113(2):201–6.30. Demir N, Kufrevioglu OI, Keha EE, Bakan E.An enzymatic method for zinc determinationin serum. BioFactors 1993;4(2):129–32.31. Makino T. A sensitive, direct colorimetric assayof serum zinc using nitro-PAPS, and microwellplates. Clin Chim Acta 1991;197:209–20.36JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEA study of Tobacco use and patterns of consumption in a rural area ofManipur1J. Ado, 2 H. Sanayaima Devi, 2 P. Romola, 3 Y. Manihar Singh,AbstractObjective: To determine the prevalence oftobacco use among rural tribal adults in ruralfield practice area of Community Medicine,RIMS and also to ascertain the patterns oftobacco consumption among the studypopulation. Material and methods: Thiscross sectional study was conducted in a ruraltribal community under Saikot Primary HealthCenter, Churachanpur district of Manipur,having a population of around one thousandseven hundred and fifty-six. Two hundred andeighty-three household were visitedcomprising of 1056 subjects with coverageof 94.3% of the total households. All personsaged 15 years and above were identified anda face-to-face interview was conducted usinga pretested, semi-structured schedule. Datawere presented in percentages, mean andstandard deviation and chi square test wasused for significance testing. Results: Theoverall prevalence of tobacco use was 67.4%.The prevalence was significantly higheramong males than females (72.1% Vs63.2%). A significantly higher proportion oftobacco use was found among Christians,married people and study subjects who were1. District Programme Officer, Govt. of ArunachalPradesh; 2. Assistant Professors; 3. Professor – Dept.of Community Medicine, Regional Institute of MedicalSciences, Imphal- 795004 Manipur, India.Corresponding author:Dr. H. Sanayaima Devi, Assistant Professor,Department of Community Medicine, RIMS, Imphal-795004, e-mail: drsanacm@Gmail.com, Mobile no.9856144830.30 years and above as well as theiroccupation. It was also observed that peoplewho were engaged in unskilled jobs havesignificantly higher proportion of tobacco useas compared to skilled persons and students.Among different types of tobacco, cigarettesmoking was the commonest form ofconsumption followed with khaini. Majority ofthem (93.2%) were regular users and startedusing it at their adolescent age. Conclusion:Using tobacco was a common practice in thistribal community, which usually started at theiryoung life. Therefore, a proper healthawareness Programme needs to be stressedupon in this community.Keywords: Tobacco, Prevalence, Crosssectional,Cigarette, Smokeless tobacco.Introduction:Tobacco use is becoming epidemicworldwide and is still expanding in developingcountries where 84% of the smokers live.Tobacco has been recognized as one of theworld’s major health hazards and showed tobe one of the most powerful poisons knownand addictive in humans. WHO estimated thatif the current smoking patterns continue, it isexpected to rise to 10 million deaths in 2025with 7 million of these deaths occurring indeveloping countries, mainly in China andIndia 1 .Tobacco consumption in India is responsiblefor half of the cancers in men and a quarterof all cancers in women, in addition to beinga risk factor for cardiovascular diseases andJMS * Vol 25 * No. 2 * May, 2011 37

ORIGINAL ARTICLEchronic obstructive pulmonary diseases 2 . Itis estimated that around 5,500 Indianadolescents under the age of 15 years startusing tobacco every day 3 . As per WHO report,194 million men and 45 million women usetobacco in smoked or smokeless form inIndia. 20% of tobacco is consumed ascigarettes, 40% as bidi and the rest assmokeless form. There are considerablechanges in the patterns by which it isconsumed 4 .Only a few studies 4 had been conducted inthe whole North East States to haveinformation on the burden of tobacco use andthe patterns of consumption. Therefore, thereis a need to have sufficient information on thisissue. So, the present study was undertakenwith the objective of assessing the prevalenceof tobacco use among rural tribal communityin this rural field practice area of Communitymedicine, RIMS and to ascertain the patternof tobacco consumption among the studypopulation.Material and methods:A cross sectional study was conductedamong a sample of 1014 study subjectscomprising both sexes and age group of 15years and above. This was a communitybased study conducted in a rural tribalcommunity under Saikot PHC,Churachandpur district of Manipur which isidentified as a rural field practice area ofCommunity Medicine Department, RIMS.Every household in the study area were visitedfrom an identified household list. All personsaged 15 years and above of both sexes wereidentified and a face-to-face interview wasconducted after obtaining an informed verbalconsent. Data were collected using apretested, predesigned semi-structuredquestionnaire. The questionnaire consisted ofsocio-demographic information and somequestions pertaining to tobacco use and thepattern of tobacco consumption. Thoseindividuals who were not willing to participateand were not at home even three revisits wereexcluded from the study.The study area has a total household of 300as enumerated by rural training canter with apopulation of one thousand seven hundred38and fifty-six. A total of 283 household werevisited comprising 1056 study subjects. Thus,94.3% of the total households were coveredin this study. Data were presented inpercentages, mean and standard deviation.Pearson chi-square test was used forsignificance testing. Prior approval of theinstitute’s research and ethical committeewas obtained.Results:Out of the total one thousand and fifty-six, 1014subjects could enroll in the study with forty-Table 1: Characteristics of study population and theprevalence of tobacco use.Characteristics Number No.of tobacco Prevalence p-valueSexN=1014(%) users rateMale 470 (46.4) 339 72.1 0.003female 544 (53.6) 344 63.2Age(yr)15-19 114 (11.2) 22 19.320-29 316 (31.2) 195 61.7 0.00030-39 184 (18.1) 158 85.940-49 143 (14.2) 119 83.2 50 257 (25.3) 189 73.5ReligionHindu 079 (07.8) 033 41.8 0.000Christian 935 (92.2) 650 69.5Type of familyNuclear 691 (69.1) 478 69.2 0.071Joint 323 (31.9) 205 63.5Income/capita/mth< Rs 500 424 (41.8) 290 68.4Rs 500-1000 414 (40.8) 273 66.0 0.954Rs 1000-2000 163 (16.1) 111 68.1>Rs 2000 013 (01.3) 004 66.7Educational statusIlliterate 187 (18.4) 135 72.2Primary 177 (17.5) 127 71.8 0.052Middle 356 (35.1) 244 68.5Matriculatee 239 (23.6) 143 59.8 Graduate 055 (05.4) 032 62.7OccupationSelf employed 179 (17.6) 154 86.0Farmer 251 (24.8) 198 78.9Employed 094 (09.3) 066 70.2 0.000Unemployed 366 (36.1) 239 65.3Professional 005 (00.5) 002 40.0Student 119 (11.7) 024 20.2Marital statusMarried 703 (69.3) 537 76.4Divorcee/widow 016 (01.6) 011 68.8 0.000Unmarried 295 (29.1) 135 45.8JMS * Vol 25 * No. 2 * May, 2011

Table 2. Age of initiation of tobacco use by the type oftobaccoType of tobacco No. of cases (%) Age of initiationMean ±SDCigarette 284(41.6) 18.4 ± 4.8Bidi 081(11.8) 19.3 ± 5.8Tuibur 019(02.8) 27.6 ±15.5Khaini 223(33.7) 21.5 ± 9.6Chewing tobacco 013(01.9) 18.7 ± 5.1Mixed 062(09.1) 22.8 ±12.9two refusals (4%). The generalcharacteristics of the study subjects showedthat the majority of the subjects whoparticipated in this study were females((53.6%) and in the age group of 20-29 years(31.2%). Nine hundred and thirty-five (92.1%)were from the Christian community, most ofthem were from nuclear families (69.1%) withper capita income of Rs 1000 (82.6). Majorityof them were married, unemployed andstudied up to middle standard.The overall prevalence of tobacco use amongthe study subjects was 67.4%. Male had higherrate of tobacco use than that of female (72.1%Vs 63.2) and the difference was statisticallysignificant. The proportion of tobacco use wassignificantly higher among Christians, marriedpeople and age group of 30 years and above.It was also observed that people who wereengaged in unskilled jobs have significantlyhigher proportion of tobacco use as comparedto skilled persons and students. The rate oftobacco use was not associated with percapita income, type of family where theybelonged as well as their educational status(Table 1).Table 2 shows the mean age of initiation oftobacco among the different types of tobaccousers. From the table it was observed thatthe mean age of initiation of any form oftobacco was 18 years and majority of them(93.2%) were regular users. Among differenttypes of tobacco, cigarette smoking (41.6%)was the commonest form of consumptionwhich was followed with khaini (33.7%).Discussion:The present study found the prevalence rateof tobacco use to be 67.4% which wascomparable to other previous studies 2 .However, it was higher than the reportedprevalence from other studies 4,5,6 . The rateof tobacco use was significantly higher amongmales as compared to females. Otherstudies 4,7 also found that males used moretobacco than females. This finding was notconsistent with another study which claimedthat female were more likely to smoke thanmales 8 . Prevalence of tobacco use washigher among Christians and it was found tobe statistically significant. However, the resultshould be interpreted with caution becausemajority of the study subjects belonged toChristian community with less number ofobservations from other communities. Ourstudy did not find significant associationbetween the rate of tobacco consumption andthe type of family, per capita income andeducational status of the participants. Thiswas in contrast to studies which showed thattobacco consumption was significantly higherin poor, less educated, schedule caste andschedule tribe populations 2,8,9 . In this study,the age wise prevalence of tobacco use washigher as the age advanced. Similar findingwas reported by other workers where the agespecific prevalence of smoking was highestin the age group of 35-54 years 10 . Our studyshowed that persons who were engaged inskilled jobs used less tobacco comparing toother unskilled workers which wascomparable with other study findings 2 .According to our study findings, married anddivorcee/widow used more tobacco thanunmarried people this may be because manyof the married people were unskilled workers.In the present study, any form of tobacco wasused commonly at around 18 years of age. Asimilar finding was reported by otherresearchers where most of the smokersbegin to smoke by age of 18 to 20 years 7 .Conclusion:The present study indicated that the overallprevalence of tobacco use among studypopulation was found to be 67.4% and it wassignificantly higher among males and in theage group of 30 years and above. TobaccoJMS * Vol 25 * No. 2 * May, 2011 39

ORIGINAL ARTICLEuse was also significantly higher amongunskilled persons than skilled ones andamong married people as compared tounmarried. The mean age of initiation oftobacco consumption was around 18 yearsand the commonest form of tobacco wascigarette followed with khaini. Tobacco usewas a common practice in rural tribalcommunity in Manipur which was initiated attheir early life. Hence a properly organizedhealth education Programme is warranted inthis community.References:1. World Health Organization. Tobacco control:strengthening national efforts, World HealthReport; WHO 1211, Geneva 27, Switzerland.2003; 91-95.2. Rani M, Bonu S, Jha P, Nguyen SN, JamjoumL. Tobacco use in India, prevalence andpredictors of smoking and chewing in a nationalcross-sectional household survey. TobaccoControl 2003;12: 1-8.3. Patel DR. Smoking and children. Indian Journalof Paediatrics 1997; 66(6): 817-824.4. Sinha DN, Gupta PC, Pednekar MS. Tobaccouse among school personnel in eight northeastern states of India. Indian Journal of Cancer2003; 4(1): 3-14.5. Shah SMA, Srif AA, Delclos GL, Khan A.Prevalence and correlates of smoking on theroof of the world. Tobacco Control 2001; 10: 1-4.6. Smith SS, Flore MC. The epidemiology oftobacco use, dependence and cessation in theUnited States. Journal of Primary Care 1999;26: 433-461.7. Brownson RC, Thomson JJ, Davis JR, OwensNW, Fisher EB. Demographic and socioeconomicdifferences in beliefs about healtheffects of smoking. American Journal of PublicHealth 1992; 82(1): 99-106.8. Giovino GA, Schovley MW, Zhu BP.Surveillance for selected tobacco usebehaviors. United States Centre for DiseaseControl, Surveillance Summary 1994; 43: 1-43.9. SubramaniamSV, Nandy S, Kelly M, GordonD, Smith DG. Patterns and distribution oftobacco consumption in India: cross-sectionalmulti-level evidence from the 19999 nationalfamily health survey.British Medical Journal2004; 328(3): 801-806.10. Jagoe K, Edwards R, Mugusi F, Whiting D,Unwin N. Tobacco smoking in Tanzania, EastAfrica: Population based smoking prevalenceusing expired alveolar carbon monoxide as avalidation tool. Tobacco Control 2002; 11: 210-214.40JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEA study of serum adenosine deaminase (ada)And CD 4count in hiv infected patients1Suchitra Chongtham, 2 M. Amuba Singh, 3 W. Gyaneshwor Singh, 4 Ng. Brajachand SinghAbstractObjective: To estimate the level of serumadenosine deaminase (ADA) and CD 4countin HIV infected cases and to compare withthat of normal controls. To find out thecorrelation between serum ADA and CD 4count in HIV infected cases. Method: 120confirmed cases of HIV infected casesadmitted in Medicine Ward as well as thosereported in ICTC and FACS count centreDepartment of Microbiology, Regional Instituteof Medical Science, Imphal, after taking fullinformed consent were taken randomly. Ageand sex matched 60 healthy individuals freefrom HIV and other diseases were taken ascontrol group randomly. Serum ADA isestimated by kit method using colorimeter andCD 4is enumerated using Becton DickinsonFACS count System, Germany. The data wasanalyzed using SPSS package. Result: Themean ADA in the case group have significantlyhigher value than the control group. CD 4, CD 8,CD 4/CD 8and CD 3decreases as stageenhances from stage I to III but value of ADAis highest in stage III followed by stage II and Ithough the difference is not statisticallysignificant. The study finds a significantlynegative correlation between serum ADA andCD 4count. Conclusion: The study finds a1. Demonstrator, Deptt. of Biochemistry, JNIMS,Imphal, 2. Professor, 3. Professor & Head, Deptt. ofBiochemistry, RIMS, 4. Professor & Head, Deptt. ofMicrobiology, Regional Institute of Medical Sciences,Imphal.Corresponding author:Dr. Suchitra Chongtham, Deptt. of Biochemistry,Jawaharlal Nehru Institute of Medical Sciences(JNIMS), Porompat, Imphal East - 795005significantly negative correlation between serumADA and CD 4count. So, serum ADA, acomparatively simpler and easier test than CDcount could be used as a prognostic marker in4the management of the people living with HIV.Key Words: ADA, CD 4, HIVIntroduction:HIV/AIDS, a modern pandemic affecting bothindustrialized and developing country is amajor concern worldwide. At the end ofDecember 2008, a total of 33.4 million (31.1 –35.8 million) people living with HIV wereestimated, out of which 31.3 million (29.2 –33.7 million) were adults, 15.7 million (14.2 –17.2 million) were women, 2.1 million (1.2 -2.9 million) were children under 15 years and2.7 million (2.4 – 3.0 million) were newlyinfected with HIV. 2.0 million (1.7 – 2.4 million)AIDS – related deaths were estimated in 2008alone. In India according to the surveillancereport for AIDS cases, 1,400,000 HIV maleadults (above 15 years) and 8,80,000 HIVfemale adults (above 15 years) wereestimated in 2009. 1In Manipur, out of 3,10,527 blood samplesscreen upto March 2009, cumulative numberof HIV positive is 31,972. Among them, 8053are women. 2Several markers like serum beta2-microglobulin, neopterin, immunoglobulin A,G and M, adenosine deaminase (ADA) andCD 4+ lymphocyte count are being studied bymany workers for the monitoring of theprogression of HIV infection. Among thesemarkers, ADA estimation is simpler and easier.JMS * Vol 25 * No. 2 * May, 2011 41

In Manipur, a sub-epidemic focus of HIV/AIDSin the country, no such study had been doneearlier. Hence, the present research wasundertaken with an aim to find out possiblecorrelation between CD 4count and ADA enzymewhich may be valuable in stating the prognosisand management of HIV infected cases.ADA (ADA;EC 3.5.4.4) is an enzyme involvedin the catabolism of purine bases, capable ofcatalyzing the deamination of adenosineforming inosine in the process 3 .Materials And Method:A total of 120 HIV infected cases (above 18years) were selected from the followingsources: i) Medicine Ward, ii) ICTC(Integrated Counseling and Testing Centre)and iii) FACS (Fluorescent Activated CellSorter) count centre, Department ofMicrobiology, RIMS Imphal . The cases wererandomly selected. Necessary informedconsent was taken from the cases forcarrying out the study during June 2004 to May2006. Patients with antiretroviral therapy, HB sAg+ve, HCV Ag+ve and pregnant women wereexcluded from the study. A brief history ofclinical information including patients age, sex,address, religion, occupation, marital status,high risk behavior such as indulges inintravenous drug injection, contact with casualsex workers, unscreened blood transfusionwere recorded in the proforma speciallydesigned for the study. Age and sex matched60 healthy individuals free from HIV and otherdiseases were taken as control group. Ethicalclearance was taken from the institutionalethical committee.Sample collection and processing:About 7 ml of venous blood was drawn fromantecubital vein between 10 am and 10:30 am(non fasting) from each patient as well as fromthe control. Out of collected amount, 5 ml wascollected in plain vial for ADA estimation and2 ml in EDTA (ethylenediaminetetraaceticacid) vial for CD 4estimation. In the presentstudy, all the ADA estimations were performedimmediately after collection of blood.Haemolysed, contaminated or lipaemicsamples were discarded as it may interferewith the measurement of enzyme.ADA was estimated colorimetrically by usingcommercially available reagent kit(manufactured by Micropress Tulip42ORIGINAL ARTICLEDiagnostics (P) Ltd., India) in the Departmentof Biochemistry, RIMS and method describedby Giusti G and Gatani B 4 was used. CD 4estimation was done by FACS count machine(Becton-Dickinson ImmunocytometrySystem, San Jose, CA 95131-1807) in theDepartment of Microbiology, RIMS. The datawas analyzed using SPSS package.Results :A total of 180 cases 120 HIV infected and 60HIV negative were studied.Table – 1:Age and sex distribution of cases and controlsFactors Control (60) Case (120) Total(180)SexMale 42(70.0) 75 (62.5) 117 (65.0)Female 18 (30.0) 45 (37.5) 63 (35.0)Age (in years)Below 30 23 (38.3) 31 (25.8) 54 (30.0)31 – 40 31 (51.7) 65 (54.2) 96 (53.3)41 – 50 6 (10.0) 17 (14.2) 23 (12.8)51 – 60 - 5 (4.1) 5 (2.8)61 and above - 2 (1.7) 2 (1.1)The figure within parenthesis indicates percentageTable-2Route and stage –wise distribution of HIV infected casesFactors Case (120)RouteIDU 64 (53.3)Sexual 47 (39.2)Blood Transfusion 8 (6.7)Assisted reproduction 1 (0.8)StageI 6 (5.0)II 27 (22.5)III 87 (72.5)Table-3Comparison of the factors between control and case groups.Factors Controls (60) Case (120) t-value d.f. P-value RemarksMean ± SDMean ± SDAge(yrs) 33.10±7.774 35.30±8.436 2.158 178 0.033 SWeight(kg) 61.08±9.25 52.95±7.47 6.346 178 0.000 VHSADA U/I 20.49±6.61 42.15±20.19 8.083 178 0.000 VHSCD 4/mm 3 679.95±167.14 223.66±175.76 16.685 178 0.000 VHSCD 8/ mm 3 614.55±339.36 908.44±605.41 3.493 178 0.001 VHSCD 4/CD 81.21±0.39 0.28±0.20 20.778 178 0.000 VHSCD 3/mm 3 1371.36±357.56 1197.04±687.92 1.817 178 0.071 ISHb gm% 14.15±1.20 8.80±1.32 25.985 178 0.000 VHSESRmm1 st hr 6.45V±2.70 76.87±22.61 23.999 178 0.000 VHSIS: Insignificant; S: Significant; VHS: Very highly Significant;JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLETable – 4Correlation Matrix for case group (120)CD 8CD 8CD 4ADA ESR Weight Hb % CD 3CD 4/CD 40.500ADA -0.160 -0.123ESR -0.188 -0.390 0.101Weight -0.019 +0.122 -0.071 -0.057Hb% 0.089 0.157 -0.005 -0.302 -0.172CD 30.779 0.712 -0.120 -0.283 -0.123 0.132CD 4/CD 8-0.066 0.577 -0.083 -0.206 0.034 0.101 0.019Figures within the parenthesis indicate P-valueP< .05: Significant; P< .01: Highly significantP< .001; Very highly significant; P> .05: InsignificantIt is found that the percentage of male outnumbers the female in the both study andcontrol group. The maximum HIV positivecases belong to the age group of 31-40 yearswhich then tapers on both side. The diseaseis more prevalent in the married group(78.3%) then the unmarried group (20.8%).Only one homosexual was found in the study(0.8%).CD 8,CD 4,ADA,ESR weight, Hb %, CD3 andCD 4/CD 8Karl Pearson coefficient ofcorrelation ‘r’ is used for study group. Thecorrelation matrix for study group is displayedon table 4. It is observed that there are twelvepositive and 16 negative correlations betweeneach pair of factors and only 9 associationsbetween each pair are found to be statisticallysignificant.Table-2 shows that IDU was the mostcommon route of infection followed by sexualroute, blood transfusion and lowestpercentage observed is in assistedreproduction.The study group has been classified into threestages I, II, III based on the CDC classification,Atlanta, 1992 5 . In the staging classification,most of the patients belong to the III rd stagenext it is II and I have least number of patients.It is observed from table- 3 that the averagevalue for study group is significantly higherthan that of control group (p=0.033). A verysignificant difference between the two groupswith respect to weight, ADA, CD 4, CD 8, CD 4/CD 8is observed. Among them weight, CD 4/CD 8of control group are found to be higherthan that for case group. On the contrary,ADA, CD 8and ESR for the case group havecertainly higher value than that of thecorresponding control group.In order to study the association between thefactors under considerationA regression analysis is applied for the casegroup and a linear regression equation ofCD 4on ADA for study group is established i.e.CD 4= 268.953-1.0743 ADA as shown in figure1. Through the fitted model so established onecan estimate CD 4for any given value of ADADiscussion:The male preponderance in the study group(62.5%) reflects their proneness to indulge inhigh risk behavior specially IDU habit andJMS * Vol 25 * No. 2 * May, 2011 43

ORIGINAL ARTICLEextramarital sexual habits. In age wiseanalysis, (31-40) years of age group hasmaximum number of HIV infection. This couldbe because of their being in the very activephase of life. HIV disease occurs morefrequently among the married group (78.3%)as compared to the unmarried group (21.7%).This may be explained by the fact that the IDUSwho contacted HIV disease before marriagehave ultimately got seroconverted and are atrisk of transmitting the disease to theirspouse. It evokes an alarming situation and agreat task for the Manipur Aids Control Society.Maximum percentages (53.3%) of HIVpatients have contacted the disease throughinjecting drug use which is rampant in this partof the country having an international boundarywith Myanmar. The next commonest andincreasing route of transmission is throughsexual route (39.2%), mostly due to spreadto their spouse. Spread through bloodtransfusion and assisted reproductioncomprises (6.7%) and (0.8%) respectively.This is justified by the fact that mandatoryscreening of blood for HIV before bloodtransfusion started a little more than a decadein this part of the country.Most of the cases belong to stage III (72.5%)followed by stage II (22.5%) and stage I (5.0%)as the HIV classification in the present studyis based on CDC classification, Atlanta, 1992 5 .A highly significant difference between the twogroups with respect to weight, ADA, CD 4andCD 8,CD 4/CD 8, Hb% and ESR is observed.Among which weight, CD 4,CD 4/CD 8,Hb% andESR in control group are found to be higherthan that for case group. The mean ADA(42.15 ± 20.19), CD 8(908.44 ± 605.41) andESR (76.87 ± 22.61) for study group havecertainly higher value than that of thecorresponding control group, (20.49 ± 6.61)µ/l,(614.55± 339.36)per mm 3 and 6.45± 2.70mm 1 st hr. respectively.Mean ADA levels of 40.3 µ/l in HIV positivecases and 11.9 µ/l in HIV negative controlreported by other workers are closed to thecorresponding levels found in our study 6 .44Significantly reduced mean weight and Hb%in the study group compared to control groupassociated with lower CD 4and CD 4/CD 8counts is in agreement with finding of otherworkers. 7,8It is observed that the mean CD 4countdecreases as the disease stage progressesfrom stage I to III. The same trend is observedfor CD 8,CD 4/CD 8and CD 3too and thedifferences between the various stages aresignificant except between stage I and II forCD 8and CD 4/CD 8The highest mean of ADA is observed in thestage III followed by stage II and stage I withno significant variation among the stages.Results are comparable with those of otherauthors. 9In the present study, negative correlation isobserved between serum ADA and CD 4(r = -0.123, p= 0.179) which is statisticallyinsignificant. Contradictory to this, there wasa highly significant association betweenserum ADA and CD 4lymphocytes, and theactivity of serum ADA increased significantlyin agreement with the grade ofimmunodeficiency in infected patients studiedby others authors 9,10 . By the linear regressionequation established (CD 4= 268.953-1.0743ADA), one can find the value of CD 4from thevalue of serum ADA.Conclusion:The study finds a highly significant increaseof serum ADA in the stage III of HIV infectedgroup followed by stage II. However, there isdecrease in the control group. It also findsnegative correlation between serum ADA andCD 4count but it is statistically insignificant.As serum ADA estimation is a comparativelysimpler and easier test than CD 4count, it couldbe used as a prognostic marker in themanagement of the HIV patients. CD 4countmay be calculated from the value of serumADA by using linear regression equation andit may be more useful in the centre wherethere is no facility of FACS count system.JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEREFERENCE:1. UNAIDS report on Global AIDS Epidemic –2010.2. Manipur State AIDS Control Society (MACS):Epidemiological analysis of HIV/AIDS inManipur. Annual Report 2008-09.3. Fox IH and Kelly WN. Human PRPP synthase.Kinetic mechanism and end product inhibition,J Boil Chem 1978; 247: 2126.4. Giusti, G. and B. Galanti. Colorimetric method.In: Methods of Enzymatic Analysis (BergmeyerH.U., ed). Weinheim Verlag Chemie 1984;315–323.5. Centres of Disease Control. Update on acquiredimmunodeficiency syndrome (AIDS), UnitedStates, MMWR 1992; 31: 507-514.6. Victoria V, Javier E, Victor R, Carlos PO,Figueredo MA and Rafael ES. Significance ofadenosine deaminase measurement in sera ofpatients with HIV – 1 infection. AIDS 1990; 4 :365 – 373.7. Uppal SS, Gupta S and Verma S. Correlationof clinical and laboratory surrogate markers ofimmunodepletion with T subjects (CD 4and CD 8)determined flow cytometrically in HIV infectedpatients. J Commun Dis 2003;35(3):140-53.8. Florence E, Dreezen C, Schrooten W, Van EM,Kestenns L, Franen K, De Roo A andColebunders R. The role of non-viral loadsurrogate markers in HIV –positive patientsmonitoring during antiviral treatment. Int J. STDAIDS 2004;15(18):538-42.9. Casoli C, Lisa A, Magnani G, Stareich R,Fiaccadori F. Bertazzoni V, and Zei G.Progrostic value of adenosine deaminasecompared to other markers for progression toacquired immunodeficiency syndrome amongintravenous drug users. J Med Virol1995;45(2):203-10.10. Martinez-Navio JM, Climent N, Pacheco R,Garcia F, Plana M, Nomdedeu M et al.Immunological dysfunction in HIV-1-infectedindividuals caused by impairment of adenosinedeaminase-induced costimulation of T-cellactivation. Immunology 2009;128(3):393-404.JMS * Vol 25 * No. 2 * May, 2011 45

