vol. 1 no. i jan-jun 1999 · marine medical society (regd f-361 i ) president surg vadm jc sharma...

s

.-.$ffi.

Vol. 1 Jan-Jun 1999No. I

: a

JAN-.IUN 1999

MARINE MEDICAL SOCIETY(Regd F-361 I )

PresidentSurg VADM JC SHARMA VSM, PHS

DGMS (NAVY)

Wce PresidentsSurg RADM VK PAHWA Surg RADM IIP MUKHERJEE VSMCMO Western Naval Command Commanding Officer, INHS Asvini

Executive Committee

Surg Cmde NR RAHA VSM Surg Cmde SP MALHOTRADirector INM DMS (P&M) Naval Headquarters

Surg Cmde WP THERGAONKAR Surg Cmde BPS Rawat, VSMCMO, Eastern NavalCommand CMO, Southern NavalCommand

Surg Cmde AK CHAUDHARI Surg Cdr S NANGPALDMS (H& S) Officer-in-Charge,Naval Headquarters SchoolofNaval Medicine

Surg Cdr AM JOGLEKAR Surg Lcdr GD BHANOTBMO, INS VAJRA BAHU SchoolofNavalMedicine

SecretarySurg Cdr KBS CHEEMA

TreasurerSurg Cdr KK DUTTA GUPTA

Addre s s for C orrespondenceSecretary

JOURNAL OF MARINE MEDICAL SOCIETYInstitute of Naval Medicine,

INHS Asvini Campus,Colaba. Mumba.i 400 005. INDIA

tr

s

1iI

Il r

It

II

:

L

?\

JOURNAL OFMARINEMEDICAL

SOCIETYVOLUME I NO. I

Published Biannuallv

Chief EditorSurg RADMVK PAHWA

EditorSurg Cdr S NANGPAL

Co EditorsSurg CdrAC PRAVEEN KUMAR

Surg Cdr GIRISH GUPTA

JAN-JUN I999

Sub EditorsNaval Headquarters Surg Cdr A AIIUJA NMWestern Naval Command Surg Cdr D D'COSTAEastern Naval Command Surg Cdr VRG PATNAIKSouthern Naval Command Surg Cdr (Mrs) N KANAN VSM

Editorial Advisory BoardSurg Cmde (D) ML GUPTA

Brig DINESH PRASADSurg Capt RAMESH KLIMAR

Surg Capt RT AWASTHISurg Cdr MJ JOHN

Surg Cdr KK DUTTA GUPTA

Address for CcruespondenceEditor

JOURNAL OF MARINE MEDICAL SOCIETYInstitute of Naval Medicine, INHS Asvini Campus,

Colaba, Mumbai 400 005.

Printed and Published by Surg KBS Cheema on ber^ 'lf

of Director General of Medical Services(Navy) and printed at Typo Craphics, Mumbai 400 103 and published at Institute of NavalMedicine, INHS Asvini, Colaba, Mumbai 400 005. Editor : Surg Cdr S Nangpal

Y

{}

JOI]RNAL OF MARINE MEDICAL SOCIETY

CONTENTS

t+,\y

. cAAtySur

OtsSurFrom the Editors Desk

NEWFRONTIERS

Telecardiolory: Ushering in a new era in CardioloryDr. Ajay Kanojia" Dr. RR Kasliwal, Dr. Naresh Trehan

PEI

HatSur

BO

SterSur

IntrLt(

LerSur

Gu

REVIEW ARTICLE

Acute Pancreatitis t

Surg Cdr AC Praveen Kumar, Surg R Adm I Karnani

ORIGINALARTICLES./"

,HryMnc oxygen therapy (HBOT) the newest anti bacterial agent in diabetic foot?\8frg Cdr VRG Patnaik, Surg Cdr PS Lamb4 Surg Cdr S Nangpal, Surg Cdr MJ John

Laboratory and field trial ofsusceptibility status ofculex quinquefasciatus larvae tobacillus thuringiensis 17Surg Cdr KK Dutta Gupta, Surg Cdr A Chatterjee, Surg Cmde NR Rah4 Surg Cdr MJ John,Surg Cdr S Nangpal, Lt Col AK Upadhyay

Arthroscopic Management of anterior cruciate ligament deficient knee 19Lt Col SM Bhatnagar, Surg Cdr P Sarin

Chronic subclinical sinus infection as a cause of recurrent eustachian tube dysfunction inNaval Divers 23Col BN Borgohain, Surg Cdr Sanjiv Badhwar, Surg Lt Cdr Niraj Sinha

Personality profile of trainee Nursing Officers 26M Sofi4 N Ramachandran

Proficiency in diving: Role of personality factors 30P Jayachander, S Subramony, KJ Uthaman

Medical Management of Ectopic Pregrancy-INHS Asvini experience 34Surg Cdr Sushil Kumar, Surg Capt RT Awasthi, Surg Capt P Tameja, Surg Cdr S Chatterji

Drowning Accidehts in children - 37Surg Lt Cdr S Das, Surg Lt Cdr BG Pawar, Surg Cdr SS Mathai, Surg Capt KS Bawq Surg Cdr G Gupta

QUtZ

X-ray diagrosisSurg Cdr PS-Tampi, Brig Dinesh Prasad

t4

42

\

. CASEREPORTS

Atypical presentation of a case of Lupus-VulgarisSurg Cdr R Dhir, Surg Capt KM Shah

Ossi$ing fibroma of the mandible associated with solitary bone cystSurg Lt Cdr SS Pandey

PERSONAL COMMUNICATION

Hand washing: An essential component in NICU careSurg Cdr G Gupta, Surg Cdr SS Mathai, Surg Capt KS Bawa

BOOKREVIEWS

Steroeoscopic atlas of macular disease: diagnosis and treatment ,'Surg Lt Cdr Vasanth Kumar

Interventional RadiologyLt COI SS ANANd

Lever's histopathology of the skinSurg Capt KK Shah

Letters to the Editors

Guidelines for Authors

46

48

5 l

5t

5 l

52

53

.a-

0OitltSese

Conplinents

7on

NOVARTIS INDIAI,ITD.Pharmaceuticals Divi sion

Royal Inusmace Bldg.,

14th Floor.

J Tata Road,

Mumbai 400020.

)nou rHE EDITOR'S DESK

Advances in communication technologr have had their influence in the field of Medicine. Specialistreferrals are now available in remote places where specialists are unavailable. These places can beelectronically connected with specialized centers and real time data can be transferred for optimal manage-ment of patients. One such recent development has been in the field of Tele cardiology. An article on thissubject by Drs. Kanojia, Kasliwal and Trehan from Escorts Heart Institute and research centre Delhi, unveilsthe intricacies of this subject in the current issue. This important advance in Information Technology (IT)has some very exciting and interesting prospects in the held of Diving and Seafarer's Medicine. The articleon telecardiology has opened up new vistase for providing care to patients who are not accessible to specialistsdue to the very nature of their occupation. With opening up new vistas for providing care to patients who arenot accessible to specialists due to the very nature of their occupation. With opening up of our extensiveExclusive Economic Zone (EEZ) and with upgradation of technology to exploit oil gas, and minerals fromthe ocean bed IT, with its vast potential will have a tremendous role to play in the field of Marine andHyperbaric Medicine. Radio Medical Advice (RMA).is a humble beginning and is proving very useful inproviding medicare to seafarers. The Australians are in the fore front of this latest advance in IT basedmedicare.

That diving is perhaps the most hazardous profession can not be over emphasized. The complexity of themental build up of a diver that make him "what it takes" are brought out in the article, "Proficiency in diving- role ofpersonality factors by Dr. Jay Chandar et alfrom Naval Psychological Research Unit Kochi. Chronicsubclinical sinus infection which may cause excessive and avoidable morbidity among divers has similarlybeen dealt with by Col Borgohain et al in the cunent issue.

In spite ofseveral advances and hectic pace ofresearch, the pathophysiology ofacute pancreatitis is notfully understood. Surg Cdr Praveen Kumar's article in this issue will help in cleaning the cob-webs a little.Similarly drowning accidents in children which is a very contemporary issue and a subject oftopical interesthas been discussed by Surg L Cdr Das et al from Asvini.

For the computer sawy, we are giving a few informative and interesting intemet sites/pages to visit. Alot of scientific and medical literature is available on these sites.

We take this opportunity once again to mentions that critical inputs about the quality of the articles in thejournal along with suggestions on how to improve the journal further, are not being received. We request thereaders to rush their comments and suggestions for implementation.

Any suggestions?

We once again emphasizethat in spite of repeated requests, authors are not submitting their articles in thestandard prescribed format, thereby, causing avoidable editorial effort. For the benefit ofthe authors, we arepublishing the guidelines to be followed for submitting articles to the Joumal.

S NANGPALSurg Cdr

Jour. Marine Medical Society, Jan-Jun 1999, VoL I, No. I

?

To Satisfy Your Quality Needs

Orthopaedics

. Screws, Plates, DHS and other Internal Fracture Fixation Devices

. Endo Prostheses - Bipolars, Thompson, Austin Moore

. Total Joint Replacements - Elbows, Hips, Knees

. External Fixation Devices - Ilizarov. Universal

. Instrumentation for Orthosurgery

. Range of CMW Products, Bone Cement, Cement Gun and Accessories

o Prevacuumed post operative wound drainage system

o Imported Pneumatic and Electric Systems - Drills, Reamers, Saws

. Arthroscopy instruments including Camera, Light Source etc. (otherendoscopes also available).

