NBE-Journal VolIV, Jan To Ocotber 2009 - WUPD

Contents
Editorial
Understanding of small, minimum and large sample size 1
and its clinical implications
S.N. Dwivedi
Facing the challenge of tobacco in India - 3

National Tobacco Control Programme
R.K. Srivastava, Jagdish Kaur
Commentaries
Tele-ophthalmology: a new initiative of 8
National Programme for Control of Blindness (NPCB)
Sandeep Sachdeva
Paradigm shift in pathology education in India 11

Karuna Rameshkumar, Bipin Batra
Occupational health and safety 14

R. Rose, Sandeep Sachdeva
Review articles
Preeclampsia and associated risk factors 21
Betsy Varughese, Manoj Dhingra, Rani Kumar, Renu Dhingra
Renal Tubular Acidosis(RTA) in children 27

Sanjiv Nanda, Ashish Marwah, Poonam Marwah
Recurrent pain abdomen in children 33

Venkatesh.C, VishnuBhat.B
Neonatal Necrotizing Enterocolitis 37

Prabha, Vishnu Bhat
Original Article
Assessment of bronchial liability on exposure to isometric 46
Exercise during different phases of menstrual cycle
Mona Bedi, V P Varshney, Shilpa Khullar
Availability and consumption pattern of iodised salt in 50

the villages of ballabgarh, district, Haryana
Radhika Sood, Misha Sharma, Chandandeep Gujral
Correspondence
Quality control program for HIV diagnostic laboratories – an Indian experience 58
Dimple Kasana
Intra abdominal desmoid tumor presenting with bleeding 59

Ram Prakash Gupta
49th Annual conference of the college of Surgeons of West Africa 62

J.K. Bnerjee
Klippel Trenaunay Weber syndrome : a case report 63

Deepak Badgujar, M K Mittal, Abhay Aryan, Sheetal Kaur
N K Bhambri, B B Thukral
Understanding of Small, Minimum and Large Sample Size
1
and Its Clinical Implications Editorial
S.N. Dwivedi
Department of Biostatistics, All India Institute of Medical Sciences Ansari Nagar, New Delhi
basic important question account of objective under study, known as a minimum sample size
A under planning of a case of one-tail (one-sided) or required to answer that specific

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

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

2 Vol. IV, No. 1-5, January-October 2009
Facing the challenge of tobacco in India -
2
National Tobacco Control Programme Editorial
R.K. Srivastava, Jagdish Kaur
Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India,
Nirman Bhawan, New Delhi
T obacco is the foremost

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

3
contributes to deforestation in Tobacco Control legislation The supply reduction strategies
three ways: forests cleared for Government of India enacted include :
cultivation of tobacco, fuel wood “Cigarettes and other Tobacco z Combating illicit trade in
stripped from forests for curing Products (Prohibition of tobacco
of tobacco and forest resources Advertisement and Regulation of z Providing alternate livelih-
used for packaging of tobacco, Trade and Commerce, oods to tobacco farmers and
tobacco leaves, cigarettes, etc. Production, Supply and workers.
Tobacco growing depletes soil Distribution) Act (COTPA),
nutrients at a much faster rate than In 2008, WHO came out with a
2003” to discourage the
many other crops, thus rapidly policy package to reverse the
consumption of tobacco in the
decreasing the fertility of the soil. tobacco epidemic, namely,
country. The specific provisions
Tobacco is a sensitive plant and MPOWER package. Specific
of this Act include:
therefore, requires huge chemical interventions for the countries,
z Prohibition of smoking listed in the package are :
inputs and fertilizers. Such
public places.
chemicals may run off into water M-Monitor tobacco use
bodies, contaminating local water z Prohibition of direct and
indirect form of advertising, P-Protect people from tobacco
supplies, causing excessive smoke
leeching etc. Frequent contact with promotion and sponsorship
and spraying of chemicals, and of cigarettes and other tobacco O-Offer help to quit tobacco use
storage of tobacco in the products. W-Warn about the dangers of
residential premises of farmers z Prohibition on sale of tobacco
have adverse health effects.A cigarette or other tobacco E-Enforce ban on tobacco
Health Cost Study conducted by products to minors (<18 advertisement and promotion
ICMR/AIIMS in 1998-99 years of age) and within 100
R-Raise taxes on tobacco products
showed that cost of treatment of yards of educational
just three diseases caused by institutions. National Tobacco Control
tobacco use i.e. cancers, lung Program
z Mandatory depiction of
disease and cardiovascular diseases pictorial warnings on all National Tobacco Control
far exceeded the economic tobacco products packs. Program (NTCP) was conceived
benefits from tobacco. It was keeping in view the provisions
International Obligations
estimated that the economic under “Cigarettes and other
estimate/health cost of these India also ratified the WHO- Tobacco Products (Prohibition of
three diseases was Rs. 30,833 Framework Convention on Advertisement and Regulation of
crores (extrapolated to rates of Tobacco Control (FCTC) in 2005. Trade and Commerce,
2002-03), which far exceeded the FCTC provides a key set of Production, Supply and
revenue collected (approx. Rs. recommendations for reduction Distribution) Act (COTPA),
27,000 crore) for the same year. in demand as well as reduction in 2003” and spirit of FCTC, by
According to another study, the supply of tobacco products.The bringing together appropriate and
total economic cost of tobacco use demand reduction strategies effective tobacco control strategies
amounted to US $ 1.7 billion for include to tackle the tobacco problem in
the year 2004. The study took into z Price and tax measures the country. The main objective is
account four major categories of z Non price measures (statu- to bring about greater awareness
tobacco related diseases – tory health warnings; about the harm effects of tobacco,
tuberculosis, respiratory diseases, comprehensive ban on and institute a regulatory
cardiovascular diseases and advertisement, promotion mechanism including laboratory
neoplasms. This was 16% more and sponsorship; cessation facility for effective monitoring
than the total tax revenue from facilities, tobacco product and implementation of anti
tobacco. regulation etc.). tobacco initiatives at State/

District level. The pilot phase of For the 11 th Five year plan, z Opposition of tobacco cont-
the NTCP was launched in 2007- Ministry of Finance approved the rol initiatives by tobacco
08 in 18 Districts of 9 States (two following components of NTCP : industry.
districts in each state) i.e. Assam, z Capacity building of states/ z Providing alternative livelih-
West Bengal, Madhya Pradesh, districts for promoting oods to large number of
Tamil Nadu, Karnataka, Gujarat, awareness and for workers engaged in tobacco
Rajasthan, Delhi, Uttar Pradesh. monitoring/enforcement of farming, manufacturing and
The main components of the COTPA will form a part of sale.
programme were : the state health delivery z Lack of inter-sectoral
z Setting up of State Tobacco
mechanism under the overall coordination- various stakeh-
Control Cells framework of National Rural older departments work in
Health Mission (NRHM).
z District Tobacco Control isolation.
z Establishment of one apex
Programme with z Lack of regulatory mechanism
research lab and five tobacco
components of training, at the national level to
testing labs.
school programme, cessation spearhead the tobacco control
facilities, IEC and monitoring, z National public awareness activities and monitor the
evaluation and reporting of campaign. implementation of tobacco
tobacco control laws. z Research in alternate crops for laws and tobacco control
z IEC campaign
tobacco will be undertaken by programme.
ICAR/DARE (Indian The way forward
z Setting up of tobacco testing
Council for Agricultural
labs India Global Health Professional
Research). Research projects
z Research
Student Survey (GHPS), 2006,
for alternate livelihoods to
persons engaged in tobacco carried out amongst third year
z Monitoring and Evaluation,
sector will be taken up by medical and dental students,
including Global Adult reported the lifetime prevalence of
Tobacco Sur vey – India Ministry of Rural
Development through their cigarette smoking (ever smoked a
(GATS) cigarette, even one or two puffs)
various ongoing schemes.
District Tobacco Control and use of other tobacco products
z Global Adult Tobacco Survey.
Programme was expanded to as 28.2% and 22% respectively.
cover 24 new districts (in 12 states) Challenges in implementation Over 70% of these students
during 2008-09. of NTCP wanted to quit tobacco. Nearly
Budget for the Pilot phase of z Low priority to tobacco 91% students expressed the need
NTCP during 2007-08 was 30 control initiatives by the policy for specific training on cessation
crores and it was 39 crores for 2008- makers. techniques. COTPA is a public
09.The Government is required z Low awareness regarding
health act. Awareness regarding
under FCTC to provide alternate tobacco laws and harm effects various provisions under it, which
of tobacco, including, health, safeguards against harm effects of
livelihoods to tobacco farmers and
socioeconomic and ecological tobacco, needs to be raised. As far
tobacco workers including bidi
effects. as hospitals, health facilities, health
rollers. Tobacco farmers are
educational institutions are
encouraged to shift to alternate z Limited capacity of states to
concerned, strict compliance with
crops and for this Ministry of undertake implementation of
smoke free rules shall be ensured.
Health & Family Welfare tobacco laws and tobacco
The undergraduate medical,
supported Central Tobacco control activities.
dental, nursing and other
Research Institute (CTRI), for a z Limited availability of paramedical curricula and
pilot project on alternate cropping resources to fund tobacco postgraduate curriculum for
strategies. control initiatives. medicine, community medicine,

5
psychiatry, and surgery need to comforting not only for you, but surprising because the movement
include tobacco control strategies, also for your supporters is a common response in other
with special focus on formal painful circumstances. Likewise,
tobacco cessation techniques. A Heat and cold-Two further
during labour, many women
tobacco cessation facility shall be simple ways of easing pain and
instinctively have a strong urge to
available at all levels of health care assisting relaxation during labour
be active. Movement provides a
delivery system. Training on are through the application of heat
source of counter-stimulation
tobacco cessation for medical, and cold. They provide a source
and may stimulate the release of
dental, nursing students and of counter-stimulation.Heat can
endorphins within the nervous
existing staff may be carried out be applied in several ways:
system. For example, rocking the
at these cessation facilities. The z by taking a hot shower pelvis backwards and forwards
tobacco control initiatives need to or bath during contractions is often
be synergised with National Rural found to be soothing. This can
z via a hot water bottle or
Health Mission and integrated be performed while standing,
hot wet towel over the
with ongoing national health sitting, kneeling, lying down or
abdomen
programmes e.g. National Cancer on hands and knees.Other
Control programme, National z by applying a hot
rhythmical movements include
programme for prevention and compress over the
tapping your fingers, rubbing
control of CVD/DM/Stroke, perineum
your abdomen, breathing
RNTCP and also state initiatives Instead of applying heat to the rhythmically and stamping your
such as school health programme, skin, some women find that cold feet. Some women find it helps
training of health professionals is more soothing. A cool, damp to count, sing, shout or howl at
and IEC/BCC campaigns etc.The face-cloth is always refreshing,
awareness campaigns regarding the same time!. Whichever
while an ice pack can easily be manoeuvre appeals to you, the
harm effects of tobacco and SHS
applied to the lower back. action should be rhythmical and
need to be intensified with focus
on BCC strategies as nicotine Imagery -Creative mental activity, repetitive, and make you feel
contained in tobacco is highly known as imagery, can also be used better.
addictive and requires behaviour to encourage relaxation and help TENS-Transcutaneous Electrical
change and treatment. women manage their pain during Ner ve Stimulation (TENS)
labour. Many people use imagery provides yet another form of
Pain relief during in everyday situations. For counter-stimulation and has been
example, when we feel hungry we used for several years in the
labor can often ‘see’ (visual imagery) management of postoperative
Music -Historical records reveal and ‘taste’ (taste imagery) an and cancer pain. It has been
that the ancient Greeks played imagined meal in front of us - postulated that TENS helps to
soothing instrumental music to even to the extent of making our relieve pain by stimulating the
women in labour. Music can have mouths water. The word imagery release of endorphins. The TENS
a relaxing effect in labour due to (or visualisation) implies that only equipment consists of a small,
its ability to alter mood, reduce the visual sense is used. However, battery driven pulse generator,
stress and promote positive all senses (vision, touch, hearing, connected to one or two pairs of
thoughts. It can be used as a taste and smell) can be included in electrodes which are attached to
trigger for a breathing response this mental activity. the skin with adhesive tape. When
or as a cue for relaxation. It may Rhythmical movements-Many it is turned on, the TENS
also be used as a distraction women find that rhythmical machine causes a tingling
although this is a less effective use movement helps to ease pain sensation underneath the
for music in labour. Music can be during labour. This is not electrodes - the strength of which

can be adjusted at the generator fact that someone cares for you z a long stroke down the
controls. TENS is most useful and that you are not alone. length of the back,
during labour in helping to relieve Moreover, by providing a source buttocks and down the
pain. Consequently, the electrodes of counter-stimulation touch and back of the legs;
are usually placed on each side of massage can sooth pain. stroking across the
the lower spine. A back-ground Therapeutic massage (eg: shiatsu) forehead, down the
stimulation is set and the hand has been recommended as a neck and down the
control unit is used to increase the means of preventing and treating arms;
intensity of the current during a many of the ailments associated z simply holding hands!
contraction. In order to be of with pregnancy and as a means
benefit, it is necessary to turn the Shiatsu- Shiatsu is a Japanese
of easing the pain of labour.
control to a setting which is form of therapeutic massage.
Perineal massage (the area
‘almost painful’. The most Shiatsu means ‘finger pressure’.
between the vagina and anus)
effective time to begin using The basis and application of
during the last six weeks of
TENS is early in labour before the Shiatsu is similar to that of
pregnancy may reduces tearing or
pain becomes too intense. TENS acupuncture. For example, when
the need for an episiotomy
is non-invasive and simple to use. using shiatsu to relieve labour
during delivery. Touch and
It does not have any side effects pain, pain-relieving pressure
massage can be provided in
(apart from irritating the skin) and points (‘tsubo’) are stimulated
several ways:
is controlled by the mother which are similar to pressure
herself. TENS is also portable and
does not interfere with the
mother’s ability to move around.
(Sometimes, TENS can interfere
with the signal from an electronic
fetal monitor. In this event,
TENS may have to be
abandoned). Women differ
considerably in their opinions
about the effectiveness of TENS
z lightly stroking the points used in acupuncture but
in labour. In practice, additional
abdomen; without the use of needles.
analgesia is often needed -
z vigorously firm
although it is possible that drug
dose requirements may be less stroking where it hurts
with the aid of TENS. Not most;
everyone finds TENS effective z firm circular massage
and some dislike the tingling using the palm of the
sensation. hand over the centre of
Massage-Touch has been the back or sacrum.
associated with the power of This is most useful
healing since the beginning of when the pain is being
civilisation. During labour, many felt mainly in the back;
women find comfort through z rhythmical squeezing
being touched, stroked and and letting go of the
massaged. touch reinforces the shoulder muscle;

7
Tele-ophthalmology: A New Initiative of
3
National Programme for Control of Blindness (NPCB) Commentar
Commentaryy
Sandeep Sachdeva
Directorate General of Health Services, Ministry of Health & Family Welfare,
Government of India, Nirman Bhawan, New Delhi
E-Health is a relatively z Evidence Based Medicine who collaborate and share
E recent term for healthcare