ORIGINAL ARTICLEA Study on Electrogastrography (EGG)1Punyabati O, 2 Len Awor LuikhamAbstractObjective: To record gastric myoelectricalactivity (EGG) of healthy subjects aspreliminary study. Methods: Fourteen normalsubjects participated in the study. Theelectrogastrogram (EGG) was recorded infasting state for ten minutes followed by tenminutes recording after drinking water.Results: Visual analysis of EGG datademonstrated gastric slow wave frequencyin the range of 2.5 – 3.1 cycles per min (mean= 2.98) in fasting state. Eighty five percent ofnormal subjects showed decrease in slowwave frequency to 2.2 – 3.0 cycles per min(mean = 2.65) after drinking water. However,post-water amplitude was increased in all thesubjects when compared to pre-wateramplitude. Conclusion: It appears that gastricelectrical activity can be successfullymeasured noninvasively using electrodesplaced on abdomen.Key words: Electrogastrogram, gastricelectrical activity.IntroductionElectrogastrography (EGG) is usually referredto as the noninvasive technique of recording1. Department of Physiology, Regional Institute ofMedical Sciences, Imphal,2. Health Services, Govt. of Manipur.Corresponding author:Dr. O. Punyabati, Associate Professor, Department ofPhysiology, RIMS, Imphal, Lamphelpat – 795004.Manipur State, India.Email: worluikham@yahoo.com46gastric myoelectrical activity by placingelectrodes on abdomen. The gastricmyoelectrical activity consist of slow wave (orelectric control activity or basic electricalactivity) and the spike potential (or plateaupotential, electrical response activity). Slowwave is omnipresent, highly regular andrecurring. Its frequency in humans is 3 cyclesper min (cpm) in stomach, 11 and 12 cpm induodenum and frequencies decline along theintestine to 3 cpm in distal ileum. The plateaupotential is superimposed on the slow waveand is associated with the contraction. In1968, Nelson and Kohatsu 1 compared theEGG with the simultaneous internal recordingfrom the implanted serosal electrodes andfound that the rhythmic activity recorded in theEGG was not peristalsis but it perfectlycorrelated with gastric slow waves obtainedfrom the serosal electrodes. The study ofPezzolla et al 2 demonstrated that the spectralpower peaks at frequencies of 3cpm areentirely related to the stomach as theydisappear after gastrectomy and the powerpeaks between 3.5 and 7.5 cpm are relatedto the colon because they are present aftergastrectomy but not after colectomy and alsothe power peaks between 7.5 and 11 cpm arerelated to small intestine because they arepresent after gastrectomy or colectomy.In recent years, there has been a noticeablegrowth of research interest in EGG becauseof its noninvasiveness and its diagnosticpotential. Gastroenterologists have beeninvestigating its correlation with gastric motilityand the possibility of using it as diagnostic toolJMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEin the diagnosis of gastric motility disorders,such as diabetes gastro paresis 3 , irritablebowel syndrome 4 , functional dyspepsia 5 ,chronic intestinal pseudo-obstruction 6 .The primary goal of the present study is todetermine the feasibility of recording gastricmyoelectrical activity in human noninvasivelyby EGG technique as a preliminary study.Material and methodsSubjectsFourteen healthy subjects (11 male and 3female; aged 16 – 64 yrs; mean age 30.28yrs) participated in the study. The subjectswere asymptomatic volunteers with no pasthistory of gastrointestinal/psychologicaldisorders. None of the subjects were takingmedications that may affect gastrointestinalmotility.ElectrogastrographyThree Ag/Agcl adhesive electrodes (Red Dot,3M Medical devices, St. Paul, MN, USA) wereattached to the abdominal skin surface. Priorto attachment of electrodes, the abdominalsurface where electrodes are to be positionswere saved and cleaned with skin-prep jelly(Omniprep; Weaver, Aston CO) to reduce theimpedance between electrodes and skinsurface to bellow 10 K&!. From thefundamental study on electrode position,which could produce constant, reliable andhigh amplitude EGG readout, the approximateposition of the electrodes in the presentcondition was as follows- two activeelectrodes were placed along the antral axisof stomach. First electrode was placed 3 cmright to midway of a line connecting xiphoidand umbilicus and the second electrode wasplaced 5 cm left and 3cm upwards from themidpoint. Reference electrode was placed onthe right lower quadrant of abdomen. A bandfilter allowing high cut off frequency at 0.2 Hz(12 cpm) and low cut off frequency at 0.02 Hz(1.2 cpm) having time constant of 6 sec. wereused to eliminate the interference of ECG andrespiratory signal and also baseline drift 7 .Three channel monopolar recordings wereconducted with a polyrite (Instrument andChemical, Ambala, Haryana).Experimental ProtocolThe subjects were asked to abstain fromalcohol and smoking and to fast for at least 2hours prior to the study. During the study, theywere asked not to move or talk during themeasurement to avoid motion artifact.Baseline recording of EGG (pre-water) wasperformed for 10 minutes and subjects wereasked to drink 200 ml of water at roomtemperature and then record EGG post-waterfor 10 minutes 8,9 .Simultaneously, respiration was alsorecorded. All subjects were sitting comfortablyin a reclining chair. The recorded EGG signalswere visually analyzed for frequency perminute (cpm), amplitude (mm), percentagechange in frequency and amplitude afterdrinking water. Normal electrical activity wasdefined as a frequency of between 2-4 cyclesper min. Activity of 0-2 cycles min was termedbradygastria and 4-9 cycles min astachycardia 10 .ResultThe normal subjects demonstrated regulargastric slow wave in the range 2.5-3.1 (mean= 2.98) cycles per min in fasting state and2.2-3.0 (mean = 2.65) cycles per min in postwaterperiod. During the first 10 min afterdrinking water the frequency was lower thanpre-water value in twelve out of fourteensubjects (85.7%). The averaged valuedecreased from pre-water value of about 2.98cycles per min to about 2.65 cycles per min.Increase in amplitude of gastric slow waveright after drinking water was observed in allsubjects. The percentage increment rangesfrom 14.2% to 154.5%. Data of each subjectare depicted in (Table 1). A typical recordingFig. No. 1: ECG Recording of Normal SubjectJMS * Vol 25 * No. 2 * May, 2011 47

ORIGINAL ARTICLETable1. Individual values of pre water and post water EGG inName/Age/Sexof pre-water and post-water EGG is shown in(Fig 1). The gastric slow wave was clearlyvisible in all the tracings.To investigate the sensitivity of EGG recordingto the position of electrode and change in filterband, some EGG data were recorded from apair of electrodes (5cm apart) placed outsidethe epigastric area, 7cm below the markedaxis of distal antrum and high cut off frequencyat 0.1 Hz (6cpm) and low cut off frequency at0.05 Hz (3cpm). Change in filter property aswell as position of electrodes did not causeany alteration in EGG frequency andamplitude.DiscussionPre-waternormal subjects (n=14)Post-waterMean Mean Mean Mean % change % changeEGG EGG EGG EGG in inFrequency Amplitude Frequency Amplitude frequency amplitude(cpm) (mm) (cpm) (mm)PR/30/M 3.1 14 2.7 16 129 14.2IT/33/M 3.0 7.5 2.7 11 10 46.7PD/40/F 3.0 15 2.7 20 10 33.3R/40/M 3.1 11 2.8 28 9.6 154.5DR/30/M 3.1 10 2.8 13 9.6 30IT/33/F 3.0 7 3.0 10 0 42.8AL/16/M 3.0 4 2.6 6 13.3 50LM/17/M 3.0 10 2.5 12 16.6 20MD/24/F 2.5 8 2.5 13 0 62.5SB/29/M 3.0 14 2.6 19 13.3 35.7KH/24/M 3.0 6 2.2 12 26.6 100CH/23/M 3.0 6 2.7 10 100 66.6RK/21/M 3.0 6 2.7 7 100 16.6DH/64/M 3.0 7 2.6 12 13.3 71.4The EGG has previously been shown to bean accurate and reliable method for studyinggastric myoelectrical activity. In this study wehave used the EGG to record myoelectricalactivity of stomach in healthy subjects. Thevalues for fasting and post-water gastricelectrical frequencies corresponds with thevalues reported in the literatures 8,9 . Themechanism and motor correlate of the postwaterfrequency dip are still unknown. Manysets of evidences may support the vagalinvolvement of post-water frequency dip. First,an inhibition of cholinergic activity with atropine48or vagotomy resulted in an increase inpacesetter potential frequency in dogs 11 andhumans 12 . Second, central vagal motor centrestimulation induced by cold stress induces adecrease in EGG frequency 13 . Amplitudeincrease in slow wave after drinking water hasbeen observed by many investigators. Smoutet al 14 showed that in dogs changes in EGGamplitude run parallel with the changes in theintensity of electric response activity and antralcontraction amplitude. In contrast, Brown etal 15 suggested a closure proximity of electrodeto the stomach is responsible for the postwaterincrease in amplitude. More studies areneeded to be done on the effects of water anddifferent types of meals on the frequencyvariation and amplitude of gastric slow wave.Unlike other electrophysiological signals suchas electrocardiogram (ECG) the electricalactivity in the stomach is weak. Thisnecessitates disturbance by ECG, respirationand motion artifacts. Although thesedisturbances and artifacts may be filtered outusing proper signal processing technique, itis always a good idea to reduce their effectswhile recording. Therefore, to procure theoriginal signal care has to be taken regardingthe preparation of skin surface whereelectrodes have to be placed, optimalelectrode location and selection of properband pass filter. In this study, we have takencare of eliminating unnecessary noises whichmay interfere EGG recording. Since thepresent study used Ag/Agcl electrodes, itseems unlikely that the potential recorded isthat of electrode origin.According to Familoni et al 16 normal gastricelectrical activity can be recognized by visualanalysis 67% of the time and with computeranalysis 95% of the time. Since the presentstudy is a preliminary study, we analyzed theEGG visually. Future endeavor is directedtowards adaptive spectral analysis whichyields higher frequency resolution, moreprecise information about frequency variationand power of dominant frequency.ConclusionThe gastric myoelectrical activity can berecorded noninvasively using surfaceJMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEelectrodes attached to antral axis of stomach.Although there is still vigorous debate relatingto the validation, physiological relevance andreproducibility of EGG, an increasing body ofliterature is accumulating, that places thistechnique in a rational clinical role.References1. Nelson TS and Kohatsu S. Clinicalelectrogastrography and its relationship togastric surgery. Am J Surgery 1968; 116: 215– 22.2. Pezzolla F, Riezzo G, Maselli MA, et al.Electrical activity recorded from abdominalsurface after gastrectomy or colectomy inhumans. Gastroenterol 1989; 97: 313 – 20.3. Abell TL, Camilleri M, Hench VS, et al. Gastricelectromechanical function and gastricemptying in diabetic gastroparesis. Eur JGastroenterol Hepatol 1991; 3: 163 – 67.4. Mazur M, Furgala A, Jablonski K, et al.Dysfunction of the autonomic nervous systemactivity is responsible for gastric myoelectricdisturbances in irritable bowel syndromepatients. J Phisiol and pharmacol 2007; 58 (3):131 – 39.5. Pfaffenbach B, Adamek RJ, Bartholomaus C,et al. Gastric dysrhythmias and delayed gastricemptying in patients with functional dyspepsia.Dig Dis Sci 1997; 42(10): 2094 – 99.6. Debinski HS, Ahmed S, Milla PJ, et al.Electrogastrography in chronic intestinalpseudo-obstruction. Dig Dis Sci 1996; 41(7):1292 – 97.7. Chen J and McCallum RW.Electrogastrography: measurement, analysisand prospective applications. Med Biol EngComput 1996; 29: 339 – 50.8. Watanabe M, ShimadaY, Sakai S, et al. Effectsof water ingestion on gastric electrical activityand heart-rate variability in healthy humansubjects. J Auton Nerv Syst 1996; 58(12): 44 –50.9. Chen J and McCallum RW. Response of electricactivity in human stomach to water and a solidmeal. Med Biol Eng Comput 1991; 29: 351 –57.10. Pfaffenbach B, Adamek RJ, Kuhn K, et al.Electrogastrography in healthy subjects.Evaluation of normal values influences of ageand gender. Dig Dis Sci 1995; 40: 1445 – 50.11. Sarna SK and Daniel EE. Threshold curves andrefractoriness properties of gastric relaxationoscillators. Am J Physiol 1974; 226: 749 – 55.12. Stoddard CJ, Smallwood RH, and Duthie HL.Electrical arrhythmias in the human stomach.Gut 1981; 22: 705 – 12.13. Fone DR, Horowitz M, Maddox A. et al.Gastrointestinal motility during the delayedgastric emptying induced by cold stress.Gastroenterol 1990; 98: 1155 – 61.14. Smout AJPM, Vander Schee EJ, and GrashuisJL. What is measured in electrogastrography?Dig Dis Sci 1980; 25: 179 – 187.15. Brown BH, Smallwood RH, Duthie HL, et al.Intestinal smooth muscle electrical potentialsfrom surface electrodes. Med Biol Eng Comput1975; 13: 97 – 103.16. Familoni BO, Bowes KL, Kingma YJ, et al. Cantranscutaneous recordings detect gastricelectrical abnormalities? Gut 1991; 32: 141- 46.JMS * Vol 25 * No. 2 * May, 2011 49

ORIGINAL ARTICLEResponse Pattern Of Wisc-iii Uk Among The Students Of A Private AndA Government School In Manipur.1Mihir Kumar Thounaojam, 2 M.Akshay Kumar Singh, 3 N.Heramani Singh.Corresponding author:-Abstract:-Objective: The present study is an attemptto examine the intelligence quotients (IQs) ofstudents studying in a private and governmentschools located at Imphal, Manipur. Methods:The schools after identification werecontacted and explained the nature of workand outcome. It was also agreed to keepconfidential of the schools and theparticipants. The sample comprised of sixty(60) students of age group of 12-15 years,studying in class VIII, IX, & X. Socio-economiccondition (SEC) of parents were correlatedwith the findings of IQs. Wechsler IntelligenceScale for Children (WISC-III UK ) was selectedfor testing the IQs. Results: The findings showhigher IQ of private school students comparedto IQ of government school students but oflow statistical significance. SEC of the parentsdo not have any impact on IQs of governmentschool students whereas SEC of privateschool parents have positive and significanteffect on Verbal Intelligence Quotient ( VIQ)and Full Scale Intelligence Quotient (FSIQ).Conclusion : I Q assessment in school goingchildren helps effective teaching and guidancein learning capabilities.According to WISC-IIIScale an I Q Score below 70 confirms mentalretardation.1. Assistant Professor, Deptt. of ClinicalPsychology, 2. Professor & Head, Deptt. ofClinical Psychology, 3. Professor & Head, Deptt.of Psychiatry, RIMS, Imphal.Mihir Kumar Thounaojam, Department of ClinicalPsychology, RIMS, ImphalKey words: Intelligence Quotient, socioeconomiccondition, Wechsler IntelligenceScale for Children, verbal and full scaleintelligence quotient.IntroductionThe theoretical and practical approaches inintelligence and intelligence testing emergedsince the day of Binet A and Simon T, 1905.Intelligence has been listed as the ability tounderstand reason and perceive quicknessin learning, mental alertness, ability to grasprelationship. It has been believed that successin life depend on the level of intelligence orIntelligence Quotient (I.Q). Intellectualcredential refers to doing well in school holdingprofessional degree and obtaining high scoresin an I.Q test. Differences in I.Q among theindividuals are obvious because of thehereditary differences and genetic materialand influences of environmental factors.Human intelligence is clearly the result of thecomplex interplay between the genetic factorsand wide range of environmental condition(Robert A Baron, 2005).The study of the application of intelligence inclinical and education institution is welldocumented. The works of Gabrielli WF Jrand Mednick SA (1983) in children ofAlcoholic; Agarwal DK et al (1989), Walker SPet al (2000) on the influence of malnutrition;study of Lucas A et al (1992), Mallay MH et al(1998) of children consuming mother’s milk;Campos Al et al (1996) study on schoolinglevel and socio-economic condition; Mccarton CM et al (1997) on low birth weight;50JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEAnna Oomen et al (1997) study on hyperkineticand conduct disorder children; Mayes SD etal (2004) study with autism, attention deficithyper activity disorder and learning disabilityand brain Injury; may be mentioned as richcontribution in the study of intelligence.The present educational system gives morestress on intelligence (I.Q). Intelligence testinghas wide clinical and educational implicationled to an upsurge of research in these areas.The country has two categories of Schooling.Besides the government run schools,privatization of schooling following the syllabusand curriculum of board of central or stateboard is permitted by the government. Privateschools are more concerned to admit childrenof higher intelligence, whereas governmentschool have less botheration . As a matter ofpolicy of rights of children education studentsare admitted without proper assessment ofI.Q status. Government schools open free andcompulsory education to children of any socioeconomic status.. Private schools collecthigher rate of fees from students and thuseconomically sound parents are in a positionto admit their children in private schools. Mostof the private schools provide learning aidsfor better motivation. Thus the students fromprivate schools are more motivated than thegovernment school students affectingexamination results. Intelligence is partlyinfluenced by environmental factors and tosome extent by socio economic conditions ofparents.Methods:The samples comprises of 60 (sixty) studentsin the age range between 12-15 years fromprivate and government schools. Subjectswith history of neurological deficit and headinjury were excluded from the study. The twoschools located at Imphal, Manipur - oneprivate and another government was identifiedfor the study. The school authorities wereapproached and explained about the detailsof the study.The consent of the schools andparents were taken before administering thetest. In addition semi-structured proforma wasused to collect demographic information ofthe students. For the study a stratified randomsample of thirty ( 30 ) students each was takenfrom the private and government schools.Each sample consisted of ten ( 10 ) studentsfrom classes VII , IX and X. Wechsler Scalefor Children ( WISC-III UK ) was used forassessment of intelligence by examining thePerformance and Verbal I Q to determine FullScale I Q.Wechsler Intelligence Scale for Children(WISC-III) was used. The scale is one of themost widely used tests world wide forintelligence testing of Children (Anuja S et al,2007). Wechsler Intelligence Scale forChildren (WISC-III UK ) was used (1949) lookingat the administrative time correlating withstudent’s age, gender and full scale intelligentquotient (FSIQ) (Ryan JJ et al, 2007). WISC-III UK measures categorically Verbal IntelligentQuotient (VIQ) and Performance IntelligentQuotient (PIQ) to determine Full ScaleIntelligent Quotient (FSIQ).Statistical analysisThe data was processed through SPSSVersion 13 and various statistical methods likemean, standard deviation etc. werecalculated and “ t” test. “R-squared” wereapplied wherever suitable and necessary.Interpretations were made accordingly.ResultsWechsler Intelligence Scale for Children(WISC III UK ) was administered on the groupsof students of a private school and agovernment school located at Imphal. Furtheran attempt was made to correlate the IQs ofthe students in private and governmentschools with socio-economic conditions(SEC) of the families as measured by themonthly income of parents. The occupationof the parents was divided into business ( 0 )and government / public sector service (1) .Table 1 :-Qualitative Description of WISC-III I. Q . Scoresof government school studentsIQ Verbal IQ Performance Full Scale Remarks(VIQ) IQ( PIQ ) IQ( FSIQ )130 and above - - - -120 – 129 - - - -110 – 119 - - - -90 – 109 30 29 30 Average80 - 89 - 1 - Low average70 - 79 - - - -69 and below - - - -Table 1 shows that government school students have averageand low average I Q level.JMS * Vol 25 * No. 2 * May, 2011 51

ORIGINAL ARTICLETable 2 :-Qualitative Description of WISC-III I. Q.Scores of private school studentsIQ Verbal IQ Performance Full Scale Remarks(VIQ) IQ( PIQ ) IQ( FSIQ )130 and above - 13 - Exceptionallyhigh120 – 129 - 6 10 High110 – 119 4 9 12 High average90 – 109 26 2 8 Average80 - 89 - - - -70 - 79 - - - -69 and below - - - -Table 2 shows that private school students have average, high averageand exceptionally high I Q levels.Table 3 :- Estimation of 95% confidence interval for thepopulation mean of the measures shows sample mean, samplestandard deviation and 95% confidence intervals of FSIQ,VIQand PIQ of private ( P) and government (G ) schools.Variable Sample Mean Sample Standard 95% confidenceDeviation intervalFSIQP 114.46 7.735 114 ± 2.89VIQP 105.03 5.423 105.03 ± 2.045PIQP 122.60 10.522 122.60 ± 1.92FSIQG 97.33 3.273 97.33 ± 2.045VIQG 100.20 3.155 100.20 ± 0.576PIQG 94.46 3.821 94.46 ± 0.697Table 4 : - 95% confidence interval for the populationmeans of IQs categorized by the occupation of parents.Variable Parent’s Sample Standard 95% of confioccupationalMean error dence level ofStatuspopulation meanPIQP a) Business 121.2 3.651 121.2 + 8.25b) Govt, service 123 2.284 123 + 4.78VIQP a) Business 103 .00 0.616 103 + 3.05b) Govt, service 106.05 1.265 106,05 + 3.37FSIQP a) Business 112.60 2.432 112.60 + 5.50b) Govt, service 115.40 1.740 115.40 + 3.641PIQG a) Business 95.30 0.879 95.30 + 1.839b) Govt, service 92.80 1.009 92.80 + 2.28VIQG a) Business 100.30 0.616 100.30 + 1.28b) Govt, service 100.00 1.265 100.00 + 2.86FSIQG a) Business 97.75 0.648 97.75 + 1.356b) Govt, service 96.50 1.249 96.50 + 2.825The finding shows that government schoolstudents have average scores in all the scalesi.e., VIQ, PIQ and FSIQ; except one who haslow average score (Table No.1). On the otherhand private school students have averagescore in VIQ but a good number has highaverage and high scores in PIQ and FSIQ(Table No.2). Thirteen students of privateschool show scores which are exceptionallyhigh in PIQ.52Table 5 : - The impact of socio economic conditions asmeasured by parents monthly income on various measuresof IQ in private and government Schools.Dependent variableIndependent SECP SECGvariableFSIQPPIQPVIQPFSIQGPIQGVIQGOverall data show that the levels of IQmeasured in 3 ways differ betweengovernment and private schools. In generalthe IQs of students in private school farexceed the IQs of students in the governmentschool. Further study as to the cause of thisshows that both the occupation of theparents in terms of their being in thegovernment service or otherwise and theirlevel of income are not important in explainingthe level of IQ.. The only exception is that ofregression of SECP on VIQP and FSIQshowing parents income is important forVerbal IQ and full scale IQ in private school.DiscussionPositive and significantInsignificantPositive and significantInsignificantInsignificantInsignificanThe results of the present study reveals thatVerbal IQ (VIQ ),Performance IQ ( PIQ )and Full Scale IQ (FSIQ ) of private schoolstudents ranges from 95 to 117, 99 to 137and 98 to 126 respectively whereas VIQ ,PIQand FSIQ of government school studentsranges from 93 to 105, 88 to 105 and 90 to104 respectively. The correlation ofsocioeconomic impact based on income ofparents in IQs of the students show littledifference. The only exception is thatregression of Socioeconomic condition ofparents of private school (SECP) on VIQP andFSIQP i.e., parent’s income is important forboth VIQ and FSIQ in private school.The Verbal I.Q, Performance I.Q and FullScale I.Q indicated in WISC-III UK manualshows that overall IQ s of private schoolstudents is better than that of governmentschool students. The students of privateschool have better social and environmentalexposure leading to higher scoring of themodel but it will be too early to arrive at anauthentic conclusion .A study involving anumber of parameters and a large number ofpopulations will enable to bring to light as toJMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEwhy the students vary in intelligence. The IQmeasuring tools used in WISC-III Scaleapplicable in western society may be givinglower score when applied in Indian contextand particularly in Manipur.The impact of socioeconomic condition (SEC)on IQ of government and private schoolstudents also does not show any significanteffect but SEC of the parents of private schoolhave significant effect on VIQ and FSIQ. Thetool (WISC – III UK ) is required to redefine tosuit the local condition.Conclusion:-performance and clinical set up. When IQScore is low (below 70), according to WISC-III Scale, mental retardation is confirmed.Another aspect of IQ evaluation is for selectionof career in life. IQ assessment in schoolgoing children helps effective teaching andguidance in learning capabilities.It may be mentioned that the recentintroduction of Psychological Aptitude Test forclass X to be conducted by Central Board ofSecondary Education ( CBSE ) on the linesof similar examinations held in other parts ofthe world may be related to IQ testing.Study of IQ assessment is considered to bevery important in term of academicReferences1. Agarwal D K, Upadhyay S K and Agarwal K N:Influence of malnutrition on cognitivedevelopment assessed by Piagetian tasks,Acta paediatric Scand.; 78 (1): 115-122, 1989.2. Anna Oommen, Malavika Kapur and V.Shanmugan: Do WISC profile discriminatebetween hyperkinetic and conduct Disorderchildren, Indian Journal of Clinical Psychology;24: 162-155, 1997.3. Anuja S, Panicker, Uma Harisone, D.K.Subbakrishna (2007): Establishment ofReliability and Validity of WISC-III in IndianPrimary school children, Indian Journal ofClinical Psychology,2007,vol 34,No 2,132-137.4. Binet A. and Simon T.: New methods for thediagnosis of the intellectual level of sub normal.The development of intelligence in children,Baltimore; William & Wilkins original workpublished; Eleventh edition, 191-244, 1905. Campos A L, Sigulem D M, Moraes D E,Escrivao A M and Fisberg (1996 ) Intelligentquotient of obese children and adolescents bythe Wechsler Scale, Rev Saude Publica; 30 (1 ) 85-906. Daniel L M, Lim S B and Clarke L: Eight yearoutcome of very low birth-weight infants bornin K. K. Hospital, Annual Academic Medicine,Singapore; 32 ( 3 ): 354-361,2003.7. Emond A M, Lira P I, Lima M C, Grantham-McGregor S M. and Ashwarth A : Developmentand behaviour of low birth-weight term infantsat 8 years in north east Brazil, Acta Paediatric,95 ( 10 ): 1249-1257,2006.8. Gabrielli W F. Jr. and Mednick S A: Intellectualperformance in children of alcoholics, J. Nerv.Mental Disorder, 171 (7): 444-447, 1983.9. Lucas A, Morley R, Cole T J, Lister G andLeeson-Payne C: (1992) Breast milk andsubsequent intelligence quotient in childrenborn preterm, Lancet; 339 (8788): 261-264.10. Malloy M H and Berendes H: Does breastfeedinginfluence intelligence quotient at 9 and10 years of age? Early Human Development,50 (2): 209-217, 1998.11. Mayes S D and Calhoun S L: Similarities anddifferences in WISC-III profiles: support forsubtest analysis in clinical referrals, ClinicalNeuropsychology, 18 ( 4): 559-572, 2004.yc12. Mc Carton C M, Brooks-Gunn J, Wallace I F,Bauer C R, Bennett F C, Bernbaum J C,Broyles R S, Casey P H, Mo Cormick M C,Scott D T, Tyson J, Tonascia J and Meinert CL: Results at age 8 years of early interventionfor low-birth-weight premature infants. The infanthealth and Development program, JAMA, 277(2): 126-132, 1997.13. Robert A Boron: Intelligence, Psychology:Pearson Education ( Singapore ) Pte, Ltd, IndianBranch, 482 F.I.E. Patparganj Delhi-110092,India, Fifth Edition, 414-415 & 428-431,2005.14. Ryann J J, Glass L A and Brocon C N:Administration time estimates for WISC-IVsubtests, composites and short forms, ClinicalPsychology, 63 (4): 309-318, 2007.15. Walker S P, Grantham-McGregor S M, PowellC A and Chang S M : Effect of growth restrictionin early childhood, IQ and cognition at age 11and 12 years and the benefits of nutritionalsupplementation and psychological stimulation,Journal of Paediatric,187 ( 1 ): 36-41,2000.16. Internet source- Yahoo News: CBSE tointroduce psychological aptitude test. Sun,Sep 26 03 : 56PM.JMS * Vol 25 * No. 2 * May, 2011 53