INOR ORTIIOPAEDICSa division of

INOR Medical Products Ltd.209, A-Z Industrial Estate,G.K. Marg, Lower Parel,Mumbai 400 013,India

Tel. :492 13861492 5805 Fax : 495 0336Telex 0ll-76779 DPIL IN

a

IN

\WTELECARDIOLOGY:USFIERTNG IN A NEW ERA IN CARDIOLOGY

Dr AJAY KANOJIA*, Dr RR KASLIWAL*,DT NARESH TREHAN*

4lelecardiology involves application of tele-

I communication technology to the practice ofI- cardiology. It combines network communi-

cation, computer, and video technologies and en-ables cardiac health care provider to deliver efficientand cost effective quality cardiac care to persons atsome distance from the provider [1]. Thus telecardi-ology is delivery ofexpert cardiac care to patients atany location by Combining communications tech-nology and multimedia technology. This is a part oftelemedicine and is capable of providing health careservices to patients whose access to health care islimited for geographic or other reason [2]. This is anemerging research and development field and goingto have revolutionary impact on the delivery ofmedical care. The goal is to improve access tohigh-quality medical care at affordable costs.

Telecardiology is being driven by two converg-ing trends : advances in digital technologies andtelecommunications, and increasing demand for ac-cess to high-quality medical care irrespective oflocation. The system includes diagnostic instru-ments that are designed to provide information fordigital transmission and reproduction. An interac-tive video component allows the doctor and thepatient to communicate interactively. The systemcan also record the examination; for example, aphysician treating a patient for heart murnur canlisten to the heart as it sounded before the treatmentand compare it to the sound of the heart after thetreatment. Real-time transmission of elechocardio-gram, echocardidgraphic images, X-rays, MRIs,CTs, pathology samples, and other diagnostic testsare possible, and the system can be configured totransfer and store these images on the physician'scomputers for later references. The most commonapplications of telecardiology (Table l) is remote

clinical consultation and diagnosis - Telelecffo-cardiography, Tele-echocardiography, Tele-con-sultation, and other common applications are Tele-education, and Tele-conferencing. With recent de-velopments in telecommunication, multimedia,virtual reality and robotics techniques, we can ex-pect near future possibility of guidance and moni-toring of treaffnent (Tele-treatment) and remote op-erative therapy (Tele-surgery).

TABLE ITypes of Telecardiology Services

l. Tele-diagnosis2. Tele-education3. Tele-therapy4. Tele-surgery

COMPONENTS OF TELECARDIOLOGY

Technology used in Telecardiology depends onthe distance between provider and consumer, typeand size of data transmitted, and transmission rate[3]. Data acquisition equipment, data transmissionsoftware and hardware and multimedia display arecritical elements of a telecardiology system (Table2) .

ADVANTAGNS dT TELECARDIOLOGY

Telecardiology appears to have number of ad-vantages. It is capable ofproviding speciality con-sultation to general physician and patients who hvein remote areas and do not have immediate accessto speciality services. Some see it as an ideal way tocombat the unequal geographic distribution ofspe-cialists, and the significant number of patients wholive in remote rural areas having no access to spe-

t Escorts Heart Institute and Research Centre N. Delhi - I I 0025.

Jour. Marine Medical Society, Jan-Jun 1999, VoL l, No. l

TABLE 2

Com ponents of Telecardiology

Digital data recording

. Video conferencing equipment

o Electronicstethoscope

o Electrocardiographicequipment

o Echocardiographyequipment

Data communication software and hardrvare

. Telephone/cellularmodem

o Switched 56 telephone line

o ISDN telephone line

o Tl-T2 telephone line

o Optical fiber Cable

o Communicat ionSatel l i te(COMSAT)

Bilateral Multimedia display

cialists [3]. This provides great opportunity for unr-versal, immediate access to advanced cardiac careat reasonable cost with no need for transportation ofeither patient or treating specialist. Currently, anumber of medical institutions are exploring the useof teleconsultation. There are many studies under-way to determine if such systems indeed increasediagnostic accuracy, result in quicker action foremergency surgerjes, enhance physicians' relation-ship, encourage education, decrease cost of care,and if they become economically self supportive.

Another exciting area of interest is Tele-educa-tion, which is defined as use oftelecommunicationstechnology to deliver cardiac education from a dis-tance. Telecommunications and the rapid advancesand availability of computer-based systems such asvirtual reality, multimedia and the Intemet give theeducators the option ofproviding effective instruc-tions. These instructional technologies can have aprofound impact on the way medical training isdelivered and received. Multimedia technology in-corporates different technologies of computer, CD-ROM, telecommunication, CD player, video cam-era, and combines them into a powerful communi-cation center. Telecommunication and multimediatechnology enable real-time, interactive communi-cation among educators and learners. An interactivevideo component allows them to view one anotherwork and exchange information simultaneously.Such Tele-education system is ideal for medicaleducation. Such system will enhance the quality ofgrand rounds and.CME presentations. Presentation

8

documents can include video and audio, theories carlbe demonstrated, and high-resolution images can bedisplayed. The advent of diagnostic insffuments thatare designed to provide digital datatransmission andreproduction befween hospitals, as well as interac-tive video, makes it possible to expose residents atindividual institutions to a greater mix of diseaseprocess and to present grand rounds directly fromthe patients room.

BARRIERS TO GROWTH

Despite recent advances and exciting potentials,wide-spread use of Telecardiology is plagued byfew barriers to growth. The most significant barrierstoday are:

.l . Inadequate telecommunication infrasff ucture

2. Regulatory distortions, limitations on competi-t ion

3. Public and private reimbursement policies

4. Physician licensing and credentials

5. Concern about'malpractice liabilities

6. Concem about confidentialify of patient infor-mation

CONCLUSION

Telecardiology is an exciting new developmentas a result of recent advances in telecommunicationand multimedia technology. This is an emergingresearch and development field and going to haverevolutionary impact on the delivery of medicalcare. Telecardiology has variety ofapplications to-day in patient care, education, research and admini-stration. The high cost and technical limitations thatinhibited the utilization of it's full potentials in thepast have significantly reduced. In near future wewill be able to witness rapid growth of clinicalTelecardiology leading to universal, and immediateaccess to advanced cardiac care, at reasonable cost.

REFERENCES

l. Khanderia BK. Telemedicine : An application in search ofusers (editorial) Mayo Clin Proc 1996; 7 | : 420-21 .

2. Balas EA, Jaffrey F, Kuperman GJ, et al. Electronic com-munication with patients : Evaluation of distance medicinetechnologies. J,4 MA 1997;'278: 152-59.

3. Perednia DA, Allen A. Telemedicine technology in clinicalapplications. JAMA 1995; 273 : 483-88.

Jour. Marine Medical Societv. Jan-Jun 1999. Vol. l. No. I

ACUTE PANCREATITIS

Surg Cdr AC PRAVEEN KUMAR*, Surg RAdm I

fT1h. name pancreas is derived from the Greek

I words 'pan' (all) and 'kreas' (flesh). In theI- past, critical analysis of this organ by anato-

mists, physiologist, physicians and surgeons wasrather slow until the middle of l6th century whenWirsugs and de Graaf reported on pancreatic ductsand secretion respectively [1].

Pancreatitis is an inflammatory disease whichhas been classified based on clinical presentationand on the aetiology [2]. The pathogenesis ofpan-creatitis remains obscure and treatment is thereforesupportive rather than specific. Although diagnosisof pancreatic disease has improved due to recentadvances, the management of the disease is stilllargely unchanged.

The incidence of acute pancreatitis varies in dif-ferent geographical areas. The mortality for the in-itial attacks is 1.6 times higher than that for recur-rences and it is higher when associated with gallstones and in idiopathic cases rather than with alco-holic patients [3]. The mortality rate of clinicallydiagnosed acute pancreatitis is about 10 per centwith little evidence of decrease in recent years.

The classification ofpancreatitis has always beena problem but it is broadly based on clinico-pathologic criteria. Pancreatitis is classified as acuteor chronic as proposed by various internationalworking groups [2,3].

ETIOLOGY AND PATHOGENESIS

Although causes of acute pancreatitis are multi-ple with list of causes growing but the pathogenesisof pancreatitis remains obscure [3].

ETIOLOGIC FACTORS IN PANCREATITIS

i. Alcoholism

ii. Biliary tract disease, occult gallstones

iii. Trauma-abdominal injuries, surgery, post

KARNANI (Retd)+

ERCP

iv. Metabolic-hyperlipidemia, hyperparathyroid-ism, uremia post-renal transplant

v. Infection-viral hepatitis, mumps, ascariasis

vi. Drugs : Various drugs have been implicatedsuch as immunosuppressives, diuretics, oralcontraceptives and steroids.

vii. Vascular - shock, lupus erythematosus'viii.

Mechanical - pancreas divisum, duodenal di-verticula, ampulla of vater tumour

ix. Penetrating duodenal ulcer

x. Hereditary pancreatitis

xi. Idiopathic

PATHOGENESIS

The final common pathway of acute pancreatitisis thought to be auto-digestion by activated pro-teolytic enrymes within the pancreas. The exactmechanism that provokes this process ofautodiges-tion remains speculative.

Obstruction and hypertension has largely beeneclipsed by autodigestion theory which proposesthat proteolytic enrymes are activated within thepancreas rather than in the intestinal lumen [4].Premature zymogen activation is arecent hypothesisactivated by lysosomal hydrolases [5,6].

PATHOPHYSIOLOGY

Activated proteolytic enzymes not only damagethe pancreas but also can activate other enzymeswhich alter the normal homeostasis. Activation ofbradykinin and vasoactive substances bring in abroadspectrum of biologic activity which includesvasodilatation and increase in vascular permeabilityand edema. Purified phospholipase causes severepancreatic parenchymal and adipose tissue necrosis.Arachidonic acid bioactive substances bring inblood coagulation. Cytotoxic substances produced

tClassified Specialist (Medicine and Gastroenterologist), INHS Asvini, Mumbai - 400 005+ Command Medical Officer, WNC, Mumbai

./Jour. Marine Medical Society, Jan-Jun 1999, Vol. 1, No. I

secondary to complement activation produce cellu-lar damage and coagulation is altered by variousthrombolytic and thrombotic factors [7].