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

to the people, whereby a revision of medical curriculum paving the way for availability
specialist provided online is under process. of high bandwidth terrestrial
consultation from z Ministry of Health and Family connectivity to build
Ahmedabad. During the Welfare has set up a National ubiquitous health network for
subsequent days, quake Task Force to address various telemedicine country wide
victims could get medical issues to promote teleme- with competing price. Some
advice from other doctors, dicine in the country and has of the other challenges and
based at Ahmedabad and launched a major country wide concerns are sustained
Bangalore. Over 750 sessions network of district hospitals funding, availability of trained
were conducted in a period of and medical colleges under the manpower, level appropriate
30 days, thus saving many Integrated Disease Surveill- infrastructure/facility
lives/limbs. ance Project [IDSP]. National development, confidentiality,
z The major support and thrust Cancer Care Network, Tele- ethical & legal practices. What
provided by Department of ophthalmology network, started as application of
Information Technolog y National Digital Medical science and technology in the
[DIT] has been through Library Consortium and field of telemedicine has now
various projects and system Medical College network are got a significant attention as
development; organizations going to be implemented in an important national
like ISRO, reputed academic the near future. Other programme.
medical institutions like international projects in the Tele-ophthalmology
SGPGI, AIIMS, PGIMER, pipeline are SAARC Under the Telemedicine progra-
AIMS, SRMC, C-DAC, telemedicine network and mme, National Progra-mme for
Arvind, Shankar nethralaya Pan-African e-network Control of Blindness [NPCB],
and corporate hospitals like z While there are over 20,000 Government of India initiated
Asia Heart Foundation, PHC’s providing primary care Tele-ophthalmology project on
Apollo Hospitals, SGRH, services in the rural areas, and pilot basis in Apr 2007 with the
Fortis, Max etc. have taken and more than 500 district objective of making eye care
continue to take significant hospitals, Telemedicine has services available to the people
initiatives for installation of reached to about 100 centers across the country especially rural/
telemedicine systems in however more than 50% of tribal/hilly and other hardcore/
different parts of the country. them are in the urban areas un served areas. Based on the
z The Department of only. Integrated information encouraging results and on
Information Technology has on agriculture, health, approval of Eleventh five-year
taken a pivotal role in defining education, natural resources plan [2007-12] period under
and shaping the future of are initially being made NPCB, tele-ophthalmology since
Telemedicine application in available in the Andaman and then has up-scaled and extended
India. DIT has been involved Nicobar Islands and some to need based areas. Till date, 20
at multiple levels including parts of Kerela & North East Tele-ophthalmology projects have
development of technology, States. been assisted by NPCB.
initiation of pilot schemes and z One of the key factors to Financial assistance for Tele-
standardization of Telemed- success of Telemedicine in ophthalmology under NPCB
icine in the country. Some of India is going to be the In the approved Eleventh plan
the other policy initiatives reliability of telecommun- under NPCB, financial assistance
have been development of ication link. Fiber optic upto Rs. 60 lakhs is being
standardi-zation guidelines, network across the country has provided to government/
national broadband policy, been laid down by public voluntary organization for
dedicated satellite for sector and private telecomm- initiating/strengthening tele-
education and health, & unication service providers ophthalmology projects in the

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

4 Paradigm Shift in Pathology Education In India
Commentar
Commentaryy Karuna Rameshkumar, Bipin Batra
Department of Clinical Pathology, St.John’s Medical College hospital
Bangalore and National board of Examinations, New Delhi
edicine is an ever- approach to the diagnosis by private labs and increase in the
M changing science. The

earlier one to one
physician patient relationship
training in different aspects of
pathology and to provide
adequate hands on experience to
establish or run a laboratory. So a
lucrative practice of laboratory
medicine, the scenario changed.
National Board of examinations
(NBE) was established in 1975,
which traditionally characterized
the practice of medicine is changed pathology postgraduate is as a response to the demand for
as the setting in which the expected to achieve at the end of increase in postgraduate programs
medicine is being practiced is the training for three years, core and the need to establish an all
changing. Now in India, 136 competency in clinical pathology India examination of high and
medical schools admit more than including hematology, histopath- uniform standard. There are 55
6000 trainees into postgraduate ology and cytology and adequate seats in pathology across the
programs1. Almost all of them exposure to microbiology and country, in different institutions
have either postgraduate diploma biochemistry. Though essentially recognized by NBE. In addition,
and or degree in pathology. The the goal has remained the same, introduction of DM and Ph.D
paradigm shift in pathology the entry, course content and the program, has changed the
education is parallel to the change evaluation has been changing over perception in the academic
in the practice of medicine. Some the years.The post graduate scenario. Recently with the concept
of the important reasons include degrees in pathology established of integration of different
– one, the increasing reliance on by Medical council of India are disciplines, a postdoctoral
technologic advances and MD, a three year course and fellowship in laboratory medicine
computerization for many aspects Diploma in Clinical Pathology, a has been instituted by NBE.
of diagnosis and treatment. two, two year course. Though the Course and Evaluation- In the
increasing mobility of both Medical council of India, which is 1970s, the emphasis was on
patients and physicians and three, the premier policy making anatomic pathology. The post
the need for more than one single Institution was established in graduate program was loosely
physician to be involved in the case 1934, by the Indian medical structured. Day in and out, the
of most patients who are council act (1933) before student worked in the same
seriously ill. The objective of this independence, the increase in department and had hands on
paper is to trace the shift through number of colleges with experience. The relationship
last 30 years.If you want to build a postgraduate programs was only between the mentor and the
ship, don’t drum up the man to go to after 1980s2. The competition was student was more one to one
forest to gather wood. Instead teach always high for the clinical subjects basis. The evaluation consisted of
them the desire for the sea. Antoine and pathology was not generally a mainly essay questions and the
Se Saint exupery, WWII fighter and primary choice for many of the grueling practical exam which
a poet.A pathological diagnosis aspirants of the postgraduate lasted for three days. There was
requires both aspects of logic – course. So many a times , the seats no dearth of autopsy material. As
analysis and synthesis and the were vacant ,especially the seats for both theory and the practical
more difficult the problem, the the diploma course. The valuation were together, the result
more important is the logical introduction of the competitive was totally dependent on the
approach to it. The primary exams for admission in 1990s did examiners. In traditional autopsy
objective of pathology training not change the scenario much. and slide and viva examination,
program is to encourage a logical With the awareness about the the examiners have liberty to ask

11
whatever questions they wish the quality over the degree course examination pattern also changed
around any one slide or specimen. by the Medical council of India. with constructed autopsies,
Although the reliability is generally But the success rate in DNBE was Instrumentation, interpretation
acceptable in this format, the low which was a deterrent to the and clinical utilization of
difficulty is that if one examines postgraduate aspirants. A major laboratory tests and the number
the correlation across session or shift happened in the 90s and the of days decreasing from three to
cases, the reliability drops to policy decisions were taken in two days. In some of the centers,
unacceptable low around of 0.35. 2000. The reasons are probably, part of the viva was conducted as
It is also compromised by lack of z An increase in the number OSPE ( objective structured
standardization of examiners, and application of laboratory practical examination) introducing
cases and questions 3,4,5 .The tests more objectivity in to the
syllabus of Diploma in clinical evaluation. However, the pattern
z Decreasing rate of autopsy
Pathology was variable in different of evaluation is not uniform,
universities across the country. z Setting up of autonomous irrespective of whether it is the
Some universities like Mumbai institutions and degree by the university or by
(earlier referred as Bombay) z 4. the most important, the National board of examinations.
included microbiology as part of emergence of subspecialties The careers which student takes
the course. Some of them allowed of pathology as major up after the training has also
a student who entered the degree disciplines like Hematology, changed. In the 1970s, once they
course to take the exam at the end transfusion medicine, Clinical finish, they entered either into an
of two years E.g. Madras pathology and cytopathology. academic setup or setup private
University (Now the medical and These disciplines were laboratories. Now the career
dental disciplines are referred advancing very rapidly and an options include administration,
under MGR university of Health exposure to all these informatics, scientific advisers for
sciences). This was possible as the disciplines required a instrumentation, research officers
curriculum was loosely structured. structured curriculum. for clinical research organizations
Later at the end of 80s, this Seeping corruption in few of the which conduct clinical trials and
practice stopped and the takers for major organizations also led to pharmaceutical companies. But
the DCP also declined. The other this shift. The stress was now laid research as the primary option,
reason was probably in an on practice based learning and remains poor unlike in the west.
academic set up, a person with improvement exercises for The responsibility for the training
DCP could not go beyond the learning by reflective practices by of pathologist is an obligation of
level of lecturer, as for further the post graduates, as they enter the faculty and the ultimate
promotion a post graduate degree postgraduate training with success of medical curriculum
was required.As the National different prior experience, reforms is largely dependent upon
Board of examinations set up a knowledge and skill. They have the faculty’s ability to adopt and
parallel postgraduate program, a different intellectual ability, sustain new attitude and behavior.
shift in the evaluation system starting points and learning rates The reforms are prompted by
started. The diploma course in are highly variable. The reconsideration of the expanding
clinical pathology which is for two introduction of log book and knowledge base and professional
years, gained popularity as after the internal assessment by some of competencies that are most
DCP, students were able to take the universities are in that essential in training the
the final DNBE exam which was direction .If effectively used pathologists for the future. The
offered by National board of during the training period, these concept of faculty development is
examination. This helped in tools of formative assessment can catching up and is already in
students not to waste many years achieve more reliability .They also practice in some of the
in waiting to get into postgraduate can provide fair direction as to institutions. However, the need
training. The All India nature of the future of assessment in post for internal quality control,
the examination gave an edge in graduate evaluation. The external review and accreditation

system to ensure uniformity program at Case Western Reserve
across the country still remains. Obstetrics forceps University so that students did
For that , policy makers at the not simply witness confinements,
To Arthur H. Bill (1877-1961),
highest level should make policies but helped deliver as many as 40
obstetrics in the early 20th century
that will encourage and drive such babies and attend innumerable
confronted a two-fold challenge.
changes and the personnel labors. By his retirement in 1948,
First, obstetrical procedures
responsible for implementation Bill had trained over 2,000
required substantial improvement
should design tools needed for obstetricians-gynecologists in this
and second, individuals needed to
effective implementation, so that manner. Bill also developed the
be trained in the application of
student and finally public will reap Bill Axis Traction Handle, which
these methods. As Bill noted at
the reward. further reduced the chance of
the end of his career, “instead of
damage to the child and
References bringing our art down to the level
lacerations to the cervix of the
1. Mendis L, Adkoli BV, of general practitioners, let us
mother. This attachment was
Adhikari RK, Huq MM and bring our art up to a higher level
placed over the front of the
Qureshi AF: Postgraduate and educate those who do
forceps handles and made the
education on south east asia obstetrics to that point.” Bill
instrument more accurate in
– Time to move on from promoted the methods of the
delivery by reducing and
post colonial era BMJ 2004; “new obstetrics” pioneered by
determining the force needed for
328:779 Joseph Bolivar De Lee of Chicago.
a forceps delivery. Arthur Bill
As Bill observed, “the old plan
2. Medical council of India. employed the forceps and axis
[which] allowed nature to take its
Directory of postgraduate traction handle seen here during
course, even in the face of
medical education courses his tenure at MacDonald House,
abnormalities with the hope that
2000. New Delhi: Medical the maternity hospital of
eventually the abnormalities
council of India, 2000 University Hospitals of
might correct themselves, has
Cleveland. For obstetricians, the
3. Hall P, weaver L. Interdis- given way to far more scientific
choice of forceps could be
ciplinary education and team and humane methods of
overwhelming; some six hundred
work, A long and winding correcting abnormal conditions
variants had been devised since the
road. Med. Edu. 2001; 35: 867- and thus assisting natural forces.”
introduction of the instrument by
75 The approach endorsed by De Lee,
the Chamberlen family in early-
Bill, and their adherents revolved
4. Menin Sp, Krekov Sk. 17th century England. For most
around such procedures as the use
Reflection on relevance, forceps assisted deliveries, Bill
of scopolamine or “twilight
resistance and reforms in preferred the Tucker McLane
sleep,” prophylactic forceps
medical education Acad. Med. forceps, introduced around 1880-
delivery, and episiotomy. The
1998; 73: supplement 860 -64 85: They were especially
“new obstetrics’ was highly
appropriate for outlet and low
5. Turnbull J, Danoff D, interventionist in character. When
forceps deliveries, where the head
Norman GR. Content specif- entering the field of obstetrics,
is less than 45 degrees rotation
icity and oral certification Arthur Bill was alarmed that many
from the occiput anterior
examination Med.Edu 1996; physicians lacked adequate training
position. The Tucker-McLane is
30: 56-59 in the proper use of forceps. The
distinguished from other forceps
consequence: damage to both
6. Website: mciindia.org by its solid or non-fenestrated
mother and child. He worked to
blades, prominent pelvic curve,
remedy this by carefully teaching
and overlapping shanks, and
his students the technique. Bill
articulating lock.
structured the obstetrics training

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

related risks i.e. exposed to vast informal sector, less health research in India has
physical, chemical, biological, attention to industrial hygiene also reflected high burden of
psychosocial and/or ergono- and poor surveillance data.9 morbidity at workplace.13 C
mic hazards. Globally, there z There are figures from various Kesavachandran et al in their
were 337 million occupational studies/estimates to provide review article concluded that
accidents causing 4 or more an insight to the burden of musculo-skeletal, ocular
days of absence from work; problem as reported figure do disorders and psycho-social
358,000 work related fatal not reflect the true magnitude. problems were some of the
accidents, 1.95 million works Some of these are, Leigh et al. key health problems observed
related fatal diseases and 2.31 estimated the annual incidence among Information Techno-
million total fatalities. 7 of occupational disease logy [IT] professionals.14
According to estimate for the between 924,700 and
year 2000 there are 2.0 million Definitions15
1,902,300, leading to over
work-related deaths per year 121,000 deaths in India. 10 Before going further we should
[WHO/ILO]. According to a survey of be clear with certain terminologies
z United States [USA] labour injury incidence in agriculture that are encountered in context of
department recorded a total of conducted in Northern India, occupational health and safety.
5,488 & 5,840 fatal work an annual incidence of 17 z Hazard: The inherent poten-
injuries in 2007 & 2006 million injuries per year (2 ial to cause injury or damage
respectively for the country. million moderate to serious to people’s health.
This figure represented the events) and 53,000 deaths per
smallest annual preliminary year was estimated.11 Nearly z Risk: A combination of the
total since the Census of Fatal 50,000 to 60,000 accidents are likelihood of an occurrence of
Occupational Injuries (CFOI) occurring annually in the a hazardous event and the
program was first conducted manufacturing sector. These severity of injury or damage
in 1992. Based on these accidents results in injuries of to the health of people caused
counts, the rate of fatal injury varied severity and about 1000 by this event.
for U.S. workers in 2007 was people die every year. The
z Occupational injury or illness:
3.7 fatal work injuries per frequency rate has not come
100,000 workers, down from down significantly over the An injury or illness is
the rate of 4.0 per 100,000 years.12 considered to be work-
workers in 2006.8 related if an event or
z Another source has mentio-
exposure in the work
Burden of problem statement ned the estimate of burden
environment either caused or
in India of occupational diseases (1.83
million) and occupational contributed to the resulting
z The major occupational injury (18.3 million) in India, condition or significantly
morbidity of concern in India the figure indicate that as a aggravated a pre-existing
include silicosis, musculoske- nation, India is contributing condition.16
letal injuries, coal workers’ nearly 20% of the global z Conventions: are interna-
pneumoconiosis, chronic burden in respective areas. tional treaties and are
obstructive lung diseases, Prevalence studies on instruments that create legally
asbestosis, byssinosis, pesti- occupational disease in many binding obligations on the
cide poisoning and noise- parts of the world have countries ratifying them.
induced hearing loss. In India, shown such burden to vary
occupational health is more from 5 to 20%.1 z Recommendations: are non-
than simply a health issue, z Agnihotram through his binding guidelines, which
which includes child labour, paper based on review of orient national policies and
poor industrial legislation, literature on occupational actions.