ORIGINAL ARTICLEComparison of Intubating Conditions of Succinylcholine, Vecuronium andRocuronium in patients undergoing elective surgery- A study.1N. Ratan Singh, 2 Tingonglei Thangluai, 3 Laithangbam PKS, 4 T. Hemjit Singh, 3 L. Chaoba Singh,5R K Shanti DeviAbstract:Background: Succinylcholine is still used forrapid endotracheal intubation, especially inemergency situations with difficult airway.However, it has many undesirable side effectswhich make the increasing use of nondepolarizing muscle relaxants. Methods:Following institutional ethical committeeapproval, 90 adult patients (ASA I & II, aged20-60 years of age of either sex ) undergoingmajor elective surgery at RIMS hospital ,Imphal from August 2007 to August 2009were evaluated for intubating conditions usingCooper et al 1992 scoring system aftercomputer generated randomization into threegroups(n= 30) to receive eitherSuccinylcholine 1.5 mg/ kg IV(Group A),rocuronium bromide 0.6 mg/ kg(Group B) orvecuronium bromide 0.08 mg/ kg (Group C).Results: 25 patients (83.33%) in Group A, 23patients (76.67%) in Group B and 17 patients(56.66%) in Group C had excellent intubatingconditions. Good intubating conditions werealso noted in 5 patients (16.67%), 6 patients(20%) and 11 patients (36.67%) in Groups A,B and C respectively. These changes werenot statistically significant(x 2 =6.42; p= 0.17).Conclusion: Rocuronium is a suitable1. Asst Prof., 2. PGT, 3. Associate Prof., 4. Registrar, 5.Professor, Department of Anesthesiology, RIMS,ImphalCorresponding authorDr. Laithangbam Pradipkumar Singh, Associate.Professor, Dept. of Anesthesiology, Regional Instituteof Medical Sciences, Imphal, Manipur54alternative to Succinylcholine for rapidendotracheal intubation.Key words: Rapid endotracheal intubation,intubating conditions.Introduction:Rapid and safe endotracheal intubation is anintegral part of administration of anesthesiaduring many surgical procedures.Succinylcholine, a depolarizing musclerelaxant, with its rapid onset and short durationof action, is still used to facilitate endotrachealintubation. Unfortunately, it may producehyperkalemia 1 , increased intraocularpressure 2 , increased intragastric pressure 3 ,increased intracranial pressure 4 , and myalgia 5and masseter spasm 6 . Rocuronium is a newnon depolarizing neuromuscular blockingagent, and has been demonstrated to havethe fastest onset among the non depolarizingneuromuscular blocking agents 7, 8 ; its onsettime approaches that of Succinylcholine withvirtually no clinically significant side effects andhyperkalemia 9 . The ED 95 is 0.3 mg/kg duringanesthetic with opioids and is reduced in thepresence of inhalational agents 10 . However,despite its dose dependant onset time 10 ,increasing the dose may not always bejustified as it may profoundly increase theduration of action 11 . With the introduction ofvecuronium in the early eighties, many of thepostulated ideal properties of theneuromuscular blocking agents were realized.Vecuronium is a mono quaternary aminosteroid non depolarizing drug with an ED 95of 50µg/ kg that has an onset time of 3-5JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEminutes and duration of neuromuscularblockade lasting 20-35 minutes. 12Using computer generated randomization,patients were divided into three groups: GroupA (n= 30) to receive Succinylcholine 1.5 mg/kg, Group B (n=30) to receive rocuronium 0.6mg/ kg and Group C (n= 30) to receivevecuronium 0.08 mg/ kg intravenously tofacilitate endotracheal intubation.The baseline hemodynamic parameters wererecorded and the monitors for heartrate(HR),electrocardiogram(ECG), noninvasive blood pressure(NIBP), saturation ofperipheral oxygen saturation(Spo2) andneuromuscular monitoring(TOF watch,Organon – Infar, Netherlands) were put in situ.After pre oxygenation with 100% oxygen for 3minutes, anesthesia was induced with inj.Propofol 2-2.5 mg/kg IV till the loss of eyelashreflex. Once the control response had beennoted, the neuromuscular blocking agent wasinjected and the endotracheal intubation wascarried out by the same person with aminimum 3-4 years experience in the field.The onset time is taken as the time taken fromthe end of injection of the neuromuscularblocking agent to the maximum depressionof twitch height following simple twitchstimulation (Supramaximal stimulation at 40mA (milli-ampere), 0.2 ms (millisecond)duration and frequency of 0.1 Hz). Intubatingconditions were assessed using a score 13suggested by Cooper et al (CJA 1992).The vital parameters of the patient such aspulse rate, mean arterial pressure, Spo2 werenoted at the time of induction of anesthesia(recorded as zero minute), then every minutefor 5 minutes, and then at 10min, 15 min, 20min, 25 min and 30 min after intubation. Theclinical duration of action of theneuromuscular blocker is taken as the timefrom injection till the reappearance of 25% ofthe twitch height. At the end of the surgicalprocedures, residual neuromuscular blockadewas reversed with inj neostigmine0.05 mg/kgand inj glycopyrrolate 0.008 mg/kg IV.Results:All the three groups had comparabledemographic profile (Table I) with nostatistically significant differences among thethree groups.Table I. Demographic profile.Patients Group A Group B Group C Statistical Pparameters Succinyl- Rocu- Vecu- test value valuecholine ronium roniumn= 30 n= 30 n= 30Age in years 36.47 43.13 38.50 F=2.56 0.09(mean±SD) ±10.49 ±12.96 ±10.49Weight in Kg 53.40 53.47 52.83 F= 0.04 0.96(mean±SD) ±10.24 ±9.70 ±8.99Sex 8:22 9:21 9:21 2 = 0.11 0.5(male:female)ASA (I: II) 28:2 27:3 26:4 2 = 0.35 0.5Succinylcholine had faster onset withmean± SD value of 61.80±7.79 sec. followedby that of rocuronium (94.13±22.50 sec) andthen vecuronium (154.8±26.36 sec). Thesedifferences are statistically significant (F=156.65; p>0.001).This findings are depictedin fig. 1.61.8±7.7994.1±22.50154.8±26.36Fig 1. Showing the bar diagram of the onset time.The mean±SD duration of action is shown inFig 2. Rocuronium has the longest durationof action (29.83±3.56 min) followed byvecuronium (25.77±2.33 min) and thenSuccinylcholine (5.24±0.5 min). Again thesedifferences are highly significant (F=848.11;p=0.001).5.24±0.529.83±3.5625.77±3.56Fig 2. Bar diagram showing the duration of action.(Succinylcholine, Rocuronium & Vecuronium)JMS * Vol 25 * No. 2 * May, 2011 55

ORIGINAL ARTICLEHowever, we could not find statisticallysignificant differences in the intubatingconditions although Succinylcholine group hadmaximum number of patients with excellentintubating conditions(score8-9) andvecuronium group had maximum number ofpatients with good (score 6-7) intubatingconditions(Table 2).Table 2 : Showing the distribution of intubating conditions inthe three groups.Intubating Group A Group B Group C Statical Pconditions test valuelevelPoor 0 0 0(0-2 score)Fair 0 1(3.33%) 2(6.67%) x 2 =6.42 0.17(3-5 score)Good 5(16.67%) 6(20.00%) 11(36.67%)(6-7 score)Excellent 25(83.33%) 23(76.67%) 17(56.66%)(8-9 score)Total 30 30 30Tachycardia associated with laryngoscopyand intubation remained significantly higher(from baseline) in both Succinylcholine androcuronium till the 30 th minute of observations.However, changes were minimal in thevecuronium group although it causedsignificant elevation from the 1 st to the 10 thminute of observation (Fig 3).Discussion.(Fig 3).Changes in the HR over timeEndotracheal intubation, except for the use offace mask or laryngeal mask airway is anintegral part of the administration ofanesthesia. Succinylcholine with its rapidonset and short duration of action is still usedto facilitate endotracheal intubation especiallyfor intubating difficult airway patients inemergency situations. Unfortunately, becauseof some of its serious adverse effects, someof the commonly available non depolarizingmuscle relaxants have been tried to facilitateendotracheal intubation, but on an average,the time lapse before intubation is usually 2-3 minutes, which is not ideal for rapid trachealintubation, especially in emergency situationsbecause of the dangers of gastric aspiration,regurgitation, hypoxia and hypercarbia.Rocuronium and Vecuronium are bothintermediate acting non depolarizing musclerelaxants with ED 95 values of 0.3 mg/kg and0.056 mg/ kg respectively. The dose mostfrequently used to facilitate intubation is 2 xED95 (0.6 mg/ kg for rocuronium). As manystudies 14, 15 have suggested rocuronium 0.9mg/kg and Succinylcholine 1 mg/kg wouldprovide the same onset time for ideal trachealintubation especially for rapid sequenceintubation in emergency surgery withouthaving the side effects of Succinylcholine.Even though the onset of rocuronium can beshortened 16 below 60 seconds by using doseslarger than 0.6 mg/kg, it would be inappropriate in many situations. For, it has beenshown that increasing the dose from 2 to 3times the ED 95 would increase the durationof action from 35 to 55 minutes 17 .We recorded the mean onset time as61.80±7.79 seconds, 94.13±22.30 secondsand 154.80±26.36 seconds forsuccinylcholine, rocuronium and vecuronium.These findings are in agreement with severalinvestigators 18, 19, 20. Again, the mean ±standard deviation (mean±SD) ofSuccinylcholine, rocuronium and vecuroniumwere 5.24±0.57 min, 29.83±3.56 min and25.77±2.33 min respectively. Theseobservations are in accordance with thereported observations 18, 21, 22, 23 .Intubating conditions were assessed usingCooper et al scoring system rated on a 0-3scale for jaw relaxation, the condition of thevocal cords and the response to intubation.No significant differences were observedbetween the quantitative values of eachcomponent of the intubating score (÷2= 6.42;p=0.17). Similar observations were made byprevious investigators 13, 23 . However, it does56JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEnot imply that any of the three drugs canproduce the same effect. Our aim is to choosea drug with rapid onset without undulyprolonging the duration of action with minimumside effects.ConclusionIn conclusion, rocuronium 0.6 mg/ kgproduced comparable intubating condition asSuccinylcholine without producing the sideeffects of the later an unduly prolonging theduration of action.References1. Martyn JA, Richtfeld M. Succinylcholineinduced hyperkalemia in acquired pathologicstates: Etiologic factors and molecularmechanisms. Anesthesiology 2006; 164:158-169.2. Pandey K, Badola RP, Kumar S. Time courseof intraocular hypertension produced bysuxamethonium. Bi. J. Anesth 1972; 44:191-6.3. Miller RD, W ay W L: Inhibition ofsuccinylcholine induced increased intragastricpressure by non-depolarising muscle relaxantsand lidocaine. Anesthesiology , 1971; 34:185-8.4. Minton MD, Grosslight K, Stirt JA, Bedford RF.Increases in intracranial pressure fromsuccinylcholine: prevention by prior nondepolarizing blockade. Anesthesiology, 1986;65:165-9.5. Brodsky JB, Brock-utne JG, Samuels SI:pancuronium pretreatment and postsuccinylcholinemyalgias.Anesthesiology.1979; 51:259-61.6. Leary NP, Ellis FR: Masseteric muscle spasmas a normal response to suxamethonium. Br JAnesth.1990; 64:488-92.7. Magorian T, Flannery KB and Miller RD:Comparison of rocuronium, succinylcholineand vecuronium for rapid sequence inductionof anaesthesia in adult patients,Anaesthesiology; 79(5): 913-8, 1993.8. Agoston S: Onset time and evaluation ofintubating conditions: rocuronium inperspective, Eur J Anaesthesiol Suppl; 11: 31-7, 1995.9. Sakles JC, Laurin EG, Rantapaa AA andPanacek FA: Rocuronium for rapid sequenceintubation of emergency department patients,J Emerg Med; 17(4): 611-6, 1999.10. Vianna PTG, Castiglia YMM, Ganem EM,Takata IH, Braz JRC and Curi PR: Onset timeand intubating conditions of rocuronium andsuccinylcholine, Braz J Anesth InternationalIssue; 9:49-54, 1998.11. Perry JJ, Lee J and Wells G: Are intubatingconditions using rocuronium equivalent tothose using succinylcholine? Acad EmergMed; 9 (8), 2002.12. Miller RD, Rupp SM and Fisher DM: Clinicalpharmacology of vecuronium and atracurium,Anaesthesiology; 61: 444-53, 1984.13. Cooper RA, Mirakhur RK, Elliot and McCarthyG: Estimation of the potency of Org 9426 usingtwo different modes of nerve stimulation, Can JAnaesth; 39:139-42, 1992.14. Huizinga ACT, Van denbrom RH, Wierda JM,Hommes FD and Hennis PJ: Intubatingcondition and onset of neuromuscular blockof rocuronium (Org 9426); a comparison withsuxamethonium, Acta Anaesthesiol Scand;36:463-8, 1992.15. Puhringer FK, Khuenl-Brady KS, Koller J andMitterschiffthaler G: Evaluation of theendotracheal intubating conditions ofrocuronium (Org 9426) and succinylcholinein outpatient surgery, Anesth Analg; 75: 37-40, 1992.16. Wierda JMKH, Dewit APM, Kuizenga K andAgoston S: Clinical observations on theneuromuscular blocking action of Org 9426,a new steroidal non-depolarizing agent, BrJAnaesth; 64: 521-3, 1990.17. Magorian T, Flannery KB and Miller RD:Comparison of rocuronium, succinylcholineand vecuronium for rapid sequence inductionof anaesthesia in adult patients,Anaesthesiology; 79(5): 913-8, 1993.18. Singh A, Bhatia PK and Tulsiani KL:Comparison of onset time, duration of actionJMS * Vol 25 * No. 2 * May, 2011 57

ORIGINAL ARTICLEand intubating conditions achieved withsuxamethonium and rocuronium, Ind J Anaesth;129-33, 2004.19. Cooper RA, Mirakhur RK and Maddineni VR:Neuromuscular effects of rocuronium bromide(Org 9426) during fentanyl and halothaneanaesthesia, Anaesthesia; 48: 103-5, 1993.20. Sehgal A, Sharma RK and Kumar IH:Comparison of intubating conditions and timecourse of action of rocuronium bromide andvecuronium bromide, Ind J Anaesth; 45(4): 255,2001.21. Verma RK, Goordayal R, Jaiswal S and SinhaGK: A Comparative study of the intubatingconditions and cardiovascular effects followingsuccinylcholine and rocuronium in adult electivesurgical patients, The Internet JA n a e s t h e s i o l . 2 0 0 7 ; 1 4 : ( 1 ) . h t t p : / /w w w . i s p u b . c o m / j o u r n a l /the_internet_journal_of_anesthesiology.html.Accessed June 10, 2008.22. Verma RK, Mishra LD, Kumar A and Kumar R:Comparative studies of Train-of-four fade profilesproduced by atracurium and vecuronium. Ind JAnaesth; 48 (6): 472-5, 2001.23. Shukla A, Dubey KP and Sharma MSN:Comparative evaluation of hemodynamiceffects and intubating conditions after theadministration of Org 9426 (rocuronium) andSuccinylcholine, Ind J Anaesth; 48(6): 476-9,2004.58JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEPattern of Psychiatric Admission in a Regional Medical Institute ofNorth-East India: A 3-year Retrospective Study1Nelson L, 2 Sameeta Ng, 3 Lenin RK, 4 Gojendra S, 5 Heramani NAbstractIn-patient care remains an important aspectin the care of mental and behaviouraldisorders. The study of the pattern ofpsychiatric in-patients is therefore pertinentto determine the socio-demographic andclinical factors for mental health planning. It isaimed at determining the pattern of in-patientadmissions in the psychiatric ward of ateaching institute of North-East India over a3year period. It is a retrospective case fileanalysis of all patients admitted between May2007 to April 2010 in the psychiatric ward ofthe Regional Institute of Medical Sciences,Imphal, Manipur, India. One thousand onehundred eighty seven cases were admittedand analyzed, comprising 718 males (60.5%),469 females (39.5%) and the mean age ofthe patients was 32.3 12.4 years. Most of theinpatients (33.4%) were from the 25-35 yearsgroup and majority of the patients came froma rural background (66.9%). Alcoholdependence syndrome accounted for majorityof the cases (300 or 25.3%) and Dissociativedisorder accounted for maximal cases amongthe females (175 or 37.3%).1. Postgraduate student, Department of Psychiatry, 2.Assistant Professor, Clinical Psychology Department,3. Associate Professor, Department of Psychiatry, 4.Registrar, Department of Psychiatry, 5. Professor andHead, Department of Psychiatry, Regional Institute ofMedical Sciences, Imphal.Corresponding author:-Sameeta Ng., Assistant Professor, Department ofClinical Psychology, Regional Institute of MedicalSciences, Imphal.Key words: Admission pattern, psychiatry,socio-demographic, clinical factors, ImphalIntroductionAmong the treatment options for psychiatricpatients, inpatient treatment is a methodemployed particularly in such situations wherethe patient behaves disorganized, presentpsychotic features or the life at home becomedifficult. According to Bobier and Warwick 1psychiatric in-patient care is often indicatedwhen a patient can no longer be managedsafely at home or as an out-patient though itmay be expensive, resource intensive andcause risk to hospital staff. Consequent uponthe psychiatric reforms and the emphasis onnon-institutional methods of treatingpsychiatric disorders, attention has thereforeshifted towards setting up of psychiatric unitsin general hospitals. 2Findings on the diagnosis of admitted patientsin such hospitals however vary. For instancestudies 3, 4 have reported that schizophreniawas the predominant diagnosis of patientsadmitted to mental health wards, with affectivedisorders, adjustment disorders and otheranxiety disorders being admitted to a lesserdegree. Another study by Thomson 5 alsofound depression and anxiety as the mostcommon reason for hospital admission whileschizophrenia and related psychosis rankednext, followed by other diagnoses.Other factors that have been reported to affectthe pattern of admission include gender andages of the patients. For instance, admissionrates were reported to be higher for malesJMS * Vol 25 * No. 2 * May, 2011 59

ORIGINAL ARTICLEthan females. 5, 6 This gender differences inadmission may indicate differences in severityor in presentation to psychiatric services andmay have important implications forpreventative services. 6 Hutchinson et al 6 notedno differences in the age of admitted patients.Thomson et al 5 reported that admission ratespeaked in those aged 25-44 for males and35-44 years for females.Hospital utilization denotes the manner inwhich a certain community makes use of itshospital resources. 7 Psychiatric servicesutilization indices are relatively less known inour country. There are limited numbers ofpsychiatry beds in India in general forpsychiatry patients who require prolonged stayat the hospital. Psychiatry clinics of medicalschools are trying to meet this importantdeficit. Due to the fact that these servicesare within general hospitals, they offer servicein more flexible conditions as compared topsychiatric hospitals.The Regional Institute of Medical SciencesHospital is the only tertiary level health institutelocated in Imphal, Manipur which is a state ofN-E India with an approximate population ofabout 25 lakhs. This institute also caters tothe neighboring states and has a total strengthof over 1074 beds with all major specialties.The Department of Psychiatry is anindependent department which has facilitiesfor providing psychiatric management to bothoutdoor and indoor patients and also deaddictionfacilities.Analysis of the socio-demographic and clinicalcharacteristics of psychiatric in-patients mightcast some light on the nature, magnitude anddistribution of these categories of patientstowards evolving strategic servicedevelopments and planning for this region.Materials and methodsThe study was conducted at the RegionalInstitute of Medical Sciences Hospital, Imphal,Manipur. The Regional Institute of MedicalSciences Hospital has a total strength of over1074 beds with all major specialties. TheDepartment of Psychiatry is an independentdepartment which has facilities for providingpsychiatric management to both outdoor andindoor patients and also de-addiction facilities.The Psychiatric unit of the hospital has 30 inpatientbeds (15 each for both genders).Adequate liaison services exist between thevarious clinical departments of the hospital(Internal Medicine, Surgery, Obstetrics andGynecology, Orthopedics, Neurology, Urology,Plastic Surgery, Radiotherapy, ENT,Dermatology, Radiology and Laboratory etc).The inclusion criteria for this study were:1. Patients should fulfill the diagnostic criteriaof ICD-10. 82. Chart analysis and case record of thepatient should be complete.A review of case notes of all patients admittedto the psychiatric ward of the hospital betweenMay 2007 and April 2010 was carried out andinformation regarding socio-demographiccharacteristics (e.g. age, gender, domicile anddiagnosis) was recorded based on a Proformadesigned by the authors.The cases were reassessed using theInternational Classification of Diseases,10edition (ICD-10) criteria based on the clinicalfeatures documented and clinical diagnosesreassigned where necessary. Data wereanalyzed using the Statistical Package forSocial Sciences, SPSS 13 for Windows.Cross tabulation, frequency statistics and chisquare test were used for relationshipbetween variables and the level of statisticalsignificance was set at 5%.ResultsA total of 1187 patients were admitted duringthe period in review but complete data wereavailable for only 1182 patients. The mean ageSD was 32.2 =12.35 years with a range of69.0 (6-80 years).Table-1. AgeAge in Years Frequency Percent6-24 359 30.225-35 397 33.436-45 245 20.646-80 186 15.7Total 1187 100.060JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEMajority (718 out of 1187) of the in-patients weremales. The mean age of males was 35.1 11.8yrs while the mean age for the females was28.111.9 years. Most (397 out of 1187 or 33.4%)of the in-patients were between the ages of 25-35 years age group followed by the 6-24 years(30.2%) years age group. Majority (794 or 66.9%)of the cases came from a rural background andmost (1041 or 87.7) were Hindus by religion.whereas among the females most (175of 469 or37.3%) had a diagnosis of dissociative disorderfollowed by BPAD (72 or 15.4%).Table-2. SexSex Frequency PercentMale 718 60.5Female 469 39.5Total 1187 100.0Maximum of the patients admitted hadlength of hospital stay to be in the 1-7 daysgroup (455 or 38.3%) followed by 8-14 days(337 or 28.4%). Median length of hospitalstay was 9 days, Mean length of hospitalstay for the total sampleMean length of hospital stay for males andfemales was 12.4 10.7 and 14. 14.2 daysrespectively. (Table-3)Table-3. Duration of hospital stayDuration of Frequency PercentHospital stay0 days 24 2.01-7 days 455 38.38-14 days 337 28.415-30 days 276 23.330 days 95 8.0Total 1187 100.0Fig. 1 shows the different psychiatric diagnoses.Psychiatric diagnosis according to ICD-10 criteriawas found to be maximum in the alcoholdependence syndrome (ADS) (300 or 25.3%)followed by dissociative disorder (201 or 16.9)then by psychosis not otherwise specified (NOS)and bipolar affective disorder (BPAD) (155 or13.1% and 121 or 10.2% respectively). Majorityof the male in-patients had a diagnosis of alcoholdependence syndrome (296 out of 718 or 41.2%)followed by Psychosis NOS and substance usedisorders (SUDS) at 13.4% and 11% respectively,Fig.1 Showing the different diagnoses of admittedpatients.We also compared some of the diagnosis withgender. (Table-4) When psychosis NOS, BPAD,schizophrenia, depression and dissociativedisorder were compared with gender by the2– test, p-value was found to be significant (p=0.000 / p= .001). In the 2 – test comparingdiagnosis with places of domicile designatedas urban and rural. Psychiatric diagnoses ofpsychosis NOS, BPAD, depression, ADS,dissociative disorder, acute stress reactionand schizophrenia was compared withdomicile the p-value was found to be notsignificant (p= 0.161).(Table-5).Table- 4. Comparing the places of residence with diagnosis.Diagnosis Domicile, n (%) p-valueUrbanRuralPsychosis 40 (37.38) 107 ( 62.62) 0.161BPAD 37 (31.62) 80 (68.38)Schizophrenia 31 (44.66) 40 (55.34)Depression 33 (41.77) 46 (58.23)ADS 95 (32.31) 199 (66.69)Dissociative Disorder 68 (33.83) 133 (66.17)Ac. Stress reaction 31 (28. 85) 40 (71.15)Table-5. Comparing sex with diagnosis.Diagnosis Sex, n (%) p-valueMaleFemalePsychosis 96 (61.94) 59 (38.06) p = 0.000 000BPAD 49 (40.50) 72 (59.50)Schizophrenia 47 (65.28) 72 (34.72)Depression 29 (36.7) 50 (63.3)Dissociative Disorder 26 (12.94) 175 (87.06)= 0.001JMS * Vol 25 * No. 2 * May, 2011 61