Hypocalcemia seen in one third of patients dur-ing the episode parallels the clinical severity ofdisease. Its pathogenesis is incompletely understoodthough parathyroid gland hyporesponse and in-traperitoneal saponification ofcalcium are held re-sponsible [8]. Hyperglycemia is common and is dueto decrease in insulin release, increased glucagonrelease and increased output of steroids [9]. Im-paired pulmonary function is due to intrapulmonaryright to left shunting secondary to microthrombibecause of disseminated intravascular coagulation[0]. Approximately 25 per cent of patients havehypoxemia which may herald the onset of adultrespiratory distress syndrome. Renal impairment isthe consequence of hypovolemia with a rising he-matocrit and declining plasma protein levels, re-flecting a generalised increase in capillary perrne-abil ity I l]. Circulatory shock having a multifacto-rial background and disseminated intravascularcoagulation due to consumption coagulopathy aresome other patho physiological problems associatedwith acute pancreatitis.

There are several causes ofacute pancreatitis andthe list of identifiable causes is growing. Some ofthe important conditions are discussed.

Gollstones.' More than 50 per cent of the caseshospitalized have gall stones. There is a definite linkbetween the passage of small gall stones into theduodenum with acute pancreatitis. The mortality isabout I 0 per cent during the first attack and tends tobe lower during subsequent attacks [2]. Chronicpancreatitis is very rare with gallstones.

Alcohol Abuse .' Association of alcohol con-sumption with pancreatitis is well documented. Themortality rate is lower than that due to other causes.Most of the alcoholics develop chronic pancreatitisbut during the initial attacks they can develop all thecomplications of acute pancreatitis.

ERCP .' Severe pancreatitis requiring surgicalintervention may follow diagnostic ERCP in 0.03per cent and with sphincterotomy in upto one percent of cases. Pancreas divisum is an anomaly de-tected by ERCP, which can produce pancreatitis

t l 3 l .

t 0

CLINICAL FEATURES ./

The hallmark of.acute pancreatitis is abdominalpain. The time from onset to peak intensity of thepain ranges from seconds to hours. Painless acutepancreatits occurs in fewer than two per cent ofpatients but has a grave prognosis because the pre-senting symptom frequently is shock or coma. Ab-dominal distension due to gastric and intestinal hy-pomotility and chemical peritonitis are also fre-quent.

Physical examination yields nonspecific physi-cal findings which include fever, tachycardia andhypotension. The combination of severe abdominalpain and a soft abdomen is a valuable clue for theearly diagnosis of acute pancreatitis. Abdominalmass is rarely palpable on initial examination. Oc-casionally in hemorrhagic pancreatitis, blood dis-sects into the flanks or around the umbilicus produc-ing Grey Turner's or Cullens sign, respectively.Bowel sounds are diminished but not absent. Hypo-calcemic tetany, subcutaneous fat necrosis, coma ortoxic psychosis are some ofthe uncommon manifes-tations.

History and physical examination are seldomdiagnostic ofacute pancreatitis. The differential di-agnosis includes all causes of abdominal pain.

Some ofthe effects on contiguous organs includemild hyperbilirubinemia, inflammation of the me-dial portion of the duodenum and antrum of stom-ach. Segmental obstruction or intestinal paralysismay develop manifesting as the 'cut off sign' in thetransverse colon or the 'sentinel loop' ofdistendedsmall bowel on radiographs of the abdomen. Para-lytic ileus, necrosis of transverse colon and/orsplenic flexure, pleural effusion, hiccups due toinitation of the diaphragm etc may occur.

Predictors of severity of acute pancreatitis helptailortherapy to the severity ofthe disease. Progno-sis is facilitated by the use of standard Ransonassessment criterion on admission.

Ranson and colleagues developed a list of I I riskfactors to help predict severity of the disease. Acomplicated course, is l ikely to ensue only whenmore than two of these criteria are met. Since earlierpapers were based on a population of mostly alco-holic patients, these. investigators modified their cri-teria to include patient with gallstone pancreatitis

Jour. Marine Medical Societv, Jan-Jun 1999, Vol. I, No. I

\t+1. Like the Ranson criteria, the Glasgow criteriarequire a 48 hour period of observation and dataaccrual. Other investigators have published otherlists of multiple criteria [5], but the Ranson andGlasgow criteria were compared to a newer, moresophisticated but more complex prognostic indicescalled the Acute Physiology and Chronic HealthEnquiry score (APACHE-l l) [6]. The APACHE-I I score is based on a weighted index of 12 physi-ologic variables, patient's age and history of majororgan disease.

No scoring system has yet been devised that canreplace close and frequent clinical observation oftheindividual patient.

LABORATORYDATA

Serum Amylase.' Amylase levels threefold abovenormal value virtually clinch the diagnosis. Themagnitude of serum amylase elevation provides noclue to the prognosis ofthe attack.

The urine amylase creatinine clearance ratio(ACR) is increased in acute pancreatitis. The clini-cal diagnostic value of this determination is limitedmainly to the detection of macroamylasemia.

Additional determinations, such as elastase,phospholipase A2, alpha 2-macro globulin andRNA ase, provide little or no further diagnosticinformation. Impaired liver function tests are tran-sient. Sustained fasting hyperglycemia is a poorprognostic sign, as is low serum calcium. Hyper-triglyceridemia occurs in l5 to 20 per cent of casesand serum amylase levels in such patients are oftenspuriously normal. Hematocrit value exceeding 50per cent is due to hemoconcentration secondary toextensive fluid sequestration. Hypoalbuminemia isassociated with more severe pancreatitis and anincreased mortality rate. Progressive fall in arterialPO2 may herald the onset of adult respiratory dis-tress syndrome.

RADIOLOGIC STUDIES

Though radiological investigations are useful inthe diagnosis of acute pancreatitis, most of them areneither specific nor frequent in acute pancreatitis.Contrast studies are far inferior to ultrasonographyand computed tomography. Ultrasound has its limi-tations owing to bowel gas overlying the area ofpancreas though it is very useful for the diagnosis ofcholelithiasis and bil iary tree dilatation [17]. Com-

Jour. Marine Medical Society, Jan-Jun 1999, Vol. l, No. I

puted tomography has become standard method todetermine the existence of acute pancreatic disease.In 14 to 29 per cent of patients scan may be normal.CT is also useful in the diagnosis of hemorrhage,necrosis, abscess, calcification, dilated ducts andtumours [18]. Dynamic CT is helpfulwhen pancre-atic necrosis is suspected.

Magnetic resonance imaging is not a routinemodality. Angiography is helpful in conditions likehemosuccus pancreaticus that is bleeding throughthe pancreatic duct..

DIAGNOSIS

ln severe acute abdominal pain, pancreatitis re-mains a diagnostic possibility but when associatedwith elevated serum amylase, other causes need tobe ruled out. When there is a delay in seekingmedical attention, normal serum amylase, does notrule out pancreatitis. Painless pancreatitis present-ing in shock or coma is uncommon.

In the differential diagnosis, acute cholecystitis,perforated viscus, myocardial infarction, renal colicand diabetic keto acidosis should be considered.

COURSE OF THE DISEASE AND COMPLI-CATIONS

Severity of acute pancreatitis and its expectedmorbidity and mortality have been guided by thevarious multiple factor scoring systems which arenot consistently used by clinicians. High mortalityrate in severely ill patients is basically due to infec-tion and warrants intensive approach. Complica-tions can be local in the form ofabscess, pseudocystand ascites. Systemic complications include renal,pulmonary, hematologic and cardiovascular abnor-malities. Retinopathy and central nervous systemabnormalities are rare. In the absence of complica-tions, recovery usually occurs in one to fwo weeks.Frequent cause ofdeath during the first few weeksof the i l lness is the development of cardiovascularcollapse and adult respiratory distress syndrome(ARDS).

MANAGEMENT

Autodigestion ofpancreas during an episode cannot be controlled by rigorous treatment. The overallmortality is about l0 per cent but the efforts shouldbe made to improve the qualitative care and preventlocal and systemic complications and also ensure

that recurrent epis.odes are prevented. Distinct clini-cal advantage of energetic treatment has not beenproved by various studies t19,20,21,221.

In more than 85 per cent cases acute pancreatitisis self limited. Efforts to put pancreas at rest include,maintenance of intravascular volume by intrave-nous fluids, nothing by mouth, analgesics for painand nasogastric suction. The fluid deficit must beassessed at regular intervals by monitoring thehaemodynamic parameters.

Though timing of resumption of oral intake var-ies fiom patient to patient, disappearance ofpain anddecrease in serum amylase levels are good markers.Diet rich in carbohydrate and small frequent mealsare recommended with monitoring of recunence ofpain. Total parenteral nutrition (TPN) should beemployed only in patients with complicated or pro-longed pancreatitis. Additional drugs and hormoneshave not shown any clinical benefit. Antibioticshave no role in acute pancreatitis of mild to moder-ate severity but in established infection have a de-finitive role.

Severe pancreatitis requires a team approach andthe various criteria to assess the severity are usefulguidelines for evaluating patients. CT scan, espe-cially a contrast enhanced dynamic CT(CECT) scanprovides valuable information on the severity andprognosis of acute pancreatitis.

Close monitoring of central venous pressure,urine output, body gas estimation, calcium, glucoseand hematocrit are mandatory. Urgent laparotomy,removal of stones impacted in the ampulla of Vaterby surgical or endoscopic means are indicated insome cases. Procedures like peritoneal lavage [21],necrosectomy [23] partial to total pancreatectomy

l24lhave not shown any value in decreasing mor-talify. Patients with ARDS require endotracheal in-tubation and controlled ventilation with positive endexpiratory pressure (PEEP) [25]. Patients with renal'insufficiency secondary to acute tubular necrosi3need volume and electrolyte restriction includingcorrection of hyper-kalemia and metabolic acidosis.Additional supportive measure include calcium tocombat severe hypocalcemia, insulin when markedhyperglycemia occurs. Weight reduction, fat re-stricted diet, reduction in alcohol intake and lipidlowering drugs are the main stay of therapy in suchcases.

t 1

Local complications like fluid collection/pseudocyst in more than fifty per cent ofthe casesresolve during the succeeding six weeks. An enlarg-ing and infected fluid collection requires drainagesurgically or by endoscopic aspiration. Pancreaticnecrosis and abscess are life threatening complica-tions with close to 100 percent mortality and needclose mon ito ring [27 l. Gastrointestinal bleeding isdue to several mechanisms and requires a promptmulti disciplinary approach.