15
z Occupational Health: is the 1000 inspectors across more than statutes could be broadly
promotion and maintenance 200 offices, and Health services in divided into three domains i.e.
of the highest degree of USA. However, 40% of the statutes for safety at workpl-
physical, mental and social workforce of some 130 million aces, statutes for safety of
well-being of workers in all people in US does not have access substances and statutes for
occupations by preventing to adequate occupational health safety of activities.
departures from health, services.2
z The acts and set of rules
controlling risks and the Institutional framework for
adaptation of work to people, framed there under have taken
OHS20 into consideration the articles
and people to their jobs.
z The Constitution of India under different ILO
(ILO/WHO 1950]
has specified provisions for Conventions and Recomm-
z Occupational Safety Health
ensuring occupational health endations. The practice
[OSH] management system: and safety for workers in the followed by India so far has
includes organizational struc- form of three Articles i.e. 24, been that a Convention is
ture, planning of activities, 39 (e and f) and 42. The ratified only when the national
assigning responsibilities, regulation of labour and safety laws and practices are in
detailing procedures, in mines and oil fields is conformity with the provis-
processes and mobilizing under the Union list while the ions of the Convention in
resources for implementing, welfare of labour including question. India has so far
reviewing and updating conditions of work, ratified 41 ILO Conventions
occupational health & safety provident funds, employers’
policy to manage the risk out of 182 conventions and
invalidity, old age pension and 190 recommendations.
associated with the business maternity benefit are in the
of the organization.17 Concurrent list. z Three schedules include list of
What is Occupational and 20 industries involving
z The Ministry of Labour,
Health Safety Administration hazardous processes, the
Government of India, nodal
[OSHA] Act18, 19 permissible levels of certain
agency for employment &
The OSHA act was created on chemical substances in work
labour-related statistics along
December 29, 1970 by United environment and the list of
with labour departments of
States of America to provide US 29 notifiable diseases.
the States/Union Territories
workers with a safe working are responsible for safety and Status in India 2, 23, 24
environment. OSHA is admini- health of workers. Directorate
stered through the department of z Industries were established in
General of Mines Safety
labour but many states have their India as early as 1850’s. After
(DGMS) and Directorate
own OSHA laws. Its statutory Independence in 1947,
General Factory Advice
authority extends to most country had about 31,000
Services & Labour Institutes
workplaces where there are factories employing about 2.5
(DGFASLI) assist the
employees and staff. Despite early million workmen. This figure
Ministry in technical aspects of
difficulties, over time, manuf- rose to 01 lakh factories and
occupational safety and health
acturers of industrial equipment 07 million workers during
in mines and factories & ports
have included OSHA-compliant 1981 and by 2005 India had
sectors, respectively.
safety features in new machinery, more than 2.3 lakh factories
enforcement has become more Occupational and Safety employing 08 million
consistent across jurisdictions, legislation in India20, 21, 22 workers. The major chunk of
inspection, recording & reporting z There are various work-related our workforce belonged to
is regular and some of the more statutes in the country agriculture sector [69%],
unpopular rules have been concerning safety, health and construction [16%] followed
repealed. OSHA now has over environment [Table 1]. These by manufacturing [11%] and

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

17
Regional institutes in Calcutta z Till few years ago, safety and ensuring basic health
and Bangalore under Indian management has been to a needs.
Council of Medical Research great extent, the concern of z Bureau of Indian Standard
(ICMR), Lok Manya Medical Government agencies limited [BIS] formulated an Indian
Research Centre, Pune and to the compliance with the Standard of OHS managem-
Centre for Occupational and laws relating to this domain. ent system based on
Environmental Health Even in situations involving voluntary adoption for a
(COEH), MAMC, New Delhi safety and health problems, comprehensive framework &
and a professional bodies like which are not specifically specification with guidance for
Indian Association of covered by the statutes, the OHS. It is called as the IS
Occupational Health [IAOH]. response to the management 18001:2000 Occupational
was only reactive. Health and Safety [OHS]
z There are few others national
level disability prevention and z India had adopted a self- Management Systems with
rehabilitation institutes in regulatory [voluntary, self- the following revised edition
New Delhi, Deharadun, compliance, certification, or IS 18001:2007. This standard
Mumbai, Secunderabad, accreditation] approach since prescribes the requirements for
Kolkata, Cuttak, Chennai and 1987 through amendments to an OH&S Management
Mysore, which offer such the factory act 1987. The vast Systems, to enable an
courses. The Master of majority of the sector should organization to formulate a
Industrial Hygiene (MIH) be encouraged to develop, policy, taking into account the
course being conducted by adopt and/or adapt quality legislative requirements. It
Sardar Patel University, Vallabh safe work practices by fostering also provides information
Vidyanagar, Anand, in a conducive environment of about significant hazards and
collaboration with Cincinnatti teaching, training, sensitizing risks to be analyzed &
University, USA. and advocacy opportunities evaluated at workplace, which
Solutions27, 28, 29, 30 for owning & empowering the organization can control
stakeholders on the issue of in order to protect its
z The requirement is to have a health and safety. employees and others, whose
single point responsibility health and safety may be
with adequate authority to z Over the year, occupational
affected by the activities of the
address needs, ensure compl- health and safety [OHS] issues
organization.
iance and disseminate OHS have improved considerably in
India due to intense advocacy Conclusion
information to all concern. In
the countries like Australia by media, activist, profess- Occupational health and safety is
and even in USA separate OH ional bodies, public interest an important strategy not only to
& S act has been made. litigation’s [PIL], and societal ensure health of workers, but also
However it also needs to be demand due to occurrence of to contribute positively to the
ensured that implementation national disasters that have national economies through
of legislation does not remain spurred management to improved productivity, quality of
confine to papers. Therefore change its approach towards products, reduced absenteeism,
public sector manpower OHS. Organizations have work motivation and job
strengthening, infrastructural started attaching importance satisfaction. Accident prevention
and commun-ication support to occupational safety & health has to be perceived not as a
is required for improving through adoption of a separate and independent
compliance of statutes, structured approach for the discipline but rather interwoven
monitoring & supervision at identification of hazards, their philosophy of any management
hazardous workplace. evaluation, control of risks function.

Table-1, Various legislative acts & rules drafted there under concerning Occupational health &
safety and social aspect, India*
The Explosives Act, 1884 The Radiological Protection Rules, 1971
The Indian Electricity Act, 1910 The Dangerous Machines (Regulations) Act, 1983
Workman compensation act, 1912 The Dock workers (safety, health and welfare) Act,
The Indian Boilers Act, 1923 1986
The Petroleum Act, 1934 Environment Protection Act, 1986
The Factories Act 1948, amended 1954, 1970, 1976, The Manufacture, Storage and Import of
1987 Hazardous Chemicals [MSIHC] Rules, 1989,
amended in 1990, 1994
Employee State Insurance [ESI] Act, 1948
Chemical Accidents [Emergency Planning,
The Plantation Labour Act, 1951
Preparedness and Response] Rules, 1996
The Mines Act, 1952
The Building and other construction workers
The Indian Atomic Energy Act, 1962 [Regulation of Employment and Conditions of
Beedi and Cigar Workers’ (Conditions of Labourers] Act, 1996
Employment) Act, 1966 Biomedical Waste Management and Handling Rules,
The Insecticide Act, 1968 1998, 2003
* Not an exhaustive list
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6 Preeclampsia and Associated Risk Factors
Review Betsy Varughese, Manoj Dhingra, Rani Kumar, Renu Dhingra
Department of Anatomy, All India Institute of Medical Science, New Delhi and
Article Department of Health, Institute of clinical Research of India, New Delhi
reeclampsia contributes preeclampsia at the beginning of For most healthy nulliparous
P about 8 to 10% of maternal

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

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

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

23
pregnancy, maternal age more than Group on High Pressure in 11. Lee CJ, Hsieh TT, Chiu TH,
40 years, renal disease, Pregnancy. Report of the Chen KC, Lo LM, Hung TH.
hypertension, ten years or more National High Blood Pressure Risk factors for pre-eclampsia
than ten years of difference Education Program Working in an Asian population. Int J
between the pregnancies, presence Group on High Blood Gynecol Obstet. 2000; 70:
of antiphospholipid antibodies, Pressure in Pregnancy. Am J 327-33.
insulin resistance in concert with Obstet Gynecol. 2000; 183: 12. Eskenazi B, Fenster L, Sidney
obesity and thrombophelia are S1–S22. SA. Multivariate analysis of
the major risk factors of 4. Levine RJ, Karumanchi SA. risk factors for preecla-
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will have an immense value as it Gynecol. 2005; 48:372-386. 13. Stone JL, Lockwood CJ,
would help to assess risk at the 5. Skjaerven R, Wilcox JA, Lie Berkowitz GS, Alvarez M,
first antenatal clinical visit. A TR. The interval between Lapinski R, Berkowitz RL.
suitable surveillance regimen pregnancies and the risk of Risk factors for severe
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rest of the pregnancy (Table-2). 6. Conde-Agudelo A, Belizan
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JM. Maternal morbidity and et al. Review of pre-eclampsia
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7. Basso O, Christensen K, 875.
steps, and or the use of early
Olsen J. Higher risk of pre-
maternal serum markers to screen 15. Odegard RA, Vatten LJ,
eclampsia after change of
for the condition together with Nilsen ST, Salvesen KA,
partner. An effect of longer
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25
Table-1, Studies on risk factors of preeclampsia
Risk factor Study Number of Unadjusted relative Reference
Design studies risk (95% CI)
Time between Cross 1 1.83(1.72 to1.94) Conde-Agudelo et al
pregnancies> 59 months sectional 2000
Age >40 primiparous Cohort 1 1.68 (1.23 to 2.29) Bianco et al 1996
Age >40 multiparous Cohort 1 1.96 (1.34 to 2.87) Bianco et al 1996
Nulliparity Cohort 3 2.91 (1.28 to 6.61) Coonrod et al 1995
Lawoyin et al 1996
Lee et al 2000
Case control 6 2.35 (1.80 to 3.06) Coonrod et al 1995
Eskenazi et al 1991
Stone et al 1994
Chen et al 2000
Odegard et al 2000
Stamilio et al 2000
Previous pre-eclampsia Cohort 5 7.19 (5.85 to 8.83) Lee et al 2000
Campbell et al 1985
Sibai et al 1986
Makkonen et al 2000
Dukler et al 2001
Family history Cohort 2 2.90 (1.70 to 4.93) Arngrimsson et al
1990
Cincotta et al1998
Twin pregnancy Cohort 5 2.93 (2.04 to 4.21) Coonrod et al 1995
Lee et al 2000
Odegard et al 2000
Santema et al 1995
Ros et al 1998
Triplet v twin pregnancy Cohort 1 2.83 (1.25 to 6.40) Skupski et al 1996
Pre-existing diabetes Cohort 3 3.56 (2.54 to 4.99) Lee et al 2000
Ros et al 1998
Garner et al 1990
Systolic >130 mm Hg at Cohort 1 3.6 (2.0 to 6.6) Odegard et al 2000
booking
Diastolic >80 mm Hg at Cohort 1 1.8 (0.7 to 4.6) Odegard et al 2000
booking
Mean Arterial pressure > 90 Case control 1 3.7 (2.1 to 6.6) Stamilio et al 2000
Autoimmune disease Case control 1 6.9 (1.1 to 42.3) Stamilio et al 2000
Antiphospholipid Cohort 2 9.72 (4.34 to 21.75) Pattison et al 1993
antibodies Yasuda et al 1995
BMI>35 Cohort 1 4.39 (3.52 to 5.49) Bianco et al 1998
Table-2, Risk factors that can be assessed at first antenatal visit

History Pre-existing medical conditions Examination
Age Insulin dependent diabetes (IDDM) Body mass index (BMI)
Parity Chronic hypertension Blood pressure
Previous pre-eclampsia Renal disease Proteinuria
Family history of pre-eclampsia Autoimmune disease
Multiple pregnancy Antiphospholipid syndrome
Time between pregnancies

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

27
z Sporadic or autosomal Clinical Profile blockers, ACE inhibitors, K +
recessive cases may have z Failure to thrive, growth sparing diuretics, cyclosporine)
associated SNHL that may retardation (most common). Clinical Profile
present at birth or later.
z Polyuria, polydipsia z Growth retardation (most
Type 2 (Proximal) RTA-It is common)
z Dehydration (due to sodium,
called as proximal RTA because
H2O Losses) z Polyuria, polydipsia,
the primary defect here is the
impaired reabsorption of z Rachitic Manifestations. dehydration.
bicarbonate ions in the proximal z (Common in fanconi z Signs and symptoms of
tubule resulting in bicarbonaturia. syndrome because of obstructive uropathy and
The primary defect in proximal hypophosphatemia) features of pyelonephritis.
RTA is the reduced renal threshold z Irritability, listlesseness, z Bone diseases are generally
for HCO 3 resulting in anorexia or preference for absent.
bicarbonaturia. The proposed savoury foods.
mechanisms include defective Diagnosis-Metabolic acidosis can
Type 4 RTA-The underlying result from either renal (RTA,
pump secretion or function of the
defect here is the impaired cation CKD) or extrarenal processes
H + /ATPase, the Na + /H +
exchange in the distal tubules with which result from an increased
antiporter, the Na+/K+ ATPase or
reduced secretion of H+ and K+. indigenous acid production
the deficiency of carbonic
It occurs as a result of impaired (ketoacidosis) or enhanced HCO3-
anhydrase in the brush border
aldosterone secretion losses (diarrhea, pancreatic/ biliary
membrane. This results in
(hypoaldosteronism) or an fistula). RTA may be due to either
increased urinary loss of HCO3
impaired renal response to HCO 3- wasting (proximal) or
causing systemic acidosis with
aldosterone. Aldosterone inability to generate new HCO3-
inappropriately high urinary pH. increases Na + reabsorption
The increased distal Na+ delivery ions to buffer endogenous acid
(pseudohypoaldosteronism) and (distal RTA).Since all types of
results in hyperaldosteronism results in a negative intratubular
with consequent renal K+ wasting. RTA are associated with a normal
potential. It also increases luminal plasma anion gap, it is the initial
As plasma HCO3- levels fall, the membrane permeability to K+ and
lowered filtered load of HCO3- step in evaluation of metabolic
stimulates basolateral Na +/K + acidosis.
can now be reabsorbed by ATPase, causing increased K+
proximal tubule resulting in a losses in urine. Since, aldosterone Plasma Anion Gap-It represents
normal distal delivery of HCO3-. directly stimulates proton pump, the difference of unmeasured
At this point, the distal nephrons aldosterone deficiency or resistance anions and cations in the plasma
can acidify urine normally resulting should lead to hyperkalemia and and is measured as -Anion gap =
in a normal excretion of daily acidosis. Other factor that causes Na+ - (Cl- + HCO3-).The normal
metabolic acid produced. a decreased H+ excretion in type 4 value of plasma anion gap is 12 +
Hypercalciuria is present but as RTA is the inhibition of 2 meq/L.
urine citrate levels are normal, ammoniagenesis due to Metabolic acidosis with normal
nephrocalcinosis or lithiasis is a hyperkalemia.4 anion gap- Diarrhea, RTA (Both
rarity. distal and proximal). This normal
Etiology-Type 4 RTA is most
Etiology- It may present as an often seen in children with plasma anion gap metabolic
isolated or generalized proximal obstructive uropathy or as a acidosis is also known as
tubular dysfunction3 (i.e. Fanconi transient phenomena during “Hyperchloremic metabolic
syndrome with tubular infancy. 5 Primar y-(Sporadic; acidosis.”
proteinuria and aminoaciduria Hereditary); Secondary (Hypoa- Metabolic acidosis with increased
with variable degrees of ldosteronism, Pseudohyp- anion gap-Diabetic ketoacidosis
bicarbonaturia, phosphaturia, oladosteronism, Chronic kidney (DKA) ,Lactic acidosis due to
Na+, K+ wasting and glucosuria). disease; Drugs (NSAIDS, b- shock, Ethylene glycol, aspirin

