Vulvar melanoma with multisystemic metastases: A rare case presentation

Malignant melanoma is the second most common vulvar malignancy which occurs in elderly females. In advanced stages of the disease, distant metastases can occur to any organ; hence, comprehensive radiological evaluation is necessary. We report a case of a 45-year-old female who presented with progressively increasing growth over the vulva for 6 months. On detailed clinical, pathological, and radiological workup, multiple metastases were found in the brain, liver, pancreas, peritoneum, lungs, and pleura. The final diagnosis of vulvar melanoma with multisystemic metastases was made after the histopathological examination

Impact of comprehensive cardiovascular risk reduction programme on risk factor clustering associated with elevated blood pressure in an Indian industrial population.

Background & objectives: Cardiovascular risk factors clustering associated with blood pressure (BP) has not been studied in the Indian population. This study was aimed at assessing the clustering effect of cardiovascular risk factors with suboptimal BP in Indian population as also the impact of risk reduction interventions. Methods: Data from 10543 individuals collected in a nation-wide surveillance programme in India were analysed. The burden of risk factors clustering with blood pressure and coronary heart disease (CHD) was assessed. The impact of a risk reduction programmme on risk factors clustering was prospectively studied in a sub-group. Results: Mean age of participants was 40.9 ± 11.0 yr. A significant linear increase in number of risk factors with increasing blood pressure, irrespective of stratifying using different risk factor thresholds was observed. While hypertension occurred in isolation in 2.6 per cent of the total population, co-existence of hypertension and >3 risk factors was observed in 12.3 per cent population. A comprehensive risk reduction programme significantly reduced the mean number of additional risk factors in the intervention population across the blood pressure groups, while it continued to be high in the control arm without interventions (both within group and between group P<0.001). The proportion of ‘low risk phenotype’ increased from 13.4 to 19.9 per cent in the intervention population and it was decreased from 27.8 to 10.6 per cent in the control population (P<0.001). The proportion of individuals with hypertension and three more risk factors decreased from 10.6 to 4.7 per cent in the intervention arm while it was increased from 13.3 to 17.8 per cent in the control arm (P<0.001). Interpretation & conclusions: Our findings showed that cardiovascular risk factors clustered together with elevated blood pressure and a risk reduction programme significantly reduced the risk factors burden.

Barriers to ART adherence & follow ups among patients attending ART centres in Maharashtra, India.

Background & objectives: Adherence to ART is a patient specific issue influenced by a variety of situations that a patient may encounter, especially in resource-limited settings. A study was conducted to understand factors and influencers of adherence to ART and their follow ups among patients attending ART centres in Maharashtra, India. Methods: Between January and March 2009, barriers to ART adherence among 32 patients at three selected ART centres functioning under national ART roll-out programme in Maharashtra, India, were studied using qualitative methods. Consenting patients were interviewed to assess barriers to ART adherence. Constant comparison method was used to identify grounded codes. Results: Patients reported multiple barriers to ART adherence and follow up as (i) Financial barriers where the contributing factors were unemployment, economic dependency, and debt, (ii) social norm of attending family rituals, and fulfilling social obligations emerged as socio-cultural barriers, (iii) patients’ belief, attitude and behaviour towards medication and self-perceived stigma were the reasons for suboptimal adherence, and (iv) long waiting period, doctor-patient relationship and less time devoted in counselling at the center contributed to missed visits. Interpretation & conclusions: Mainstreaming ART can facilitate access and address ‘missed doses’ due to travel and migration. A ‘morning’ and ‘evening’ ART centre/s hours may reduce work absenteeism and help in time management. Proactive ‘adherence probing’ and probing on internalized stigma might optimize adherence. Adherence probing to prevent transitioning to suboptimal adherence among patients stable on ART is recommended.

Measuring Obesity among School-aged Youth in India: A Comparison of Three Growth References.

Objective: To compare three growth references that can be used to assess the weight status of school-aged youth living in India, with a particular focus on identifying overweight and obese youth. Study Design: Cross-sectional study. Kappa scores were used to measure agreement between growth references. Regression models were used to test for differences in weight status by grade level, gender, and school type, using each growth reference. Setting: Private (n=4) and Government schools (n=4) in Delhi, India. Participants: Students (n=1818) in eighth and tenth grade attending the schools. Main outcome measures: Weight status was derived using age- and gender-specific cut-points provided by: (a) a national growth reference specific to India; (b) an international reference recommended by the International Obesity Task Force (IOTF); and (c) a new international reference recommended by the World Health Organization (WHO). Results: The IOTF reference consistently classified participants in a lower weight status category, compared with the national reference (κ=0.57) and the WHO reference (κ=0.69). The agreement between the WHO and the national references was higher (κ=0.84). Conclusions: To date, all published studies of childhood obesity in India have used the IOTF reference, the national reference, or an old WHO reference to measure weight status among school-going youth. The new WHO reference may be a better choice. Compared to the IOTF reference, it does not appear to underestimate obesity and can still be used to compare trends, globally.