Once the patient has recovered from acute pan-creatitis the chances ofrecurrence in the next one totwo years are between 25 and 60 per cent. A sys-temic search for an associated and correctable con-ditions must therefore be undertaken promptly128,291.

In conclusion, inflammatory disease of pancreasmay be acute or chronic. The diagnosis ofpancrea-titis is difficult due to its inaccessibility and nonspecificity of abdominal pain. Only a minority ofpatients with pancreatitis will be diagnosed cor-rectly if one goes strictly by its classical symptoms.The pathogenesis of pancreatitis remains obscureand ffeatment is therefore supportive rather thanspecific. There has been a tremendous improvementin the areaofdiagnosingthis disabil ity butthe abil ityto influence the course of disease has progressedvery little during the past decade.

REFERENCES

l. Clarke RS. History of Castroenterology. ln Paulson M. (ed).Gastroenterologic Medicine, Philadelphia, Lesa and Fe-biger. 1969.

2. Sarles H. Definitions and classifications ofpancreatitis. Pan-creas 6:470. San MG, Sanfey H and Cameron JL. Prospec-tive randomized trial ofnasogastric suction in patients withacute pancreatitis surgery. 1986: 100: 500.

3. Corfield AP, Cooper MJ, Williamson RCN. Acute pancrea-titis. A lethal disease ofincreasins incidence. Gut 1985-26- 1 1 A

4. Nakamura K, Sarles M, Payan Il. Three dimensional recon-struction of the pancreatic ducts in chronic pancreatitis.G as troente ro logt 197 2; 62 : 942.

5. Farmer RC, Maslin SC, Reber HA. Acute pancreatitis roleof ducts permeability. Surg Forum 1983; 34 : 224.

6. Leach SD, Modlin IM, Scheele GA, Gorelick FS. Intracellular activation of digestive zymogens in rat pancreaticacini. Stimulation by high dose of cholecystokinin. J C/tnIrnent l99l:87 : 362.

7. Lasson A. Acute pancreatitis in man. A clinical and bio-chemical study of pathophysiology and treatment. Scar J


- Gastroenterol 1984; 19(Suppl. 9) : l.

8. Allam BF, lmrie CW. Serum ionized calcium in acute pan-creatitis. Br J Surg 1977 64 : 665.

9. Drew SI, Joffe B, Vinik A, Seftel H, Singer F. The first 24hours of acute pancreatitis. Changes in biochemical andendocrine homeostasis in patients with pancrealitis com-pared with those in conhol subjects undergoing stress forreasons other than pancreatitis. An J Med 1978',64 : 795.

10. Murphy D, Pack AJ, Imrie CW. The mechanism of arterialhypoxia occuring in acute pancreatitis. Role of hypovolemia.

QJ Med 1980;49 : l5 l .

I |. Levy M, Geller R, Hymovitch S. Renal failure in Dogs withexperimcntal acute pancreatitis : role ofHypovol emia- Am JPltysiol 1986', F969 : 251 .

12. Moreau JA,Zinsmeister AR, Melton JL, Dimagno EP. Gdl-stone pancreatitis and the effect of cholecystectomy: Apopulation based cohort study. Mryo Clin Proc 1988; 63 :466.

13. Cotton PB. Pancreas divisum, curiosity or culprit? (Edito-i^l) l; i rslrenterologt 1985 89 : 143 I,

14. Blamey SL, lmrie CW, O'Neill J, e t al. Progrostic factors inacute pancreatitis. Gut 1984; 25 : 134046.

15. Agarwal N, Pitchumoni CS. Simplified progrostic criteriain acute pancreatitis. Pancreas 1986; I : 69-73.

16. Larvin M, McMohan MJ. APACHE-ii score for assessmentand monitoring ofacute pancreatilis. Lancet 1989; 2 : 201-5.

17. Van Dyke JA, Stanley RI, Berland LL. Pancreatic imaging.Ann Intern Med 1985'. 102 ,2122.

18. Warshaw AL, Gonglin J. Improved survival in 45 patientswith pancreatic absooss. Ann Surg 1985;20 : 5.

19. Soergel KH. Medical treatment of acute pancreatitis. Whatis the evidence? G astroe nte rol ogt 197 8: 7 4 : 620.


20. TykkaHT, Vaittinen EJ, MahibergKL, RailoJE, PantzarPJ,Sama S, Tallberg T. A randomized double blind study usingCaNa2, a phospholipasc ,42 inhibitor, in the management ofhuman acute pancreatitis. N Engl J Med 1983; 12 : 399.

21. Mayor AC, McMahoyt MJ, Cortifeld AP, Cooper MJ, Wil-liamson RCN, Shearer MC, Imrie CW. Controlled clinicaltrial of peritoneal lavage for the treatment of severe acutepancreatitis. N Engl J Med 1983; 12 : 399.

22. Choi TK, Mok F, Zhan WH, Fan ST, Lai ECS, Wong J.Somatostatin in th€ treatment of acute pancreatitis. A pro-spective randomized controlled tri al. Gut 1989 : 30 : 223.

23. Bradley EL, Allen KA. A prospective longitudinal study ofobservation versus surgical intervention in the managementof necrotizingpancreatitis. AmJ Surg l9l; l6l : 19.

24. Nordback IH, Auvlnen OA. Long term results after pancreasresection for acute necrotizing pancreatitis. Br J Surg 1985;7 2 : 6 8 7 .

25. Wanhaw AL, Lesser PB, Rie M, Cullen DJ. The pathogene-sis ofpulmonary edema in acute pancreatilis. Ann Surg1975;185 : 505.

26. Mac Erlean DP, Bryan PI, Murphy JJ. Pancreatic pseduocystmanagement by ultrasonically guided aspiration. Gastroin-test Radiol 1980: 5: 255.

27. Stanten R" Frey CF. Management of acute necrotising pan-creatitis and pancreatic abscess. lrci Surg 1990;125 : 1269.

28. Venu RP, Geenen JE, Hogan WJ, Store J, Johnson GK,Soerel KH. Idiopathic recunent pancreatitis. An approach todiagnosis.and treatment. Dlg Drs.Sc, 1989; 34 : 56.

29. Geenen JE, Hogan WJ, Dodds WJ, Stewart ET, AmdorferRC. Infraluminal pressure recording from the human sphinc-ter ofOddi. GastroenErologt 1980; 78 : 317.

t3

Original ArticlesHYPERBARIC OXYGEN TFIERAPY (HBOT)TI{E NEWEST ANTI BACTERIAL AGENT IN DIABETIC FOOT?

Surg Cdr VRG PATNAIK*, Surg Cdr PS LAMBA+,

Surg Cdr S NANGPAL**, Surg Cdr MJ JOHN**

ABSTRACT

Diabetic foot is one of the most dreaded long term complication of diabetes mellitus. Of the three types of diabeticfoot, the infected foot is most common in India due to the socio-economic characteristics prevalent in the country.Most mild infections are caused by aerobic gram positive cocci. Deeper, limb threatening infections are usuallypolymicrobial. To assess the roll of HBOT as an antibacterial agent a study was conducted at the Institute of NavalMedicine in an age matched group. Control group consisted of three females and 12 males (mean age 67 i 9.81).Study group consisted of 13 males and two females (mean age 63.1 t 8.74). Both groups were given standardantibiotic and surgical care. Study group was pressurised to 2.8 ATA (atmospheres) using 1007o oxygen for onehour. Controls were pressurised to the same depth but using 7.5o/o 02 and92.5Yo N2 as the breathing mixture soas to ensure thatthe beneficial effect is due to'hyperbaric 02' alone by keeping pressure as a constant denominatorin both groups. Thc most striking effect of HBOT was seen in the control of infection. Statistical analysis showedthat78.9o/o of the control group had positive wound cultures as compared to only l0% in the study group (p <0.001) post HBOT. Most effective antibacterial action was seen in the case of pseudomonas and E Coli.

KEY WORDS : HBOT, Diabetic foot, Antibacterial agent

INTRODUCTIONiabetic foot is defined as a compromised footdue to neuropathy, macro vascular diseaseor infection occurring singly or in combina-

tion. The long term complications including diabeticfoot have caused the most morbidity and mortalitysince the introduction of insulin therapy. Ofthe threetypes of diabetic foot the infected foot is most com-monly encountered in clinical practice in India. Inthis country purely infected foot is associated nei-ther with neuropathy nor vascular disease []. Itusually occurs in freshly detected IDDM or at timesdiabetes is detected afterthe infection has set in. Thepathological process starts with injury and break-down of skin because ofnail or thorn prick or anyother trauma. A major factor contributing to diabeticfoot in India is walking barefoot. Other factors arepatient's surgical attempts at home, use of non ster-ile creams, delay in seeking medical attention andoften undetected diabetes.

Most mild infections are caused by aerobic gram

positive cocci such as staphylococcus aureus orStreptococci [2,3]. Deeper, limb threatening infec-tions are usually polymicrobial and caused by aero-bic gram positive cocci, gram negative bacilli (e.g.E Coli, Klebsiella species and Proteus species) andanaerobes (e.g. Bacteroides species and peptostrep-tococcus) [4].

OXYGEN AS AN ANTIBIOTIC AND RA-TIONALE FOR HBO THERAPY IN INFEC-TroNS lsl

1. Oxygen acts as an antibiotic by impairing thebacterial metabolism. The effect of HBO is notselective but covers a broad spectrum ofgrampositive and negative organisms. It is most ef-fective in anaerobic infections.