poisoning, Uremia, Some inborn defective distal secretion of H+. secretion and is considered a
errors of metabolism Acidic Urine-Proximal RTA; sensitive indicator of distal
Urinary Anion Gap (UAG)- The Alkaline Urine- Distal RTA, acidification. After achieving a
next step is to distinguish RTA Acute/chronic Diarrhea , Urinary urine pH >7.5 and plasma HCO3-
from extrarenal causes. Urinary tract infection (with urea splitting levels > 23-25 meq/L, difference
anion gap (net charge) provides organisms). between the urine and blood
an estimate of urinary NH4+ ion Ammonium Chloride (Nh4Cl) PCO2 (i.e. U-B PCO2) is measured
excretion. According to Principle Loading Test-Administration of as- U-B PCO2 >20mmHg -
of electroneutrality- Sum of oral NH4Cl (0.1mg/kg) challenge Normal / Proximal RTA; U-B
urinary cations = Sum of urinary might be given followed by PCO2 <10mmHg - Distal RTA
anions. i.e. Na+ + K+ + Ca2+ + measurement of urine pH every Fractional Excretion of
Mg2+ + NH4+ = Cl- + So42- + Po43- hour for the next 8 hours to look Bicarbonate (FeHCO3%)- It is
etc. On usual diets, excretion of for renal response to the induced an important marker of proximal
Ca2+, Mg2+, So42-, Po43- and other metabolic acidosis. Normally, a tubular handling of bicarbonate.
organic ions is fairly constant. fall in plasma total HCO3 levels Normally, proximal tubules
Also, urinary Na+, K+, Cl- can be by 3-5meq/L induces urinary pH reabsorb most of the filtered
easily measured but NH4+ and to be <5.5. If in the presence of bicarbonate (i.e. Fractional
other ions are usually unmeasured metabolic acidosis Urinary pH excretion is < 5%). The fractional
and since the contribution of <5.5( Normal response rules excretion of bicarbonate is
HCO 3- to urinary anion is out distal RTA); Urinary pH calculated following adequate
negligible unless the urine is >5.5(Distal RTA – likely cause). alkalinization as shown -
alkaline, therefore, Urinary Na+ However, patients with chronic FeHCO3% = urine bicarbonate x
+ K + + NH 4+ = Cl - + other metabolic acidosis (e.g. after plasma creatinine x 100 plasma
anions; Urinary Na+ + K+ - Cl- = - chronic diarrhea) show increased bicarbonate x urine creatinine
NH4+ + other anions. Now, from ammoniagenesis that consumes
FeHCO3 < 5% - Normal / Distal
a practical point of view:- urinary most distally secreted H+ ions
RTA; FeHCO3 > 5% - Proximal
anion gap i.e. ( Na+ + K+ - Cl- = - resulting in an enhanced urine
RTA; Hyperchloremic distal RTA
NH4+ ) and this gives us a fair NH4+ excretion, therefore, “urine
- FeHCO3 varies from 5-10%.
estimation of NH4+ ion excretion. pH in these cases may be high
Normal value of urinary anion gap is despite appropriate H+ excretion.” Tests for phosphate handling-
30-35 meq/L. Fractional excretion of PO 4
Bicarbonate Loading Test-
( Fe P O 4 % ) - P h o s p h a te
Positive UAG-RTA (because of Sodium bicarbonate is
homeostasis is chiefly regulated at
decreased NH 4+ production, administered as half strength
level of proximal tubules. FePO4
DKA, toluene poisoning, intravenous infusion at 3 ml/
(%) determined on timed (6hr,
alcoholic ketoacidosis.) min, while measuring urine pH
12hr, 24hr) urine specimen is used
Negative UAG-Diarrhea in timed samples every 30-60
as a measure for phosphate
minutes apart. A steady state is
URINE pH-It assesses the handling.
achieved after 3 to 4 hours of start
overall integrity of distal urinary FePO4 (%) = Urine phosphate x
of infusion, and the test
acidification and provides an plasma creatinine x 100 Plasma
terminated when three urinary
estimate of the number of free phosphate x urine creatinine
samples with pH > 7.5 are
H+ ions in the urine secreted in
collected. Interpretation of this Now, tubular reabsorption of
response. In the presence of
test allows characterization of type P O 4 (%) = 100 - FePO4
systemic acidosis present
of RTA as follows: (%).Normal range is 85 - 95%. It
spontaneously or induced by
Urine to Blood CO2 Gradient- is reduced in cases of proximal
ammonium chloride (NH 4Cl)
In alkaline urine (i.e after a tubular defect and hyper-
loading, the urinary pH is <5.5
NaHCO3 loading) urine PCO2 parathyroidism. Since, tubular
normally. If the pH >5.5 during
increases due to distal H + reabsorption is markedly
metabolic acidosis, it suggests

29
influenced by changes in GFR and Frusemide Test- Response to bicarbonate required to maintain
dietary changes, it has led to frusemide helps determine the acid base status may be as high as
anincreasing use of the index: possible site and mechanism of 5-10meq/kg/day and the
Tubular maximum of PO 4 defect in type 1 RTA. Frusemide duration of therapy is usually
corrected for GFR i.e TmP/GFR increases the luminal electronega- lifelong. Various alkali solutions
(Bijovet index). tivity by increasing Na+ delivery to used are-Sodium bicarbonate
Bijovet Index (TmP/GFR)- and reabsorption in the cortical solution (7.5%);Citrate solutions
Tubular maximum of phosphate collecting tubule. The changes (Polycitra solution (2 meq/
corrected for GFR (TmP/GFR) brought about by frusemide in ml),Shohl solution (1 meq/
represents the concentration above H+ and K+ excretion in normal ml),Potassium alkali salts should
which most phosphate is excreted subjects and in those with various be used if hypokalemia is a
and below which most is defects of distal RTA (Table- persistent problem). In case of
reabsorbed. It is an index of renal 1).8Once the diagnosis of RTA is associated rickets or osteopenia,
threshold for phosphate which established, it can then be Vitamin D should be
can be calculated as follow- TmP/ categorized further as supplemented. The relatives of
GFR (mg/dl) = Plasma PO4 - summarized by the results of patients with idiopathic distal
urine phosphate x plasma investigations in different forms RTA should be screened for this
creatinine. Normal value = 2.8 - of RTA (Table-2). In addition disorder as timely intervention can
4.4 (mg/dl). to these, children with proximal prevent growth retardation in
Transtubular potassium (Type 2) RTA should undergo children.
gradient (TTKG)-Renal tubular evaluation for other proximal Type 2 (Proximal) RTA-
disorders are associated with both tubule functions (phosphate, Alkali supplementation again
hypokalemia and hyperkalemia. electrolytes, glucose, amino acid remains the treatment of choice.
TTKG provides an accurate excretion) and screening for an Children with proximal RTA
estimate of aldosterone effect on underlying etiology (wilson generally require greater amounts
sodium potassium exchange in disease, cystinosis). Children with of alkali per day (approximately
the late distal and cortical collecting distal RTA, on the other hand 5-20 meq/kg/day) as compared
tubules. TTKG is an index of the should be investigated for urinary to distal RTA patients. A thiazide
gradient of potassium in distal calcium excretion, ultrasound for diuretic can be used in conjunction
tubular lumen and interstitial renal calcification, a work up for with low salt diet to reduce the
blood capillaries, independent of secondary causes (e.g. obstructive amount of bicarbonates required.
urine flow rates.7 It is calculated as uropathy, reflux nephropathy, Thiazides act by causing
follows: chronic tubulointerstitial extracellular fluid contraction and
TTKG = urine K+ × plasma nephritis) and hearing evaluation. increasing proximal bicarbonate
osmolality plasma K+ x urine Management reabsorption. Potassium
osmolality Alkali supplements are the supplementation is done to
Normal value = 6-12;TTKG < 2 standard therapy in all types compensate for the increased
- hypokalemia (extrarenal causes); Type I (Distal) RTA-Electrolyte potassium excretion caused by
TTKG is higher - hypokalemia abnormalities should always be thiazides.Phosphate supplements
(renal losses) e.g hypoaldo- corrected before treating acidosis. (e.g. joulie solution, neutral
steronism. In hyperkalemia - Acidosis is corrected by phosphate solution) and
expected TTKG is >10; an administration of alkali solutions. moderate doses of Vitamin D
inappropriately low TTKG (<8) Initial dose is 2-3meq/kg/day may be required. Joulie solution-
in hyperkalemia sug gests and can be increased until the 1ml= 30mg inorganic
hyoaldosteronism or renal blood bicarbonate levels become phosphorous; Neutral phosphate
tubular resistance to aldosterone. normal. The amount of solution-1ml=20mg inorganic

phosphorous. Specific therapy for distal RTA. 4. Soriano JR. Renal tubular
an underlying disorder (cystea- Prognosis- Usually depends on acidosis, the clinical entity. J
mine for cystinosis, D- the nature of underlying disease. Am Soc Nephrol 2002; 13:
penicillamine for wilson disease Subjects with RTA usually 2160-70.
and lactose free diet in demonstrate a dramatic improve- 5. Hanna JD, Scheinman JI,
galactosemia) is indicated in few ment in growth provided serum Chan JCM. The kidney in acid
patients. bicarbonate levels are maintained base balance. Pediatric Clinics
Type 4 (Hyperkalemic) RTA- within the normal range. Patients of North America 1995; 42:
The main goal of therapy here is of fanconi syndrome and systemic 1365-94.
to reduce serum potassium levels illnesses may have difficulties with
growth failure, rickets and various 6. Goldstein MB, Bear R,
(as acidosis improves once the
signs and symptoms pertaining Richardson RMA, Marsden
hyperkalemic block of ammo-
to their disease. PA, Halperin ML. The urine
nium production is removed).
anion gap: a clinically useful
Children are put on a low References index of ammonium
potassium diet and any drug
1. Dell KM, Avner ED. Renal excretion. Am J Med Sci 1986;
suppressing aldosterone produc-
tubular acidosis. In Behrman 292: 198-9.
tion is discontinued. Mineraloco-
rticoid supple-mentation with RE, Kliegman RM, Jenson 7. DoBose TD Jr. Hyperkalemic
fludro-cortisone will improve HB, ed. Nelson Textbook of hyperchloremic metabolic
hyperkalemia and acidosis. In Pediatrics. Philadelphia; WB acidosis: pathophysiologic
children with hypertension or Saunders, 2003; 1758-62. insights. Kidney Int 1997; 51:
heart failure, mineral- 2. Soriano JR. New insights into 591-602.
ocorticoids are contraindicated, the pathogenesis of renal 8. Bagga A, Sinha A. Evaluation
potassium exchange resins (e.g tubular acidosis from of renal tubular acidosis.
kayexelate), however, may be functional to molecular Indian J Pediatr 2007; 74: 670-
required. studies. Pediatr Nephrol 2000; 86.
Follow Up- A regular follow up 14: 1121-36.
must be done for Assessment of 3. Bagga A, Bajpai A, Menon S.
growth;Blood levels of electro- Approach to renal tubular
lyes, pH and bicarbonate levels; disorders. Indian J Pediatr
Ultrasound screening for 2005; 72: 771-6.
nephrocalcinosis in subjects with
Table-1, Response of urine Ph and potassium (K+) excretion following frusemide
administration in normal subjects and various defects causing distal RTA.8
Defect Site of Defect Urine pH K+ Excretion
During After Baseline After
Acidosis Frusemide Frusemide
Normal None <5.5 Further Normal Increased
Decline
H+ ATPase defect Diffuse, cortical >5.5 >5.5 Normal Increased
collecting tubule
H+ ATPase defect Medullary >5.5 <5.5 Normal Increased
collecting tubule
alone
Voltage defect Cortical collecting >5.5 >5.5 Decreased Unchanged
tubule

31
Table-2, comparison of various types of RTA
Proximal RTA Distal RTA Type 4 RTA
Classic Hyperkalemic
Plasma K+ Normal/Low Normal/Low High High
Urine pH <5.5 >5.5 >5.5 <5.5
Urine anion gap Positive Positive Positive Positive
Urine NH4+ Low Low Low Low
Fractional HCO3- >10-15% <5% <5% 5-10%
excretion
U-B PCO2 mmHg >20 <20 L</>20 >20
Urine Ca2+ Normal High High Normal/low
Other tubular defects Often present Absent Absent Absent
Nephrocalcinosis Absent Present Present Absent
Hippocrates different schools. It has thus contradistinction to the

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

8 Recurrent Pain abdomen in children
Review Venkatesh.C, VishnuBhat.B
Article Department of Pediatrics, J.I.P.M.E.R, Puducherry.
organic cause for pain 1, 3.
R
ecurrent abdominal pain school going child or adolescent
(RAP) in children is with evidence of limitation in daily Causes of RAP- The causes of
defined as continuous or activities1, 2. RAP is a description recurrent pain abdomen are
near continuous abdominal pain and not a diagnosis. It affects extensive. It is useful to classify
on 3 or more occasions over a 15% of middle and high school them as either organic or
period of at least 3 months in a children. Five to 10% percent have functional (non organic) causes.
Functional Organic
Gastrointestinal GB&Pancreas Genitourinary Miscellaneous
Functional abdominal Chronic constipation Cholelithiasis Urinary tract Abdominal epilepsy
pain syndrome Lactose intolerance Choledochal infections Gilbert syndrome
Nonulcer dyspepsia Parasitic infestation cyst Recurrent Hydronephrosis Sickle cell crisis
Irritable bowel Fructose/sorbitol pancreatitis Urolithiasis Lead poisoning
syndrome ingestion Henoch -schonlein
Aerophagia Crohn disease purpura
Abdominal migraine Peptic ulcer Angioneurotic- edema
Esophagitis Acute intermittent
Meckel‘s diverticulitis porphyria.
Recurrent
intussusception
Inguinal/abdominal
wall hernias
Chronic appendicitis
Appendiceal mucocoel
Functional Gastrointestinal Functional abdominal pain For all of the above subtypes,
disorders 4, 5- Specific functional syndrome-It is diagnosed when there should be no evidence of
gastrointestinal disorders are there is abdominal pain with one inflammatory, anatomical,
diagnosed if the following criteria or more of the following-Some metabolic or neoplastic processes
are met-Functional dyspepsia-( loss of daily functioning, to explain the pain and the criteria
Persistent or recurrent pain Additional somatic symptoms should be fulfilled for at least once
centered over upper abdomen (headache, limb pain, sleep a week for 2 months prior to
(above umbilicus);Not relieved by difficulty) diagnosis.
defaecation or associated with Abdominal migraine- Pathophysiology of Functional
change in form or frequency of Paroxysmal episodes of intense pain abdomen-There are
bowel action periumbilical pain lasting 1 or multiple factors which are
Irritable bowel syndrome- more hours (2 or more times in thought to influence the
Abdominal discomfort or pain the preceding 12 months) ; perception of pain by the brain
associated for 25% of the time or Healthy in between for weeks or from stimuli emanating from
more with 2 or more of the months; Pain interferes with visceral receptors in the
following-Improvement with normal activities; Pain associated gastrointestinal tract (G.I.T).
defaecation ,Change in frequency with 2 or more of Some of these factors are genetic
of stool , Change in form or Anorexia,Nausea, Vomiting, and environmental whereas
appearance of stool Headache, Photophobia, Pallor others are either physiologic or