ORIGINAL ARTICLEDiscussionThe observed finding of male dominance in thisstudy was similar to various studies. Hirsch 9found that men are heavy users of psychiatricservices more often than females. Likewise,the Epidemiological Area Catchment Area (ECA)survey Shapiro et al 10 reported that higherproportion of women made mental health visits,but in seeking help men were more likely to turnto the specialized sector than to the generalistwhile women used both sector.Overall admission rates were higher for malesthan for females with maximum admissionamong males in the 25-35 years age group(35.1%) followed by the 36-45 years age group.Among the females the maximum admissionwas in the 6-24 years age group (46.3%) followedby the 25-35 years age group (30.9%). Thisfinding was similar to a large British study. 5In an Indian study the duration of hospital staywas found to be less than two weeks. 11 In thisstudy for majority of the patients the durationof hospital stay was 1 to 2 weeks and themedian duration of hospital stay was 9 days.This finding is similar to other studies whichreported a mean duration of hospital stay tobe 9-11 days. 12In this study maximum of the patients wereadmitted for alcohol dependence syndromewhich was maximal in the male patients. Nextcame dissociative disorder and this was morein the female patients. Psychosis NOS andBPAD followed the above two psychoses,while the former was more in the males thelatter was found to be more in the females.The high levels of alcohol use disorders amongthe males of this state tally with the findingsof the National Health Survey (NHS). 17 Thepredominance of females in dissociativedisorder is a well known finding in psychiatricepidemiology, a study of outpatients in anIndian study found the prevalence to bebetween 6-11%. 18 Another finding of this studywas that the cases of BPAD in mania wasmore in the younger age group and were mostlikely to be females. Bipolar disorder affectsapproximately 2.3 million American adults orabout 1.2 % of Americans aged 18 and older ina given year-the average age at onset for a firstmanic episode is during the early 20s. 19One interesting finding is that neurotic disorderslike generalized anxiety disorders, phobicdisorders, personality disorders and obsessivecompulsive disorders were much less commoncompared to other disorders like PsychosisNOS, Schizophrenia and BPAD . This is in noway an indication of low prevalence of thesedisorders. This appears to be due to the factthat these disorders are treated mostly in theoutpatient settings.There were some limitations in the study,interpretation of diagnosis patterns must betreated with caution as the cases werediagnosed by different psychiatrists over a 3 yearperiod. Admission rates do not directly representclinical need or morbidity differences, only theuse of existing services. Some of the case fileswere found to have incomplete data abouteducational qualification, marital status and socioeconomic class etc. and hence could not becompared.ConclusionMost of the patients were males, young and froma rural background. Commonest psychiatricdiagnosis for which admission was done in RIMSwas alcohol dependence syndrome. Theabundance of alcohol related disorders inspiteof prohibition being in place in the state may haveimportant implications for care and planning inthe community.REFERENCES:1. Bobier C and Warwick M. Factors accociatedwith readmissions to adolescent psychiatriccare. Aust NZ J Psychiatr 2005; 3:600-6.622. Fisher WH, Dorwat RA, Schlesinger M et al.The role of general hospitals in the privatizationof inpatient treatment for serious mentalillness. Hospital Commun Psychiatr 1992; 43:1114-9.JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLE3. Nowels A. A review of the medical records ofadolescents psychotic inpatients in a generalhospital. Hospital Commun Psychiatr 1997;28(12): 903-6.4. Abu Madini, Rahim MS and Rahim SI.Psychiatric admission in a general hospital:Patients profile and patterns of serviceutilization over a decade. Saudi Med J 2002;23(1):44-50.5. Thomson A, Shaw M, Harrison G, Verne J, HoD and Gunnel D. Patterns of hospitaladmission for adult psychiatric illness inEngland: Analysis of hospital episodestatistics data. Br J Psychiatr 2004; 185:334-341.6. Hutchinson G, Ramcharan C, and Ghany K.Gender and ethnicity in first admission to apsychiatric unit in Trinidad. West Indian MedJ 2003; 52(4):300-3.7. Sakharhar BM, editor. Hospital UtilizationStatistics. Principles of Hospital Administrationand Planning. 1 st ed. New Delhi: JaypeeBrothers; 1998. pp. 240-5.8. The ICD -10 Classification of mental andBehavioural Disorders: Clinical descriptionsand diagnostic guidelines. Geneva: WorldHealth Organization; 1992.9. Hirsch SR. Psychiatric beds andresources:Factors influencing bed use andservice planning. Report of a working party ofthe section for social and communityPsychiatry Of the Royal College ofPsychiatrists. London; 1988: Gaskell.10. Shapiro S, Skinner EA, Kessler LG et al.Utilization of health and mental health services.Three epidemiologic catchment area sites.Arch Gen Psychiatr 1984; 41:971-8.11. Khanna BC, Wig NN, Varma VK. Generalhospital psychiatric clinic: An epidemiologicalstudy. Indian J Psychiatry.1974; 16:211-20.12. Yyldz A, Onur E, Turgut K, Tunca Z. Factorsaffecting duration of hospital stay or thepsychiatric patients at an urban universityhospital. Bull Clin Psych 2003;13: 122-8.13. Wengle HP, Initial experiences with anelectronic information system in a psychiatrictreatment clinic. Psychiatr Prax 1995; 22(5):209-12.14. Mates JA. The optimal length ofhospitalization for psychiatric patients: A reviewof the literature. Hospital & CommunityPsychiatry 1982; 33:824-8.15. Liberman PB, Strauss JS, Brief psychiatrichospitalization: what are its effects? Am JPsychiatry 1986; 143:1557-62.16. Heggestad T. Operating conditions ofpsychiatric hospitals effect of high patientturnover. Acta Psychiatr Scand 2001; 103:196-202.17. Rakesh Lal, Substance use disorders manualfor physicians. In: Hem RP, Amardeep K.Epidemiology of substance use. New Delhi:National Drug Dependence Treatment Centre,All India Institute of medical Sciences; 2005:16-22.18. Wig NN et al. A follow up study of hysteria.Ind Psychit 1982; 50:519. Gregory I, Smeltzer DJ. Community and SocialPsychiatr. An essential of clinical practice.Boston; Little Brown; 1983; p.139-48.JMS * Vol 25 * No. 2 * May, 2011 63

ORIGINAL ARTICLEChronic Low Back Pain and Its Correlation with Life Stress and Depression1Sameeta Ng, 2 Ak. Joy Singh, 3 Debina L, 4 Th. Khelendro SinghAbstract:A cross sectional study was conducted on 30patients with chronic low back pain withoutorganic causes in the age group of 15 to 50years to find out the correlation betweenstressful life events and depression withchronic low back pain by using Stressful LifeEvents Inventory and Beck DepressionInventory tools.Chronic low back pain patients were found toexperience more distress and stressful lifeevents. Family, financial, marital and healthrelated issues were significant causes ofdistress among patients with chronic low backpain. High prevalence of depression amongpatients with chronic back pain was found,though majority of the patients were only mildlydepressed.Keywords: Chronic low back pain, Lifestress, DepressionIntroductionUp to 80% of the population may be affectedby low back pain sometimes in their lifetime.1. Assistant Professor, Department of ClinicalPsychology, 2. Professor, Department of PhysicalMedicine & Rehabilitation, 3. MPhil Trainee in ClinicalPsychology, Department of Clinical Psychology,4. Postgraduate student, Department of PhysicalMedicine & Rehabilitation, Regional institute ofMedical Sciences, ImphalCorresponding authorSameeta Ng, Assistant Professor, Department ofClinical Psychology, Regional Institute of MedicalSciences, ImphalHowever, the cause of low back pain is nonspecificin most cases. The chronicity of lowback pain in the absence of a defined organicdiagnosis has lead researchers to seekpsychosocial explanation. Conditions such asinappropriate attitudes and belief about backpain, inappropriate pain behaviour, workrelated problems or compensation issues,emotional problems which includesdepression, anxiety and stress, tendencytowards a low mood and withdrawal fromsocial interaction are considered as possiblereasons for chronic non-organic low backpain 1 . This study is to find out the correlationbetween stressful life event and depressionwith chronic low back pain.Material and MethodsA cross sectional study was conducted in theDepartment of Clinical Psychology incollaboration with the Department of PhysicalMedicine and Rehabilitation, Regional Instituteof Medical Sciences, Imphal during 2005among 30 patients in the age group between15 to 50 years with low back pain lasting morethan 3 months without demonstrable organiccauses. Thirty sex and age matched healthysubjects were randomly selected as controls.Patients with major depression, somatizationdisorders and those who were underpsychiatric treatment for psychosis wereexcluded from the study.Stressful Life Events Inventory and BeckDepression Inventory tools were used in thepresent study.64JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLE‘t’ test was used to find out differencesbetween the groups on stressful life events,depression and chronic low back pain.ResultsOut of the 30 subjects in the study groups, 10were males and 20 females. Illiteratesconstituted 30% followed by under matric(23.33%), undergraduates (26.67%) andgraduate and above (20%). Majority of thesubjects (33%) were housewife and only16.67% were employed in the governmentestablishments. Again, 36.67% of subjectswere in the monthly income range of Rs.2001-4000 and only 13.33% of subjects werehaving income range of Rs 8000 and above.Majority of the subjects in the study group weremarried (73.33%). There were 22.23%unmarried subjects and 3.33% widower in thestudy group.Table I – Showing differences in Stressful Life Event Inventorysubscales among two groupsSubscale Study group Control group(n=30) (n=30)Mean SD Mean SDWork 1.07 1.63 1.17 1.29 0.26 > 0.05Education 1.2 1.815 0.57 0.76 1.75 > 0.05Marital 1.8 2.66 0.6 1.38 2.18 < 0.05Family 3.5 3.92 0.73 0.97 3.74 < 0.01Finance 3.6 3.04 1.27 1.36 3.82 < 0.01Health 6.6 3.895 2.43 1.84 5.28 < 0.001Bereavement 4.43 3.07 3.5 2.81 1.22 > 0.05Legal 0.87 1.3 0.7 1.07 0.53 > 0.05Table I shows that there are statisticallysignificant differences between the study andcontrol groups on marital, family, finance andhealth subscales of the Stressful Life EventInventory, however difference between thegroups in other subscales like work,bereavement and legal were insignificant.Table II – Frequency distribution of depression among studyand control groupsSubjects Not Depressed Mean ‘t’ ‘p’Depressed Mild Moderate Severe (SD)Study 4 15 7 4 18.4(7.27)group 9.61 < 0.001(n=30)Control 27 3 0 0 4.17(3.64)group(n=30)‘t’‘p’Table II shows frequency distribution ofdepression in both the groups. Twenty sixsubjects out of 30 in the study group werefound having associated depression against3 out of 30 subjects in the control group. Againin the study group, 15 persons were havingmild depression, 7 with moderate depressionand another 4 persons with severe depression.Difference between the two groups werestatistically significant (p < 0.001)DiscussionIn the present study, chronic low back paingroup experienced more negative life eventsthan the control group. This is in accordanceof findings of Saarijarvi et al 2 who reported thatmarital dissatisfaction in female CLBP patientswas significantly associated withpsychological distress and patient’s selfreported pain and disability.Naidoo P and Pillay YG 3 found that subjectswith chronic low back pain experienced morenegative life events and certain familycharacteristics (decreased score oncohesion, independence, organization andincreased scores of conflict) were unique tothat group.Finding of more score among chronic lowback pain patients on the “health’ subscale inthe present study was comparable with thefindings of Yip YB 4 who reported increasedrisk of low back pain among those patientswhose family members or relatives were verysick, needed their involvement to take care ofthem within the past 12 months.In the present study, the chronic low back paingroup had experienced significantly moresubjective units of distress than the controls.Craufurd DI 5 also found that before the onsetof back pain, there was significant excess ofadverse life events in those with definite onsetback pain of uncertain causes. Nwuga 6reported that life stressing events were foundto be correlated with pain factors. Lampe etal 7 also found that stressful life events anddepression had a significant impact on theoccurrence of chronic pain.The present study showed significantrelationship between chronic low back painand depression. Several researchers likeJMS * Vol 25 * No. 2 * May, 2011 65

ORIGINAL ARTICLEFishbain DA 8 , Maloney P and McIntosh EG 9also found similar findings. Atkinson JH 10reported that men with chronic low back painhad significantly higher lifetime rates of majordepression.ConclusionNon-organic chronic low back patientsexperienced more distress and stressful lifeevents. Family, financial, marital and healthrelated issues were significant causes ofdistress among patients with chronic low backpain. Also, there is high prevalence ofdepression among patients with chronic backpain though majority of the patients were onlymildly depressed.References1. Van Tulder M, Becker A, Bekkering T, Breu A,Hutchison A. European guidelines for themanagement of active non-specific low backpain in primary care. Proceedings of the 5 thInterdisciplinary World Congress on low backand pelvic pain. November 10-13, 2004;Melbourne, Australia.2. Saarijarvi S, Rytokoski U, Karpii SL. Maritalsatisfaction and distress in chronic low backpain patients and their spouses. ClinicalJournal of Pain 1990;6:148-52.3. Naidoo P, Pillay YG. Correlations amonggeneral stress family environment,psychological distress and pain experience.Perceptual and Motor Skills 1994;78:1291-96.4. Yip YB, Ho SC, Chan Socio-psychologicalstressors as risk factors for low back pain inChinese middle aged women. Journal ofAdvanced Nursing 2001;36(3):409-16.5. Craufurd DI, Creed F, Jayson MIV. Life eventsand psychological disturbances in patientswith low back pain. Spine 1990;15:490-94.6. Nwuga VC. Relationship between low backpain and life stress events among Nigerianpatients. Journal of Tropical Medicine andHygiene 1985;88:17-20.7. Lampe A, Sollner W, Krismer M, Rumpold G,Rumplmain WK, Ogon M, Rathner G. Theimpact of the stressful life events onexacervation of chronic low back pain. Journalof Psychosomatic Research 1998;54:361-67.8. Fishbain DA, Cutler R, Rosomoff HL, RosomoffRS. Chronic pain associated with depression:antecedents and consequences of chronicpain? A review. Clinical Journal of Pain1997;13:116-137.9. Maloney P, McIntosh EG. Chronic low backpain and depression in a sample of veterans.Perceptual and Motor Skills 2001;92(2):348.10. Atkinson JH, Slatter MA, Patterson TL, GrantI, Steven GR. Depression mood in chronic lowback pain: relationship with stressful life events.Pain 1988;35:47-55.66JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEA retrospective study of 22 consecutive cases of ocular injuries due to Airsoftgun pellets during a one-year period.1Ng. Sangeeta Devi, 2 R.K. Bhabanisana, 3 R.K. Vidyarani, 4 Kh. Kaminibabu Singh, 5 H. BeemaAirsoft gun pellet ocular injuriesAbstractObjective: As airsoft toy guns have gainedpopularity in Manipur, India, there have beenan increasing associated ocular injuries. Thisstudy reviews and evaluates the ocular effectsof blunt trauma due to injury from airsoft gunpellets.Methods: We conducted a retrospectivestudy of a series of 22 patients who sufferedocular injury from airsoft guns and attendedthe Ophthalmology department of oneteaching hospital in Imphal, Manipur during aone year period.Results: A total of 22 eyes in 22 patients wereexamined. Nineteen male and three femalepatients were affected. Mean age was 13.63years (range 7– 28 years). Mean follow-uptime was 19.8 days (range 1–120 days). Oninitial examination, we found: hyphaema (n=18), corneal abrasion (n =12), retinal oedema(n = 4), subconjunctival haemorrhage (n =7),lid contusion (n =3), iris dialysis (n =5),intraocular pressure (IOP) >31 mmHg (n =8),vitreous haemorrhage (n =3) and cataract (n=1). One patient had the pellet lodged in the1. Senior Resident, 2. Professor, 3. AssistantProfessor, 4. Senior Ophthalmologist 5. Juniorresident, Department of Ophthalmology, JawaharlalNehru Institute of Medical Sciences, Imphal, Manipur.Corresponding authorDr. Ng. Sangeeta Devi, Senior Resident, Departmentof Ophthalmology, Jawaharlal Nehru Institute ofMedical sciences, Imphal, Manipur, Email :lai.sangi@yahoo.comupper fornix that requiredaintervention forremoval under topical anaesthesia. The finalvisual acuity was 6/6 in 14(63.63%), 6/9 in3(13.63%), 6/12 in 3(13.63%) and 6/24 in one(4.5%) case who developed cataract.Conclusion: The airsoft gun trauma resultedin anterior and posterior segment ocularinjuries that required acute medicalintervention and for which some patients werehospitalized. Trauma mainly occurred inchildren and youths. A long-term risk ofglaucoma and cataract is b expected. Eye careprofessionals and parents as well asmanufacturers of airsoft guns should adviseparticipants to wear adequate protection wheninvolved in this activity.Key words: airsoft, pellet, gun, eye, oculartrauma, child, adolescent, injuryIntroductionIn Manipur, India, we have seen increasingnumbers of eye injuries from airsoft gunsmisused by children and adolescents as toyweapons. Airsoft guns are 1:1 scale replicasof actual firearms. Compared with air gun andpaintball projectile, a 0.2-g airsoft plasticprojectile would not be expected to causemuch damage 1,2,3 . There are very few reportsin the English literature that document the riskof ocular damage caused by airsoft guns 4,5,6. We would like to compare our findings withthose of previous studies, document theincidence of airsoft gun ocular injury inManipur, describe the resulting lesions andincrease the awareness of the potentialhazard posed by the use of airsoft toy guns.JMS * Vol 25 * No. 2 * May, 2011 67

ORIGINAL ARTICLEMaterials and MethodsApproval was obtained from the institutionalethical committee at the J.N. Institute ofMedical Sciences, Imphal, to conduct aretrospective study of 22 patients who sufferedinjury from airsoft gun pellets. All the patientswere examined and treated at the institute’seye department, during the one-year periodbetween April 2010 to March 2011. Weregistered the patients’ age, gender,symptoms, ocular findings, and use of eyeprotection. Initial and final follow-upexaminations included visual acuity, slit-lampbiomicroscopy, applanation intraocularpressure (IOP) and indirect ophthalmoscopy.Treatment profile and follow-up time were alsodocumented. The terms used in thedescription of the ocular injuries conform tothe recommendations of the United States EyeInjury Registry and the International Societyof Ocular Trauma 7 .ResultsAirsoft gun injuries occurred in 19 males and 3females. Only one eye was affected in eachpatient. Mean follow-up time was 19.18 days(range 1– 120 days). The mean age of thesubjects was 13.63 years (range 7–28 years).Only three patients in our series were over 18years of age; the majority were 10-15 yearsold. None of the patients was reported to havebeen wearing eye protection (protectiveglasses) at the time of injury. Twelve (54%) ofthe patients were hit in the right eye. Pain wasthe presenting symptom in 18 (82%) of thepatients, while 16 (68%) reported visionimpairment and 2 (9%) patients suffered fromnausea and vomiting. The final visual acuitywas 6/6 in 13 patients, 6/9 in 4 patients, 6/12 in3 patients and 6/24 in one case who developedtraumatic cataract. One case whose initialvision was 6/24 did not report back for followup.All the cases were treated conservatively.In one patient, the pellet was found lodged inSCH=subconjunctival haemorrhage; LC=lid contusion; CA = corneal abrasion; CO = corneal oedema; Hyph =hyphaema; TM = traumatic mydriasis; ID = iris dialysis; IOP = intraocular pressure raised temporarily; Cat = cataract;VH=vitreous haemorrhage; RO= retinal oedema; HM = hand movements; CF=finger counting; FU= follow-up68JMS * Vol 25 * No. 2 * May, 2011

the upper fornix that required removal undertopical anaesthesia. The demographic andocular findings are listed in Table 1.DiscussionAirsoft guns are replicas of actual guns. Theyfire 6-mm, round, ceramic, metallic or plasticpellets propelled by compressed air. Theairsoft pellets weigh 0.12–0.43 g. The initialpellet velocity is 76–168 mD second, with ashooting range of up to 150 m depending ongun model and bullet type 8 . These toys havethe potential to cause serious eye injuries. Inalmost all the cases, patients experiencedhyphaema or microhyphaema as a result ofblunt trauma. This finding is consistent withother studies 5 . Other injuries consisted ofcorneal abrasion, traumatic mydriasis, lidcontusion, iris dialysis, subconjunctivalhaemorrhage, vitreous haemorrhage andretinal oedema. Other firearms are alsoknown to cause ocular injury. Air guns (BBguns), which use 4.5-mm lead or steel pellets,have a speed of approximately 140 mDsecond and a range of 300 m, can result ineye and life-threatening injury 9,10 . Paintballpellets, 17-mm gelatine projectiles filled withpaint, weigh approximately 3.2 g, have a(muzzle velocity up to 130 mD second and arange of approximately 150 m and are knownto result in globe-damaging injury for whichsome patients require enucleation 11 .Compared with the latter two weapons, thelightweight airsoft gun pellet might beconsidered less harmful, but the risks ofsignificant ocular injury remains. This isevident from the fact that 82% of the cases inthis study presented with severe pain andhyphaema, 13% suffered from severe visualimpairment due to vitreous haemorrhagethough temporary and several needed therapyfor raised IOP. Retinal oedema can result inpersistent retinal dysfunction. For a child,airsoft pellet-related ocular injuries representa traumatizing experience with a longterm riskof cataract 5 and glaucoma 12,13 . We found nopatients with rupture of the globe, retinal tearsor retinal detachment in our series. Nearly allthe patients recovered completely after a fewdays, but the follow-up time in this study wasshort, and further investigations into eventuallong-term effects, such as glaucoma andcataract, should be conducted.ConclusionORIGINAL ARTICLEOcular traumas from airsoft gun pelletsrepresents a significant share of all severeocular trauma registered in our EyeDepartment in a one year period. A total of86% of the airsoft injury patients in our serieswere under 18 years of age. The patientssuffered acute ocular injuries with risk oftraumatic cataract, corneal discoloration, andlasting pupil dysfunction, as well as retinaldysfunction from Berlin’s oedema. In ourseries, children as young as 7 years of agesuffered from eye injury due to airsoftprojectiles, which highlights the need to restrictthe availability of these weapons to children.All patients hit by airsoft pellets should bereferred to an ophthalmologist for furtherinvestigation. Airsoft guns are regarded astoys, but they have the potential to causesevere eye injury. Some upgraded modelspropel the pellets faster, with potential for evenmore severe injury. Hence, safety gogglesshould be included with the guns and wearingthem should be mandatory while playing. Ageand sales restrictions must be followed.References1. Drummond J & Kielar RA (1976): Perforatingocular shotgun injuries: relationship of ocularfindings to pellet ballistics. South Med J 69:1066–1068.2. Fineman MS, Fischer DH, Jeffers JB, BuergerDG & Repke C (2000): Changing trends inpaintball sport-related ocular injuries. ArchOphthalmol 118: 60–64.3. Harris W, Luterman A & Curreri PW (1983):BB and pellet guns – toys or deadly weapons?J Trauma 23: 566–569.4. Endo S, Ishida N & Yamaguchi T (2000): TheBB gun is equivalent to the airsoft gun in theJapanese literature. Arch Ophthalmol 118: 732.5. Endo S, Ishida N & Yamaguchi T (2001): Tearin the trabecular meshwork caused by anairsoft gun. Am J Ophthalmol 131: 656–657.JMS * Vol 25 * No. 2 * May, 2011 69

ORIGINAL ARTICLE6. Fleischhauer JC, Goldblum D, Frueh BE &Koerner F (1999): Ocular injuries caused byairsoft guns. Arch Ophthalmol 117:1437–1439.7. Kuhn F, Morris R, Witherspoon CD & MesterV (2004): The Birmingham Eye TraumaTerminology system (BETT). J Fr Ophtalmol27: 206–210.8. Wikipedia: Airsoft guns. Available at http://en.wikipedia.org/wiki/Airsoft_guns. AccessedSeptember 2010.9. Shanon A & Feldman W (1991): Seriouschildhood injuries caused by air guns. CMAJ144: 723–725.10. Shuttleworth GN & Galloway PH (2001):Ocular air gun injury: 19 cases. J R Soc Med94: 396–399.11. Thach AB, Ward TP, Hollifield RD et al. WA(1999): Ocular injuries from paintball pellets.Ophthalmology 106: 533–537.12. Kaufman JH & Tolpin DW (1974): Glaucomaafter traumatic angle recession. A 10-yearprospective study. Am J Ophthalmol 78: 648–654.13. MacCumber M (1997): Management of ocularinjuries and emergencies. Hagerstown, MD:Lippincott-Raven; 229.70JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEA Clinicopathological Study On Solitary Thyroid Nodules.1S. Thingbaijam, 2 Nicola C. Lyngdoh, 1 R K Bedajit, 3 N.Y. Savizo, 3 Anirudh Mazumder 4 Th. IbohalAbstractObjective: To study the clinical, cytologicaland histopathological profile of solitary thyroidswellings. Methods: 50 (fifty) patientsirrespective of age, sex, religion and socioeconomicstatus with solitary thyroid noduleswere prospectively studied between August2006 to September 2008. Results : Solitarythyroid nodules was between the age groupof 30 – 39 years with a male: female ratio of1: 6.1. The commonest mode of presentationwas a swelling in the neck with the majority ofpatients (92%) giving history of gradualprogression in size. Other complaints suchas dysphagia, pain, hoarseness wereassociated with rapidly progressing andmetastatic disease. Location of the nodulewas slightly more on the left (44%) ascompared to the right and isthmus. Mostnodules were firm in consistency. Fine needleaspiration cytology was a highly accuratemeans of investigation with an accuracy of86% in the study. However, it was unable todifferentiate the forms of follicular neoplasmsand a couple of papillary variants were1. Associate Professor 2. Assistant Professor 3. PGT,4. Professor and Head, Department ofOtorhinolaryngology, Head & Neck Surgery, RegionalInstitute of Medical Sciences, Imphal – 795001,Manipur.Corresponding author :Prof. Dr. Th. Ibohal Singh, Professor and Head,Department of Otorhinolaryngology, Head & NeckSurgery, Regional Institute of Medical Sciences,Imphal – 795001, Manipur.undetected. Histopathological examinationwas carried out for all operated thyroidspecimens.Conclusion: Fine needle aspiration cytologyhas become the diagnostic tool of choice forthe initial evaluation of any thyroid swellingbecause of its accuracy, safety and costeffectiveness.However, histopathologicalexamination remains the gold standard for thecorrect diagnosis of solitary thyroid nodules.Keywords: thyroid swelling/ solitary thyroidnoduleIntroductionThe thyroid gland is unique among otherendocrine glands and because of itssuperficial location, it is the only glandamenable to direct physical examination andbiopsy. 1 A solitary thyroid nodule is a palpablediscreet swelling within an otherwiseapparently normal thyroid gland. Nodulesmust approach 1cm in diameter to beconsistently recognized on palpation althoughtheir size varies according to the location ofthe nodule within the gland. 2Thyroid nodules are reported in up to 8% ofthe adult population. The incidence of thyroidnodules has increased in recent decades withthe advent of neck imaging. Therefore, theincidental finding of a thyroid nodule in anasymptomatic patient is not rare. The primaryaim in investigating a thyroid nodule is toexclude the possibility of malignancy, whichoccurs in about 5 – 10% of nodules. 3 Thyroidnodules in childhood need special attentionJMS * Vol 25 * No. 2 * May, 2011 71