2. HBO improves phagocytosis, which is im-paired by hypoxia.

3. Hypoxia impairs the immune mechanism ofthebody, whereas HBO improves it.

4. HBO produces free radicals which are toxic tomicroorsanisms.

*Craded Specialist; **Classified Specialist; Dept of Marine Medicine; +Classified Specialist in Medicine and Endocrinologist; InStituteof Naval Medicine, INHS Asvini. Colaba Mumbai - 400 005.

Jour. Marine Medical Society, Jan-Jun 1999, Vol. 1, No. I14

!{

:5. HBO has a synergistic effect when combinedwith sulfonamides and increases the effect fiveto ten fold.

6. HBO is effective in drug resistant infections.

7. Adequate tissue oxygen tension is required forachieving an optimal effect of the antibiotics.The effect of aminoglycosides is reduced inanoxic conditions as oxygen is needed fortrans-porting the drug into bacteria.

8. Oxygen has a direct bactericidal or bacte-riostatic effect equal to that of some antibiotics

9. HBO inhibits exotoxin production, e.g. alpha-toxin of C perfringens or detoxifies oxygen-labile exotoxins, e.g. theta-toxin of Cperfringens.

The rationale of employing HBO in diabetic footis based on physiochemical and haemodynamicconsiderations. However, recent studies have indi-cated that HBOT acts as an effective antibacterialagent. When administered at pressures greater thanI ATA (atmospheres) 02 can assume propertiesmore akin to a drug than a simple support for meta-bolism. On facultative anaerobes and strict aerobicmicro organisms there is no direct bactericidal ef-fect. Hyperbaric conditions cause an increased pro-duction of toxic 02 radicals, but there is also furtherproduction of superoxide dismutase by which aero-bic micro organisms are able to detoxifu the 02radicals even under hyperbaric conditions. It actsindirectly by raising 02 tensions in infected tissuesto normal thereby restoring the 02 dependent mi-crobicidal properties of polymorphs to normal [6,7].It also improves antibiotic efficiency. Further it hasbeen shown that the transport ofantimicrobials, such

TABLE IBacterial profile of wounds

as aminoglycosides inside bacteria requires 02. Aninteraction with HBO has been demonstrated forthese types of antibiotics. Extra cellular white cellkilling of aerobic bacteria and some fungi is alsogreatly enhanced at high 02 pressures [8].

MATERIAL AND METHODS

The study was conducted in an age matchedgroup in a randomised prospective procedure. Atotal of 30 volunteer patients were included duringthe period of 1995 to 1997.

The study group consisted of l3 males and twofemales. Average age was 63.1 !8.74 years (range5l to 75 years). Fifteen patients comprised the con-trol group with three females and 12 males. The

. average age was 67 ! 9.81 years (range 45 to 85years). Male to female proportion was 80:20 in thecontrol and 87:13 in the study group. The facilitiesavailable in the Hyperbaric Center at the INM wereused for this study which included a monoplace anda multiplace recompression chamber.

The control group was subjected to 2.8 ATApressure and were made to breathe 7.5%io 02 and92.5%N2. This en'sured on 02 partial pressure of0.21 ATA at bottom. To avoid hypoxia, compres-sion and surfacing were done using air as the breath-ing medium.

The study group were also subjected to the same2.8 ATA but 100% 02 as the breathing medium.Both groups had a bottom time of one hour. Bothstudy and control groups were given standardwound care, antibiotic cover and insulin.

Rigid acceptance criteria were adopted and pa-tients were thoroughly examined for HBOT fitness.

t4

t 7

l 9

z3

26

30 I

t ;I

t

ry

Control Study

34

) t

Gupta

Pseudomonas

E Col i

Staphylococcus

Klebsiella

Bacteroides

Peptostreptococcus

6 (31.6)s (26.3)3 ( r s .8)3 (1s.8)r (s.2)r (s.2)

8 (53.3)5 /' l ' t ' l \

02 (13.4)

00

5 r?5\

7 (3s)4 (20)l (0s)2 ( r0 )r (0s)

r (50)r (s0)

0000

20l 942 Total l 5 (78.9) 2 ( 1 0 )

* X" = I1.2 * < 0.001 (Signif icant)

Jour. Marine Mediial Society, Jan-Jun 1999, Vol. I , No. I I5

The pre HBO therapy included wound swab cultureand antibiotic sensitivity testing of the detected mi-cro organisms of patients in both groups before andafter HBOT protocol completion.

RESULTS

The results ofthis study are presented below in atabular form.

TABLE 2Mean no of days for infection to clear

Control Study

20.4 + 6.89 12.2+ 4. t2

T :3.96, p < 0.001 (Significant)

DISCUSSION

The average age of both groups were compatible(control 67 !9.81 years, range 45 to 85 years andstudy group 63.1 !8.74years, range 5l to 75 years).The male:female ratio for the control group was80:20 and for the study group was 87:13.

The most striking effect was seen in infectioncontrol (Table l). 7 8.9Yo of the controls had positivewound cultures post HBO compared to only l0% inthe study group, which is significantly less (p <0.00 1 ). Further wounds became ste rile in 12.2 + 4.12HBO sittings in the study group compared to 20.4 +6.89 in the control group (Table 2). Significantantibacterial effect of HBOT was observed in thecase of Pseudomonas and E Coli (Table l).

Doctor et al, in a study of 30 diabetic patientswith foot lesions treated with routine care or withcare plus four 45 mins. HBOTs, observed a decreasein positive cultures from 16 to 12 in the study group(p < 0.05) [9]. The difference was most pronouncedfor E Coli. Of the available literature this is the onlyknown reference of the use of HBOT as an antibac-terial agent in diabetic foot. Many non healing dia-betic feet are hypoxic and tissue 02 tensions may bein the range of 0-15 mm Hg. Although hypoxiamayserye as an initial stimulus to the healing process,tissue 02 tensions of 30-40 mm Hg are hecessarysubsequently for enhancement of leucocyte killingof bacteria. Local hypoxia predisposes wounds toinfection, because the neutrophil mediated killing of

bacteria by free radicals is decreased [0,1 1]. Hy-perbaric 02 restores this defence against infectionand increases the rate of killing of some commonbacteria by phagocytes [8]. In addition, HBO aloneis bactericidal for certain anaerobes, including Clos-tridium perfringens, and bacteriostatic for certainspecies of Escherichia and Pseudomonas [2-l5].REFERENCES

l. Pendsey S. Diabetic foot - More than a pedestrian problem.. NNDU NOVO Nordisk Diabetes Update 95, Proceedings.

Heafth care communications, Mumbai 65. 1995.2. Jones EW, Edwards R, Finch R, et al. A microbiological

study of diabetic foot lesions. Diabet Med 1984: 2 : 213-5.3. Lipsky BA, Pecoraro RE, Wheat LJ. The diabetic foot: soft

tissue and infection. lnfect Dis Clin North Am 1990 4 :409-32.

4. Wheat LJ, S, Allen SD, Henry M, et al. Diabetic footinfections: bacterial analysis. Arch Intern Med 1986;146 :135-40.

5. Jain KK. ln Textbook of Hyperbaric Medicine, 2nd Edition1996, Hogrefe and Huber Publisher. .1996; 2 : I 8 l.

6. Babior BM. Oxygen dependent killing by phagocytes. NEngl J Med 197 8: 298 : 12,659-68,13,721 -25.

7. Stossel TP: Phagocytes. N Engl J Med 1974:717-23,774-80,833-39.

8. Mader JT, Brown GL, Guckian JC, Wells CH, Reinarz JA.A mechanism for the amelioration by hyperbaric oxygen ofexperimental staphylococcal osteomyelitis in rabbits. J 1n-fect Dis 1980; 142 (6):915-22.

9. DoctorN, Pandya S, Supe A. Hyperbaric Oxygen Therapyin diabetic foot. J Post grad Med Jul.-Sep. 1992; 38 (3) :l l 2 - 4 . l l t .

10. HuntTK. Thephysiologyofwoundhealing.lnn Emerg Med1988; l7 :1265-73.

I l. Knighton DR, Halliday B, Hunt TK. Oxygen as an antibiotic:- a comparison of the effects of inspired oxygen concentra-tion and antibiotic administration on in vivo bacterial clear-ance. Arch Surg 1986; 121 : l9l-5

12. Hill GB, Osterhout S. Experimental effects of hyperbaricoxygen on selected clostridial species in In-Vitro studies. JInfect Dis 1972:125: 17-25.

13. Boehm DE, Vincent K, Brown OR. Oxygen and toxicityinhibition of amino acide bio svnthesis Nature 1976. 262 :418-20.

14. Brown OR. Reverse inhibition of respiration of EscherichiaColi by hyperoxia Microbios. 1972;5 :7-16.

15. Park MK, Muhvich KH, Myers RAM, Marzella L. Hyper-oxia prolongs the aminoglycoside induced post antibioticeffect in Pseudomonas Aeruginosa. Antimicrob AgentsChemoTher l99l:35 : 691-5.

Jour. Marine Medical Sociev, Jan-Jun 1999, Vol. l, No. It 6

a

L-ABCOF CTBACII

Surg CdrSurg CrnSurg Cdr

ABSTRAI

Field andLC 90 vahfield.

KEYWOl

INTROD

T\ acil{t ivtI'-Dfou

ment. DurI 984, out <breeding Iisolated wCulex quir

Bacticiravailable isporogenicraelensis Fhost larvaetoxin andralysis andresulting inreports beigarding eflpropriate trtrials.

MATERII

The init;a stock solrin distilledmade as pe;

*Classified SpTrainee in PSMedicine; Inst005.

Jour. Marine

.HvFctionlmonaloneClos-;rtainI sl.