33
psychosomatic in nature. Studies rigidity can be present on local H.pylori infection and
have found that children with examination. Systemic symptoms recurrent pain abdomen-
recurrent pain abdomen have like fever, weight loss, rash, Community based case control
increased sensitivity to stress vomiting, diarrhea, hematochezia studies from the west have shown
which impact the physiology of and joint pain may be present. that there is no association
the G.I.T leading to pain as well Child may have jaundice. The pain between H.pylori infection and
as slow recovery of autonomic disturbs sleep and may cause recurrent pain abdomen and
ner vous system following growth deceleration. In one large therefore investigating for
stressful responses. They have Indian series, parasitic infestation H.pylori infection in these children
abnormal perception of was found to be the most are not recommended9. However
gastrointestinal sensation and also common cause of recurrent pain the data was obtained from
have a lower threshold to pain. abdomen in children aged between children from higher
Studies in patients with irritable 3 and 12 years 8). socioeconomic strata and hence
bowel syndrome indicate that Red flag symptoms indicating extrapolating the same to the
these patients have altered brain organicity5- Involuntary weight Indian context would not be
response to rectal stimuli and may loss;Growth faltering; applicable. Indian studies on
be related to central noradrenergic Gastrointestinal bleeding; Pain recurrent pain abdomen have
modulation6. Children with RAP abdomen in right upper or right yielded mixed results with some
have also been found to have lower quadrant; Significant studies not recommending
attentional biases and often vomiting or chronic diarrhea. evaluation for H.pylori10 and other
associate their pain to certain studies indicate the need for
Evaluation-Extensive lab tests are H.pylori eradication therapy11.
environmental factors or normal not necessary for nonorganic pain.
gastrointestinal sensations and Treatment-Treatment of
However following screening tests
increase their anxiety and fear underlying cause if organic
may be helpful - Complete blood
which in turn exacerbates the (antibiotics for urinary tract
count for evidence of infection or
pain7. And finally parents and infection & bacterial overgrowth
inflammation; ESR (increased in
caregivers may reinforce the child’s syndrome, deworming for
inflammatory bowel diseases,
symptoms and encourage the parasitic infestations, surgery for
infections and neoplasm); Stool
child to adopt a sick role. acute appendicitis,
microscopy, reducing substance,
Clinical features-Non organic intussusception etc).
occult blood, parasite ova and cyst;
pain (Age is usually more than 6 Urine analysis and culture Non organic Pain-Reassurance
years and the commonest site is sensitivity for cystitis, of children and family members
periumbilical. Pain can sometimes pyelonephritis or renal calculi. is important. Instructions to
be localized to epigastric or Other investigations depending avoid reinforcing symptoms for
suprapubic region. It interrupts upon history and clinical findings secondary gain. Provide less
routine activity. Pain is not for organic pain (Liver function attention to the symptoms and
associated with vomiting or tests, serum amylase, more attention to the child.
diarrhea and has no relation to ultrasonography of abdomen, Biofeedback and relaxation
meals. It does not wake up the radiograph of abdomen, barium techniques for stress management
child from sleep. In case of IBS, series, fluoroscopy, Upper are often helpful. Medications
pain is associated with bloating G.I.endoscopy. Breath hydrogen have a limited role particularly
sensation and incomplete test, breath urea and rapid urease visceral muscle relaxants and
evacuation and relieved by test to diagnose H.pylori antacids. Close follow up is
defecation). Organic Pain(More particularly in patients with necessary in doubtful and difficult
common in children less than 6 gastritis and peptic ulcer disease, cases.
years. Site is usually away from the EEG, urine for porphyrias, serum Specific Treatment
umbilicus, well localized and lead levels and Hb electrophoresis z Irritable bowel syndrome
consistent. Tenderness and in selected cases). (IBS): Dietary modification in

the form of avoiding or ing for parents and self regulation erology 2006; 130(5): 1459-65.
limiting fat, alcohol, caffeine, training for the affected child has 5. Chronic abdominal pain in
sorbitol, fructose and corn. shown to be effective in the children. American academy
Medical management includes management of recurrent pain of Pediatrics subcommittee
anti cholinergics like abdomen. When compared to on chronic abdominal pain.
dicyclomine or hyoscine daily standard pediatric care, children Pediatrics 2005;115(3):812-5
initially and then as and when receiving cognitive behavioral
6. Naliboff BD, Derbyshire SW,
necessary. Low dose tricyclic therapy have shown significant
Munakata J, Berman S,
antidepressants or 5HT3 improvements in the domains of
Mandelkern M, Chang L,
receptor antagonists and pain intensity and pain behavior
Mayer EA. Cerebral activation
5HT4 receptor blockers like with complete resolution of
in patients with irritable bowel
tegaserod may be useful. symptoms and a very low relapse
syndrome and control
z Functional Dyspepsia: A diet rate12.
subjects during recto sigmoid
similar to that of IBS. Medical Prognosis 13 - One third of stimulation. Psychosom Med
management essentially Children with recurrent pain 2001; 63(3):365-75.
consists of H2 receptor abdomen can go on to develop
7. Vasey MW, Daleiden EL,
blockers or prokinetics and chronic abdominal pain in
Williams LL, Brown L. Biased
low dose tricyclic antidepr- adulthood. Children with chronic
attention in childhood anxiety
essants. abdominal pain are more likely to
disorders: A preliminary study.
z Abdominal Migraine: Prop- have emotional and psychological
J Abnormal Child Psychology
ranolol, cyproheptadine, problems later in life. Irritable
1995; 23:267-279.
pizotifen, tricyclic antidepre- bowel syndrome is likely to persist
well into adulthood often needing 8. Bansal D,Patwari AK,
ssants or carbamazepine can
longer duration of treatment Malhotra VL, Malhotra V,
be tried.
especially cognitive and behavioral Anand VK.Helicobacter
z Aerophagia: Reassurance and pylori infection in recurrent
therapy.
limitation of gum chewing abdominal pain. Indian
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carbonated beverages. 1. Apley J, Naish N. Recurrent
9. Macarthur C, Saunders N,
z Functional constipation:
abdominal pains. A field
Feldman W, Ipp M, Winders-
Increase dietary fibres, fruits sur vey of 1000 school
Lee P, Roberts S, Best L,
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Sherman P, Pencharz P,
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Veldhuyzen van Zanten SV.
to ease the pain associated 2. Schurman JV, Friesen CA, Helicobacter pylori and
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required stool frequency. agreement. J Pediatr Gastroen-
10. Poddar U, Yachha SK.
Chronically distended rectum terol Nutr 2005; 41(3):291-5.
Helicobacter pylori in children:
and fecal impaction are 3. Liebman WM. Recurrent an Indian perspective. Indian
managed by administration of abdominal pain in children. A Pediatr 2007; 44(10):761-70.
rectal enema. retrospective study in 119
11. Biswal N, Ananathakrishnan
z Cyclical vomiting: Adequate patients. Clin Pediatr 1978; 17:
N, Kate V, Srinivasan S, Nalini
hydration and antiemetics like 149-153.
P, Mathai B. Helicobacter
ondansetron are helpful. 4. Drossman DA, et al. Rome pylori and recurrent pain
Cognitive behavioral therapy- III, the functional gastroint- abdomen.Indian J Pediatr
Contingency management train- estinal disorders. Gastroent- 2005 72(7):561-5

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

9
Neonatal Necrotizing Enterocolitis
Review Prabha, Vishnu Bhat
Article Department of Pediatrics, JIPMER,Puducherry
N
ecrotizing enterocolitis intestinal ischaemia are thought intestinal epithelial cells, leading to
(NEC) is primarily a to play central role in disease a reduction in the severity of
disease process of the pathogenesis. The sequence of intestinal injury. In animal
gastrointestinal (GI) tract of events leading to the development models, EGF administration
premature neonates that results in of NEC is complex and still increased intestinal barrier
inflammation and bacterial incompletely defined. Although strength and reduced the severity
invasion of the bowel wall. It the pathophysiology of NEC has of experimental NEC.
occurs in 1%to 5% of all NICU not been completely elucidated, Furthermore, decreased levels of
admissions and 5% to10% of very progress has been made in the EGF have been shown in the
low birth weight infants. More characterization of the molecular saliva and serum of premature
than 75% of cases occur in infants events which may take place infants with NEC, decreased
born at less than 36 weeks of during an episode of ischemia. heparin-binding EGF-like growth
gestation and weighing under This possible initiating event is factor have been found in NEC-
2000 g. The postnatal age of onset followed by a complex cascade of affected areas of the intestine and
is a function of the gestational age, inflammatory mediators active in a recent study suggests that
with the peak incidence occurring NEC; epidermal growth factor, salivary EGF levels in the first and
approximately 3 weeks after birth platelet activating factor and nitric second week of preterm life may
in infants born at <32 weeks, oxide. Platelet-activating factor has have predictive value for NEC.
whereas disease develops been considered as one of the Nitric oxide plays a paradoxical role
approximately 2 weeks after birth most important mediator in the in intestinal physiology, low levels
in infants born between 32 and pathophysiology of NEC. PAF enhance the mucusal blood flow
has a short half-life, and is and are key to maintaining
36 weeks and under 1 week of
regulated by PAF-degrading mucusal intergrity , whereas
postnatal age in infants born at
enzyme acetyl hydrolase (PAF- sustained high levels cause
>36 weeks of gestation.
AH) activity of which degrades cytopathic effects on gut
Although NEC occurs primarily
PAF into the inert lyso-PAF. There epithelium. Upregulation of
in infants born prematurely,
is considerable evidence that PAF- nitric oxide plays an integral role
approximately 10 % 0f NEC
AH may play a role in the in the development of epithelial
occurs in full term
occurrence of NEC. PAF-AH injury in NEC. Nitric oxide (NO),
infants.Necrotizing enterocolitis is an important second messenger
predominantly a disease of activity is decreased in sick infants
and inflammatory mediator and
preterm. NEC in term infants is with NEC, and the administration
its reactive nitrogen derivative,
often assosciated with risk factors of PAF-AH in animal models of
peroxynitrite, may affect gut
like maternal toxemia, birth NEC reduces the incidence of
barrier permeability by inducing
asphyxia, cyanotic heart disease, NEC. PAF-AH activity has also
enterocyte apoptosis (progra-
polycythemia, acidosis ,shock, been demonstrated in breast milk,
mmed cell death) and necrosis, or
exposure to cocaine etc. suggesting it might be one of the by altering tight junctions or gap
Pathophysiology- Epidemio- factors which makes breast milk junctions that normally play a key
logic studies have identified protective against NEC1. EGF role in maintaining epithelial
multiple factors that increase an also plays an important role in monolayer integrity2. As a result,
infant’s risk for the development intestinal barrier function. In some treatment strategies have
of NEC, although premature response to injury, EGF enhances been aimed at abrogating the toxic
birth, bacterial colonization and the migration and proliferation of effects of nitric oxide.

37
Prematurity- In the preterm may render the mucosal barrier to luminal pathogens and may be
infant, mucosal cellular more susceptible to induced by collections of small
immaturity and the absence of injury. Intestinal regulatory T-cell lymphoid aggregates, which are
mature antioxidative mechanisms aggregates are a first-line defense absent or deficient in the
premature infant3
Fig-1, Pathogenesis of NEC

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

Intestinal ishaemia-NEC in X-ray should be obtained if any and peritoneal space. Depending
term infants is due to risk factors sign sug gestive of NEC is on the baby’s age and feeding
which implicate an insult to the present Laboratory studies regimen, baseline sodium levels
intestinal blood supply. The are helpful if the baby is having may be low-normal or
diving seal reflex is a mechanism systemic signs-CBC count with subnormal, but an acute decrease
by which intestines suffer most manual differential to evaluate the (<130 mEq/dL) is more
following a hypoxic injury. The WBC, hematocrit and platelet significant; Metabolic acidosis:
ileocaecal region is most frequently count; WBC count: marked Low serum bicarbonate (<20) is
involved which is watershed area elevation may be present, but seen in conjunction with poor
in the intestine, also suggesting leukopenia is more concerning; tissue perfusion, sepsis, and
the hypoxic ishaemic event in the RBC count: Premature infants are bowel necrosis. Thrombo-
pathophysiology of NEC. prone to anemia due to iatrogenic cytopenia, persistent metabolic
Despite convincing that evidence blood draws,as well as anemia of acidosis and severe refractory
that hypoxic ishaemic stress is prematurity; however, blood loss hyponatremia constitute the most
involved in term NEC, preterm from hematochezia and /or a common triad of laboratory
NEC appear to involve a different developing consumptive signs; Stool analysis- presence of
disease altogether , althogh it still coagulopathy can manifest as an blood and carbohydrate is a
plays a secondary role due to acute decrease in hematocrit; frequent and early indicator of
immature circulatory regulation Platelet count: NEC is commonly NEC when associated with the
in response to ishaemia. associated with thrombocytopenia signs of NEC; Serial CRP may
Clinical Features-Initial (<100,000/ì L). Thrombo- help in monitering the progress
symptoms may be subtle and can cytopenia may become more of the disease. Although all of
include one or more of the profound in severe cases that these initial laboratory studies
following:Feeding intolerance, become complicated with taken together may aid in the
delayed gastric emptying consumption coagulopathy. diagnosis of NEC, they do not
,abdominal distention, Consumption coagulopathy is substitute for an appropriate
abdominal tenderness decreased characterized by prolonged PT, appreciation of clinical
bowel sounds ,abdominal wall prolonged aPTT, and decreasing presentation and appearance of
erythema, bloody stools, fibrinogen and increasing fibrin the infant. The laboratory values
persistent localized abdominal degradation product can give insight into the severity
mass, ascites. Systemic signs are concentrations; Blood culture: of the disease and can aid in
nonspecific and can include any Obtaining a blood culture is the provision of appropriate
combination of the following: recommended before beginning therapy.
Respiratory distress, apnea antibiotics in any patient Imaging Studies- The mainstay
,lethargy, decreased peripheral presenting with any signs or of diagnostic imaging is
perfusion, temperature symptoms of sepsis or NEC. abdominal radiography. An
instability,poor feeding, irritability, Although blood cultures do not anteroposterior (AP) abdominal
acidosis , shock, cardiovascular grow any organisms in most cases radiograph and a left lateral
collapse, bleeding diathesis.The of NEC, sepsis is one of the decubitus radiograph (left-side
physical findings in patients who major conditions that mimics down) are essential for initially
develop NEC can be primarily NEC and should be considered evaluating any baby with
gastrointestinal, systemic, in the differential diagnosis. abdominal signs. Abdominal
indolent, fulminant, or any Therefore, identification of a radiograph should be taken serially
combination of these. A high specific organism can aid and at 6-hour or greater intervals,
index of clinical suspicion is guide further therapy; Serum depending on presentation and
essential to minimize potentially sodium: Hyponatremia is due clinical course. Characteristic
significant morbidity or mortality. to capillary leak and “third findings on an AP abdominal
Laboratory Studies- Abdominal spacing” of fluid within the bowel radiograph include an abnormal

39
gas pattern, dilated loops, and distention that changes over time. venous system and occurs when
thickened bowel walls (suggesting Pneumatosis intestinalis is a intramural air is absorbed into the
edema/inflammation). Serial radiologic sign pathognomonic mesenteric venous circulation
radiographs helps in assessing of NEC. It appears as a Ascites is a late finding that usually
disease progression. A fixed and characteristic train-track lucency develops when peritonitis is
dilated loop that persists over configuration within the bowel present or after bowel
several examinations is especially wall. Intramural air bubbles result perforation. Ascites is observed
important. The finding of a fixed from bacterial invasion, on an AP radiograph as centralized
loop that remains unchanged for fermentation and hydrogen bowel loops that appear to be
24 to 48 h is often associated with production in the intestinal wall. floating on a background of
transmural necrosis. Radiographs Pneumatosis intestinalis is density.
can sometimes reveal scarce or thought to be the hallmark of Ultrasonography- It can be used
absent intestinal gas, which is NEC disease but may also be to identify areas of loculation and
more significant than diffuse present in advanced cases of abscess consistent with a walled-
Hirschsprung’s enterocolitis or off perforation when patients
severe gastroenteritis. with indolent NEC have scarce gas
or a fixed area of radiographic
density. Ultrasonography is
excellent for quantifying ascites.
Serial examinations can be used
to monitor the progression of
ascites as a marker for the disease
course. Portal air can be easily
observed as bubbles present in the
venous system. Ultrasonographic
Abdominal free air is ominous assessment of major splanchnic
sign. The presence of abdominal vasculature can help in the
free air can be seen as oblong differential diagnosis of NEC
Fig-3, Pneumatosis intestinalis lucency over the liver and from other more benign
abdominal contents. It represents disorders. Doppler study of the
the air bubble that has risen to splanchnic arteries early in the
the most anterior aspect of the course of NEC shows increased
abdomen in a baby lying in a
peak flow velocity and it can help
supine position.Left lateral view
distinguish developing NEC
allows the detection of
from benign feeding intolerance
intraperitoneal air which rises
in a mildly symptomatic baby.
above the liver shadow and can
Imaging techniques, such as
be visualized easier than on other
views. Free air in the abdomen can contrast radiography, portal vein
be seen as a central collection of ultrasonog raphy, MRI, and
air on the anteroposterior film of radionuclide scanning, may play a
the abdomen, or can highlight the role in diagnosis. These techniques
falciform ligament. Portal gas is are not currently in common use.
thought to be ominous when GI tonometry is an infrequently
detected. Portal gas appears as used technique that may be
linear branching areas of decreased helpful in distinguishing benign
density over the liver shadow and feeding intolerance from early
Fig-4, Pneumoperitonium represents air present in the portal NEC.