Social determinants of cardiovascular disease outcomes in Indians.

Cardiovascular diseases (CVD) are the leading cause of death and disability in both developed and developing countries. In developed countries socio-economic mortality differentials have been studied extensively showing that the low socio-economic group suffers the highest mortality. As the epidemiological transition is taking place against a background of economic globalization, CVD risk factors among the urban poor and middle class are rapidly increasing in India. Recent evidences from India also suggest reversal of social gradient with excess burden of CVD morbidity in the low socio-economic group. Understanding the social determinants of environmental and behavioural exposures, in determining the risk factors for cardiovascular disease is an important challenge for public health professionals as well as communities. Socio-economic disadvantage is not simply a proxy for poor cardiovascular risk factor status, but also an indication of the likely trajectory that an individual or a community may follow in the course of their life. The paucity of intervention research seeking to address the role of social determinants in shaping lifestyle practices among individuals in culturally and socially diverse population groups within India is definitely a measure of inadequacy in public health research. This review article provides an overview of the role of social determinants of CVD and its possible conceptual pathways with special focus on acute coronary syndrome (ACS) outcomes among Indians.

Validation of self-reported smoking status by measuring serum cotinine levels: An Indian perspective.

Background. Serum cotinine levels are a reliable marker of tobacco use. Few studies have validated questionnaires assessing smoking and exposure to environmental tobacco smoke (ETS) against serum levels. We undertook such a study in industrial workers in India. Methods. We chose 426 individuals by stratified random sampling from a database of 3397 individuals surveyed at New Delhi for the cardiovascular disease surveillance programme in a large industrial setting. Questionnaires assessing details of smoking practices and duration of exposure to ETS (if any) were administered. Cotinine levels were measured in the blood samples of these individuals. Results. The study population comprised 142 nonsmokers not exposed to ETS, 142 non-smokers exposed to ETS and 142 active smokers. Cotinine levels among nonsmokers not exposed to ETS were non-detectable; and for non-smokers exposed to ETS and active smokers, the median (interquartile range) levels were non-detectable (non-detectable to 46.1 ng/ml) and 336 ng/ml (204–500 ng/ml), respectively. The best combined sensitivity (91%) and specificity (87.2%) yielded a cotinine cut-off level of 40.35 ng/ml to differentiate active smokers from non-smokers not exposed to ETS and those exposed to ETS (area under the curve 0.902). The cut-off cotinine level was estimated at 10.95 ng/ml using a similar analysis (sensitivity 43%, specificity 82%; area under the curve 0.64) to distinguish non-smokers not exposed to ETS from those exposed to ETS. The misclassification rate was estimated at 19% and 57.1% among self-reported non-smokers not exposed to ETS and those exposed to ETS, respectively. Conclusions. Obtaining a history of tobacco use is an accurate method of detecting smokers in epidemiological studies whereas serum cotinine levels accurately differentiate smokers from non-smokers. However, a brief questionnaire assessing passive exposure to smoke has poor sensitivity in distinguishing non-smokers exposed to ETS from those not exposed to ETS.

Public health law in India: A framework for its application as a tool for social change.

Public health law focuses on the nexus between law, public health and the legal tools applicable to public health issues. Though there have been consistent interventions to address public health concerns in the past, there exists a need for a contemporary framework to appropriately use modern legal tools for complex health challenges. We identify a checklist of imperative indicators to assess whether public health legislations would be an effective form of intervention to bring about the desired social change.

Double burden of underweight and overweight among children (10–19 years of age) of employees working in Indian industrial units.

Background. Along with the existing problem of underweight, overweight in children is increasing in the developing world. However, there is little information on its magnitude and pattern in the Indian context. We aimed to study the pattern and correlates of overweight in Indian children and adolescents. Methods. A total of 3750 children in the age group of 10–19 years, who were family members of randomly selected employees from 10 different industrial sites in India, were surveyed using an interviewer-administered questionnaire. Results. The prevalence of underweight was highest in peri-urban areas (30.2% and 53.2% according to Indian and international criteria, respectively). In urban and highly urban areas, the prevalence of underweight was 14.1% and 9.8%, respectively, according to the Indian criteria, and 27.1% and 19.2%, respectively, according to international criteria. The proportion of overweight children was highest in the highly urban category (19.1% and 13.4% according to Indian and international criteria, respectively). The level of urbanization (OR 3.1 and 4.7 for overweight in urban and highly urban areas, respectively, compared with peri-urban areas, p<0.001), physical activity (OR 0.4, p<0.001, in children with physical activity score >75th percentile compared with a score <75th percentile) and frequency of meals outside the home (OR 12, p<0.001, if >25% weekly meals taken outside the home compared with <25% of weekly meals outside home) were significant predictors of overweight. Conclusion. There is a double burden of underweight and overweight among Indian children and adolescents.