\LABORATORY AND FIELD TRIAL OF SUSCEPTIBILITY STATUSOF CULEX QUINQUEFASCIATUS LARVAE TOBACILLUS THURINGIENSI S

Surg Cdr KK DUTTAGUPTA*, Surg Cdr A CHATTERJEE**,Surg Cmde NR RAHA VSM#, Surg Cdr MJ JOHN##,Surg Cdr S NANGPALf#, Lt Col AK UPADHYAY*

ABSTRACT

Field and Laboratory trial of Bacillus thuringiensis against larvae of Culex quinquefasciatus were carried out.LC 90 value was found to be 0.019 mglL.0.5o/o suspension was found to be effective for more than two weeks infield.

KEY WORDS :

INTRODUCTION

oblem.edings.

rlogical2B-5.

rot: soft9 o ; 4 :

tic foot6 ; 1 4 6 :

Edition

;ytes. N

23,774-

naz JA.<ygen ofits. J In-

Therapy38 (3) :

rcrgMed

ntibiotic:)ncentra-'ial clear-

yperbaricstudies. J

I toxicity176;262 ' .

;cherichia

-.Hyper-antibioticb Agents

l, No. I

acillus thuringiensis is an aerobic gram posi-tive rod shaped spore forming bacteriumfound mainly in soil and aquatic environ-

ment. During a four year study, between 1980 and1984, out of total 1892 samples of soil and mosquitobreeding habits in South India, 101 sffains wereisolated which showed larvicidal activity againstCulex quinquefasciatus I I ].

Bacticide is a biological larvicidal formulationavailable in form of a wettable power based onsporogenic strain of Bacillus thuringiensis var is-raelensis H-14 strain. These bio larvicides act onhost larvae through its parasporal crystal delta endo-toxin and bacterial spores causing starvation, pa-ralysis and septicemia of larval bodies ultimatelyresulting in death ofthe larval bodies. In view ofthereports being received from all over the world re-garding efficacy of this biocide, it was thought ap-propriate to carry out a field as well as laboratorytrials.

MATERIAL AND METHODS

The initial laboratory trial was carried out usinga stock solution of 100 ppm concentration preparedin distilled water and subsequent dilutions weremade as per requiiement. Tests were calried out as

*Classified Specialist in Preventive Medicine; **Post GraduateTrainee in PSM; #Director; ##Classified Specialist in MarineMedicine; lnstitute of Naval Medicine, Colaba, Mumbai - 400005.

Jour. Marine Medical Societv, Jan-Jun 1999, Vol. l, No. I

per standard WHO technique and 20 numbers ofsecond and third instar larvae were used in eachcontrol and replicate beaker. Four different concen-trations were tried. Three replicates of each concen-tration and two controls were kept with each set oftests. Mortality was recorded after 24 hours. Testswere carried out under controlled laboratory condi-tions. Values obtained were analysed to obtain LC50 and LC 90 values. Abbotts correction was appliedwhere required. Larvae used as control was hatchedto confirm mosquito species.

FIELD TRIALS

Field trials were carried out with 0.5%o suspen-sion of Bacticide which was first made into a thickhomogeneous paste and then diluted with water.Different mosquito breeding habitats in the selectedfield were identified. Pre spray larval density wasfound out with a ladle. The quantity of biociderequired for each area was calculated by determin-ing the total surface area ofwater. Knapsack sprayerwas used to ensure continuous mixing and uniformspray. Two breeding sites were kept as control. Postspray density was checked after 24 hours and thenon every altemate day.

RESULTS

The result of laboratory trials is shown in Table I .

FIELD TRIALS

Four selected habitats and two control were se-lected on field trials. The result of f ield trials is

1 7

TABLE I

Susceptibility status ofCulex quinquefasciatus larvae to Bacticide in hboratoryrt

NOExposed

Conc(ppm)

No. Killed % Mortality CorrectedMortality

EmpiricalProbit

Log conc.

60606060

0.0010.0050.0250.125

mcltodithprbr

2644

5660

1 5 . 5 5

I J . J 5

93.33t00

37.0370.3692.58100

4.67

5.546.45

000.6990

1.39732.0969

LC 50LC 90Co-efficient of correctionSlope (b)Intercept

TABLE 2Result of field trials with bacticide

0.001838 PPM0.01861 PPM0.9971.27324.663s

cadifirne

ofat(B

Sl. HabitatNo.

Mean no. ofLarvae/Dip Post spray density

l 3Day 3I

l .

J .

68

NIL4.

PollutedCemented drainDitchWaterStagnation inkutch a channelPollutedcemented drain infield area

7290

5

NILJ

2

NIL

NIL

NIL

NIL

NIL

NILNIL

NIL

NIL

NILNIL

NIL

ML

NIL

NIL

NIL

NIL

NIL

NIL 3NIL NIL

sernagotra

AI

pett o r

M]

I

NIL

NIL

NIL

shown in Table 2.

In control (untreated habitat) no statistically sig-nificant change in the density of mosquito larvaewas found in each set of experiments.

DISCUSSION

Biological control is a safe and effective additionin vector control l2l.LC 50 and LC 90 value calcu-lated in this study were 0.0018 mgm/L and 0.019mgm/L. LC 90 values calculated in a study at Tezpur(Assam) against Culex quinquefasciatus was 0.453mgm/L [3]. In a study canied out in Armed ForcesMedical College, Pune, 100 per cent mortality wasachieved with I PPM, with the biocide being usedin pellet form. Mean larval reduction of 90 percentwas achieved for a period of2l-35 days dependingon degree of pollution [4]. Findings of this studyindicate that reappearance of larvae takes 14 days

18

which means that weekly larval control activitiesmay be replaced by fortnightly operation ifbacticideis introduced. However, a more detailed study willbe required before implementing the findings ofthisstudy.

REFERENCES

l. Indian Council ofMedical Research. Bacillus thuringiensisH 14 and its prospect for mosquito control 1986',16.3 :25-9.

2. Jason AN Obeta - Effect of inactivation by sunlight on thelarvicidal activities of mosquitocidal Bacillus thuringiensisH - 14 isolates from Niserian Soil. J Com Dis 1996'.28.2 :94-100.

3. Baruah I, Das SC. Laboratory and field evaluation ofBacil-lus thuringiensis anil B phaericus against mosquito control.J Com Dis 1994;26.2:82-7.

4. Srivastava R, Tilak VW, Mukherjee S, Yadav JD. Field trialofBacillus thuringiensis. Pellet formulation in the control ofmosquitoes. MJA FI 1996: 52.4 : 233-5.

Jour. Marine Medical Societv, Jan-Jun 1999, Vol. I , No. I

sal,cotchia lstur

2(D

Jot

\ARTHROSCOPIC MANAGEMENT OFANTERIOR CRUCIATE LIGAMENT DEFICIENT KNEE

Lt Col SM BHATNAGAR*, Surg Cdr P SARIN+

ABSTRACT

Arthroscopic reconstruction ofACL using bone patellar tendon bone (BPTB) autograft technique is consideredto be a gold standard. To the best ofour knowledge this procedure is not being done in any ofthe Armed Forceshospitals except at our hospital, We describe the above technique with certain modifications as adopted by us.The advantages and draw backs ofthe above technique are discussed.

KEY WORDS : Anterior cruciate ligament, Arthroscopy, Knee.

INTRODUCTION

nterior cruciate ligament (ACL) is the mainstabiliser ofthe knee. Tears ofACL are quitecommon. ACL mav tear in isolation or in

association with capsular, ligamentous or meniscalstructures and even along with osteochondral injury.

Twisting of knee during sports activities andactivities of daily living are the commonest cause ofACL tear. Pivoting over a planted foot is a com-monly performed action occurring in various sportslike football, hockey and cricket; and during suddendeceleration while landing after a long jump. It mayalso occur in volley-ball, basket-ball or after over-head shot in badminton. 18 percent of ACL tearsoccur from the femoral attachment. These can bere-attached with pull though sutures. This procedurecan be performed arthroscopically as well as byopen arthrotomy. Two percent of ACL tears areavulsions from the tibial attachment. These can beradiologically diagrosed if associated with boneavulsion. These can be ideally re-fixed with screwor by pull-through sutures, which can be anchoredexternally. It is possible to pass a screw arthroscopi-cally to fix the avulsion, but the direction of thescrew may not be perpendicularto fracture fragmentand therefore the fixation in such cases is not ideal.Mini arthrotomy is preferred in fixation of theseavulsions. These avulsion fractures should be fixedprimarily as early as possible, otherwise the ACLmay become contracted and subsequent callus for-rnation makes fixation difftcult.

80 percent ofthe tears occur through the mid-sub-stance, which results in "mop-end" tears and theACL tends to get shredded. They are difficult torepair and have a high failure rate. If primary repairis attempted, it should ideally be augmented with agraft. This surgical procedure is then as good as anACL reconstruction [].' 'ARTHROSCOPIC'' OR''ARTHROSCOPICAIDED'' ACL RECONSTRUCTION

Arthroscopic ACL reconstruction can be per-formed if allo or synthetic grafts are used and. screwfixation is done endoscopically.

Due to non-availability of allo/synthetic graftsand the cost factor involved. we have becin usins.

Fig. | : Artist's depiction of Tibial anatontic attachment sitc(TAAS). Central point is identified on the anterolateralslope of the medial intercondylar eminence using theresidual ACL stump as a reference.

*Classified Specialist Surgery and Orthopaedic Surgery,+ Classified Specialist and Ortho Surgeon, INHS ASVINI, Colaba, Mumbai400 005.

Jour. Marine Medical SoCiety, Jan-Jun 1999, Vol. I, No. I 19

l ' i g . 2 : Sc l cc t i r c r r o t c l r p l a : t y

autograft for ACL reconstruction. The illo-tibial(lT) band, the Semitendinosus with Gracillis and thepatellar tendon are commonly used autografts.

We prefer the central l/3 of the patellar tendonalong with bone plugs from tibial tuberosity andinterior pole of patella as a free graft for harvesting.This is because ofinherent strength ofthe graft andit offers the advantage of bone-to-bone fixatio,Jr.

Arthroscopic ACL reconstruction can be de-scribed in three stages.