Modified Bells Staging
Stage Systemic signs Intestinal signs Radiological signs Treatment

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

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

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

weight. Necrotizing enterocolitis enzymes, enhance digestive optimized. Further under-
was an independent risk factor for hormone release, intestinal blood standing of the pathogenesis of
an abnormal neurologic flow, and motility in premature NEC and the mechanisms by
examination . infants. In addition, infants which probiotics prevent it may
Prevention provided early trophic feeds lead to evidence-based treatment
appear to have improved feeding strategies.
Feeding practices- Human milk
tolerance, improved growth, Epidermal growth factor-
feeding reduces the incidence of
reduced sepsis, and reduced Heparin-binding epidermal
NEC. Human milk contains
hospital stay compared with growth factor-like growth factor
secretory immunoglobulinA
infants who do not receive trophic (HB-EGF) is a potent intestinal
(IgA), which binds to the
feeds. Furthermore, early trophic cytoprotective agent. HB-EGF
intestinal luminal cells and
feeds do not increase the incidence reduces the incidence and severity
prohibits bacterial transmural
of NEC. of NEC in a neonatal rat model,
translocation. Other constituents
of human milk, such as Probiotics-A proposed strategy with simultaneous preservation
interleukin (IL)-10, EGF, TGF-â1, for the prevention of NEC is the of gut barrier integrity. These
and erythropoietin may also play administration of oral probiotics. results support that HB-EGF
a major role in mediating the Probiotics are food supplements administration may represent a
inflammatory response. containing live bacteria that benefit useful therapeutic and
Oligofructose encourages the recipient by improving the prophylactic therapy for the
replication of bifidobacteria and microflora balance within the treatment of NEC. In addition,
inhibits colonization with lactose- intestine. Several studies suggest several investigators have reported
that the administration of the cytoprotective effect of
fermenting organisms. However,
probiotics may have a prophylactic epidermal growth factor, which is
breast milk alone does not prevent
effect for NEC and may reduce found in high levels in breast milk,
the development of NEC.
morbidity and mortality rates for on the intestinal epithelium.
Whereas conservative feeding
low birth weight infants. The Thus, fortification of infant
practices can reduce NEC,
most frequently used probiotics formula with specific growth
prolonged NPO treatment may
are lactobacillus and factors could soon become a
worsen gut function by causing
Bifidobacterium. Potential preferred strategy to accelerate
gut atrophy and worsened
mechanisms by which probiotics intestinal maturation in the
inflammatory responses, which
may protect high risk infants premature neonate to prevent the
can predispose to NEC. Diet plays
from developing NEC and/or development of NEC6,7
an important role in intestinal
development and defense. sepsis include increased barrier to Oral antiobiotics- There have
Nonnutritive dietary substances, migration of bacteria and their been reports published
such as epidermal growth factor products across the mucosa , suggesting that the use of enteral
and polyamines, stimulate competitive exclusion of potential antibiotics may be effective as
intestinal epithelial growth. pathogens , modification of host prophylaxis8. However concerns
Furthermore, certain nutrients response to microbial products , about adverse outcomes persist,
(glutamine, arginine, omega-3 augmentation of IGA mucosal particularly related to the
fatty acids) have been shown to responses, enhancement of development of resistant bacteria.
counteract proinflammatory enteral nutrition that inhibit the Pentoxiyflline- Agents that
activation and promote intestinal growth of pathogens, and up- modulate inflammation may
barrier function, proliferation, and regulation of immune responses improve outcome in NEC.
4,5
healing. Therefore, initiation of . However, the data are Pentoxifylline, a phospho-
trophic feeds should be insufficient to comment on their diesterase inhibitor when used as
considered in all VLBW infants. short- and long-term safety. Type an adjunct to antibiotics reduces
Trophic feeds have been shown of probiotics used, as well as the mortality without any adverse
to improve activity of digestive timing and dosage, are still to be effects9

43
Arginine-Metabolic role in intestinal development. 3. Hunter CJ, Upperman JS,
abnormalities are also associated Further, Epo has been shown to Ford HR, Camerini V. Under-
with NEC, one of which is increase cell migration and to have standing the susceptibility of
reduced plasma arginine protective effects when cells are the premature infant to
concentrations. Decreased arginine exposed to injur y. These necrotizing enterocolitis
availability causes diminished NO encouraging findings provide (NEC). Pediatr Res
production via the NOS pathway, rationale to further investigate the 2008;63(2):117-23.
and that this may be involved in possible role of Epo as a 4. Barclay AR, Stenson B,
the pathophysiology of NEC. preventive strategy for NEC13. Simpson JH, Weaver LT,
Both oral and intravenous Carbon monoxide- Carbon Wilson DC. Probiotics for
arginine supplementation monoxide (CO), a byproduct of necrotizing enterocolitis: a
suggests a beneficial role against the catabolism of heme, is known systematic review. J Pediatr
NEC in premature infants10. to have anti-inflammatory and Gastroenterol Nutr 2007
Immunoglobulins- antiapoptotic properties. Animal ;45(5):569-76.
Immunoglobulins are one of studies have shown that carbon 5. Gaul J. Probiotics for the
many possible factors in human monoxide decreases enterocyte prevention of necrotizing
milk responsible for it is protective production of inducible nitric enterocolitis. Neonatal Netw
effects on NEC. Neonates have oxide synthatse(iNOS) and nitric 2008;27(2):75-80.
decreased immunoglobulin levels, oxide ,inflamatory cytokines and
particularly secretory IgA. 6. Feng J, El-Assal ON, Besner
nitrites14.
However, oral immunoglobulin GE. Heparin-binding
Resveratrol- Resveratrol, a epidermal growth factor-like
administration has largely been
polyphenol compound from growth factor decreases the
ineffective in preventing NEC,
phytoalexins has antioxidant and incidence of necrotizing
although studies of enteral IgA
scavenger properties and also play enterocolitis in neonatal rats.
are lacking. Intravenous
a critical role in modulating key J Pediatr Surg 2006 ;41(1):144-
immunoglobulin(IVIG) has also
enzymes in cell cycle including 149.
failed to demonstrate significant
iNOS. Animal studies with
reductions in NEC, sepsis, or 7. Nair RR, Warner BB, Warner
newborn rats have shown that
mortality11. BW .Role of epidermal
enteral resveratrol has beneficial
Glucocorticoids-Clinical studies growth factor and other
effect on NEC by attenuating the
have shown that the antenatal growth factors in the
realese of iNOS and preservation
administration of glucocorticoids prevention of necrotizing
of mucosal integrity15.
decreases the incidence of NEC. enterocolitis. Semin Perinatol
References 2008 ;32(2):107-132.
However, postnatal steroids do
not appear to be as promising12. 1. Patricia W. L, Tala R. N and 8. Bury RG, Tudehope D.
Stoll BJ . Necrotizing Enteral antibiotics for
Erythropoitien-Erythropoeitin
enterocolitis: Recent scientific preventing necrotizing
(Epo) is another breast milk
advances in pathophysiology enterocolitis in low birthwe-
component that may play a role
and preventon. Semin ight or preterm infants.
in intestinal development,cell
migration, and intestinal Perinatol 2008; 32(2):70-82. Cochrane Database Syst Rev
restitution. Receptors for Epo are 2. Chokshi NK, Guner YS, 2000;(2):CD000405.
also present in the intestine. Hunter CJ, Upperman JS.The 9. Haque KN, Mohan P.
Contact with Epo occurs both role of nitric oxide in intestinal Pentoxifylline for treatment
pre- and postnatally, through epithelial injury and restitution of sepsis and necrotizing
exposure to amniotic fluid and in neonatal necrotizing enterocolitis in neonates.
breast milk, respectively. These enterocolitis. Semin Perinatol Cochrane Database of Systematic
findings suggest that Epo plays a 2008;32(2):92-9. Reviews 2003, CD004205.

10. Josef N. Arginine supple- the Nestorian Abu Zeid Honein
mentation for neonatal Arabian medical ben Ishak ben Soliman ben Ejjub
necrotizing enterocolitis: are science el ‘Ibadi (Joannitius, 809-about
we ready? Br J nutr 873), a teacher in Baghdad who
2007;97:814-815. Arabian medical science forms an
translated Hippocrates and
important chapter in the history
11. 11.Foster J, Cole M. Oral Dioscurides, and whose work
of the development of medicine,
immunoglobulin for “Isag oge in artem par vam
not because it was especially
preventing necrotizing Galeni”, early translated into Latin,
productive but because it
enterocolitis in preterm and was much read in the Middle
preserved Greek medical science
low birth-weight neonates Ages. Wide activity and
with that of its most important
Cochrane Database Syst Rev independent obser vation —
representative Galen. It was,
2004;(1): CD001816. based, however, wholly upon the
however, strongly influenced by
doctrine of Galen — were shown
12. Crowley P, Chalmers I, oriental elements of later times.
Keirse MJ. The effects of by Abu Bekr Muhammed ben
The adherents of the heretic
corticosteroid administration Zakarijia er-Razi (Rhazes, about
Nestorius, who in 431 settled in
before preterm delivery: an 850-923), whose chief work,
Edessa, were the teachers of the
overview of the evidence from however, “El-Hawi fi’l Tib”
Arabs. After the expulsion these
controlled trials. Br J Obstet (Continens) is a rather
Nestorians settled in
Gynaecol 1990;97:1125. unsystematic compilation. In the
Dschondisapor in 489, and there
Middle Ages his “Ketaab altib
13. Ledbetter DJ, Juul SE. founded a medical school. After
Almansuri” (Liber medicinalis
Erythropoietin and the the conquest of Persia by the
Almansoris) was well known and
incidence of necrotizing Arabs in 650, Greek culture was
had many commentators. The
enterocolitis in infants with held in great esteem, and learned
most valuable of the thirty-six
very low birth weight. J Pediatr Nestorian, Jewish, and even
Surg 2000;35:178–182. productions of Rhazes which
Indian physicians worked
have come down to us is “De
14. 14.Zuckerbraun BS, Otterbein diligently as translators of the
variolis et morbillis”, a book
LE, Boyle P, Jaffe R, Greek writings. In Arabian Spain
based upon personal experience.
Upperman J, Zamora R, Ford conditions similarly developed
We ought also to mention the
HR. Carbon monoxide from the seventh century. Among
dietetic writer Abu Jakub Ishak
protects against the important physicians in the first
ben Soleiman el-Israili (Isaac
development of experimental period of Greek-Arabic medicine
Judaeus, 830-about 932), an
necrotizing enterocolitis.Am J — the period of dependence and
Egyptian Jew; the Persian, Ali ben
Physiol gastrointest liver of translations — come first the
el Abbas Ala ed-Din el-
physiol 2005;289(3):G607- Nestorian family Bachtischua of
Madschhusi (Ali Abbas, d. 994)
G613. Syria, which flourished until the
author of “El-Maliki” (Regalis
15. Ergün O, Ergün G, Oktem G, eleventh century; Abu Zakerijja
dispositio, Pantegnum). Abu
Selvi N, Doðan H, Tunçyürek Jahja ben Maseweih (d. 875),
Dshafer Ahmed ben Ibrahim ben
M, Saydam G, Erdener A. known as Joannes Damascenus,
Abu Chalid Ihn el-Dshezzar (d.
Enteral resveratrol supple- Mesue the Elder, a Christian who
1009) wrote about the causes of
mentation attenuates was a director of the hospital at
the plague in Egypt. A work on
intestinal epithelial inducible Bagdad, did independent work,
pharmaceutics was written by the
nitric oxide synthase activity and supervised the translation of
physician in ordinary to the
and mucosal damage in Greek authors, Abu Jusuf Jacub
Spanish Caliph Hisham II (976-
experimental necrotizing ben Ishak ben el-Subbah el-Kindi
1013), Abu Daut Soleiman ben
enterocolitis. J Pediatr Surg (Alkindus, 813-73), who wrote a
Hassan Ibn Dsholdschholl.
2007 ;42(10):1687-94. work about compound drugs, and

45
Assessment of Bronchial Liability on Exposure to Isometric
10
Exercise during Different Phases of Menstrual Cycle Original
Article
Mona Bedi, V P Varshney, Shilpa Khullar
Department of Physiology, Maulana Azad Medical College, New Delhi
he effect of sex hormones .Some studies have concluded cycle.
T on airway function has not
been well studied inspite of much

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

was taken as the luteal phase. grip exercises.Statistical analysis who showed that inspiratory
11
The pulmonary functions were was done with the statistical muscle endurance in the mid
tested under basal conditions and package PRISM. The data before luteal phase of the menstrual cycle
then following hand – grip and after had grip test was when the plasma progesterone
exercise in the three phases of compared using student’s ‘t’ test level was relatively high was greater
menstrual cycle. The spirometric with ‘P’ < 0.05 considered to be than in the mid follicular phase.
lung functions were recorded in significant. The muscle strength and resting
the sitting posture using Results - The general characteri- pulmonary function , on the
precalibrated spirometer ‘spirolab – stics of subjects are given in Table- contrary , were similar in these two
II’ with nose clip on. All 1. Sex hormones level fluctuated phases of the menstrual cycle.7 It
spirograms were recorded by one as expected with highest level of is possible that the effect of sex
investigator to minimize inter – progesterone during luteal phase hormones relate not to peak
observer variation. The ambient and that of estradiol during serum levels but rather to falling
laboratory temperature was proliferative phase as shown in levels.8The general fall seen in all
maintained between 20-250C. In Table-2. The pre- exercise and respiratory parameters in our
order to allay anxiety and post- exercise values of different study could be due to psychic
apprehension associated with parameters of pulmonary factors or fatigue.It could also be
testing , they were explained the functions in the three phases of attributed to isometric exercise
purpose of the study and also the menstrual cycle can be seen in mediated bronchoconstriction
technical procedures to be Table -3.All values are expressed due to á adrenergic discharge.13-15
performed. Before the actual as mean ± S.E . Fall in FVC, In our study, significant decrease
testing, each subject was
PEFR, FEV1 (%) and FEF25-75% in PEFR was seen in all the phases
familiarized with various test
was seen following exercise in all of menstrual cycle when exposed
procedures viz breathing through
three phases of menstrual cycle . to hand grip test. This is in
mouth piece and valve. The forced
However only the fall in PEFR contrary to the findings of Pauli
expiratory maneuvers were
was found to be significant (P< and co-workers (1989) 16 who
performed atleast 3 times for each
0.05) (Fig-2) ,whereas FVC (Fig- stated that an increase in asthma
subject and best of three attempts
1), FEV1 (%) (Fig-3) and FEF25- symptoms and a slight decline in
were selected for data
(Fig-4) decreased non – PEFR only in luteal phase was
computation.A hand – grip 75%
significantly (p>0.05) after seen in asthmatics. Therefore it
sustained isometric contraction
isometric exercise. seemed worthwhile to study the
(SIC) was performed in the
supine position using a hand Discussion-There is compelling relationship between the
mechanical dynamometer . Initially evidence for hormonal influence menstrual cycle and the measures
each subject was familiarized with on airways and changes in airway of airway function and airway
the experimental device and responsiveness might occur reactivity in normal subjects also.It
systematically trained. The during menstrual cycle. Our is well known that there is isotonic
subjects were asked to grip results showed a generalized fall exercise induced broncho-
maximally with their dominant in pulmonary function after constriction after completion of
hand.The highest value of three sustained isometric contraction exercise rather than during it. This
contractions was taken as the during all three phases of has been attributed to increased
maximum voluntary contraction menstrual cycle. No difference was nor – adrenaline levels in the early
(MVC). Hand grip was observed in pulmonary function post-exercise period which
maintained steadily at 30 % of test under resting conditions in interacts with histamine , a
MCV till the subject got the menstrual,proliferative and probable mediator of broncho –
fatigued. 12 Spirometric luteal phases of the menstrual constriction after exercise. 17-18It
measurements were done within cycle. This is in accordance to the has been seen in our study that
five minutes of cessation of hand findings of Chen and Tang (1988) there is significant fall in PEFR