Management of acute coronary syndromes in secondary care settings in Kerala: impact of a quality improvement programme.

BACKGROUND: Evidence-based therapies that have been shown to improve outcomes in acute coronary syndromes (ACS) are often underused in clinically eligible patients. We evaluated the impact, efficacy and acceptability of a quality improvement programme to manage ACS. METHODS: A well-defined geographical area was identified and a situational analysis done. All physicians in the area, who were actively involved in the detection and management of ACS, were invited to participate in the quality improvement programme. The programme involved the use of a service delivery package which consisted of standard admission orders and patient-directed discharge instructions. Concurrently, health education in the community to promote self-detection, self-administration of aspirin and self-referral were carried out. All participating physicians were asked to register consecutive cases of ACS (20 each) presenting to their clinics before and after the intervention programme. The pre- and post-intervention data were compared. RESULTS: The use of aspirin at discharge increased from 89.7% to 96.8% (p < 0.05) and that of heparin from 57.6% to 66.3% (p < 0.05). The use of beta-blockers increased from 48.6% to 63.4% (p < 0.05) and that of lipid-lowering therapy from 74.1% to 96.3% (p < 0.05). There was a significant reduction in the use of calcium channel blockers from 21.6% to 8.1% (p < 0.05). The time to thrombolysis decreased significantly (median difference of 54 minutes, p < 0.05) after the intervention programme. CONCLUSION: Structured quality improvement programmes aimed at both patients and providers can be successful in secondary care settings of developing countries.

Surveillance for risk factors of cardiovascular disease among an industrial population in southern India.

BACKGROUND: We assessed (i) the risk of cardiovascular disease in an industrial population in Chennai, southern India and (ii) whether the status of treatment and control of diabetes and hypertension would be different in an industrial population, which is provided free healthcare, compared with the general population of Chennai. METHODS: Subjects residing in the residential areas of 2 industries (Indian Airlines and Integral Coach Factory) in Chennai in southern India were recruited. The subjects were employees (n = 440) selected by an age- and sex-stratified random sampling method, and their family members (n = 727) in the age group of 20-69 years; a total of 1167 subjects. Fasting plasma glucose, lipid estimations and anthropometric measurements were done in all the subjects. Information on demographic and lifestyle determinants was obtained using a questionnaire. Diabetes was diagnosed using the American Diabetes Association criteria and metabolic syndrome was defined by the Adult Treatment Panel III criteria with modified waist definition for Asian Indians. RESULTS: Age-adjusted prevalence of major risk factors for cardiovascular disease using the 2001 Census of India were as follows: diabetes 11.9%; hypertension 25.4%; dyslipidaemia 40.2%; hypertriglyceridaemia 28.3%; overweight (body mass index > or = 23 kg/m2) 60.2%; and metabolic syndrome 34.1%. Use of tobacco in any form was present in 22.9% of men and 0.5% of women; 79% of the subjects followed a sedentary lifestyle. Among subjects receiving medication, 42.1% of subjects with diabetes and 55.3% of subjects with hypertension had their disease under adequate control. A comparison of these results with the general population of Chennai showed that the industrial population had a higher prevalence of cardiovascular risk factors in spite of having better access to healthcare facilities. CONCLUSIONS: The prevalence of cardiovascular disease was high in this industrial population of Chennai. Although the overall treatment and control of diabetes and hypertension was better than that in the general population, it was still inadequate and this emphasizes the need for greater awareness about non-communicable diseases.

Risk factors related to the development of diabetes in men working in a north Indian industry.