STAGE-I

A routine video arthroscopy is carried out usingstandard antero-lateral and antero-medial portals.Menisci which cannot be repaired are treated bypartial or sub-total meniscectomy.

The narrowed inter-condylar notch is widened toaccommodate the reconstructed ACL. The roof andmedial wall of lateral femoral condyle are debrided.

STAGE-2

A l0 mm BPTB graft is lifted free through a

20

Fig. 3 : Tibial Aimer with Drilling Outriggcr in position.

midline incision. Middle l/3 of patellar tendon istaken with about 2.5 cms of bone pegs, one fromtibial tuberosity and another from lower pole of thepatella. The patellar tendon defect is loosely ap-posed and paratenon is sutured over it.

A wire is passed at either end ofthe graft throughthe bone plug and the bony ends are tapered tofacilitate rail-roading of the graft.

STAGE-3

A specially designed, commercially available jigis introduced through the antero-medial portal. Thisis used to determine the tibial attachment of ACLgraft.

The tip of the jig is impaled at the site, 5-8 mmin front of posterior cruciate ligament (PCL) and atwo mm K-wire is drilled from the medial tibialcondyle to emerge at the site where jig was impaled.

A 9-l I mm cannulated drill is selected accordingto the size ofgraft and bony pegs. The appropriatecannulated drill is then passed over this wire and anintra-osseous tunnel is made in the medial tibial

Jour. Marine Medical Societv, Jan-Jun 1999, Vol. I, No. I

liig. .l : Overdrilling K-wire with appropnate cannulated drillbir.

condyle. This gives adequate room to select theprecise isometric point on the femoral condyle.

The femoral entry point is 3-5 mm anteriorto theposterior margin of the inter-condylar notch on themedial wall of the lateral femoral condyle. TheK-wire is again passed through the tibial tunnel anddrilled from the femoral ACL site to exit on lateralside of the thigh at the junction of lateral condyleand the femoral shaft. Over this K-wire, drilling isdone by the appropriate sized cannulated drill.

lncision is then made over the lateral aspect ofthigh to define the exit of the femoral tunnel. Afterthorough inigation of the tunnel and the knee jointto wash out any bony dust, the graft is rail-roadedinto the joint. Using 6.5 mm fully threaded headlesscancellous screw, the femoral side is fixed first [2]. .


Fig. 5 : Chamfbring'l ibial 'funncl.

With knee in 40 degree flexion and tibia in inter-nal rotation. the normal tension in the ACL is createdby pulling the graft from tibial side then fixing it ina similar way. The wounds are closed in layerswithout drainage. Bulky compression dressing isgiven and knee iminobilised in extension in a re-movable stiffknee brace [3].

Aggressive physiotherapy is instituted in imme-diate post-operative period to avoid the ill-effects ofimmobilisation of the joint. lsometric exercises arestarted from second day onwards. Weight bearing isstarted on third post-operative day and at the end ofsecond week the patient can take full weight on theoperated leg.

Isotonic exercises are started gradually after sixweeks and with weights after patient has achieved90 degrees of flexion which is usually within six to

1 t

eight weeks.

Patients can be permitted to cycle and swim afterl2-18 weeks ofrehabilitation exercise, jogging after9-12 months and contact sports after 12 months.

Following complications may occasionally de-velop.

a. Restricted range of motion.

b. Impaired sensation over lateral side ofknee andupper part oftibia.

c. Screw protruding in the skin and sub-cutaneoustissue.

d. Arthro-fibrosis due to haematoma.

e. Adhesions

f. Infection

Restricted range of movements may be due toinadequate notch-plasty and error of graft place-ment.

Impaired sensation over the lateral aspect of theknee and conesponding upper part of leg are mostcommon complaints, caused by severing of cutane-ous nerve while giving lateral incision. Sensationshowever improve with passage of time.

Ideally the screw should sink in the bone butinadequacy of subcutaneous tissue may cause thescrew to protrude but. Ifthis causes undue inconven-ience to the patient the screw can be removed afterthree to six weeks provided the bony plugs are wellincorporated within the mhin bone.

ADVANTAGES

The advantages of ACL reconstruction by this

procedure out weigh the disadvantages or complicftions:

a. This procedure involves minimal dissection oftissue leading to early healing and early mobi-lisation.

b. Tension in the graft and adequacy of notchplasty can be visually observed and adjusted.

c. This surgery is cosmetically better and can beperformed almost as an out patient.

d. This method provides aggressive rehabilitationand early return to sports [4].

CONCLUSION

Arthroscopic ACL reconsffuction has been foundto be superior compared to the procedure by openarthrotomy. It involves minimal dissection, enablesprecise placement ofthe graft and early mobilisationof the knee. Return of normal function of the kneeis accelerated by this method.

REFERENCES

l. Joshi A. Arthroscopy of ACL deficient knee CME cumproceeding book ofNorth zone chapter. India OrthopaedicsA ssoc iation C onfe rence 1994.

2. Mathews LS, Lawrence SJ, Yahero MA, Sinclair MR. Fixa-tion strengths of patellar tendon bone grafts. Arthroscopy1993;9 ( l) : 76-81.

3. Samuelson TS, Drez Ob Jr. Maletis GB Anterior cruciategraft rotation, reproduction ofnormal graft rotation. Ameri-canJ Sports Medicine 1996;24 (1) : 67-71.

4. Baker CL Jr, Graham J. Intra articular ACL reconstructionusing patellar tendons; arthroscopic technique Orthopaedics1993; t6 (4):43741.

22 Jour. Marine Medical Society, Jan-Jun 1999, Vol. l, No. I

JT*,oNIC SUBCLINICAL SINUS INFECTION AS A CAUSE oFRECURRENT EUSTACHIAN TUBE DYSFLINCTIONIN NAVAL DIVERS

Col BN BORGOHAIN*, Surg Lt Cdr SANJMADHWAR+,Surg Lt Cdr NIRAJ SINHA#

ABSTRACT

Eustachian tube dysfunction is a common cause of otalgia in divers.45 consecutive naval divers with recurrenteustachian tube dysfunction (ETD) were subjected to nasal endoscopy in search of a cause for ETD. ll (24o/")were found to have evidence of mild acute/chronic anterior ethmoiditis on nasal endoscopy. These divers weresubjected to medical management for three months and then allowed to resume diving. Seven out of I I showedno significant improvement and these were olfered endoscopic sinus surgery. Six divers showed marked improve-ment after a minimum of six months follow up. The study shows the value of routine ollice nasal endoscopy in thediagnosis ofrecurrent ETD in naval divers and the value of,functional endoscopic sinus surgery (FESS) in themanagement of the same.

KEY WORDS : Functional Endoscopic Sinus Surgery; Eustachian Tube Dysfunction; Hyperbaric Conditions.

INTRODUCTION

Tl ecurrent Eustachian Tube Dysfunction

l'r{ terol cari be both distressing and danger-l\ous in the context of the hazardous condi-tions faced by divers. Failure to equalise middle earpressure to ambient atmospheric pressure can resultin severe otalgia and otic barotrauma and incom-plete and asymmetrical equalisation may give riseto altemobaric vertigo []. The major cause ofrecur-rent ETD in hyperbaric conditions is allergic tubo-tympanitis [2]. This study was conducted to find outthe role, if any, of non allergic tubo-tympanitis incausing ETD.

Chronic and acute on chronic ethmoid infectioncommonly causes a post nasal discharge [3]. Thisdischarge passes in the vicinity of the torus tubalisand may cause spread of infection to the tube andthus lead to recurrent ETD. Working on this premiseoffrce nasal endoscopy may be a worthwhile addi-tion to the armamentarium of the modem ENT sur-geon due to its ability to pick up silent subclinicalsinus inflammation, which would be missed on rou-tine ENT examination. Subclinical paranasal sinusinfection which is otherwise asymptomatic does notneed to be aggressively managed in usual ENT

practice. However, in hyperbaric conditions the re-sult of ETD can be disashous. This study was there-fore carried out to see the effects ofFESS on recur-rent ETD in a selected subgroup ofnaval divers withrecurrent ETD.

MATERIALS AND METHODS

This study was conducted in the ENT departmentof INHS Asvini from March 94 to March 97. Thestudy was designed as a clinical trial with the pa-tients acting as their own controls.

50 consecutive naval divers who presented to theout patient departrnent with symptoms of recurrentotalgia (minimum three episodes) on diving wereinterviewed in detail followed by a thorough ENTexamination. There aftertympanometric assessmentof eustachian tube function using our modificationof Holmquist criteria was done [4].

Failure to equalise 300 mm water column pres-sure with oxygen swallows implied ETD.

The patients were then subjected to office nasalendoscopy for evidence ofsubclinical paranasal si-nus infection. Of the 45 patients who were found tohave ETD by our criteria, I I were found to haveevidence of subclinical paranasal sinus infection.

*Senior Adviser and Head; +Classified Specialist, Dept of ENT, INHS Asvini. #Graded Specialist ENT and PMO, INS Dunagiri.

Jour. Marine Medical SocieM, Jan-Jun 1999, VoL I, No. I 23

These consisted of1. Muco-pus trailing from osteo meatal complex

(OMC)

2. Hyperemic mucosa in region of OMC

3. Polypoid mucosa in the region

4. Middle meatal polyposis

Subjects with anatomical variations in the regionbut signs of inflammation were excluded from thestudy. All the I I patients were put on long termantibiotics (Doxycycline 150-300 mg per day as itpenetrates to the paranasal sinuses in adequate con-centration) and other supportive therapy as appro-priate [5]. These included non steroidal non salicylicanti-inflammatory agents, steam inhalations aque-ous nasal sprays etc. Antihistaminics and steroids inspray form and orally were only sparingly used.Progress was monitored endoscopically. Patientswere followed up to three months and then allowedto resume diving. Seven of the I I patients so se-lected, had recurrent otalgia (otalgia on diving on atleast two occasions in the next five dives exceedins30 mts depth).