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

Table-1,Baseline characteristics Table-2, Serum sex hormone levels (values are expressed
of the subjects (values are as mean ± SD)
expressed as mean ± SD) Proliferative phase Luteal phase
Age (years) 29.2 ± 0.98 Estradiol (pg/ml) 156 ± 12.6 123 ± 10.6
Height (cms) 159.4 ± 1.98 Progesterone 1.06 ± 0.22 10 ± 0.98
Weight (kg) 56.3 ±1.67 (ng/ml)
Table-3, Pre exercise and post exercise values of pulmonary function parameters in the
menstrual, proliferative and luteal phases (values are expressed as mean ± SE)
Parameter Mentrual phase Proliferative phase Luteal phase
Pre- Post- Pre- Post- Pre- Post-

exercise exercise exercise exercise exercise exercise
FVC (L) 2.94±0.12 2.89±0.11 2.93±0.09 2.90±0.11 2.93±0.09 2.90±0.09

* *
PEFR(L/s) 6.29±0.3 6.07±0.3 6.30±0.2 5.92±0.2 6.35±0.3 6.08±0.2*
FEV1(%) 86.8±1.1 85.9±1.05 85.8±1.1 85±1.1 86.5±1.1 86.4±1.0
FEF25-75%(L/s) 3.02±0.18 2.92±0.16 2.9±0.16 2.84±0.15 3.01±0.17 2.9±0.14
* - p value < 0.05

49
Availability and Consumption Pattern of Iodised Salt in
11
the Villages of Ballabgarh District, Haryana Original
Radhika Sood, Misha Sharma, Chandandeep Gujral Article
Department of Nutrition, Lady Irwin College, University of Delhi
odine deficiency is the world’s UNICEF global database region has shown that, the second
I most prevalent, yet easily

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

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

51
z To determine availability of random number tables.For Laboratory Analysis-Iodine in
iodised salt. household section, 7 households the salt samples from retail
z To find out the awareness of were selected from each cluster. outlets were analysed by
the community about Nearly all retail shops selling salt iodometric titration at ICCIDD
different types, and brands of in the cluster were included. lab, Shahapurjat, New Delhi.
salt and cost. Hence, the sample size comprised Data Processing and Analysis-
z To study the cooking and
of 210 households and retail shop The responses to the questions
storage practices of salt at owners (a maximum of 6 in each were entered into Epi info and
household. cluster) analysis was done in Statistical
Package for the Social Sciences
z To assess the knowledge Survey Instrument(s) / Tools
(SPSS).
among people regarding the and Techniques- The
advantages and disadvantages standardized ICCIDD interview Results
of iodised salt and health schedules were used to assess, A total of 211 households and
impact of iodine deficiency. knowledge, attitude, practices and 135 retailers were interviewed.
beliefs about IDD and Iodised The iodisation status of salt
Methodology
salt amongst household and samples taken from house holds
Study Design-The study was a (211) and retailers (234) was tested
shopkeepers. The inter view
cross-sectional community based with Salt Testing Kit (STK). A
schedule had both closed and
field survey. The probability total of 13 salt samples, collected
open ended questions. The
proportionate to size (PPS) 30 from the retailers were analysed for
interview was conducted in the
cluster methodology was used for iodine content by iodometric
Hindi and the answers were
sample selection. analysis.
translated into English and were
Study Area-The study was done marked on the inter view Responses of retailers on sales
in villages under the schedule. Salt testing kit (STK) by of salt- According to retailers
Comprehensive Rural Health ICCIDD lab, was used to interviewed (Table-2), the type of
Services Project, Ballbagarh, determine the presence of iodine salt that was being sold most in
district Faridabad, Haryana. The in salt samples. This is a qualitative the villages, was iodised salt (88.9
study area was selected because it and rapid test at field level and at %). The reason given by the
has been adopted by the Centre retailers for maximum sale of a
consumer level.
for Community Medicine, All given brand of salt, irrespective of
India Institute of Medical Data collection-The interview
it being iodised or non-iodised
Sciences, New Delhi. schedule was administered by the
was that the customers asked for
students involved in the project it (77 %). Only 10.4 % of the
Study population-The study with the help of local coordinators
population comprised of the respondents mentioned that the
(health workers). The household iodised salt is good for health
shop keepers selling salt and the questions were asked from the
adult female house-hold member reasons.
women of the selected
involved in cooking and who Responses of household on
households. If there were more consumption of salt-In the
could give information on its than one woman in the house,
storing and addition of salt household sur vey data was
the senior-most one who looks collected from 211 respondents
during cooking in the selected after the family kitchen was
houses. (Table-3). Majority of the
interviewed. The data collection respondents (53.6 %), procured 1
Sampling-Twenty one villages of was started on 30th May 2008 and kg of salt at a time, and 43.6 %
Ballabgarh were selected to be the was completed by 13 th June mentioned that they procured
part of the study. Thirty clusters 2008.All participants were more than 1 kgs of salt at a time.
from these villages were explained the purpose of the 90.6 % of these respondents
determined by the method of study and a verbal consent was procured company packed salt,
simple random sampling, using taken. 7.6 % loose salt and the rest had

no fixed choice.Besides the retailers. Another reason given was Testing Kit (STK), revealed that
human consumption of salt, 84.1 that iodised salt was important to most households were
% of these households were also prevent goiter. From the results consuming iodised salt (Table-5).
using the same salt for feeding the obtained, it was seen that most Also, of the various salt samples
cattle and 15.9 % used the salt for of the respondents were ignorant kept with the retailers, 90.5 % were
agricultural purposes. Most of the regarding the importance of iodised.Of the various salt brands
respondents (48.8 %) were not iodised salt in the diet. Prevention available, most were within the
aware how to differentiate iodised of cretinism as a reason for use price range of Rs.3-10/- per
salt from non-iodised salt. Some of iodised salt was given by very kilogram. The iodised salt
gave reasons that iodised salt was few households and retailers.The samples available were available in
cleaner (2.8%) or that it was finer major source of information the range of Rs. 3-10/-per
(1.4 %), and only 1.4 % said that (Figure-2) regarding the use and kilogram, while the company
they identified iodised salt by advantages of iodised salt at the packed non-iodised salt brands
looking at the smiling sun logo. rural level were television were available for Rs.3/- or Rs.4/
The households were also (households, 83.9 % and retailers, - per kg. The loose or the crystal
questioned on the cooking and 64.2 %). As most of the salt was within the price range of
storage practices regarding salt, as respondents were illiterate only Rs.1-4/-per kg. The availability of
the iodine in salt is a volatile iodised salt at the retail level was
4.9 % households said teachers as
substance, 88.2 % respondents adequate as all shopkeepers store
the source of information,.
said that they stored salt in a iodised salt. A total of 13 salt
separate container with a lid, while Among retailers, 13.8% reported
that they got information samples, collected from the
4.2 % stored in containers retailers were analysed for iodine
without lid. Most of the regarding iodised salt from their
school teachers. Health workers as content by iodometric analysis
households (65.4 %) added salt (Table-6). A number of brands
while cooking right in the a source of information scored
very low responses. of salt were available at the rural
beginning. Only 3.3 % responded level, of which very few brands
that they add salt in the end. Salt Analysis-The iodisation had salt that was adequately
Awareness of retailers and status of salt, on testing with Salt iodised (>15 ppm).
household on consumption of
salt-The awareness level about Table-2, Responses of retailers on the type of
iodised salt of retailers and salt sold in the villages of Ballabgarh
households were computed
(Table-4), 34.6 % women
perceived that consumption of Aspect covered No of Response
iodised salt was important, while (n=135)
54.1 % of the retailers thought
¾ Type of salt sold
that consumption of iodised salt
was important. Of the small maximum*
percentage (33.4 %) of Iodised 121 (88.9)
households, who had heard Non-iodised 12 (9.3)
about iodised salt, 17.8 % did not
know the reason as to why ¾ Reason for
consumption of iodised salt was maximum sales
important (Figure-1). Amongst Customers ask for it 104 (77)
the reasons given for the use of Easy to store 5 (3.7)
iodised salt, “good for health” was Health reasons 14 (10.4)
the most common response given Others 12 (8.9)
by the 75.3 % respondents from
the households and 52.1 % from The figure in parentheses denotes percentage,* n=133

53
Table-3, Responses of household on consumption of salt
Aspect covered No of Response
(n=211)
Procurement
¾ Quantity of salt bought at a time
< 1 Kg 6 (2.8)
1 Kg 113 (53.6)
>1 Kg 92 (43.6)
¾ Type of salt bought
Company packed 191 (90.6)
Loose 16 (7.6)
No fixed pattern 5 (1.8)
Consumption
¾ Use of salt besides human consumption*
Agriculture 7 (15.9)
Cattle 37 (84.1)
Storage and cooking practices
¾ Storage of salt
Same packet 16 (7.5)
Container with a lid 186 (88.2)
Container without lid 9 (4.2)
¾ Addition of salt while cooking
In the end 7 (3.3)
Beginning 138 (65.4)
In between 61 (28.9)
Others 5 (2.4)
Awareness
¾ Identification of iodised salt
Cleaner 6 (2.8)
Finer 3 (1.4)
Smiling logo 3 (1.4)
Don’t know 103 (48.8)
Others 15 (7.1)
No answer 81 (38.5)
The figure in parentheses denotes percentage;* n=44
Table-4, Retailers and household perception on consumption of salt
Type of salt Retailers (n=135) Household (n=211)

Iodised 73 (54.1) 73 (34.6)
Non-iodised 17 (12.6) 19 (9)
Don’t know 44 (32.6) 101 (47.9)
No answer 1(0.7) 18 (8.5)
The figure in parentheses denotes percentage

Table-5, Iodisation of salt on testing with salt testing kit
Type of salt Retailers (n=234) Household (n=211)
Company packed Loose
Iodised 212 (90.5) 0 (0) 189 (90.5)
Non-iodised 4 (2.1) 18 (7.4) 22 (9.5)

Table-6, Iodisation status according to brands of the salt
Brand No. of Shopkeepers Iodisation status on Iodine content of the

keeping each salt testing with spot test salt
(n=135) kit (ppm)
Crystal 18 (13.3) Non-iodised 0
International 1 (0.7) Iodised 5.3
i-shakti 7 (5.2) Iodised 31.7
Tata 76 (53.3) Iodised 43.4
Prince 1 (0.7) Non-iodised 0
Sri Ram 1 (0.7) Iodised 9.5
Captain cook 42 (31.3) Iodised 34.9
Shudh 58 (42.9) Iodised 6.3
Reliance 22 (16.2) Iodised 14.8
Taja 1 (0.7) Iodised 8.5
Amber 3 (2.2) Iodised 5.8
Sharma 2 (1.4) Iodised 5.3
Hindustan shudh 2 (1.4) Non-iodised 0
Figure-1, Benefit stated by retailers and households for consumption of iodised salt
(n=73, household and retailers)

55
Figure-2, Benefit stated by retailers and households for consumption of iodised salt
(n=81, household and n=87, ratailers)
Discussions-The study was done Ballabgarh. While studying, the NFHS-3. Bhat et al. (2008)
in twenty one villages of awareness of iodised salt reported that nearly 98.17 % of
Ballabhgarh. The study was a amongst retailers (64.2 %) and powdered salt samples in Jammu
cross-sectional community based households (83.9 %), television region had an adequate iodine
field survey. The probability was found to be the major source content of 15 ppm, which was
proportionate to size (PPS) 30 of information. The present found to be very high when
cluster methodology was used for study shows that, 65.4 % compared with the present study.
sample selection. The study respondents added salt in the Kapil et al. (1996) reported from
population comprised of 211 beginning during cooking, which Delhi that 41 % of the families
households and 135 retailers.In was known to be a wrong practice, consume salt with adequate
the study it was observed, that as salt should be added at the end iodine. According to NFHS-3
90.5 % of the respondents were so that iodine content is retained. data, 41.2 % of the rural
consuming iodised salt but most As observed only 3.3 % of the households in India are
of them were not aware of it. households were adding the salt consuming adequately iodised
They used company packed salt as at the end.Two brands of salt were salt. The data also shows that, in
it was easy to store and use as found to be non-iodised on the state of Haryana the use of
compared to crystal salt. A study iodometric analysis, but they gave adequately iodised salt has
done by ICCIDD and UNICEF wrong information on the label deteriorated substantially from 71
in the state of Orissa in 2003 of being iodised. The present % (NFHS-2) to 55 % (NFHS-3).
showed that most people believe study reports that 53.4 % of salt The consumption of adequately
that only refined and packet salt is available at the retailer level in the iodised salt in Haryana state is 55.3
iodised, which is expensive. The villages was adequately iodised (i.e. %, while 28.2 % of the
same belief was observed among >15ppm), which was found to be households are not consuming
subjects of the villages of consistent with the recent studies, iodised salt at all. Northeast India

is perceived to have poor access ICCIDD, for helping us Due to Iodine Deficiency.
and availability to adequately understand the concept of International Council for the
iodised salt, but the results show iodometric titration. We thank Mr Control of Iodine Deficiency
that the entire Northeast region Rajesh, in conducting iodometric Disorders, 2008 http://
has access to adequately iodised titrations at ICCIDD lab. We www.iccidd.org (Last accessed
salt. 93.8 % households in the would like to thank Dr Vivek on 2008 June 28).
state of Manipur are consuming Gupta, Senior Resident, for his 6. Towards sustaining elimina-
adequately iodised salt. While the invaluable help in the statistical tion of Iodine Deficiency
salt producing state of Gujrat has analysis of data. We are grateful Disorder, Orissa India, 2003.
only 55.7 % households that are to him for giving us the benefit
using adequately iodised salt. of his experience and his time for National Board of
Conclusion-The study has completion of the work. We are
shown that iodised salt is available also thankful to all the health Examinations offers
in the villages of Ballabgarh but workers in the villages we visited following gold
people are not aware that they are during the survey, for helping us
consuming iodised salt. The approach the community. We are medal to the
health workers and the grateful to Mrs. Saroja Narayanan meritorious DNB
Anganwadi workers need to be for her utmost cooperation
trained to dissipate the knowledge throughout the project. candidates
on the benefits of consumption References Dr. H S Wasir Gold Medial for
of adequately iodised salt and its 1. Bhat I A, Pandit I A, Cardiology
cooking and storage practices. Mudassar S. Study on Dr. H L Trivedi Gold Medal for
Acknowledgements-We express prevalence of Iodine Nephrology
our sincere gratitude to Dr C.S Deficiency Disorder and Dr. S K Sama Gold Medal for
Pandav, Professor and Head, Consumption Patterns in Gastroenterology
Centre for Community Medicine, Jammu region. Indian Dr. C S Sadasivam Gold Medal
for Cardio thoracic Surgery
All India Institute of Medical Journal of Community
Dr H S Bhat Gold Medal for Genito
Sciences, New Delhi, for giving us Medicine. 2008; 30:11-14.
Urinary Surgery
an opportunity to work with the 2. Kapil U, Saxena N, Dr R.K Gandhi Gold Medal for
village community. We would like Ramachandran S, Nayar D. Paediatric Surgery
to express our heartfelt thanks to Assessment of IDD using Dr. B.R. Santhanakrishanan Gold
Dr Puneet Misra, Assistant cluster approach in the Medal for Pediatrics
Professor and Dr Sanjay Rai, National capital territory of Dr Sam G P Moses Gold Medal for
Assistant Professor, CRHSP- Delhi. Indian Pediatr. 1996; General Medicine
AIIMS, Civil Hospital Ballabgarh, 33:1013-7. Dr Satyapal Agarwal Gold Medal for
for guiding and advising us in
3. National Family Health Radio Therapy
conceptualizing the research work.
Survey, India. National Family Dr. Arcot Gajaraj Gold Medal for
Dr Anil Goswami, Supervising
Health Sur vey Report-3 Radio-Diagnosis
Medical Social Service Officer and
http://www.nfhsindia.org Dr. B Ramamurthi Gold Medal for
Dr Arijit Chakraborty, Program
(Last accessed on 2008 June General Surgery
Manager- Advocacy, were a source
16). Dr. K Bhaskar Rao Gold Medal for
of much needed encouragement. Obstetrics and Gynaecology
We are also thankful to Dr Kapil 4. Sustainable Elimination of
Iodine Deficiency. UNICEF, Dr G Venmkataswamy Gold Medal
Yadav, Senior Resident and Dr for Ophthalmology
Rupa, Senior Resident, for 2008 http://www.unicef.org
(Last accessed on 2008 July 1). Dr S. Kameswaran Gold Medal for
teaching us sampling techniques. Otorhinolaryngology
We extend our gratitude to Dr 5. Towards The Global Dr Balu Sankaran Gold Medal for
M.G Karmarkar, President, Elimination of Brain Damage Orthopaedic Surgery