BACKGROUND: Epidemiological and lifestyle changes have been implicated in the high burden of diabetes in urban India. However, longitudinal data on the determinants for the development of diabetes in this population are not available. We investigated the determinants for the development of diabetes in workers in an Indian industrial organization. METHODS: Two cross-sectional surveys were done, using similar methodology (Survey 1 during 1995-98 [n=2548] and Survey 2 during 2002-03 [n=2800]) among all employees (age 20-59 years) of an industrial organization. A large majority of these were men (89.5% in Survey 1 and 92.8% in Survey 2). Men with no diabetes at baseline, who participated in both the surveys (n=942), constituted the study population. Development of new-onset diabetes was defined using history and fasting glucose concentrations > or =7 mmol/L. RESULTS: The mean (SD) age of the participants at baseline was 40 (2) years. Diabetes developed in 8% of the study population over 6.8 (1.7) years. Individuals who developed diabetes had significantly higher age, blood pressure, body mass index, waist circumference, fasting and post-prandial glucose, post-prandial insulin and fasting triglyceride levels at baseline. On multivariate regression analysis, only impaired glucose tolerance (OR 3.8, 95% CI: 2.1-6.8) and waist circumference (OR 1.09, 95% CI: 1.02-1.16) predicted the development of diabetes. Presence of the metabolic syndrome, as defined by the modified National Cholesterol Education Program Adult Treatment Panel (NCEP-ATP) III and WHO criteria, increased the odds (95% CI) of developing diabetes by 2.2 (1.3-3.6) and 4.5 (2.7-7.4) times, respectively. CONCLUSION: Impaired glucose tolerance, high waist circumference and the metabolic syndrome are powerful predictors for the development of diabetes among urban Indian men.

Co-occurrence of emphysematous cystitis and emphysematous myositis in type 2 diabetes.

Emphysematous cystitis (EC) and emphysematous myositis (EM) are rare disorders and concurrent occurrence of both in a patient with type 2 diabetes has not been reported previously. We report a patient who presented with pneumaturia and later with pain in thigh and diagnosed of both concurrently.

Rhino-orbital-cerebral mucormycosis in type 1 diabetes mellitus.

AIM: To describe the presentation and outcome of rhino-orbital-cerebral mucormycosis (ROCM) in adolescents with type 1 diabetes mellitus (T1DM). METHODS: The medical records of six patients of T1DM with ROCM admitted between October 2001 to January 2004 were analysed. RESULTS: The mean (+/- SD) age and duration of DM of these patients were 16.1+/-3.0 years and 26.3 +/- 24.9 months respectively. Four patients had ROCM at presentation, while two developed it during their hospital stay when recovering from diabetic ketoacidosis. Proptosis (100%) and ptosis (100%) were the most common symptoms, and ophthalmoplegia (85%) and vision loss (85%) were the most common signs. Maxillary sinus (85%) was the commonest paranasal sinus to be involved. All patients received amphotericin B and had appropriate surgery except one. Four patients survived. Patients who had altered sensorium, facial necrosis, palatal perforation and cerebral involvement at presentation had poor outcome. CONCLUSION: High index of suspicion of ROCM in T1DM and combined approach with amphotericin B and appropriate surgery is rewarding.

Effect of anticholinesterase compound phosalone on blood-brain barrier (BBB) permeability.

To elucidate the role of acetylcholinesterase (AChE) enzyme in BBB function, phosalone, an organophosphorous compound, was studied using rat brain micro vessels in vitro. Phosalone at 100 mg/kg b. wt. induced convulsions and caused a significant inhibition of AChE resulting in increased permeability as assessed by volume distribution. The anaesthetized phosalone treated group also increased permeability as compared to the control but the values were significantly (P<0.05) lower than phosalone alone treated group. The inhibition of AChE enzyme has altered the barrier function at the dose level at which it caused convulsion and had an added effect on permeability of BBB.

Role of template guided interstitial implants in breast conservation therapy.

Breast conservation therapy is currently considered as a viable alternative to mastectomy in early breast cancer. Radiotherapy by virtue of its ability to reduce local recurrences is an integral component of breast conservation therapy. Apart from irradiating the whole breast, the tumor bed is usually delivered a boost dose in breast conservation therapy to increase the local control rate. One of the methods which has been adopted to selectively boost the tumor bed to high doses is the use of per-operative high dose rate interstitial implants. This particular paper deals with our department's experience with breast conservation therapy using per-operative template guided, High Dose Rate (HDR) interstitial implants in early breast cancer. Local control rates, disease free survival and cosmetic benefit with this technique will be discussed along with literature review.

Button battery ingestion.

Button batteries represent a special category of pediatric ingested foreign body because of the possibility of serious complications particularly if impacted in the esophagus. We report a case of a 3-year-old girl with severe mid esophageal burns due to a lodged battery. More awareness is required amongst physicians to avert such dangers and ensure prompt removal.

Infliximab in the treatment of ulcerative colitis with toxic megacolon.

Toxic megacolon is a gastrointestinal emergency requiring prompt management to avoid fatal outcome. Although a majority of patients respond to conservative treatment, those not responding have been treated with intravenous cyclosporine or emergency surgery. Infliximab has been tried in patients with severe steroid-refractory ulcerative colitis. We report the successful use of this drug in the management of toxic megacolon in a 48-year-old woman not responding to the routine measures and who refused surgery.