ORIGINAL ARTICLEdue to a higher incidence of malignancy, i.e.15 – 25% as compared to adults. Further, itruns a more aggressive course and isassociated with early locoregional as well asdistant metastasis. 4Solitary thyroid nodules may be noticed by thepatient, a family member or the attendingphysician. At times, the patient may seekmedical advice because of cosmetic reasons,pressure symptoms or signs of thyrotoxicosis.A clinically solitary thyroid nodule is moresinister as it has a higher incidence ofmalignancy (15 – 20%). 3Evaluations of thyroid nodules remain achallenge for primary care physicians as thediagnosis is associated with considerableanxiety for the patient. A thorough historyincluding previous exposure to radiation andany family history of thyroid cancer isimportant. Clinical examination of the neckshould focus on the thyroid nodule and thepresence of cervical lymphadenopathy.Biochemical assessment of the thyroid needsto be followed by thyroid ultrasonographywhich may demonstrate features that areassociated with a higher chance of the nodulebeing malignant. Fine needle aspiration biopsyis crucial in the investigation of a thyroidnodule. It provides highly accurate cytologicinformation about the nodule from which adefinitive management plan can beformulated. 5. There is a lot of controversyregarding the diagnostic workup andmanagement of a thyroid nodule. The goal,however, is to rule out the possibility ofmalignancy in the nodule so as to avoidunnecessary surgical interventions in benigncases while tackling the cases as the needmay be.Material and methods:After obtaining institutional ethics approval anda written informed consent, fifty (50) patientswith solitary thyroid nodule were admitted inthe Department of Otorhinolaryngology Headand Neck Surgery, RIMS, Imphal, irrespectiveof age, sex, religion and socio-economicstatus. The criterion of selection was entirelyclinical, with the patient being euthyroid andwith a single palpable nodule in the thyroid. Allother patients with multinodular goitre or72abnormal thyroid hormonal assays were notincluded in the study. Every patient wasmeticulously worked up with a thoroughhistory and clinical examination followed byroutine laboratory investigations, thyroidhormonal assay, Fine-needle aspirationcytology (FNAC) and Ultrasonography of thethyroid. Post-operatively, all thyroidectomyspecimens were sent for histopathologicalexamination (HPE).Results And Observations:The age of the patients ranged from 15 – 70years and the mean age was 37.20 years. Amajority of the patients (34%) were in the agegroup of 30 – 39 years. The youngest patientwas a 15 year old male while the oldest patientTable 1: Showing age distribution of patientsAge (Years) No. of cases %0 – 9 0 010 – 19 7 1420 – 29 8 1630 – 39 17 3440 – 49 8 1650 – 59 4 860 – 69 5 1070 and above 1 2Table 2: Showing correlation between age and malignancy.Age Group Total cases Malignancy %< 20 years 7 3 42.85 %21 – 60 years 37 6 16.21 %> 60 yrears 6 2 33.33 %was 70 years old. (Mean = 37.20, Standarddeviation = 14.57). Out of the fifty patients,43 (86%) were female and 7 (14%) were malewith a Female : Male ratio of 6.1 :1. (Table 1)The incidence of malignancy was 13 out of43 cases (30.2%) in the females and 3 out of7 cases (42.8%) in males. There was asignificant increase in the occurrence ofmalignancy at both extremes of age ascompared to the general population, i.e. 42.85%below 20 years of age and 33.33% above 60years of age. The youngest patient was a 15JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEyear old male and the oldest patient was a 70year old male, both of which were diagnosedwith papillary carcinoma. (Table 2)Table 3. Showing presenting symptoms of the patientsSymptoms No. of cases %Swelling in front of neckGradual progressionRapid progressionAssociated pain 1 2Dysphagia 2 4Difficulty breathing 1 2Hoarseness 1 2Decreased appetite 1 2Weight loss 1 2Cervical lymphadenopathy 1 250464100Table 4: Showing results of Fine needle aspiration cytology.FNAC results No. of cases %Colloid Goitre 30 60Papillary carcinoma 9 18Follicular neoplasm 7 14Hurthle’s neoplasm 2 4Hashimoto’s thyroiditis 1 2Lymphocytic thyroiditis 1 2Table 5 : Showing results of Ultrasonography of the Thyroid glandUltrsonography report No.of cases %Cystic 30 60Solid 12 24Suspicious of malignancy 8 16Table 6 : Showing Histopathological Examination resultsHPE results No. of cases %Colloid Goitre 27 54Papillary carcinoma 14 28Follicular adenoma 6 12Hashimoto’s thyroiditis 1 2Hurthle’s carcinoma 1 2Squamous cell carcinoma 1 2928In the present study, all the 50 patients camewith the chief complaint of a swelling in frontof the neck of whom 46 (92%) cases had agradual and progressive increase in size,while 4 cases (8%) had a rapid increase inthe size of the swelling. There was dysphagiain 2 cases (4%). Associated pain, dysphagia,difficulty in breathing, hoarseness, decreasedappetite, weight loss and cervicallymphadenopathy was seen in a 70 year oldman with papillary carcinoma. (Table 3)The location of the nodule was seen on theright thyroid gland in 22 cases (44%), on theleft gland in 18 cases (36%) and on theisthmus in 10 cases (20%). The consistencyof the swelling was firm in 38 cases (76%),soft in 8 cases (16%), cystic in 3 cases (6%)and hard in 1 patient (2%). On Fine needleaspiration cytology (FNAC), 30 cases (60%)showed features of colloid goiter while featuresof papillary carcinoma was seen in 9 (18%)cases. There were 7 cases (14%) withfollicular neoplasm, 2 cases (4%) withHurthle’s neoplasm and 1 case each (2%) withHashimoto’s and lymphocytic thyroiditis.(Table 4).On Ultrasonography study of the thyroid in all50 patients, 30 cases (60%) were cystic innature, while 12 cases (24%) were solid.There were 8 cases (16%) which reportedsuspicious for malignancy. (Table 5)On histopathological examination of theoperated thyroid specimens, 27 cases (54%)were colloid in nature. 11 cases (22%) showedfeatures of papillary carcinoma, 3 cases (6%)were of papillary – follicular variant. FollicularTable 7: Showing comparison between FNAC/ HPE reports.Type FNAC % HPE %Colloid Goitre 30 60% 27 54%Papillary Ca. 9 18% 14 28%Follicular neoplasmFollicular adenomaFollicular carcinoma7 14%6012%Hashimoto’s thyroiditis 1 2% 1 2%Hurthle’s neoplasm 2 4% 1 2%Lymphocytic thyroiditis 1 2% - -Squamous cell carcinoma - - 1 2%0%JMS * Vol 25 * No. 2 * May, 2011 73

ORIGINAL ARTICLEadenoma was seen in 6 cases (12%) whileno cases of Follicular carcinoma weredetected. There was 1 case (2%) each ofHurthle cell carcinoma and Hashimoto’s.There was also a case of Squamous cellcarcinoma reported in a 26 years old femalepatient who was earlier diagnosed as a caseof Colloid nodule on FNAC. (Table 6)A comparison between the results observedon Fine Needle Aspiration Cytology andHistopathological Examination was done. Outof 30 cases of colloid nodule on FNAC, 27cases were found to correlate on HPE. Theremaining turned out to be Papillary carcinomain 2 cases and squamous cell carcinoma in 1case. All the cases of papillary carcinoma,Hashimotos and Hurthle’s carcinoma onFNAC had similar results on HPE. All casesof Follicular neoplasm on FNAC turned out tobe Follicular adenoma on HPE. The statisticalindices of FNAC as a diagnostic tool in thisstudy showed a sensitivity of 92.71%,specificity of 78.26%, and an accuracy of 86%.(Table 7)DiscussionIn the present study, it was found that themaximum number of cases were seen in theage group of 30 – 39 years and contributed to17 cases (34%) of the total number of cases,and a female : male ratio of 6.1:1 which issimilar to the findings of Mandrekar SRS etal 6 . The rarity of thyroid nodules at extremesof age was also noted in our study. There wereno cases below the age of 10 and only 1 case(2%) above 70 years. Studies by Niedzela Mhave also mentioned the rare incidence ofsolitary thyroid nodules in the first twodecades of life putting it below 1.5% beforepuberty. 7 Several studies have highlighted agreater risk of thyroid malignancy in theyounger age group and in the older agegroups, especially males. Similar findingswere observed in our study with an incidenceof 42.85% of malignancy below 20 years andabout 33.33% above 60 years age group.The most common presenting feature was aswelling in the front of the neck which wasseen in all 50 cases similar to other reports. 3The presentation of thyroid neoplasms in earlycases as a solitary thyroid nodule is often of74indeterminate consistency. There was agradual increase in the size of the swelling in46 cases (92%) while 4 cases (8%) who hada rapid increase in the size of the thyroidswelling were found to have papillarycarcinoma after surgery. Other clinicalindicators of malignancy like dysphagia, pain,hoarseness, weight loss, difficulty in breathingand cervical lymphadenopathy which wasseen in our 70 year old patient with papillarycarcinoma have also been reported in otherstudies. 8,9.The presence of a nodule on the right lobewas 44%, 36% on the left lobe and 10% onthe isthmus. Amjad I et al also reported asimilar finding of 64% in the right lobe followedby the left lobe and the isthmus. 3 Fine needleaspiration cytology has become a diagnostictool of choice for the initial evaluation of solitarythyroid nodule because of its safety, accuracyand cost effectiveness. In this study, FNACproduced a sensitivity of 92.71%, a specificityof 78.26%, a positive predictive value of83.33% and a negative predictive value of90%. The accuracy rate of the FNAC wascalculated at 86% consistent with Bouvet M 10who reported similar statistical findings.Inability to differentiate indeterminatecytological groups such as follicular adenomaand carcinoma in follicular neoplasms wereobserved on FNAC in our study and was also11, 12.reported in several other studies.Sonographies as well as TSH determinationare the basic constituents of any thyroiddiagnostic work-up. Thyroid ultrasounddifferentiates solid from cystic lesions, solitaryfrom multinodular and diffuse enlargement,and extra-thyroidal lesions. In our series of 50patients, Ultrasonography studies reportedthat the consistency of the swelling in 30cases (60%) were cystic in nature, while 12cases (24%) were solid. There were 8 cases(16%) which reported suspicious formalignancy. Out of the 8 cases (16%) whowere reported suspicious for malignancy, 5cases (10%) were diagnosed with papillarycarcinoma. A majority of the cystic noduleswere diagnosed as Colloid Goitre on HPE.These findings correlated with the studiescarried out with Razmpa E. 13JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEHistopathological examination of postoperativespecimens showed features ofcolloid goitre in 54%, papillary carcinoma in28%, Follicular adenoma in 12%, Hashimoto’sthyroiditis and Hurthle’s carcinoma in 2%each. However, the percentage of papillarycarcinoma in our study was slightly higher thanother studies. 2 The presence of squamous cellcarcinoma which was reported in a 26 yearsold female is one of the rare and unusualfindings of thyroid neoplasms reported in onlyvery few literature. 14 A comparison betweenthe results observed on Fine Needle AspirationCytology and Histopathological Examinationwas done. Out of 30 cases of colloid noduleon FNAC, 27 cases were found to correlate onHPE. The remaining turned out to be Papillarycarcinoma in 2 cases and squamous cellcarcinoma in 1 case. All the cases of papillarycarcinoma, Hashimotos and Hurthle’scarcinoma on FNAC had similar results onHPE. All cases of Follicular neoplasm on FNACturned out to be Follicular adenoma on HPE.The statistical indices of FNAC as a diagnostictool in this study showed a sensitivity of92.71%, specificity of 78.26%, and an accuracyof 86%. 10Conclsion:From the results of this study, it may beconcluded that Fine needle aspiration cytologyplays a crucial role in the diagnosis of thyroidnodules and is an effective procedure inassessment of lesions that require surgeryfrom those that can be managed otherwise.Ultrasonography has a good accuracy in theevaluation of thyroid nodules and can help ustake some important clinical decisions,supplementary to FNAC. However,Histopathological examination still remains thegold standard for the correct diagnosis ofsolitary thyroid nodules.Bibliography1. Damanjov I & Linder J. Thyroid Gland.Anderson’s Pathology. In. Anne S Patterson,Missouri. 10 th Edn. 1996. 2: 1943.73.2. Ali Z. New insight into the diagnosis andmanagement of thyroid nodules. Shiraz-E MedJ. 2005. 6(1): 1- 2.3. Amjad I et al. Management of solitary thyroidnodule. J Post Grad Med. 2005. 19 (1): 1-2.4. Wilmar MW. Management of thyroid nodulesin children and adolescents. Hormones. 2007.6(3): 194 – 99.5. Meei JY & Jonathan WS. Management of thesolitary thyroid nodule. The Oncologist. 2008.13(2): 105 – 112.6. Mandrekar SRS et al. Role of fine needleaspiration cytology as the initial modality inthe investigation of thyroid nodules. Acta. Cytol.1995. 39: 898 – 903.7. Neidzela M. Pathogenesis, diagnosis andmanagement of thyroid nodules in children.Endocrine-related Cancer. 2006. 13(2):427 – 453.8. Ashok RS. Controversies in the management ofthyroid nodule. Laryngoscope.2000. 110:183– 85.9. Barroeta JE et al. Is fine needle aspiration ofmultiple thyroid nodules justified? EndocrinoPathol. 2006. 17 (1): 61 – 66.10. Bouvet M. Surgical management of thyroidnodule – patient selection based on the resultsof fine needle aspiration cytology.Laryngoscope. 1992. 102: 1353 – 56.11. Pu RT et al. Does Hurthle cell lesion/neoplasmpredict malignancy more than follicular lesion/neoplasm on thyroid fine needle aspiration?Diag. Cytopathol. 2006. 34(5): 330 – 334.12. Rago T et al. Combined clinical, thyroid, USGand cytological features help to predict thyroidmalignancy in follicular and hurthle cell thyroidlesions ; results from a series of 505 cases.Clin. Endocrinol (oxf). 2007. 66(1): 13 – 20.13. Razmpa E et al. Comparison of US findingswith cytological results in thyroid nodules. Actamedica tranica. 2002. 40(3): 146 – 151.14. Celina GK et al. Squamous cell carcinoma ofthyroid: an aggressive tumour associated withtall cell variant of papillary thyroid carcinoma.Mod. Pathol. 2000. 13(7): 742 – 46.JMS * Vol 25 * No. 2 * May, 2011 75

CASE REPORTMalignant transformation of Sino-nasal inverted papilloma: Our experiencein RIMS Imphal.1Lyngdoh N, 2 Ori J, 3 S.Thingbaijam, 3 R.K. BedajitAbstracts:Objectives: To review all cases of Malignantinverted papilloma treated in our departmentand to discuss our experience in diagnosis,management and outcomes of treatment.Methods: Retrospectively reviewed all casesof malignant inverted papilloma treated in ourdepartment of Otorhinolaryngology RIMSImphal over a 10 year periods from August2000 to September 2010.The clinicalpresentations, treatment protocol and followup result are discussed. Result: we treated33 cases of inverted papilloma over a 10 yearsperiod of which four cases (12%) wereassociated with malignancy with mean followupof one and half years (range from 6 monthsto 5 years) .Four cases were diagnosed bynasal biopsy as associated sqamous cellcarcinoma of which two cases hadmetachronous involvement and two hadsynchronous involvement. The unilateral nasalobstruction, mass occupying the nasal cavityEpistaxis off and on were the main presentingcomplaints.The first two cases were treated with a courseof palliative cobalt therapy as it was in-operabledue to extensive lesions involving bilateralnasal cavity in one patient and medial1.Assistant Prof. 2. Post Graduate Trainee3. Associate Prof. Department of OtorhinolaryngologyRIMS,Imphal.Corresponding authorDr S. Thingbaijam, Associate Prof, Department ofOtorhinolaryngology, RIMS Imphal.76pterygoid plate and intracranial involvementin other patient .Lateral Rhinotomy with medialmaxillectomy was done in other two casesfollowed by Radio therapy after 6 weeks ofoperation.None of the patients had any signs ofrecurrence after routine check-up at 2 yearshowever, One case who received palliativeradiotherapy, with extensive lesions died afterfour months of follow-up.Conclusion: Malignant transformation ofinverted papilloma is rare diseases (12.12%).Lateral Rhinotomy is the treatment of choice,In the present experience ,Combine radiation& surgery offers excellent long term control. Iftumor is not resected completely there is highrecurrence rate, propensity to spread to orbitand intracranial with fatal consequences.Key words: Malignant inverted papilloma,Lateral Rhinotomy.Introduction:Sino-nasal inverted papilloma is relatively rarebenign epithelial neoplasm originating from theschneiderian membrane of the nose andparanasal sinusesWard reported the first case of invertedpapilloma in 1864. It is a relatively rareneoplasm, constituting 0.5% to 4% of allprimary nasal tumours. It has been reportedin all age groups, peak incidence being in thefifth and sixth decades of life. There is a maleto female predominance in the ratio of 3 to 1.Caucasians are more commonly affected 1 .JMS * Vol 25 * No. 2 * May, 2011

CASE REPORTThe aetiology of this tumour is unknown.Possible theories include proliferation of nasalpolyp, allergy, chronic inflammation,environmental carcinogens, and viral infection.It generates considerable interest due to localaggressiveness high rate of recurrence andmalignant transformation. The rate ofrecurrence is reported to be 0-78 % whereasmalignant transformation is reported to be 2-4 % 2 .Methods: Retrospectively reviewed all casesof malignant inverted papilloma treated in ourdepartment of Otorhinolaryngology RIMSImphal over a 10 year periods from August2000 to September 2010.The clinicalpresentations, treatment protocol and followup result are discussed.Results :Table 1.Shows Age and Sex distribution. Theage of the patients in all four cases varied from45-75 years with three male and one female.Table 1.Showing Age and Sex distribution:Age in group Male Female Percentage0-44 0 O O45-75 3 1 10075 % 25 %Table 2: Shows Symptoms of malignantinverted papilloma. The Common symptomswere unilateral nasal obstruction, whichoccurred in 3 (75%) cases, nasal dischargein 4(100%) cases, mass in nasal cavity4(100%), epistaxis 4(100%), headache 4(100%), hyponasal voice 4 (32%), sinusitis 4(100%), anosmia 2(50%).Table 2: Showing SymptomsSymptoms No. of cases PercentageUnilateral nasal obstruction 03 75 %Nasal discharge 04 100%Mass in nasal cavity 04 100%Epistaxis 04 100%Sinusitis 04 100%Anosmia 02 50%Hyponasal voice 04 100%Head ache 04 100%Table 3 Shows site of erosion in CT scan.Maxillary and ethmoid sinus involvement in4(100%) of cases, nasal septum 01(25%),medial orbital wall 01(25%), interfrontal sinusseptum, 01(25%), floor of sphenoid,01(25%),cribriform plate 01(25%).Site of erosionTable 3 Showing site of erosion in CT scan:No. of cases PercentageLateral and medial wall of maxilla 04 100Medial orbital wall 01 25Inter frontal sinus septum 01 25Nasal septum 01 25Floor of sphenoid 01 25Cribriform plate 01 25Total 04 100Table 4.Shows treatment modalities.Twocases (50%) were treated with LateralRhinotomy with medial maxillectomy, followedby Radio therapy. Two cases (50%) weretreated with a course of palliative cobalttherapy.Table 4.Showing treatment modalities:Treatment No. of cases PercentageLateral Rhinotomy with 02 50medial maxillctomyfollowed by post-operativeRadiotherapyPalliative radiotherapy 02 50Total 04 100Table 5.Shows follow up result: Three patients(75%) had no any signs of recurrence afterroutine check-up at 2 years. One case (25%)died after four months of follow-up.Table 5.Showing follow up result:Follow up result No. of cases PercentageNo recurrence after 2 years 03 75Died after 4 months 01 25Total 04 100Discussion:Although Sino-nasal Inverted Papillomaassociated with malignant transformation arerelatively rare (1-4 %) 2 but in this study 4(12.12%) cases were seen in 10 years out of33 cases of Sino-nasal inverted papillomatreated in our department ofOtorhinolaryngology RIMS.JMS * Vol 25 * No. 2 * May, 2011 77

CASE REPORTThe age of the patients in all four cases variedfrom 45-75 years, and the male: female ratioof 3:1; which consistent with the findings ofMyers et al 4 .All four cases were diagnosed by nasal biopsyas associated sqamous cell carcinoma ofwhich two cases had metachronousinvolvement and two had synchronousinvolvement. The presenting symptoms seenin this study were similar with the findings ofmany authors who believed that the signs andsymptoms of the disease depend on thelocation and extent of the tumour. Commonsymptoms in this study (table 2) wereunilateral nasal obstruction, which occurredin 3(75%) cases, nasal discharge in 4(100%)cases, mass in nasal cavity 4(100%) . whileMishra D1 et al. reported nasal obstruction in100 % cases, nasal discharge in 96 % cases,nasal mass in 72% of cases. Thisdiscrepancy may be because of geographicaland socio-economical barriers. Othersymptoms were epistaxis 4(100%), headache4 (100%), hyponasal voice 4 (32%), sinusitis4 (100%), anosmia 2(50%). The reportedduration of symptoms in our series was 4weeks to 3 years.In present study CT scan showed maxillaryand ethmoid sinus involvement in 100 ofcases, nasal septum was eroded in 75%cases. Lamina papyracaea was found to beeroded in 75 % of cases. Radiological CTscan study showed extensive destruction in2 cases, involving bilateral nasal cavity in onepatient, medial pterygoid plate and intracranialinvolvement in other patient.The first two cases (table 4) were treated witha course of palliative cobalt therapy as it wasin-operable due to extensive lesions involvingbilateral nasal cavity in one patient and medialpterygoid plate and intracranial involvementin other patient .Lateral Rhinotomy with medialmaxillectomy was done in other two casesfollowed by Radio therapy after 6 weeks ofoperation.Three patients (75% )had no any signs ofrecurrence after routine check-up at 2 yearshowever, One case (25%) who receivedpalliative radiotherapy, with extensive lesionsdied after four months of follow-up.78In case of orbital involvement, there is adilemma whether to exenterate the orbit or not.Sacrificing the eye with some visual equitycarries with significant psychological problembut if the eye is not removed and patient islater subjected to radiotherapy, patient isbound to lose the utility of eye in addition toincreased risk of residual malignantdiseases 5 . However Podo j 6 et al says thatMalignant inverted papilloma invading the orbitcan still be removed without touching the eyeball if it is extraperiosteal, but once it becameintraperiosteal it cannot be removedcompletely, in such cases eye ball has to beremoved.On review of literature 4 neither the aetiologyof inverted papilloma nor the factorsresponsible for malignant transformation aredescribed so far However Lawson etal 1995reported that HPV type 16 was identified byDNA hybridization technique and Suggestedthat this virus may be involve in developmentof sqamous cell carcinoma from pre existinginverted papilloma and incidence ofassociation was reported as 1- 56%.In most cases, surgery is the treatment ofchoice. Lateral rhinotomy approach is bestsuited to give adequate exposure withacceptable cosmetic and functional result.If not tumor is not resected completely thereis high recurrence rate, propensity to spreadto orbit, intracranial with fatal consequences.Precise determination of the sites of the tumororigin and attachment during operation is thekey to the successful treatment. Recurrentinverted papilloma tends to behave moreaggressively, higher post operative recurrencerate than primary lesions.Radiotherapy has role as Palliative inunresectable, extensive lesions and recurrentcases and post operative radiotherapy is ofvalue only in 40% of cases. Radiotherapy andChemotherapy when use for bulky macrospicdisease is of no value 6 .Conclusion:Malignant transformation of inverted papillomais rare diseases (12.12%). Lateral rhinotomyis the treatment of choice.In the presentexperience Combine radiation & surgery offersJMS * Vol 25 * No. 2 * May, 2011

CASE REPORTexcellent long term control. If tumor is notresected completely there is high recurrencerate, propensity to spread to orbit, intracranialwith fatal consequences.Given the right choiceof treatment patient do survive with minimalcosmetic and functional limitation.Reference:1. D. Mishra, R. et al: A Study on the ClinicalProfile and Management Of Inverted Papilloma.J laryngol Otol 2009 Jan 10; 10(2): 11-7.2. Lawson et al.Inverted papilloma: a report of 112cases. Laryngoscope 1995; 105:282-8.3. The frontal sinus. In Gorge G.B,editors.Scott-Browns Otorhinolaryngology, Head & NeckSurgery, 7 th ed. London, HodderArnold,2008.p.15501-25.4. Myers EN et al.Management of invertedpapilloma.Laryngoscope 1990; 100:481-90.5. Bielamowiez S,et al.Inverted papilloma of Headand neck. The UCLA update. OtolaryngologyHead Neck Surg 19 93; 109:71-6.6. Podo J et al, Laryngoscope.2009 Jan 9;114:106-12.7. Lang j. paranasal sinuses. In clinical anatomyof nose and paranasal sinuses. Stuttgart, NewYork: Thime, 1989:56.8. The frontal sinus. In Gorge G.B,editors.Scott-Browns Otorhinolaryngology, Head & NeckSurgery, 7 th ed. London, HodderArnold,2008.p.15501-25.9. Ringertz N. Pathology of malignant tumoursarising in nasal and paranasal cavities andmaxilla. Otolaryngol 1983; 27:31-42.10. Vrabec PD.The Inverted Papilloma: A Clinicaland Pathological Study. Laryngoscope 1975;85:186-220.JMS * Vol 25 * No. 2 * May, 2011 79