57
Correspondence
12
Quality Control First Phase-A written EQAS participated in EQAS run by

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

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

59
particular area of the body may and help the doctors to plan the various degrees of success. When
occasionally trigger the growth of best treatment. These may include an operation is not possible,
a desmoid tumor there. The X-ray. Ultrasound, CT or MRI radiotherapy, may be used to
trauma could be a injury, an Scans and finally taking a Biopsy shrink the growth or to stop it
operation or radiotherapy. from the tumor and examining it from increasing in size. Because
Desmoid tumors, that occur in under a microscope. the tumors are often slow
people with Familial adenomators Treatment – Depends on the growing, it may take months
Polyposis (FAP) often develop in location of the tumor, its size, before the effects of radiotherapy
an area, that has been previously how quickly it is growing and can be seen so it may be several
operated on. Although desmoid whether it is causing symptoms month before a Scan can show
tumors are rare sometimes more and what are the whether the tumor has shrunk or
than one person in a family is symptoms.Treatment may stopped growing as a result of
affected. In particular, people with include -Surgery ; Radiotherapy ; treatment. Occasionally a desmoid
an inherited condition called Chemotherapy; Hormonal tumor completely disappears
familial Adenomatous Polyposis therapy; Anti Inflammatory without any treatment. This is
(FAP) have a much higher risk than drugs. The most commonly used called spontaneous regression or
average of developing them. FAP treatment is surgery to remove all sometime a desmoid tumor
is mainly linked to an increased the tumor. Unfortunately grows quickly and then stops
risk of Bowel Cancer. But about sometimes, these recur. growing. Because of this, in some
one in ten people with FAP Treatment maybe given after situations, doctors may keep the
develop desmoid tumors. It is surgery to try to reduce chances of tumor under observation rather
universally agreed that desmoid recurrence. ( Tamoxifen or than treat at once.
tumors are not cancers because nonsteriod anti inflammatory Conclusion-Desmoid tumours
they cannot spread to other parts drugs).Sulindac is an example of are slow growing deep
of the body, although they can an NSAID that is commonly fibromatosis with progressive
grow into surrounding tissue. used. It induces cell cycle arrest infiltration of adjacent tissue but
They are usually slow growing and and apoptosis in cancer cells lines without any metastatic potential.
the first sign is often painless or by decreasing prostaglandin Although rare, fibromatosis
slightly painful lump. Many synthesis through the inhibition should enter into the differential
desmoid tumors occur in the of cyclooxygenase – I enzyme diagnosis of masses developing
tummy area (Abdomen) or in the (COX – 1). The anti-angiogenic in irradiated areas in patients treats
Pelvis. Other parts of the body property of Sulindac and the more for Hodgkin’s disease. Complete
that can be affected include the recently used interferon alfa – 2b excision is often impossible and
chest, shoulders, thighs and the have been employed successfully therefore adjuvant treatments
head and neck area. They can affect to achieve tumor regression and have been employed with various
people of any age but are rarely sustained remission. Anti- degrees of success.
found in children. The most oestrogens such as tamoxifen and References
common first sign of a desmoid other selectie oestrogen receptor 1. Stout AP, Raffale L. Tumours
tumor is a painless lump growing modulators (SERMs) e. g. of soft tissues. In Atlas of
deep under the skin. But raloxifene, have been shown to be Tumor Pathology, Second
symptoms vary depending on effective in regression of the series, Fascide A, Armed forces
where the lump and its size. If tumor. Tumors may respond to Institute of Patholog y.
the mass is pressing on nearby second-line hormonal therapy as Washington DC 1967.
nerve, organs or muscles this gosereline acetate (Zoladex) and 2. Murayama T. Imoto S. Ito M
might cause pain. Rarely a tumor medroxyprogesterone acetate. Matsushita K, Matozaki S,
growing in the abdomen or pelvis Cytotoxic chemotherapy has been Nakagawa T et al, Mesenteric
may cause blockage or bleeding for used in cases of symptomatic fibromatosis presenting as
the GIT. A number of tests may desmoid tumor unresponsive to fever of unknown origin Am J
be done to diagnosis the tumor onventional medical therapy with Gastroentrol 1992;69: 1503 – 05

3. Lai KKT, Chan YYR, Chan
HCE, Chin CWA
intraabdominal desmoid
tumor, JHK Coll Radiol 2003;
6: 97-99.
4. Clark SK, Neale KF,
Landgrebe JC, Philips RK.
Desmoid tumors complicating
familial adenomatous Fig-5, Low power picture of the
Fig 1 : Scanner picture showing muscle
polyposis. Br J Surg 1999; 9: coat and a mass made up of fibrous centre of the polyp showing the
1185-89 connective tissue in submucosa. fibrous connective tissue.
5. D Alteroche L, Benchellai ZA,
Salem N, Regimbeau C, Picon
L, Metman EH. Complete
remission of a mesenteric
fibromatosis after taking
Sulindac. Gastroentrol Clin
Biol 1998; 22 (12); 1098 – 101
6. Heidemann J, Ogawa H,
Otterson MF, Shidham VB,
Fig-2, Scanner picture showing disruption Fig-6, Scanner picture of
Binion DG Antiangiogenic
in muscle coat due to proliferation of mucosa showing haemorrhagic
treatment of mesenteric
fibrous connective tissue which is necrosis at the tip of polyp.
desmoid tumors with
extending from submucosa to serosa
tamoxifien and interferon alfa
– 2b. Report of two cases. Dis
Colon Rectum 2004 Jan ; 47
(1) 118-22.
7. Tonelli F, Ficari F, Valanzano
R, Brandi ML. Treatment of
desmoids and mesenteric
fibromatosis in familial
adenomatous polyposis with
Fig-7, Another picture showing
reloxifene. Tumori 2003; 89 (4) Fig-3, Low power picture showing the haemorhage in lamina propria
391-96. fibroblastic tissue creeping through the and shedding off of the surface
8. Hamilton L, Blackstein M, muscle coat. epithelium.
Berk T, Meleod RS, Gallinger
S, Madlensky L, Cohen Z.
Chemototherapy for desmoid
tumors in association with
familial adenomatous
polyposis ; a report of three
cases. Can J Surg ; 1996; 93 (3)
247-52.
Fig-8, Naked eye-Gross picture
Ram Prakash Gupta Fig-4, High mag showing the of microsection showing the
Shanti Mukand Hospital fibroblasts with plump nuclei polyp sitting over the muscle
Karkardooma, Delhi and fibrillary cytoplasm and lined by mucosa.

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

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

63
syndrome (6). Typically, capillary involved bones, chronic venous Trénaunay Weber syndrome is
malformations involve the insufficiency, stasis dermatitis, conser vative and includes
enlarged limb, although skin poor wound healing and application of graded compressive
changes may be seen on any part ulceration.Complications are most stockings or pneumatic compre-
of the body. The lower limb is often related to the underlying ssion devices to the enlarged
the site of malformations in vascular pathologic condition. extremity. Percutaneous sclerosis
approximately 95% of patients. These include thrombophlebitis; of localized venous malforma-
When found on the trunk, the cellulitis; and more serious tions or superficial venous
malformations rarely cross the sequelae such as thrombosis, varicosities may be indicated in
midline. If large enough, the coagulopathy, pulmonary some patients. Surgical treatment
cutaneous lesions may sequestrate embolism, congestive heart failure may include epiphysiodesis to
platelets, possibly leading to (in patients with arterio-venous control leg length discrepancy,
Kasabach-Merritt syndrome, a malformations), and bleeding
excision of soft-tissue hypert-
type of consumptive from abnormal vessels in the gut,
rophy, stripping of superficial
coagulopathy(7). Varicose veins are kidney, and genitalia (6,8) .At
varicose veins, or, less commonly,
present in a majority of patients radiography, bone elongation
reconstructive surgery at sites of
with Klippel-Trénaunay Weber contributing to leg length
deep venous obstruction.
syndrome. Venous malformations discrepancy, soft-tissue thickening,
can occur in both the superficial or calcified phleboliths may be References
and deep venous systems (2) . seen. At lymphangiography, 1. Klippel M, Trenaunay P. Du
Superficial venous abnormalities hypoplasia of the lymphatic noevus variquex osteo-
range from ectasia of small veins system has been reported. hipertrophique. Arch Gen
to persistent embryologic veins Sonography may be used to Med 185: 641-672, 1900.
and large venous malformations. identify the abnormal veins and
2. Kanterman RY, Witt PDt,
Deep venous abnormalities varicosities. CT of the abdomen
Hsieh PS, Picus D. Klippel-
include aneurysmal dilatation, and pelvis provides a simple,
aplasia, hypoplasia, duplications, noninvasive means of assessing Trenaunay syndrome: imaging
and venous incompetence. The visceral vascular malformations. findings and percutaneous
Klippel-Trenaunay vein is a large, Spin-echo MR images intervention. AJR 167: 989-
lateral, superficial vein sometimes demonstrate a lack of enlarged 995, 1996.
seen at birth(8). This vein begins high-flow arterial structures, and 3. Cihangiroglu M, Serhatlýoglu S,
in the foot or the lower leg and T2-weighted images show Akfýrat M, Murat A, Özdemir
travels proximally until it enters malformed venous and lymphatic H., Üst ekstremitede geliºen
the thigh or the gluteal area.In our lesions as areas of high signal Klippel-Trenaunay sendromu.
patient, the triad of marked intensity. MR imaging depicts TRD 33: 349-352, 1998.
enlargement of the right lower deep extension of low-flow 4. Philips GN, Gordon DH,
extremity, a cutaneous vascular vascular malformations into Martin EC et al. Klippel-
lesion, and findings of extensive muscular compartments and the
Trenaunay Syndrome: Clinic
combined venous and lymphatic pelvis and their relationship to
and Radiological Aspects.
malformations suggested the adjacent organs as well as bone or
Radiology, 28: 429- 434, 1978.
diagnosis of Klippel-Trénaunay soft-tissue hypertrophy(9). More
Weber syndrome.Other features recently, MR venography has been 5. Lindenauer SM. Congenital
of this syndrome includes reported to display the significant Arteriovenous fistula and the
lymphatic obstruction, spina findings in extremity venous Klippel Trenaunay syndrome.
bifida, hypospadias, polydactyly, malformations with a capability Ann Surg, 174: 248-263,
syndactyly, oligodactyly, equal to that of conventional 1971.
hyperhidrosis, hypertrichosis, venography (10).Treatment in a 6. Jacob AG, Driscoll DJ,
paresthesia, decalcification of majority of patients with Klippel- Shaughnessy WJ, Stanson

AW, Clay RP, Gloviczki P.
Klippel-Trénaunay syndrome:
spectrum and management.
Mayo Clin Proc 1998;73:28–
36.
7. Ghahremani GG, Kangarloo
H, Volberg F, Meyers MA.
Diffuse cavernous hemang-
ioma of the colon in the
Klippel-Trénaunay syndrome.
Radiology 1976;118:673–678.
8. Baskerville PA, Ackroyd JS,
Thomas ML, Browse NL. The Fig- 3, Ultrasound reveals
Klippel-Trenaunay syndrome: subcutaneous edema and a
clinical, radiological and linear venous channel
haemodynamic features and (Trenaunay vein) on the lateral
management. Br J Surg 1985; aspect of right leg and thigh.
72:232-236
Fig-1, Clinical photograph of
9. Gloviczki PS, Stanson AW, the patient reveals marked
Stickler GB, et al. Klippel- enlargement and swelling of
Trenaunay syndrome: the right lower limb in contrast to
risks and benefits of vascular the other limb with features of
interventions. Surgery 1991; dermatitis.
110:469-479.
10. Laor T, Burrows PE, Hoffer
FA. Magnetic resonance
venography of congenital
vascular malformations of the
extremities. Pediatr Radiol
1996; 26:371-380.
Deepak Badgujar, M K Mittal
Abhay Aryan, Sheetal Kaur
N K Bhambri, B B Thukral
Department of Radiodiagnosis
VMMC & Safdarjang Hospital,
New Delhi-110029
Fig- 2, Plain Radiograph of Fig-4, Volume Rendered(SSD)

bilateral thighs show coronal CT image of bilateral
hypertrophy of the soft tissue lower extremities shows
with relative enlargement of the hypertrophy of femur and tibia
femur on right side. on right side.

65
Fig-5, Volume Rendered(MIP) Fig-7, CECT image reveals nonenhancing hypodense foci in the
coronal CT angiography(venous retroperitoneum encasing the common iliac vessels consistent with
phase)image of bilateral thighs lymphangiectasia
show multiple prominent
venous channels on the right the doctor brought along the
side.
Anatomical diagnostic doll. By marking the
Manikins section giving her discomfort, the
woman could communicate her
The anatomical manikin pictured problems to the physician. While

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

The Journal of Postgraduate Medical Education,
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Contents

Facing the challenge of tobacco in India - 3

Paradigm shift in pathology education in India 11

Occupational health and safety 14

Renal Tubular Acidosis(RTA) in children 27

Recurrent pain abdomen in children 33

Neonatal Necrotizing Enterocolitis 37

Availability and consumption pattern of iodised salt in 50

Intra abdominal desmoid tumor presenting with bleeding 59

49th Annual conference of the college of Surgeons of West Africa 62

Klippel Trenaunay Weber syndrome : a case report 63

A under planning of a case of one-tail (one-sided) or required to answer that specific

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

T obacco is the foremost

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

E recent term for healthcare

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

M changing science. The

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

P about 8 to 10% of maternal

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Table-2, Risk factors that can be assessed at first antenatal visit

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Hippocrates different schools. It has thus contradistinction to the

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Fig-1, Pathogenesis of NEC

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research

Journal of Postgraduate Medical Education, Training & Research