ORIGINAL ARTICLELaparoscopic Tubal ligation: a comparison between inj saline and injlignocaine sprayed on the fallopian tube in relieving pain1N. Jitendra Singh, 2 L. Chaoba Singh, 1 Th. Nonibala Devi, 3 Th. Bidhumukhi Devi, 3 Ch. Manglem SinghAbstract:Objective: The present study is to observethe efficacy of relieving pain by spraying 1.5ml of inj 2% lignocaine over the fallopian tubesin laparoscopic tubal ligation. Methods : Inthis study 100 patients attending the PostPartum Centre RIMS, Imphal Manipur forlaparoscopic tubal ligation were selected atrandom ( at the age group 20 to 40 yrs). Thestudy period was from January 2007 to June2008. The patients were randomly divided intotwo groups of 50 each. Group A received injNormal Saline and Group B received inj 2%lignocaine. The drugs were sprayed over thefallopian tube and Fallop ring were applied.Results: All the patients in Group B who weresprayed with 2% xylocaine experienced nopain during and after the tubal ligation. Butwhereas in Group A experienced of abdominalcolicky type of pain. Conclusion: Tuballigation by spraying the tubes with 2%lignocaine is simple, safe, painless and canbe managed at the minimal cost.Key words:- Laparoscopic tubal ligation, 2%lignocaine, spinal (Lumbar) needle No. 23G,spraying.1. Assoc Prof, Dept of Post Partum Center,2. Registrar, Dept of Anaesthesia, 3. Prof , Dept ofObs and Gynae, RIMS ImphalCorresponding authorDr N Jitendra Singh, Associate Professor, Dept of PostPartum Center, RIMS80IntroductionLaparoscopic tubal ligation is being done forthe last many years at various hospitals andprivate clinics all over the World. But thesimilar findings were that, apart from patientswho receive general Anaesthesia / Spinal orepidural anaesthesia every patientsexperienced some sort of colicky pain andexpressed it in the form of wining movement,writhing, moan or shouting etc during ligationof the tubes, in spite of receiving various painkiller drugs like injections pethidine, morphine,pentazocin & phenergan, diclofenac etc.intramuscularly or intravenously.The agony of these women stimulated us toinvestigate any painless method that can bepracticed as OPD procedure. This study hadbeen carried out at random trial to find out howmuch pain could be reduced by spraying thefallopian tubes with injection 2% lignocaine.Materials and MethodsAfter obtaining approval by institutional ethicalcommittee and informed written consent, 100(hundred) patients of ASA I and II grades, agebetween 20-40 yrs who attended the PostPartum Centre, Regional institute of MedicalSciences, Imphal, Manipur for laparoscopictubal ligation from Jan 2008 to June 2010 wereselected for the study. Patients withneurological diseases, bleeding disorders,psychiatric disorders, on chronic painmedication were excluded from the study. Atthe preoperative room, patients werefamiliarized with the recording of postoperativepain using 10 cm visual analog scale (VAS)JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEanchored at one end by “ no pain at all” and atthe other end by “worst pain imaginable”. Theywere randomly divided into two groups of 50(fifty) each.Groups A- Laparoscopic Tubal ligation ( LTL)following spraying of the tubes with 3ml of injNormal Saline.Group B- LTL following spraying of the tubeswith 3ml of inj 2% lignocaine.All the patients were premedicated with injAtropine 0.6 mg I.M. and inj Diclofenac 75 mgI.M. 15 minutes before the procedure. At thepreoperative room intravenous (IV) accesswas established and inj 5% dextrosecommenced. Patients were monitored withHeart Rate, Non Invasive Blood Pressure,ECG and Peripheral Oxygen saturation(SpO2) intra operatively. For the bettervisualization and to avoid injury to the bladdereach of the patients were advised to passurine before putting in the lithotomy positionon the operation table. With aseptic andantiseptic precaution per vagina (P/V)examination was done and a small cervicaldilator no. 9/10 or 5/6 was introduced to guidethe uterus for better visualization duringlaparoscopic ligation.After cleaning the abdomen under aseptic andantiseptic procedure infra-umbilical incisionabout 2 cm in length was made after localinfiltration of the skin with 2% lignocaine. It wasfollowed by insertion of verses needle andcreation of pneumoperitoneum.After introducing trochar and cannula,laparoscope was introduced and a lumbarpuncture needle no 23G was introduced 1.5to 2 inches above the symphysis pubis underthe vision of laparoscope to avoid injury tobladder and then the tip of the needle wasdirected over the tubes.In Group A, about 1.5 ml of inj Normal Salinesprayed over each fallopian tube. After theinterval of 3 min the Fallop ring was appliedIn the Group B, about 1.5ml of 2% lignocainesprayed over each fallopian tube. After theinterval of 3 min the Fallop ring was applied.VAS score were recorded at the time of ligationof the tube, 30min, 60min, 90minpostoperatively. Any adverse effects during theprocedure were recorded.Results: -The groups were similar in respect to age,weight, height and ASA status (table 1)Table 1. Patient characteristicsGroup A (mean)Age (Yr) 37.3 35.5Weight (Kg) 52 53.6Height (cm) 149.2 150.7ASA grade I/II 24/26 20/30Group B (mean)Table II shows the visual analogue scale painscore. In Group A, it was observed wining andwrithing movements during the procedure(ligation). They expressed VAS score of 5-8with mean of 6.8 at the time tube ligation andexperienced post operative pain (VAS score3-6) for more than one hour. 38 patients couldnot leave the hospital within 1 to 2 hours and12 patients even 2 hours post-operatively(Table III). Some of these patients need antispasmodic injections.In the Group B, average VAS score was 3.1at the time of tube ligation. Postoperativelyalso they recorded significantly lower VASscore 2-4. The entire patient in this groupcould leave the hospital within 2 hour.Table II. Visual analogue scale: pain scores ofthe groupsTime Group A (mean) Group B(mean)At the time of ligation 6.8 3.130 min 5.5 360 min 5 2.590 min 3.3 2Age and parity of the patients had no relation to the degree ofpain.Table III Discharge from the hospitalGroup A( n=50)< 1 hour 0 361-2 hours 38 14> 2 hours 12 0Group B (n=50)JMS * Vol 25 * No. 2 * May, 2011 81

ORIGINAL ARTICLEDiscussion:-Laparoscopic sterilization is a common daycase procedure. It is, however, known to beassociated with more post operative pain dueto the effects of clips or rings applied duringthe procedure to the fallopian tubes. This paincan delay or prevent discharge from thehospital. In Europe and America laparoscopictubal ligations are usually done under spinal /general anaesthesia. Various studies hadbeen carried out to observe and post operativeeffect of intra peritoneal instillation /mesosalpinx infiltration of local anaesthetic (e.g. lignocaine, bupivacaine ).Wheatley SA et al 1 noticed that topicalapplication of bupivacaine to the fallopian tubesduring laparoscopic sterilization was an easyand effective contribution to the managementof pain in the immediate post-operative periodafter day case laparoscopic sterilisation. Intheir study all the patient received generalanaesthesia during the procedure which wasdifferent from our study.The data of Kaplan P et al 2 support the valueof topical bupivacaine applied to the serosalsurface of the fallopian tubes for the reductionof postoperative pain after outpatientlaparoscopic mechanical (band or clip) tuballigationTool Al et al 3 studied topical bupivacineinstillation to the patients undergoinglaparoscope ligation with silastic bands underGA and found that post-operative pain wasreduced significantly.Benhamon D et al 4 found that intra peritonealinstillation of 80 ml of 0.5% lignocaine withepinephrine combined with musosalpnixinfiltration (lignocaine 2%) during tubal ligationunder GA produced effective, long lasting postoperativeanalgesia. Analgesia requirements,nausea, vomiting and time to return to normaldaily activation were significantly reduced.Garwood S et al 5 , observed that instillation of1% lignocaine into fallopian tubes reduced painscores in awake patients who undergolaparoscopic sterilization with Filishic clipsand reduced the analgesia required. Hisfindings were comparable with our findingsexcept that we used 2% lignocaine instead of1% lignocaine and Fallope rings instead ofFilshic clips. We also observed that the painscores (visual analog scales) were very muchlower in groups who received lignocaine.Wittels B et al 6 found that injection of 1/VKetorolac, metoclopromide and infiltration ofthe incised skin and uterine tubes with 0.5%bupivacaine in addition to either spinal orepidural anaesthesia during post partum tuballigation could eliminate pain, nausea, vomitingand cramping and maintain good analgesiafor 7 days post operatively.DreherJ.K. et al 7 found that administration of200 mg of inj ropivacaine through the umbilicalport following laparoscopic sterilizationsignificantly reduced post operative pain,nausea and parental analgesia requirements.In all the above studies the authors usedgeneral /spinal or epidural anaesthesia inaddition to the instillation of the tubes withvarious anaesthetic agents. In our technique,we used only topical application of injlignocaine and found to be useful with noadverse effects.Conclusion: - From the above study it hasbeen shown that spraying of the fallopiantubes with 2% lignocaine is very mucheffective in reliving pain during and after theprocedure. It is cost effective technically easyand does not take much time.82JMS * Vol 25 * No. 2 * May, 2011

ORIGINAL ARTICLEReference1. Wheatley SA, Millar JM, Jadad AR. Reductionof pain after laparoscopic sterilisation with localbupivacaine: a randomised, parallel, doubleblindtrial. Br J Obstet Gynaecol1994;101:443–6.2. Kaplan P, Freund R, Squires J, Herz M. Controlof immediate postoperative pain with topicalbupivacaine hydrochloride for laparoscopicFalope ring tubal ligation. Obstet Gynecol1990;76:798–8023. Tool Al, Kammerer-Doak DN, Nguyen CM, etal. Postoperative pain relief followinglaparoscopic tubal sterilization with silasticbands. Obstet Gynecol 1997;90:731–44. Benhamou D, Narchi P, Mazoit JX, FernandezH. Postoperative pain after local anestheticsfor laparoscopic sterilization. Obstet Gynecol1994;84:877–805. Garwood S, Reeder M, Mackenzie IZ,Guillebaud J. Tubal surface lidocaine mediatespre-emptive analgesia in awake laparoscopicsterilization: a prospective, randomized clinicaltrial. Am J Obstet Gynecol. 2002Mar;186(3):383-86. Wittels B, Faure FA, Chowes R, Maowarch A,Hibbarch J, Principe D, Toledano AY. Effectiveanalgesia after bilateral tubal ligation. AnaesthAnalg1998; 87(3):619-23.7. Dreher JK, Nemeth D, Limle R. Pain relieffollowing day case laparoscopic tubal ligationwith intraperitoneal ropivacaine: a randomizeddouble blind control study. Aust NZ ObstetGynaecol 2003 Nov; 40(4):434-7.JMS * Vol 25 * No. 2 * May, 2011 83

REVIEW ARTICLEINVISALIGN: Is it the epitome of orthodontics?1Angela Laithangbam, 2 Waikhom Robindro SinghIntroductionAdults with orthodontic problems are oftenaverse to wearing traditional appliances withwires, bands and brackets, mainly becauseof esthetic concerns. 1 In 1998, the first clinicaltrial of orthodontic tooth movement using atechnique which provided an agreeablesolution to this inherent limitation ofconventional orthodontics was conducted.This technique, called the Invisalign andcreated by the Align Technology Inc. using asoftware programme, employs a series ofclear, overlay-type removable appliancescalled “aligners”, that fits over the buccal,lingual/palatal and occlusal surfaces of theteeth. 2 Kesling and Ponitz, at different times,had used similar appliances in the past toinduce minor tooth movement. In 1993,Sheridan and others introduced the Essixappliance, but the method required laborious,manual repositioning of the teeth on the studycastwith each increment of tooth movement. 3The Invisalign technique photo-scans a singleimpression of the patient’s dentition and usescomputer-aided-design and computer-aidedmanufacturingtechnology to create a finalsetup, project stages of tooth movement from1. Ex-house, Deptt.of Dentistry, 2. Asst. Prof, Deptt ofDentistry, RIMS, Imphal.Corresponding address:-Dr. W. Robindro Singh, Asst. Prof. Department ofDentistry. RIMS, Imphal84the initial state to the final state, and finallycreate a series of clear aligners which canbe worn to move teeth in small increments. 1Current techniquePatient Selection: A candidate for treatmentwith the Invisalign System should havecompletion of growth with fully eruptedpermanent teeth. There is no agerequirement, but the ability to comply with thetreatment regimen of 20-22 hours per day ismandatory. 1Records: Once a patient is determined to bea good candidate for Invisalign treatment, theusual orthodontic records are taken, includingstudy casts, bite registration with maximumintercuspation, intraoral photographs, andradiographs.Polyvinylsiloxane impressionmaterial must be used for taking impressionand for bite registration. 1Fabrication of Aligners: The maxillary andmandibular impressions, bite registration,photographs, and x-rays in addition to a webbasedtreatment prescription form are sentto Align Technology Inc. Align Technologyproduces a three-dimensional digital modelof each dental arch after the impressions aresubjected to a CT scan and, using thesedigital models, a software programme followsthe doctor’s instruction to simulate toothmovement and performs a “virtual treatment”.A graphic version of the treatment is thenmade available on “ClinCheck” for the clinicianto download. 1,4 Once the result of the virtualtreatment is approved, the set of digitalmodels representing steps of the virtualJMS * Vol 25 * No. 2 * May, 2011

REVIEW ARTICLEtreatment are transferred to a cast productionfacility, where a stereo lithographic model foreach step is fabricated. The stereolithographic models are sent to a separateproduction facility, where the clearpolyurethane aligners are formed over themodels . 4 Each aligner is about 0.030 inch thickand each in the series incorporates a smalladjustment, allowing for 0.25-0.33 mm ofmovement with the change of each aligner.The number of aligners required for a patientdepends on the number of stages required tocomplete the treatment. 1 The aligners are thendelivered to the clinician with instructions foruse. The patient wears each pair of alignersfor one to two weeks at 20-22 hours per day,before moving on to the next pair in the series. 1Interproximal reduction: Interproximalreduction (IPR), to obtain space for aligningcrowded teeth, is often a part of the invisaligntreatment, the amount of interproximalreduction being dependent on the doctor’sprescription. 4 A new protocol has outlined anautomatic staging of the IPR to assure thatIPR is done only when required at theappropriate sites. Simultaneous movementsof all teeth using expansion instead of IPR toprovide visible space for correction ofcrowding is also part of the new protocol. 5Bonded attachments: The use of bondedattachments along with the aligners greatlyincreases the span of tooth movementincluding torque of roots, closure of open bitesand correction of rotation. 4 Attachments arecritical in closure of extraction space. 6 A recentprotocol suggests placement ofproportionately sized vertical attachments inthe middle of the crown for derotation andtranslator movement, and 1mm thickhorizontally bevelled rectangular attachmentson premolars during intrusive, extrusive andtorquing movements. 5Current prospectsInvisalign was developed as a treatmentalternative for ClassI malocclusion, with mildto moderate crowding in adults. 7 As per earlierliteratures, the invisalign appliance was mostsuccessful in mild crowding or spacing, deepoverbite problems which could be correctedby intrusion or advancement of incisors,nonskeletally constricted arches that could beexpanded with limited tipping of the teeth, andin mild relapse conditions after fixed appliancetherapy, but showed limitation in more complexsituations like closure of extraction spaces,torquing of roots, derotation, extrusion,interarch mechanotherapy, and correction ofbuccal malocclusions, anterior open bite anddeep overbite in Class II and Class III cases. 2,8-10Later reports showed that those complexsituations could be successfully treated. 5, 6 Itwas reported that tipping movement of thetooth can be routinely achieved with theinvisalign system while extrusion, bodilymovement through extraction spaces andmolar distalization of more than 2mm, areless predictable. 2 Excessive tipping was notedwhile closing extraction spaces. 9,11 Stagingof tooth movements may be done enablingcombination movements to occursimultaneously for each tooth, with the tooththat needs to move the most determining theminimum number of stages required. 5 Lately,a combination treatment approach to complexcases, using a short phase of fixed applianceor auxiliaries in addition to the aligners,enhances the feasibility to treat almost alltypes of orthodontic problems. 4,12Clinical implications - Invisalign versusfixed appliancePatient acceptability: The transparent,almost invisible aligner which is inconspicuouswhile wearing is its primary advantage whichmotivates more adults towards orthodontictreatment. 1 There is a psychological wellbeingknowing that the aligners can be removed forsocial purposes. 2 Invisalign scores over thefixed appliance in terms of patient comfort,soreness of teeth and mucosal irritation. 5Clinician involvement: The invisaligntechnique is largely dependant upontechnology with limited role for clinicians. 3‘ClinCheck’ provides a default scenario anddefault rates of movement for different typesof malocclusions and teeth concerned. 4 Theclinician’s role includes initial assessment,diagnosis, treatment planning and completionof pretreatment records, all of which must besent to the Align Technology Inc., California.The virtual treatment set-up provided byJMS * Vol 25 * No. 2 * May, 2011 85

REVIEW ARTICLE‘ClinCheck’ is downloaded in order to evaluatethe final positioning of the teeth and check forany required modification. 1, 3 Monitoring toverify whether the tooth movement is trackingwith the series of aligners is mandatory.Tracking failure implies that the toothmovement is not corresponding with that ofthe ‘ClinCheck’. 4Clinical outcome: Though there werenumerous case reports, no scientific evidenceor published data existed in any professionaljournals about the outcome of invisaligntreatment to allow any comparison with thefixed appliance treatment and to support theindications and contraindications of Invisaligntreatment. 4,13,14 Based on the reports ofexperienced users, the invisalign technique,as it exists today, fell short of the completerange of tooth movement possible with thefixed appliance. 4 Very recent studies reportedsome shortcomings in the clinical results ofinvisalign treatment as compared to thetraditional braces. 15-17Treatment time: A period for documenting thecase is required before treatment, the lag timebetween formulating a treatment plan andinserting the appliance being upto 2 months.Incomplete treatment due to delay in deliveryof the aligners have been reported. 3 Patientsneed to be upgraded to a new set of alignersin their treatment series every 2 weeksrequiring more frequent recall visits. 3 In a studyreport, traditional appliances took an averageof 35.92 months with a maximum of 96months while invisalign takes between 12-189, 15,18months .Patient compliance: Being a removalappliance, patient’s compliance is critical. 3Since each aligner has to be worn a minimumof 20-22 hours a day, for a total of 400 hoursfor each aligner, it is presently recommendedonly for adults. It should be removed only wheneating, drinking hot beverage, brushing andflossing. 3Posterior dental intrusion: Intrusion ofposterior teeth ranging from 0.25mm to 0.5mmcould be observed due to the double thicknessof the pair of aligners covering the occlusalaspect, compensation of which is done during86the retention period by removing part of the1, 2, 19aligner covering the occlusal surface .Periodontal implications: As plaque makesthe aligners cloudy and more conspicuous,invisalign users are extra-conscious about thepresence of plaque and oral hygiene, therebyimproving the periodontal health. Theremovability of the appliance facilitates properoral hygiene unlike in fixed appliance therapywhich is usually associated with plaqueaccumulation and gingivitis. 20,21 While teethmobility typically increases during conventionalorthodontic treatment, the Invisalign techniqueassures that teeth that require no treatmentare held stationary without receiving anyforce. 20 Aligners avoid the side effects of fixedappliances on gums and supporting tissues,15, 22, 23and the shortening of dental roots.ConclusionComputerized diagnosis is firmly entrenchedin orthodontics but the concept ofcomputerized treatment in orthodontics isnew. A computerized treatment plan fed withthe data of a patient has the potential of anintelligent system working towards an idealtreatment to bring the teeth, the arches andthe two jawbones into perfect alignment. Thelaser scan creating a 3D surface map of theteeth, the software executed ‘virtual treatment’done by simulating tooth movement, and thesoftware aided conversion of the virtualtreatment stages into laser-cured plasticmodels on which the aligners are fabricated,are important aspects of the Invisaligntechnique which can be evolved for executingthe treatment plan of more complexorthodontic problems. Now, in its infancy andpending more studies, the invisalign techniquewhich is associated with shortcomings mayinvite disdain from many in the profession.Time-tested and biomechanically proficient,orthodontics associated with bands, bracketsand wires may still exist, even though patientsare esthetically and psychologicallychallenged during the treatment. Yet, in thepresent scenario, when a treatment plan isdigitalized and when technology breeds newtechnology in the blink of an eye, one canforesee a vastly improved invisalign techniqueJMS * Vol 25 * No. 2 * May, 2011

REVIEW ARTICLEcreeping into mainstream orthodontics andtake charge of a wider spectrum of orthodonticproblems. Presently, the software-dependentinvisalign treatment has a limited role for theclinician and is suitable for milder problems,but provides excellent esthetics, ease of use,comfort of wear and superior oral hygieneduring treatment, thereby motivating moregeneral dentists and socially conscious adultsto go for orthodontic treatment.Reference1. Boyd RL, Miller RJ, Vlaskalic V. The invisalignsystem in adult orthodontics: Mild crowdingand space closure cases. Journal of ClinicalOrthodontics 2000; 34(4): 203- 12.2. Vlaskalic V, Boyd RL. Orthodontic treatmentof a mildly crowded malocclusion using theinvisalign system. Australian OrthodonticJournal 2001; 17(1): 41-6.3. Phan X, Ling PH. Clinical limitations ofinvisalign. Journal of Canadian DentalAssociation 2007 April; 73(3): 263-6.4. Proffit W R, Fields HW, Sarver DM.Contemporary Orthodontics, 4 th edition,St.Louis: Mosby; 2007.p.404-7.5. Boyd RL. Esthetic Orthodontic TreatmentUsing the Invisalign appliance for moderate tocomplex malocclusions. J Dent Edu.72 (8):948-67.6. Womack WR. Four-Premolar extractiontreatment with invisalign.case report. Journalof Clinical Oorthodontics2006; 40 (8):493-500.7. Mc Kenna S. Invisalign: technology ormythology? J Mass Dent Soc 2001; 50(2):8-9.8. Joffe L. Invisalign: early experiences. J Orthod2003; 30(4):348-52.9. Bollen AM, Huang G, King G, Hujoel P, Ma T.Activation time and material stiffness of sequentialremovable orthodontic appliance. Part 1: Abilityto complete treatment. Am J Orthod DentofacialOrthop 2003; 124(5):496-501.10. Clements KM, Bollen AM, Huang G, King G,Hujoel P, Ma T. Activation time and materialstiffness of sequential removable orthodonticappliance. Part 2: Dental improvements. Am JOrthod Dentofacial Orthop 2003; 124(5):502-8.11. Miller RJ, Duong TT, Derackhshan M. Lowerincisor extraction treatment with the Invisalignsystem. J Clin Orthod 2002; 36(2):95-102.12. Proffit W R, Fields HW, Sarver DM.Contemporary Orthodontics, 4 th edition, St.Louis: Mosby; 2007.p.673.13. Lagravere MO, Flores-Mir C. The treatmenteffects of invisalign orthodontic aligners: asystematic review. Journal of American DentalAssociation 2005 December; 136:1724 -914. Turpin DL. Clinical trials needed to answerquestions about Invisalign. Am J OrthodDentofacial Orthop 2005; 127: 157-8.15. Humber PV. One hundred consecutiveInvisalign cases analysed. Aesthetic DentistryToday 2008; 2(1):36-41.16. Kuncio D, Maganzini A, Shelton C, FreemanK. Invisalign and traditional orthodontictreatment post-retention outcomes comparedusing the American Board of orthodonticsobjective grading system. Angle Orthodontist2006; 77(5):864-9.17. Djeu G, Shelton C, Maganzini A. Outcomeassessment of Invisalign and traditionalorthodontic treatment compared with theAmerican Board of Orthodontics objectivegrading system. American Journal ofOrthodontics and Dentofacial Orthopedics2005; 128(3):292-8.18. Tsung-Ju H, Yuliya P, Eugene RW. Assessmentof orthodontic treatment outcomes: Earlytreatment versus late treatment. AngleOrthodontist 2005; 75(2):162-70.19. Womack WR, Ahn JH, Ammari Z, Castillo A. Anew approach to correction of crowding. Am JOrthod Dentofacial Orthop 2002; 122(3):310-6.20. Boyd RL. Improving Periodontal Health throughInvisalign. Access 2005 November: 24-6.21. Boyd RL, Leggot PJ, Quinn R, Eakle WS,Chambers D: Periodontal implications oforthodontic treatment in adults with reducedor normal periodontal tissues vs. adolescents.American Journal of Orthodontics 1989;96:191-8.22. Taylor MG, McGorray SP, Durrett S, PavlowS, Downey N, Lenk M, Oxford D, Dolce C,Wheeler TT. Effect of invisalign aligners onperiodontal tissues. Journal of Dental Research2003; 82(Special Issue A):1483.23. Linge BO and Linge L. Apical root resorptionin upper anterior teeth. J Dent Res 1983;5(3):173-83.JMS * Vol 25 * No. 2 * May, 2011 87

CASE REPORTA case report of Guillain-Barre Syndrome in pregnancy1K.Pratima Devi, 2 S. Randhoni Devi, 3 L. Bimolchandra SinghCase HistoryGuillain-Barre Syndrome is a rare occurrencein pregnant women. A 27 years pregnant ladypresented with loss of fetal movementperception and weakness of all the limbs for3 days. The weakness increased to nomovements in both lower limbs but shedelivered a full term intrauterine dead fetusspontaneously. Subsequently, her conditionimproved with supportive care. Guillain-Barresyndrome and its association to pregnancyhad been discussed.A 27 years old patient G 2P 1+0with 38 weeks ofpregnancy was admitted in the department ofObstetrics and Gynecology on 30 th of October2010 with complaint of loss of fetal movementand weakness in all the limbs for 3 days.During the hospital stay for the next two daysthe condition of the patient deteriorated further.There was complete loss of movement oflower limbs and also increased weakness inupper limbs. There was history of commoncold around two weeks back for which shetook medicine. There was no historysuggestive of diarrhea, trauma, joint pains,altered sensorium, convulsions or othersystem involvement. There was no significantpast, family or other obstetric history.On examination, patient was afebrile,conscious, oriented and vitals were normal.On neurological evaluation, tone was foundto be normal in all the limbs. The power inupper limbs was 4/5 bilaterally and 3/5 in lowerlimbs bilaterally. On deep tendon reflexexamination, in upper limbs biceps reflex wasabsent and triceps reflex and supinator reflexwas present. In lower limbs, the deep tendonreflex were absent bilaterally. There was a mildsensory loss from the level of D2D3. Highermental status and cranial nerve examinationwas normal. Per abdomen examination uteruswas term size, cephalic and FHS could notbe localized. Per vaginal examination showedcervical os was closed and partially effaced.Other systemic examination including boweland bladder were normal.On laboratory examination, bloodhaemogram, urine routine, kidney functiontest, liver function test, random blood sugar1. Registrar, 2. Associate Prof, 3. Assistant Prof, Depttof Obst & Gynae.Corresponding author:Dr. S. Randhoni, Associate Prof. Department of Depttof Obstt & Gynae, Regional Institute of MedicalSciences, Imphal, India, Manipur, Pin-795004Fig1. Showing inflammatory axonal neuropathyof sural nerve88JMS * Vol 25 * No. 2 * May, 2011

CASE REPORTFig2. Showing pericapillary lymphocyticinfiltration of the sural nervewere found to be in normal limits.Cerebrospinal fluid examination showed aprotein level of 48mg% which was on a slightlyhigher side and a normal cell count.Transabdominal ultrasound confirmedintrauterine death. Histopathologicalexamination of the Sural nerve on 10 th day ofadmission showed inflammatory axonalneuropathy and nerve conduction studyshowed decreased amplitude and conductionin sensory component over sural nerve (fig 1& fig 2). HIV and CMV serology was negative.A diagnosis of Guillain Barre Syndrome withfull term intrauterine death was made. Aspatient could not afford immunoglobulintherapy, supportive management was done.Labour started spontaneously 2 days afteradmission and delivered a macerated malebaby of weight of 3.7 kg by vaginal route withepisiotomy. Following delivery condition of thepatient improved steadily. She was kept inhospital for 15 days post delivery forobservation and supportive management. Ondischarge patient was stable and had attainedreasonable movement and power (4/5) in allfour limbs and deep tendon reflexes werenormal. She had no residual sequelae at twomonths postpartum follow up.DiscussionGuillain Barre Syndrome (GBS) is aheterogeneous grouping of immune mediatedprocesses generally characterized by motor,sensory and autonomic dysfunction. In itsclassic form, GBS is an acute inflammatorydemyelinating polyneuropathy characterizedby progressive symmetric ascending muscleweakness, paralysis and hyporeflexia with orwithout sensory or autonomic symptoms;however, variants involving the cranial nervesor pure motor involvement are not uncommon.In severe cases, muscle weakness may leadto respiratory failure and involvement of eyemovement, swallowing as well as autonomicfunction. It is possibly less common inpregnancy. 1 The incidence of GBS is very low1.7/100000 population. 2 It is an uncommonneurological disorder associated withdemyelination of the peripheral nerves, moreoften seen in the first few weeks of puerperiumthan in pregnancy. 3 GBS occurs at all ages,but a bimodal distribution with peaks in youngadulthood (15-35years) and in elderly persons(50-75 years) appears to exist. GBS is a rareacquired neurological disorder and is usuallypreceded by a bacterial or viral infection. It hasalso been linked to underlying systemicdiseases, certain malignancies, surgery,pregnancy, trauma, severe infection andtissue transplantation. Up to 60% of patientshave had a preceding upper respiratory illness.However, about 27% of patients with GBS haveno identified preceding illness. Epidemiologicstudies from Japan indicate that, in this region,a greater percentage of GBS cases areassociated with antecedent C jejuni infectionsand a lesser number are related to antecedentCytolomegalovirus infections compared withthat in North America and Europe. Similarly, ithas been reported that 69% of GBS in Dhaka,Bangladesh, have clinical evidence ofantecedent C jejuni infection. Although itspathogenesis is unclear, it is likely to be aconsequence of an immune-mediatedprocess. Risk of prematurity is low, andoccasionally fetal death may occur as is ourcase report. Sensitisation of T lymphocytesto protein in the myelin sheath is necessaryfor disease induction . Patchy areas ofdemyelination occur along peripheral nerves,nerve roots and myelin sheaths as a result oflymphocytic infiltration, causing impairedconduction of action potential leading to slowconduction velocity and conduction blocks. Inaxonal neuropathies, the conduction velocityJMS * Vol 25 * No. 2 * May, 2011 89

CASE REPORTis normal, but the number of functional motorunits is decreased. 4 Cerebrospinal fluid (CSF)protein levels are elevated in the second weekof illness. Within 2-3 weeks of thedemyelination process, the inflammationresolves and re-myelination commences. 5The supporting measures are criticallyimportant to provide optimal treatment.Outcome is generally good, with virtually fullrecovery in 70-80% of the patients. At the timeof delivery expulsive efforts are usually normal,but inadequate, normal obstetric managementcan be used. Unnecessary obstetricintervention should be discouraged. GBS hasno effect on uterine contraction or cervicaldilation. However, ability to bear down may beweakened. Indeed, in the acute phaseinduction of labour or Caesarean section mayprovoke deterioration of the patient’s condition.High maternal and perinatal mortality rate(>10%) is associated with GBS. The deliveryof the baby should improve thecardiorespiratory parameters and aid morerapid recovery. 6 This could have beenresponsible for early recovery in our patientafter the delivery. Apart from conservativetreatment, plasmapherisis and intravenousimmunoglobin are used in severe cases formodifying the disease course. Its role in mildercases is debatable.ConclusionEarly diagnosis and prompt intensivemultidisciplinary supportive care followed byIVIG therapy is better in GBS-complicatedpregnancy and can improve the prognosis ofmother and fetus. Obstetrician must be vigilantif pregnant women complain of generalizedmuscle weakness. Physical andpsychological support is also important forbetter recovery. GBS does not affect theuterine contraction and cervical dilatation. Weneed further studies regarding that the GBSis linked with intrauterine dead or it is just corelation.References1. Brooks H, Christian AS, May AE. Pregnancy,anaesthesia and Gullian-Barre Syndrome.Anaesthesia 2000; 894-8.2. Jiang GX,de Pedro-Cuesta J, StrigardK, OlssonT, Link H. Pregnancy and GBS: a nationwideregister cohort study. Neuroepidemiology 1996;15:192-200.3. Cheng Q, Jiang GX, Fredrikson S, Link H, dePedro-Cuesta J. Increased incidence ofGuillain-Barre syndrome postpartum.Epidemiology1998; 9: 601-44. Hallum A. Neuromuscular diseases. In:Neurological Rehabilitation. Umphred DA, ed.4 th edn. St Louis: Mosby, 2001; 363-415.5. Ropper AH. The Guillain Barre Syndrome. NewEngland Journal of Medicine 1992; 326: 1130-1136.6. Ruchi G, Balbir Ch, T.A.Senthilnathan, et al.Critical care of a pregnant patient with Guillain-Barre Syndrome. Indian J.Anaesth. 2003; 47:50-52.90JMS * Vol 25 * No. 2 * May, 2011

CASE REPORTSuperficial cervical plexus block for total thyroidectomy1L. Chaoba Singh, 2 O. Priyokumar Singh, 3 N. Ratan Singh, 4 N. Jitendra SinghCase presentationA-75-year-old patient presented with a 2½ yearhistory of a painless, progressively enlarginganterior neck swelling, which moves onswallowing. There was no associateddysphagia, change in voice, orthopnoea,paroxysmal nocturnal dyspnoea and no pedaloedema with dyspnoea on exertion. She hadlost considerable weight. She was not adiabetic but hypertensive for the last fifteenyears and on tab amlodipine 5mg once daily.Her physical examination revealed an elderlywoman with an emaciated look. She wasafebrile, not jaundiced and acyanotic. Herpulse was 110 beats/ min, regular, goodvolume and no arrhythmias and a bloodpressure of 130/80 mmHg. The heart soundswere normal. She had a moderate sizeanterior neck swelling, which was nodular andhard in most areas measuring 7 cm by 7 cmwith prominent veins. The air entry wasdiminished on the apical region of the rightside and upper lobe of left lung.The electrolytes and urea and thehaematogical results were within normallimits. Echocardiogram (ECG) shows leftventricular hypertrophy. On chest X- ray, there1. Registrar, Dept of Anaesthesia, RIMS 2. Registrar,Dept of Otolaryngorhinology,RIMS 3. Asst Prof, Deptof Anaesthesia, RIMS, 4. Associate Prof, Dept of PostPartum Centre, RIMS, Imphal.Corresponding authorDr L. Chaoba Singh, Registrar, Dept OfAnaesthesiology RIMS Imphal, drchaoba@gmail.comwas consolidation on left upper lobe and rightapical region with cardiomegaly. CT scanshows multiple bullae on left upper lobe. Therewas a cavity measuring 3.5× 1.5 cm 2 leftapical region with internal content. Multiplecystic lesion on lingual &lower lobe (left) andsmall bullae on the right side. Significantpleural effusion was seen bilaterally. Thethyroid function test results were T3 1.4 nmol/L (1.0 – 3.25), T4 36 nmol/L (65 – 175) andTSH 2.6 mU/L (0.5 – 6.5).Fig 1. Intraoperative procedure under superficialcervical plexus blockThe operative procedure was planned underregional anaesthesia in view of the poorgeneral condition. The patient was put insupine position with a slide head elevation.Bilateral superficial cervical blockade wasgiven using a mixture of 10ml inj 0.5%bupivacaine, 10mls of inj 2% xylocaine withadrenaline 1:200,000 and 10ml normal saline.The patient was lightly sedated with injmidazolam1mg and inj pethidine 25mg duringthe operation. Verbal communication wasJMS * Vol 25 * No. 2 * May, 2011 91

CASE REPORTmaintained with her throughout the procedure.Fig. 1 Anaesthesia was effective, except forminor complaints of pressure symptomsduring mobilization of the gland and posturalaches. Intraoperative haemodynamicparameter, peripheral oxygen saturation weremaintained and the operative procedure wenton uneventfully.DiscussionTraditionally, thyroidectomy is performedunder general endotracheal anaesthesia.Regional anesthesia is another alternative togeneral anesthesia in selected patientsundergoing thyroid and parathyroid surgerywithout compromising the respiratoryfunction 1 . These include inadequateanaesthetic personnel and infrastructure,especially in rural/ semi-urban centres indeveloping countries, growing surgical list,condition of the patient and in some cases ofdifûcult intubation . Thyroidectomy is not verystimulating to patients. A deep plane ofanaesthesia is not necessary and nosignificant muscle relxation is required 2 .Superficial cervical plexus block alone hasbeen found adequate for thyroidectomy as thesuperficial branches are sensory and theremainder of the cervical plexus is motor 1 .The block takes care of the pain of skin incisionand the necessary tissue dissection. Moreoversuperficial cervical plexus block is easier andsafer than the combined superficial and deepcervical plexus block 3 . Some authors 4,5 usedcombine block of both the superficial and deepcervical plexus block. Deep cervical plexusblock is often accompanied by at least subtotalphrenic nerve block 6 , which might bedangerous in a technique of bilateral block.Furthermore, the block places the needlesnear the vertebral artery, which may beaffected by the local anaesthetic.As the patient had multiple cardio-pulmonaryproblems, conduction of the operativeprocedure in the present case underendotracheal anaesthesia was risky. Thepresent technique allows the patient to be alertand able to warn the surgeon of any trespasson the recurrent laryngeal nerve. Hoarseness,crowing or respiratory obstruction during theoperation provides early signs which maysuggest encroachment on the integrity of therecurrent laryngeal nerve. 8ConclusionSuperficial cervical plexus block is simple,safe, effective and cheap procedure for totalthyroidectomy operation.Reference1. Kolawole I.K, Rahman G.A. Cervical plexusblock for thyroidectomy. South Afr. J.Anaesthes Analges. 2003; 9: 10-l72. Yerzingatsian KL. Thyroidectomy under localanalgesia: The anatomical basis of cervicalblocks. Ann R. Coll Surg. Engl. 1989; 71 (4):207 – 10.3. Kulkarni RS, Braverman LE, Patwardhan NA.Bilateral cervical plexus block forthyroidectomy and parathyroidectomy inhealthy and high risk patients. J EndocrinolInvest. 1996 Dec;19(11):714-8.4. Rahman GA, Kolawole IK. Cervical plexusblock for thyroidectomy: experience with agiant goitre: case report. Niger J Clin Pract.2008 Jun;11(2):158-61.925. Mamede RC, Raful H Comparison betweengeneral anesthesia and superficial cervicalplexus block in partial thyroidectomies. BrazJ Otorhinolaryngol. 2008 Jan-Feb;74(1):99-105.6. Fernandez FH. Cervical block anesthesia inthyroidectomy. Int Surg. 1984; 9: 309-311.7. Spanknebel, K., Chabot, J. A, DiGiorgi, M., etal: Thyroidectomy using local anaesthesia: areport of 1,025 cases over l6 years. J. Am.Coll. Surg. 2005; 201: 375-385.8. Musa A.A, Lasisi O.A, Fatungase, Oyegunle.General and regional anaesthesia forthyroidectomy in rural/semi-urban Nigeriancentres. East African Medical Journal. 2009;86 (6): 287-90.JMS * Vol 25 * No. 2 * May, 2011

CASE REPORTGorham’s Disease of Humerus: A case Report.1Sanjib Waikhom, 2 I. Ibomcha Singh, 3 T. Umesh, 4 P. PunyabatiCase report.A 4 years old boy weighing 9.5 kg was admittedin orthopaedics unit II of RIMS hospital withcomplaints of pain and swelling of the left armsince 6 months. The swelling started at theupper part and gradually increased in size toinvolve the whole arm. He had mild fever offand on. There was no history of any dischargefrom the swelling. He was treated as a caseof chronic osteomyelitis 5 months back withantibiotics without any relief from symptoms.Physical examination revealed poor nutritionalstatus, gross pallor, a circumferential swellingLegend:Figure 1: A- Showing clinical picture of patient. B-Showing x-ray of affected limb. C- Showinghistopathological appearance under high powermagnification.1. Assistant Professor. Dept. of Orthopaedics,2. Professor. Dept. of Orthopaedics, 3. PGT. Dept. ofOrthopaedics, 4. Professor. Dept. of Pathology, RIMSImphal.Corresponding author :Prof. Dr. I. Ibomcha Singh, Department ofOrthopaedics, RIMS, Imphalinvolving the whole left arm with plenty of dilatedveins (Fig 1-A). No discharging sinus or ulcerwas present. There was abnormal mobilityindicating a pathological fracture. Routineinvestigations were: Hb- 6gm%, TLC- 7600,Chest x-ray – NAD. Plain x-ray of the partshowed complete absorption of the humerusexcept for a small portion at its distal part (fig1-B). No periosteal reaction was detected.Differential diagnosis of Gorham’s disease,skeletal angioma, angiosarcoma andhereditary osteolysis were considered.Incisional biopsy was taken. Tissue was veryvascular and bled profusely. Histopathologicalexamination (fig 1-C) showed featuressuggestive of Gorham’s disease withabundant thin walled blood vessels with someamount of inflammatory cells. No malignantcell was detected. Culture for pyogenicorganism and fungus was negative.Treatment options of á-interferon therapy andsurgical management with limb amputationwas explained to the patient’s parents. Dueto financial reasons, the parents refused anyform of treatment and patient was dischargedon request.DiscussionGorham’s disease, also known as Gorham-Stout syndrome, massive osteolysis,vanishing bone disease, phantom bonedisease, haemangiomatosis or lymphangiomatosisof bone, is a rare disease of unknownaetiology and is characterised by uncontrolledproliferation of blood vessels or lymphaticsleading to osteolysis of bone. It was describedJMS * Vol 25 * No. 2 * May, 2011 93

CASE REPORTby Gorham and Stout in 1955 for the first time. 1More than 200 case reports are published inEnglish medical literature after this initialreport. But there is no established treatmentregimen till today.It is common in children and young adults.Common sites are mandible, ribs, scapula,humerus, pelvis and femur. 2 It can also involvethe spine. The usual clinical presentation is adull aching swelling which gradually increasesin size for some months or sometimes someyears. When thoracic cage is involved, patientcan develop chylous pericardial or pleuraleffusion. 3 Clinical course varies from deathto spontaneous cure. 4,5 There is no laboratorytest to confirm it. Radiographically, earliestchanges are foci of intramedullary andsubcortical lucency resembling osteoporosis.More advanced changes are tapering of boneends or complete disappearance of the bone.Sclerosis or osteoblastic activity andperiosteal reaction are usually absent. Thereis no evidence of infection, either pyogenic orfungal. Histopathologically it is characterisedby abundant thin walled blood vessels orlymphatics with a few inflammatory cells.Some amount of osteoclasts are also usuallypresent. Heyden et al 6 opined that perivascularcells might be osteoclast precursors andassociated with bone resorption as theydemonstrated strong acid phosphatase andleucine aminopeptidase activities. Heffer et al7proposed a diagnostic criteria, (1) a positivebiopsy for angiomatous tissue, (2) absenceof cellular atypia, (3) minimal or noosteoblastic response and absence ofdestrophic calcification, (4) evidence of localprogressive osseous resorption, (5) nonexpansile,non ulcerative lesion, (6) absenceof visceral involvement, (7) osteolyticradiographic pattern, (8) negative hereditary,metabolic, neoplastic, immunogenic orinfection etiology.Recommended treatments are á-2binterferon, surgical resection withreconstruction or amputation, radiotherapyand medication with bisphosphonates. 8,9Alpha-2b interferon is used because of its antiangiogenicproperty. The role of radiotherapyis controversial and there is a risk ofsecondary malignancy. 10 Grafted bone forreconstruction usually gets absorbed if thedisease is not controlled. 5 Because of itsrarity, no definite treatment regime can beestablished till today. We report this casebecause of its rarity. Since the generalcondition is very poor, the best treatmentoption for this patient would be amputation.References1. Gorham WL, Stout AP. Massive osteolysis(acute spontaneous absorption of bone,phantom bone, disappearing bone): its relationto hemangiomatosis. J Bone Joint Surg 1955;37:985-1004.2. Patel DV. Gorham’s or massive osteolysis. ClinMed Res 2005; 3:83-6.3. Prasanna R, Sankar J, Ramachandra P.Gorham’s disease: vanishing bone syndrome.Indian paediatrics 2009; 46:255-6.4. Campbell J, Almond HGA, Johnson R. Massiveosteolysis of the humerus with spontaneousrecovery. J Bone Joint Surg 1975; 57:238-40.5. Woodward HR, Chan DPK, Lee J. Massiveosteolysis of the cervical spine: A case reportof bone graft failure. Spine 1981; 6:545-9.946. Heyden G, Kindblom LG, Nielson JM.Disappearing bone disease. J Bone Joint Surg1977; 59:57-61.7. Heffer L, Doker HC, Carter BL, Feeney JE.Perspectives on massive osteolysis: Report ofa case and review of the literature. Oral MedOral Pathol 1983; 55:331-43.8. Hagberg H, Lamberg K, Astrom G. á-2binterferon and oral clodronate for Gorham’sdisease. Lancet 1997; 350:1822-3.9. Cannon SR. Massive osteolysis: A review ofseven cases. J Bone Joint Surg 1986; 68:24-6.10. Dunbar SF, Rosenberg A, Mankin H, RosenthalD, Suit HD. Gorham’s massive osteolysis: Therole of radiation therapy and review of theliterature. Int J Radiat Oncol Biol Phys 1993;26:491-7.JMS * Vol 25 * No. 2 * May, 2011

CASE REPORTThrombocytopenic purpura with extrapulmonary tuberculosis1Th. Brojendro Singh, 2 Th. Bhimo Singh, 3 N. Biplab, 4 LalbiakdikiIntroduction:Tuberculosis (TB) continues to be thepredominant cause of morbidity and mortalityin the developing world. The disease affectsall the organ systems and presents in variouspathologic disease states. It is associated withnumerous hematological manifestations.There is scant case reports of TB associatedwith thrombocytopenia in the literature. Severethrombocytopenia with pulmonary TBpresenting as thrombocytopenic purpura israre. An immune basis for TB induced Immunethrombocytopenic purpura (ITP) wassupported by the presence of either plateletantigen specific antibodies or platelet surfacemembrane IgG. 1 Here we report a rare caseof extrapulmonary TB presenting asthrombocytopenic purpura.Case history:A 22-year-old male was admitted withcomplaints of mild to moderate fever for onemonth and epistaxis for about 3 weeks. Hehad come back from Delhi 1 month backwhere he was studying. He had no history ofalcoholism or substance abuse. There wasno history of taking any medication or anyknown systemic illness in the past.1. Asst. Prof. 2. Professor 3. Associate Prof. 4. PGT,Department of Madicine, RIMS, Imphal.Corresponding author :Dr. N. Biplab, Associate Prof., Department of Madicine,RIMS, ImphalOn clinical examination he was found to befebrile (103 æ% F). He had pallor with purpuricspots over the trunks, arms and neck. Therewere enlarged lymph nodes, 4X5 cms,matted, firm and tender in the cervical andbilateral axillary regions. Liver was enlarged6cms below right costal margin at the midclavicular line, firm and non-tender. Spleenwas 2 cms below left costal margin, firm andnon-tender. Rest of the systemic examinationwas normal.Investigations (on admission)Haemogram: Haemoglobin= 9.7 gm%TLC =4320/cumm (N67, L29, M04)platelets= 20,000/cummESR= 70mm1 st hrMalarial parasite- NegativeWidal test- NegativeLiver Function Test: Bilirubin =0.4mg%SGOT =51 IU/L; SGPT=15 IU/LProtein=7.0(A-3.5, G-3.5)GGT=50IU/LAlk. Phosphatase =84IU/LKidney Function Test: Creatinine=1.2mg%urea=55.0mg%sodium=136mEq/Lpotassium=4.1mEq/L.Urine routine: normal.Blood sugar: Fasting=83mg%Post prandial=134mg%JMS * Vol 25 * No. 2 * May, 2011 95

CASE REPORTChest X-Ray PA view showed mediastinalmass with bilateral hilar nodes.Chest X-Ray: mediastinal mass with hilarnodetomography (CT) thorax showed extensiveanterior mediastinal soft tissue mass withextension into right pleura with scatterednodular parenchymal lesions. Needle biopsy(CT guided) of anterior mediastinal mass wasinconclusive. FNAC of cervical and axillarylymph nodes also showed nonspecificreactive lymphadenitis.Fever persisted inspite of 1 week of antibiotics,Axillary and cervical nodes increased in sizeand number. Finally, excision biopsy of axillarylymph nodes was done which shows mattednodes with caseation on gross examination.Microscopic examination showed numerouswell formed epithelioid granulomas withLanghans giant cells and extensive caseationnecrosis.Chest X-Ray:mediastinal masswith hilar nodeCT thorax: anteriormediastinal softtissue massCourse in the hospital:Patient was initially put on Pipperacillin/Tazobactum and later on added Amikacin asfever was not controlled. He was furtherinvestigated for the cause of fever andthrombocytopenia:Microphotograph of lymph node, low powerview showing areas of caseation and fewLanghans giant cells.Blood and Urine C/S- sterile.Hepatitis B surface antigen and Hepatitis Cantibody, Retrovirus antibody, Mycodot,Dengue, Toxoplasma and Cytomegalovirusand Herpes Simplex antibodies were allnegative.ANA, RA factor were negative.USG abdomen did not show any mesentericlymphadenopathy.On 3 rd day of admission his haemoglobin was10g%, TLC- 3570/cumm (Lympho=120,granulocyte=2230), platelets-15,000/cumm,ESR-78mm1st hr, no abnormal cells. Bonemarrow was normal reactive. Computed96Microphotograph of lymph node, high powerview showing Langhans giant cell, epithelioidcells and lymphocytes.JMS * Vol 25 * No. 2 * May, 2011

CASE REPORTA final diagnosis of Tubercular axillarylymphadeitis with thrombocytopenia wasmade.TreatmentAntitubercular treatment (rifampicin,Isoniazide, Pyrazinamide and Ethambutol)was started. Fever was controlled within aweek and general condition improved andrepeat haemogram after 1 week of treatmentshowed Hb=11.4, TLC=4,000 andPlatelet=35,000.Haemogram at 1 month: Hb-11.7g%, TLC-5050/cumm (Lympho1120, Granuloctye2230), platelets-80,000/cumm, ESR-75mm1st hr.Chest X-Ray after 1 month treatmentDiscussionCases of thrombocytopenia associated withpulmonary TB had been reported rarely in theliterature. A case report from Japan reportedimmune thrombocytopenia with pulmonary TBin a 22 yrs old patient. 2 Another case ofimmune thrombocytopenia with pulmonary TBin 48 year old female presented asgeneralized purpura was reported. 3 FahirOzkalemkas et al reported a case of a 29year-old male who was presented withimmune thrombocytopenia-inducedhemoptysis, macroscopic hematuria andgeneralized petechiae. The patient was foundto have clinical, microbiological andradiological evidence of active pulmonarytuberculosis. The immune thrombocytopenicpurpura was successfully treated with antituberculousdrugs combined withcorticosteroids and high dose immuneglobulin therapy. 4 Four cases of TB andimmune thrombocytopenia withoutantitubercular drug administration werereported. All patients had elevated antiplateletantibodies level with normal bone marrowcytology. 5 A 24 yrs male havingthrombocytopenia with pul. TB was reportedfrom India. 6 There is one report ofsupraclavicular lymph node TB presentingwith immune thrombocytopenic purpura by LUHua et al. 7It has been postulated that anti plateletantibodies generated in some cases of TBinduced ITP are secreted by lymphocytes. 8,9The immunological results in immunethrombocytopenia complicating pulmonarytuberculosis is that, although IgG was boundto the patient’s platelets, there were nocirculating antiplatelet antibodies that reactedwith normal donor platelets. This is not thepattern seen in idiopathic thrombocytopenicpurpura, where antibodies generally react withnormal platelets. 1 Thrombocytopenia mayresult from a direct or indirect toxic effect ofinfection or, less likely, the TB may haveactivated latent idiopathic thrombocytopenicpurpura. 10This may be the first case report of T.B.lymphadenitis presenting as thrombocytopenicpurpura from this part of the country.Conclusion:Incidence of TB is still high in our country,more so with increasing incidence of HIV andmay present with different hematologicmanifestations. Thrombocytopenia can be thehaematological manifestation of TB apart fromchronic Hepatitis B and C infection. Furtherstudy is needed to explore the pathophysiologyand immunological abnormalities in TB relatedimmune thrombocytopenic purpura.JMS * Vol 25 * No. 2 * May, 2011 97

CASE REPORTBibliography:1. Boots RJ, Roberts AW, McEvoy D. Immunethrombocytopenia complicating pulmonarytuberculosis. Thorax 1992; 47: 396-7.2. KImori T, Hideyuki K, Akira M, Hitoshi Y.Immune thrombocytopenic Purpura associatedwith pulmonary tuberculosis. J Hepatol Res.2006; 19.3. Spedini P. Tuberculosis presenting as immunethrombocytopenic purpura. Haematologica2002; 87: ELT09.4. Fahir Ozkalemkas, Ridvan Ali, Atilla Ozkan,Tulay Ozcelik, Vildan Ozkocaman, Esra Kunt-Uzaslan et al. Tuberculosis presenting asimmune thrombocytopenic purpura. Ann ClinMicrobiol Antimicrob. 2004; 3: 16.5. Madkaikar M, Ghosh K, Jijina F, Gupta M,Rajpurkar M, Mohanty D. Tuberculosis andimmune thrombocytopenia. Haema-tologica2002; 87 (08):ELT38.6. S. Verma, S. K. Verma. Thrombocy-topenicPurpura with Pulmonary Tuberculosis: A CaseReport. The Internet Journal of PulmonaryMedicine ISSN: 1531-2984. Accessed10.11.2010.7. LU Hua, WANG Yong-ren, JI Ou, XU Wei,ZHANG Jian-fu, FAN Qin-he, LI Jian-yong.Supraclavicular lymph node tuberculosispresenting with immune thrombocytopenicpurpura. Chinese Medical Journal2007;120(19): 1730-31.8. Tsuro K et al. Immune ThrombocytopenicPurpura associated with PulmonaryTuberculosis. Intern Med 2006; 45: 739-42.9. Jurak SS, Aster R, Sawaf H. Immunethrombocytopenia associated withtuberculosis. Clin Pediatr. 1983; 22: 318-9.10. D. W. Cockcroft et al, Canadian MedicalAssociation Journal; 115,(9) 871-73.98JMS * Vol 25 * No. 2 * May, 2011

CASE REPORTHerpes zoster in a healthy adult:presentationsReport of a case with oro-cutaneous1Ng. Sangeeta, 2 W. Robindro Singh, 3 O.Brajachand SinghThe caseThe case concerned a well built 43yrs old maleof medium height with no history of pastmedical illness and with a negative HIV status.He was not associated with any habits liketobacco or prohibitive drugs, though he tookalcohol occasionally. His blood sugar,complete hemogram, KFT, and LFT profilewere within normal limits. He had a history ofmultiple tooth extraction related to dental cariesand hence was partially edentulous. On hisfirst visit, his main complaint was pain on theFig 2: unilateral distribution of vesicles covered withplague in the oral cavity.Fig 3: improvement of the oral lesions after 7 days oftreatment.Fig 1: erythematous swelling with overlying vesicleson the left side of the face.1. Asst. Prof., 2. Associate. Prof. Deptt. of Dentistry,RIMS, Imphal., 3. Prof. & Head, Department ofDentistry, RIMS, Imphal.Corresponding authorDr. W. Robindro Singh, Asst. Prof. Deptt. of Dentistry,RIMS, Imphal – 795004, Manipur.Email: www.waikhomro@.yahoo.inleft cheek with a couple of painful white lesionsin the mouth associated with malaise. The oralulcers which were present in the buccalmucosa were non-specific, irregularlyshaped, whitish in colour, with anerythematous border and without thepresence of vesicles. Considering it to be anapthous ulcer we prescribed an analgesic,antiseptic mouth wash, a topical anaestheticgel, and a multivitamin. Three days later, hecame back complaining that his pain andlesions had become worse after theJMS * Vol 25 * No. 2 * May, 2011 99

CASE REPORTtreatment. On examination at the second visit,erythematous elevations were present in thetemporal and the malar region following adistinctive pattern, with overlying vesiculareruptions (fig.1). A couple of similar but smallerlesions were seen on the upper lip and chin.Some of the cutaneous vesicles had becomecloudy because of pustulation. No skin lesionswere seen on the right half of the face. Intraorally,there were multiple vesicles of whitishor yellowish white colour, some arranged inclusters, predominantly over the lateral aspectof the palate, retromolar region and residualridge. The laterally situated lesions in thepalate were covered with a yellowish whiteplaque. Few lesions were present in thebuccal mucosa and over the mid palatal raphebut there were no crossover to the contralateral side (fig 2). The case was shown to adermatologist because of the cutaneouspresentations and a diagnosis of herpeszoster was made based on the clinicalmanifestations. No specific diagnostic testwas done except for the routine investigationsand the test for retroviral antibody. Thetreatment regimen for the patient consists ofTab Microvir (Famciclovir), 250mg, giventhrice daily for seven days, along with ananalgesic, a neurotropic vitamin, and achorhexidine mouth wash. A clotrimazole oint.was also applied to the oral lesions.Prednisolone was added three days after theinitiation of the antiviral drug as there was notmuch symptomatic relief till then. The protocolfor prednisolone was 5 tabs. (Dispred 4mg)given simultaneously once daily for 3 days,tapered to 4 tabs for the next 3 days, followedby 2 tabs. daily for another 3 days, and finally,one tab daily for the last 3 days. Follow up ofthe patient one week after the initiation of thetreatment showed marked improvement of theoral (fig.3) and dermal lesions (fig.4). Therewas marked reduction in the intensity of painand the patient felt much better. Tiny newvesicular eruptions were sparsely scatteredon the face as scabs were formed at the sitesof the older lesions on the 7 th day of treatment.The signs and symptoms completelydisappeared by the twelfth day of the initiationof the treatment.DiscussionHerpes Zoster (HZ) is a painful rash resultingfrom the reactivation of the varicella zostervirus (VZV) in the dorsal root ganglia. Itcommonly involves C 3,T 5,L 1, L 2, and theophthalmic division of the trigeminal nerve. 1The maxillary and mandibular division of thenerve were less commonly involved but it iswhen these two divisions were involved thatorofacial lesions are present. 2 Motor nervesmay be involved but they are usuallyunnoticed. 2 The risk factors include increasingage, immunosuppresion, intrauterineexposure to varicella, and outbreak of varicellaat an age younger than 18months. HZ iscontagious to those who have not hadvaricella or have not received the varicellavaccine. 1 There were reports of its occurrencein healthy young adults though. 3 Our case isreported because of its occurrence in anunsuspecting healthy individual, because ofthe marked oral presentations, because of therapid resolution of the condition withoutcomplications, and because of theconsiderable time lag in the dermalmanifestations after the appearance of the orallesions. Precipitating factors includeimmediate trauma, immediate exposure to X-ray radiation, immunosuppressive drugs ordisease, and malignancies. 4 In our case theattack began for no apparent reason as therewas no exposure to any of these factors. Sincepain is one of its significant presentations, itshould be differentiated from other conditionswhich cause orofacial pain like pulpitis. 5 Postherpetic neuralgia (PHN) is the most commoncomplication of HZ, which is defined as painlasting longer than 30 days after thedisappearance of the mucocutaneous lesion. 2Other complications include secondaryinfections of the lesions leading to cellulitis,ocular infection leading to blindness, motorparesis and encephalitis. 1 Early diagnosis andtreatment of HZ may offer the best chance ofavoiding PHN while early treatment of thiscomplication, once it develops, provides thebest chance of pain relief. 6 A study involving1071 elderly people showed that PHN has apredilection for females, older age groups,people who had severe rash during thedisease, and for people who were alone duringthe acquisition of HZ. 7 Diagnostic aids include100JMS * Vol 25 * No. 2 * May, 2011

viral culture, immunofluorescent antigenstaining,serologic demonstration of varicellazoster specific immunoglobulin M, andpolymerase chain reaction (PCR)techniques. 1 Correlation of clinical symptomswith serologic demonstration of antibody titremay be required in cases of diagnosticchallenge when pain is present withoutmucocutaneous lesions, as it occurs in zostersine eruptione or during the prodormal period. 2In our case, no specific diagnostic test wasconsidered necessary because of thedistinctive clinical presentations. The nature,course and pattern of distribution of thecutaneous lesions in our case were similar tothose reported in the literature. But there wasno scarring at the site of the cutaneous lesionsin our case. Acyclovir, famciclovir andValacyclovir are the antiviral drugs availablefor HZ. 1,2 They are found to accelerate healingand reduce pain. 2 Some literatures proposethe 50-50-50 rule: 50 hours or less since onsetof lesions, to be given in 50 years or older and50 or more lesions, to improve theeffectiveness of the antiviral drugs. 1 Steroidsgiven with acyclovir provide greater reductionin pain and discomfort requiring less time inleading the patient to normal activity. 1 It wasalso our experience in our case where therewas significant improvement in the orallesions after the addition of oral prednisoloneon the third day of treatment.ConclusionCASE REPORTPresence of oral lesions without dermallesions, in an unsuspecting individual, duringthe early stage of HZ can mislead the diagnosisand management of the condition. Earlydiagnosis and prompt management with anantiviral agent and a corticosteroid, as shownin our case, can markedly decrease themorbidity of the disease, and also avoidcomplications like post herpetic neuralgia.Considering this and the fact that it can becontagious to those who are not vaccinatedor previously unexposed to the varicella zostervirus, the importance of ruling out HZ whennonspecific painful oral ulcers occur in young,healthy individuals cannot beoveremphasized.References1. Mounsey AL, Matthew LG, SlawsonDC.Herpes Zoster and Post herpetic Neuralgia:Prevention and Management. Am FamPhysician. 2005; 72:1075-80.2. Greenberg MS. Ulcerative, Vesicular, andBullous lesions. In: Greenberg MS, Glick M,editors. Burket’s oral medicine diagnosis andtreatment.10 th edn.New Delhi: Harcourt, IndiaPvt. Ltd.; 2003.p.50-84.3. Mc Kenzie CD, Gobetti JP.Diagnosis andtreatment of orofacial herpes zoster: report ofcases. J Am Dent Assoc.1990; 120: 679.4. A text book of oral pathology. Shafer WG, HineMK, Levy BM, Tomich CE, editors, 4 th edition.New Delhi: Harcourt India Pvt.Ltd.; 1993.p.55-7.5. Lopes MA, de Souza Filho FJ, Jorge J Jr, deAlmeida OP. Herpes Zoster as a differentialdiagnosis of acute pulpitis. J Endod. 1998;24:143-4.6. Manke JJ, Heins JR. Treatment of Postherpetic Neuralgia. J Am Pharm Assoc.1999;39: 217-21.7. Wood MJ, Shukla S, Fiddian PA, Crooks RJ.Treatment of acute Herpes Zoster: Effect ofearly versus late therapy with acyclovir andvalacyclovir on prolonged pain. J InfectDis.1998; 178(Suppl 1): 81- 4.JMS * Vol 25 * No. 2 * May, 2011 101

CASE REPORTMultiple Anomalies in the Lower Limb—A Case Report1Irungbam Deven Singh, 2 Th. Naranbabu Singh, ,3Y. Ibochouba Singh, 4 M. Matum SinghCase ReportDuring the dissection of an old male cadaver,multiple—venous, muscular and neuralanomalies—were found. The left small (short)saphenous vein instead of draining into thepopliteal vein, ran further upwards and passedover the short head of biceps femoris beingpartly buried in it and joined a tributary of theprofunda femoris vein (Fig.1A). Nocommunication was found between the smallsaphenous vein and popliteal vein. The leftpopliteal vein had two duplications 2.5 cm and7 cm in length (Fig.1B). The anterior tibialveins, after union, drained into the lateral limb.The posterior tibial veins, after union, drainedinto the medial limb of the lower duplication.The left plantaris muscle had two heads(Fig.2A). The lateral head represented thenormal head and the medial head was muchsmaller and tendinous arising from the obliquepopliteal ligament. The tibial nerve, poplitealvessels passed in between the two heads ofplantaris. The small saphenous vein andplantaris on the right side were normal. Theschiatic nerve on the right side divided nearthe apex of the popliteal fossa. The commonperoneal nerve was almost as thick as thetibial nerve and gave—at about 3 cm from itsorigin—a communicating branch to the tibialnerve (Fig.2B).Demonstrator, 2. Professor, 3. Professor & Head,Regional Institute of Medical Sciences, ImphalCorresponding author:Dr. M. Matum Singh, Associate Prof. Department ofAnatomy, RIMS, Imphal.Fig. 1. A: Short saphenous vein (arrow); B: Duplicatedpopliteal vein (arrows I&II).Fig. 2. A: Two heads of plantaris (arrows; open arrow—accessory head); B: Communication between commonperoneal and tibial nerves (arrow).DiscussionSmall saphenous vein usually drains into thepopliteal vein and it does so in 57% of thecases. 1 The termination into profunda femorisvein has been rarely reported. Jiji PJ et al 2reported a case of a popliteal vein which, afterreceiving the small saphenous vein, gave abranch that continued as profunda femorisvein. Duplication of the popliteal vein has beenreported to be present in 5% of the lower limbswith equal age or sex incidence and laterality. 3To our knowledge, a plantaris having twoheads has not been reported earlier. Themuscle is regarded to be evolutionarilydisappearing. It could be absent on one orboth sides. It is hard to find any literature onany direct communication between the tibialnerve and common peroneal nerve. Normally,102JMS * Vol 25 * No. 2 * May, 2011

CASE REPORTthe common peroneal and tibial nervescommunicate indirectly through the peronealcommunicating and sural nerve. In the presentcase the common peroneal nerve was almostthe same size as the tibial nerve suggestingthat those fibres which are destined to go withthe tibial nerve joined the common peronealnerve, getting separated and then rejoining thetibial nerve.Important clinical conditions affecting the veinsof the lower limb include varicosity andthrombosis and many others. Interpretationof diagnostic procedures like Duplexultrasonograghy or venography and surgicaltreatment of these pathological conditionsrequire sound knowledge of the normalanatomy of these veins as well as theirvariations. The saphenous vein draining intothe profunda femoris vein could cause wronginterpretation in venography. Venousduplications have been known to predisposeto deep vein thrombosis as a result of thedecrease in blood velocity. 3 Furthermore, suchduplications are likely to lead to missedthrombus if only a single vein is visualized invenographies.References1. Kosinski C. Observations on thesuperficial venous system of the lowerextremity. J of Anatomy 1926;60:131-142.2. Jiji PJ, D’Costa S, Prabhu LV, Nayak SR,Skariah S. A rare variation of the profundafemoris vein in the popliteal fossa.Singapore Med J 2007; 48(10): 949.3. Quinlan DJ, Alikhan R, Gishen P, SidhuPS. Variations in lower limb venousanatomy: implications for us diagnosis ofdeep vein thrombosis. Radiology 2003;228:443–448.JMS * Vol 25 * No. 2 * May, 2011 103

CASE REPORTAccidental subdural block in spinal anesthesia – A report1N.Ratan Singh, 2 Laithangbam PKS, 3 L.Chaoba Singh, 4 R.K Shanti DeviCase ReportA 35 year old male patient (ASA grade I, 55kg, height 5 ft 3 inches) was posted for rightpyelolithomy. He had no other medicalcondition in particular and laboratoryinvestigation findings were within normal limitsbefore the surgery. The patient was not onany medication and the operative procedurewas planned under spinal anesthesia (SA).The baseline blood pressure was 120/80 mmHg with a pulse rate of 78 beats /min. Afterpreloading with Ringers lactate solution,subarachnoid block was initiated in the rightlateral position with a Quincke 25G spinalneedle in L 2-3interspace in the midline with2.0 ml of 0.5% Bupivacaine (heavy). He waskept in the right lateral position for about 2-3minutes until the block level had reached T 6level on the right side; and then, he waspositioned in the supine position forapproximately 1 minute before finallypositioning in the left lateral kidney position.The sensory block level was checked bypinprick, which had reached T 6level on theleft side. The patient had no discomfort whenthe kidney bridge was applied and skin incision1. Asst. Professor, 2. Associate Professor, 3. Registrar4. Professor, Department of Anaesthesiology, RegionalInstitute of Medical Sciences, ImphalCorresponding authorLaithangbam PKS, Asst. ProfessorDepartment of Anaesthesiology,Regional Institute of Medical Sciences, Imphal –795004e-mail: drlaithangba@gmail.comwas made. However, after about 10 minutes,the patient complained of mild pain duringmobilization of the kidney and the attendinganesthetist gave intravenous injectionKetamine 25 mg and midazolam 0.5 mg toprovide sedation.Then, after about 20 min of the administrationof the intrathecal drug, the patient was notresponding to verbal command or to deeppain. The blood pressure was recorded at 100/70 mm Hg with a heart rate of 70/min. Onexamination, the pupils were reacting to light,but there was downward gaze with medialrotation of the left eyeball. The head end ofthe operation table was elevated and afterabout 40 minutes, the patient was respondingto deep pain with movements of the rightupper limb. At this time, the patient openedhis eyes to verbal command and a normalgaze of his left eye was observed. The musclepower in the left upper limb at this stage wasgrade 4 and his sensory level was at T 2onthe left side. In the next 5 to 10 minutes, thepatient was fully alert and his left upper limbmuscle power was grade 5 with a sensorylevel at T 5.W hen questioned about the loss ofconsciousness, he expressed that he heardthe verbal commands but could not answer.Around four hours after the loss ofconsciousness, the spinal block had totallyworn off, with grade 5 muscle-powers in allfour limbs. The patient was shifted back tothe ward where the anesthetist visited him inthe next few days.104JMS * Vol 25 * No. 2 * May, 2011

CASE REPORTThe patient was discharged 1(one) week afterthe incident with no further complaints.DiscussionThe safety of spinal anaesthesia lies in thefact that the patient is conscious throughoutanaesthesia and is not exposed to the hazardsaccompanying endotracheal intubation andexposure to the various inhalation andinjectable drugs used in general anesthesia1. Patients can lose consciousness in thepresence of a total spinal block, 2 usuallycharacterized by severe hypotension; 3 but,loss of consciousness with stablehaemodynamic parameters in spinalanaesthesia is unusual. Moreover, pointsagainst unilateral high block in this case wereabsence of haemodynamic instability andrespiratory compromise.A patient with ASA grade I patient, like thepresent case undergoing subarachnoid blockshould never lose consciousness even if hewas subjected to sedation. The effect ofintravenous sedation with inj. Ketamine 25 mg+ midazolam 0.5 mg would not have lastedthat long as was observed in the present case.There was no haemodynamic change exceptfor the drop in the peripheral saturation to 89%for which oxygen supplementation wasprovided. Apart from this, the patient also hadno history of diabetes, epilepsy or that of anypsychotic medications to cause loss ofconsciousness.Hence, a subdural spread was suspected,sthe signs of cranial extension of localanesthetic (LA) have been cited as difficultyin breathing, 4 arm weakness and dysarthria.5In our case, the loss of consciousness after20 min of relatively uneventful spinal blockadewas the first sign of a possible cranialextension. The loss of consciousnessprecluded detailed sensory and motor testing,but the gradual and progressive return offunction indicated that it could have beencompatible with anaesthetic blockade thatreceded with time. During subarachnoid block,the duramater is intentionally pierced with thesubdural space being traversed beforepiercing the arachnoid mater and the chancesof placing the needle in the subdural spacemay be greater than with epidural anesthesia. 6The type of the needle and a long beveledneedle used during SA may further increasethe chances of part placement in the subduralspace. 7Lubenow et al 8 described two major and threeminor clinical criteria for the diagnosis of asubdural block. Major criteria included anegative aspiration test and unexpectedextensive sensory block, while minor criteriaincluded a delayed onset by 10 minutes ormore of a sensory or motor nerve block, avariable motor block and sympatholysis outof proportion to the administered dose of localanaesthetic. A subdural injection should beconsidered to have occurred if both of themajor criteria and at least one minor criterionare present.Recently, another diagnostic algorithm wasproposed by Hoftman and Ferrante 9 . Theyanalysed the clinical presentation of all theradiologically proven cases of subdural blockand suggested a four-step diagnosticalgorithm to detect subdural block.Although we do not have radiological evidenceto prove that this incident was caused bysubdural blockade, we believe that the clinicalevents that occurred in our patient are inkeeping with the suggestions of Collier C 3and Reynolds F et al 10 . These includerelatively stable arterial pressure, slow onsetof symptoms after 20 min and completerecovery after almost 1 hour.The findings of transient medial rotation anddownward gazing of the left eyeball in thepresent case could be due to the paresis ofthe VI cranial nerve. But, literatures suggestparesis 11 /palsy 12 of the VI cranial nerve a fewdays after central neuroaxial blockade withdelay in recovery, requiring at least 3 weeksto 3 months or more. In the present case, theparesis was a transient phenomenon whichwas detected on the table, and could probablybe the first reported case of transient paresis/palsy of VI cranial nerve to our knowledge. Thisis not surprising, considering the small doseof LA we have used (2.0 ml) and the possiblesmall amount of LA that might have percolatedinto the subdural space.JMS * Vol 25 * No. 2 * May, 2011 105

CASE REPORTThe possibility of pulmonary embolism or airembolism was ruled out in this case as therewas remarkable haemodynamic stabilityalong with absence of any dyspnoea or chestpain.ConclusionIn this paper, we have reported the loss ofconsciousness in a patient who had asuccessful spinal block, which turned out tobe a possible accidental subdural block.REFERENCES:1. Report on confidential enquiries into maternaldeaths in the United Kingdom 1988–1990.London, HMSO, 1994.2. Gillies IDS, Morgan M. Accidental total spinalanalgesia with bupivacaine. Anaesthesia 1973;28: 441–53. Collier C. Total spinal or massive subduralblock? Anaesth Intens Care 1982; 10: 92–34. Skowronski GA, Rigg JRA. Total spinal blockcomplicating epidural analgesia in labour.Anaesth Intens Care 1981; 9: 274–65. Philip JH, Walter UB. Total spinal anesthesialate in the course of obstetric bupivacaineepidural block. Anesthesiology 1976; 44: 340–16. Abouleish E, Goldstein M. Migration of anextradural catheter into the subdural space. Acase report. Br J Anaesth 1986; 58:1194-77. Stevens RA, Stanton Hicks MD. Subduralinjection of local anesthetic: a complication ofepidural anesthesia. Anesthesiology 1985; 63:325–68. Lubenow T, Keh-Wong E, Kristof K, IvankovichO, Ivankovich AD. Inadvertent subduralinjection: a complication of an epidural block.Anesth Analg 1988; 67:175-99. Hoftman NN, Ferrante FM. Diagnosis ofunintentional subdural anesthesia/analgesia:analyzingradiographically proven cases todefine the clinical entity and to develop adiagnostic algorithm. Reg AnesthPain Med2009; 34:12-16.10. Reynolds F, Speedy HM. The subdural space:the third place to go astray. Anaesthesia 1990;45: 120–311. Lopez-Soriano F & Rivas-Lopez FA. VIthCranial Nerve Paresis After Spinal Anesthesia. The Internet Journal of Anesthesiology. 2002Volume 5 Number Date of assessment 14/11/201012. Inal MT & Celik NS. Abducens Nerve PalsyAs a Complication of Spinal AnesthesiaFollowing Knee Arthroscopy . The InternetJournal of Anesthesiology. 2007 Volume 13Number 2. Date of assessment 14/11/2010106JMS * Vol 25 * No. 2 * May, 2011

CASE REPORTRoberts - SC phocomelia syndrome – a case report1Ch.Shyamsunder Singh, 2 Jayanta K. Poddar, 3 L.Ranbir Singh, 4 A.Meina SinghA full - term female with a birth wt. of 3.4 kg.,length - 43 cm, head circumference of 37cm.was born to a 22 yr.-old 2 nd gravida motherby an emergency cesarean section forobstructed labour. The family history wasnegative for consanguinity and congenitalmalformations. There was history of antenatalexposure to nimesulide, tinidazole andnorfloxacin during the early first trimester. Themother in the first few weeks of pregnancy,unaware of her pregnancy and suffering fromdysentery was treated with the above threedrugs in recommended doses for five days.Physical examination revealed multiple birthdefects. Symmetrical limb defects includedbilateral upper limb amelia, shortened anddeformed lower limbs, syndactyly of the right4 th and 5 th toes. Cranio-facial abnormalitiesincluded brachycephaly, occipitalencephalocele, low set ears, cleft lip andpalate, hypertelorism, flat nose andmicrognathia (Fig – 1). Left leg was rotated180 degrees laterally and there wasplanovalgus of the left foot. Left 5 th toe wasabsent. Genital examination revealed clitoralenlargement. The baby died soon after birth.1. Assistant Professor, 2. Ex –PGT, 3. Professor &Head Department of Pediatrics, RIMS, 4. Professor& Head, Department of Immuno-Haematology andBlood Transfussion.RIMSCorresponding authorProf.L.Ranbir Singh, Department of Pediatrics, RIMS,Imphal .e-mail - drranbirlai@yahoo.co.inFig: 1 Frontal and Dorsal view showing typicalcraniofacial defects and symmetrical limbdeficiencies.Radiological skeletal examination wasperformed which showed bilateral absenceof bones of upper limbs, bilateral proximalfemoral focal deficiency(PFFD) and bilateralabsence of fibulae. Complete autopsy wasperformed. Heart showed absence oftricuspid orifice and valves and kidneys hadfocal areas of immaturity with poorly formedducts and presence of blastomal tissues.Cytogenetic and chromosomal study couldnot be performed as facilities were notavailable.Discussion:Robert syndrome (RBS) is a rare geneticdisorder characterized by pre -and post-natalgrowth retardation, cranio-facial abnormalitiesand symmetrical limb reduction of variableJMS * Vol 25 * No. 2 * May, 2011 107

severity. 1 Since its first description in 3 affectedsiblings of first-cousin Italian parents by RobertJB 2 in 1919 several cases of Robertssyndrome (RBS) with a wide range of severityin clinical presentation have appeared in theliterature. 3 RBS is a rare disease with onlyabout 150 cases reported so far, and inheritedas an autosomal recessive manner. RBSoccurs as a result of chromosomal damageduring cell division which has been interpretedas a human mitotic mutation syndromeleading to secondary developmental defects.The cytogenetic abnormalities associatedwith this disorder consist of prematurecentromere division (PCS) and separation ofthe heterochromatic regions [heterochromatinrepulsion (HR)] in most chromosomes in allmetaphases. Vega et al had demonstratedthat ESCO2 is the only gene with documentedRBS – causing mutations. 4Our case represents a severe form of Robertssyndrome. The range of severity in clinicalpresentation differs from case to case andalso among siblings affected by RBS. 5 Thisvariable phenotypic expression could beexplained by the cell damage occurring atdifferent points of time of organogenesis,though in our case the final cytogeneticdiagnosis could not be made due to lack offacilities. Cases with severe skeletalabnormalities usually result from cell damageduring first few days of conception. Variousassociated anomalies includingcardiovascular defects - atrial and ventricularseptal defects have been reported. Howevertricuspid atresia is not found in the availableliterature. Van den berg 6 introduced a ratingsystem for quantitating severity depending onthe clinical presentation. Cases with featuresof RBS are being reported following ingestionof drugs by pregnant women. Strolls et al 7described a case with features of RS born toa mother who took clonidine, anantihypertensive drug during pregnancy. Heraised the question of a relationship betweenthe child’s abnormalities and clonidine.Pourissa M et al 8 reported a case of RobertSC Syndrome born to a diabetic mother witha history of exposure to mebendazole andglibenclamide. However, in the availableliterature, there is no report of Robertssyndrome resulting from prenatal exposureto nimesulide, tinidazole and norfloxacin. Ascongenital lower limb deficiencies result froma disturbance of growth and development ofthe embryonic limb occurring by 3 to 7 weekspostconception, the drugs taken by the motherduring the period of organogenesis could havecaused genetic mutation and produced thedefects. The mother, in the first few weeks ofconception, unaware of her pregnancy, tookthe drugs in the usual recommended dosesfor dysentery for five days. The drugsparticularly norfloxacin is thought to producecartilaginous defect in lower animals and theother two drugs are also contraindicatedduring first trimester of pregnancy. So, we alsowould like to raise the question of the possibilityof the drugs taken by the mother producinggenetic mutation and causing the defects.The outcome of Roberts syndrome isuniformly poor. Most babies with severecraniofacial and limb abnormalities have beenstill born or have died soon in early childhood.Occasional mildly affected patients survivebeyond infancy, most developing severegrowth retardation and mental deficiency. 3As there are no effective therapeuticstrategies, genetic counseling for thosefamilies with a earlier birth of RBS is required.Ultrasound examinations combined withcytogenetic testing or prior identification of thedisease causing mutations in the family arerequired for at risk pregnancies. 9 Chorionicvillous sampling for cytogenetic studies duringthe first trimester of pregnancy should beoffered. Amniocentesis or cordocentesisduring the second and third trimesters, isrequired to confirm the diagnosis prenatally.Detection of the characteristic chromosomalabnormalities or identification of two ESCO2mutations establishes the diagnosis of RBSin individuals with suggestive clinical findings. 3The risk of recurrence in families with apositive history of RBS is approximately 25%.RBS patients who survive beyond infancyneed corrective surgery for facial and limbdefects. Prosthetic devices forunderdeveloped and missing limbs can beused to increase independence. Othertreatment modalities are according toindividual needs.108JMS * Vol 25 * No. 2 * May, 2011

References :1. Van Den Berg DJ,Francke U. Roberts syndrome: a review of 100 cases and a new rating systemfor severity. Am J Med Genet 1993;47:1104-1123.2. Roberts JB.A child with double cleft lip andpalate, protrusion of the intermaxillary portionof the upper jaw and imperfect development ofthe bones of the four extremities.Ann Surg1919;70:252-255.3. Gordillo M, Hugo V and Ethylin WJ. “Robertssyndrome.” Gene Reviews. 2009. University ofW ashington,Seattle,2009.www.ncbi.nlm.nih.gov.4. Vega H, Waisfisz Q, Gordillo M, Sakai N,Yanagihara I, Yamada M, van Gosliga D,Kayserili H, Xu C, Ozono K, Jabs EW, Inui K,Joenje H. Roberts syndrome is caused bymutations in ESCO2, a human homolog ofyeast ECO1 that is essential for theestablishment of sister chromatid cohesion. NatGenet. 2005;37:468–470.5. da Silva EO, Bezerra LH. The Robertssyndrome. Hum Genet 1982;61(4):372-374.6. Van Den Berg DJ, Francke U. Robertssyndrome : A review of 100 cases and a newrating system for severity Am J Med Genet.1993;15:1104-1123.7. Stoll C, Levy JM, Beshara D. Roberts syndromeand clonidine. J Med Genet 1979;16(6):486-487.8. Pourissa M, Refahi S, Garaaghagi N. Prenataldiagnosis of Robert/SC syndrome in adiabetic mother with a history of mebendazoleand glibenclamide intake. Acta Medica Iranica2003;41(3): 147-149.9. Kennelly MM, Moran P. A clinical algorithm ofprenatal diagnosis of Radial Ray Defects withtwo and three dimensional ultrasound. PrenatDiagn. 2007;27:730–737.JMS * Vol 25 * No. 2 * May, 2011 109