Seven symptomatic patients were operated byMesserklingers technique to eradicate the problem.Written informed consent was taken from all sub-jects.

RESULTS

The operated patients were followed up for aminimum of nine months and maximum of 15months. Diving was allowed after a minimum ofthree months. The minimum follow up afterresump-tion of diving was four months and all patientscompleted a minimum of five dives exceeding 30 mdepth. The results of surgery were evaluated bothsubjectively as well as objectively by nasal en-doscopy. Ofthe seven cases operated upon five werecompletely symptom free after three months of sur-gery and had no otalgia on resumption of diving. Ofthe two patients who were failures by Schitakinsclassification, one was found to have developedexcessive granulations and later synechiae in theregion of OMC, giving rise to recurrent anteriorethmoiditis and occasional larger sinus infection [6].This patient was re-operated and is now divinguneventfully for the last eight months. One patientdid not respond to surgery and was symptomatic ondiving and thus is currently not able to dive.

24

DISCUSSION r'

The role ofnasopharynx in eustachian tube dys-function has been recognised by many authors [7,8].Allergic tubotympanitis is an undisputed factor inETD, Chronic Otitis Media and Otitis Media withEffusion [9-l l]. Literature is however not so clearon the subject ofeustachian tube dysfunction secon-dary to non allergic subclinicaltubo tympanitis sec-ondary to asymptomatic sinusitis. The reason forthis is clear. These patients would not present underordinary circumstances to the ENT surgeon. How-ever, due to the extreme conditions faced by Navaldivers even a minimal ETD would cause problemsin hyperbaric conditions. Each l0 m dive belowMSL raises the ambient pressure by one atmosphere.Thus divers have to have excellent esustachian tubef0nction. This study was undertaken to explore thepossibility of subclinical sinus infection causingminimal eustachian tube dysfunction which wouldbe undetected in routine ENT practice.

Of the 50 patients who presented with symptomssuggestive of ETD, 45 were found to have a minimalderangement of eustachian tube function usingmodified Holmquist criteria. The criteria weremodified as the variation in pressure faced by thedivers is clearly not the same as general population.The criteria are of course arbitrary, but in absenceof any accepted criteria for eustachian function indivers we had no recourse but to use these. A totalof I I patients (22oh)were found to have identifiablesinus disease as a cause ofrecurrent otalgia. Seven(63.6%) required surgery. A high percentage(85.7%) responded to surgery and are now divingregularly. Though the percentage ofthose who re-quired surgery is small (14%) it is neverthelesssignificant. These divers are still under follow-upand will continue to be so for two yrs. for long termeffects to be seen.

CONCLUSION

This study shows the importance of sinusitis(which is otherwise asyptomatic) in causing recur-rent eustachian tube dysfunction in divers. lt alsounderscores the importance of nasal endoscopy asroutine examination of these patients in particularand in ENT in general. The long term effects ofthissurgery on recurrent ETD is not known and will becommented upon on completion of the follow upperiod. Clearly, the difficult conditions faced by

Jour. Marine Medical Society, Jan-Jun 1999, Vol. I, No. I

?ivers warrant a separate and more exacting set ofcriteria for eustachian tube function. Until that isstandardised there is no alternative to using arbitarycriteria for the same.

REFERENCES

l. Benson AJ. AVM King PF. Pathophysiology ofthe Ears andNasal Sinuses in Flying and Diving. In Scott Brown's Dis-eases ofEarNose and Throat Vth Ed. Butterworth Publish-ers .1987; l :194-95.

2. Benson AJ. AVM King PF. Pdhophysiolory ofthe Ears andNasal Sinuses in Flying and Diving in Soott Brown's Dis-eases ofEar Nose and Throat Vth cd. ButErwortlr Publish-e r s . l 9 E 7 ; l : 1 8 6 .

3. Ransome J. ASOM and Acute Mastoiditis. In Scott Brown'sDiseases of Ear Nose and Throat Vth ed. Butterworft Pub-lishen. 1987; III :204.

4. Holmquist J. Eustachian Tube Evaluation. In proceedings ofShambaugh Fiftr Workhop on Middle Ear Miorosurgeryand Fluctuant Hearing loss. Hunbville, AL, Strode Publish-


ers. 1977; 135-38.

5. Wigand ME. In Endoscopic Surgery of paranasal sinuses andAnterior skull Base. Thiemc Medical Publishen. | 990.

6. Schiatkin B, et a/. Endoscopic Sinus Surgery. 4 year followup on the first 100 patients. Laryngoscope 1993; 103 :nl7-20.

7. Bellucci RI. Selection of cases and classification of Tym-panoplasty. In Otolaryngological Clinics of North America.1989;22:914.

8. Scott JH. The cartilage of the Nasal Septum. B Dental J1953;95 :37-43.

9. Shambaugh GE Jr, Glasscock ME. Diagnosis of Ear Disease.In surgery of the ear,4th ed, WB Saunders Publishers. 1990:r293-9s.

10. Bluestone CD. Diseases and Disorders of the EustachianTube Middle Ear. Otolaryngology Paparella. 3rd ed. 1990;1293-95.

' I I . Paparella MM , et al. Otitis Mcdia with Effusion. In Otolar-

yngolory. Paparellq. 3rd ed. 1990; 1324-1325.

25

PERSONALITY PROFILE OFTRAINEE NURSING OFFICERS

M SOFIA*. N RAMACHANDRAN*

ABSTRACT

An exploratory study was undertaken to have an idea ofthe personality structure ofTrainee nursing officers.Thirty-two young, healthy MNS trainee officers from a training establishment were administered StandardProgressive Matrices and a comprehensive and objectively scorable personality test (16 PF). Both the tests weregiven in tandem as these were expected to provide information on both cognitive and noncognitive aspects ofpersonality. Results revealed that the mean score of progressive matrices was low for a selected group, On l6 PFboth the primary and second order factors were assessed. Among the primary factors, low score on emotionalstability was seen at Ieast in case ofone fourth ofthe subjects taken for the study. This is a significant linding inthe sense that low score in this key factor is likely to pose problems for the successful adaptability to, andperformance in nursing profession especially in times ofstress and strains. Apart from the foregoing, the resultsgenerated a non-homogenous mixed trend. These results might be of some use for any selection procedure adbptedfor the selection of officer trainees of MNS in future.

INTRODUCTION

election ofa trainee nursing officer is an ardu-ous task on many counts. The basic difficultyis the absence of any identifiable, assessable

and quantifiable criterion measures. It is true thatcertain universally accepted ideals are often pro-pounded as the requirement of a nursing officer.How farthese have been assessed at the time oftheirselection is a moot point. Personality variables cer-tainly play a role in moulding a young girl into aprofessional nurse although one is not sure of itsextent of involvement. Further, the cognitive aspectsof personality also might play a definitive role asthese officers have to understand and comprehendthe intricacies of a given milieu which is one ofsuffering, hope or lack of it.

Discussions with the authorities of a trainingestablishment revealed that the following factorswere of importance for successfully carrying out theprofession ofa nursing officer. Care for fellow hu-mans and a readiness to help them in distress couldbe termed as an 'aptitude' for nursing and the aimof every nursing training course was to mould thenursing officers into such professionals who wouldexhibit the above 'aptitude' in adequate measure. Asecond important quality that would likely be going

with success in nursing profession was stress toler-ance or a readiness to bear personal privation. Thisis quite important especially in the context where theofficer has to take the responsibilities once she iscommissioned. When they start taking responsibili-ties the social and environmental factors also wouldcome into play. Not only the physical and socialenvironment, the young nursing officer also has tocontend with the control and modulation of her innerenvironment as well, as they would still be in an agegroup which often confuses between imaginationand reality. Also of importance in this context areinsight and the ability to communicate well. Thenegative points would be shyness, aloofness, andintroversion in general. This point regarding intro-version might be contentious in the sense that, evenin professions that value extroversion, high introver-sion was not found to be an impediment.

In addition, experienced nursing officers andmedical practitioners generally list a number ofqualities of characteristics that typically go withsuccess in nursing profession. It is universally ac-cepted that nursing is a high stress profession andMilitary Nursing is all the more so as these officershave to withstand the acute wartime stresses with allthe attendant coping problems. A key to the success

* Naval Psychological Research Unit, (Defence lnstitute ofPsychological Research), Naval Base. Kochi - 682 004.

Jour. Marine Medical Society, Jan-Jun 1999, I'ol. l, No. I26

-,like any other profession is the interaction of thepersonality of the individual officer with her socialand physical environment. However the authorshave not come across any recent studies that throwlight on the personality configuration or profile of atrainee nursing officer. 'Burn out' has been an oc-cupational hazard of nurses. In fact Matarazzo f4fhas identified it as a major occupational hazard ofall health workers. Burn out is characterised bypsychological strain resulting from occupationalstress. The symptoms of this strain could be changeof behaviour toward clients, change in the qualityand involvement in work and depression. It is asso-ciated with an occupational exhaustion with work,lack of personal accomplishment, the role ambigu-ity. This personality in a different context, while notdirectly touching upon 'burn out', is likely to throwsome light on the adjustment of trainee nursingofficers.

Recently at onb of the Military Nursing trainingestablishments, one of the first yearNursing OfficerTrainees was withdrawn citing later what tumed outto be adjustment problems as the cause. This hasbeen the immediate prompting factor to have a lookinto the personality paftern of Trainee Nursing Of-ficers. The absence of an objectively determined setof criterion variables in respect of Military NursingOfficer was acutely felt. Lack of such a compendiumof criterion values gives a tinge of arbitrariness toany personality study in this sphere and this study isnot an exception.

AIM AND SCOPE

The study broadly aimed to have an objective andcomprehensive understanding of the personalityprofile of a Trainee Nursing Officer. The findingsmay be of use as an input at the time of selection ofcandidates in future. However it may be borne inmind that this is only a pilot study with a smallsample size.

MATERIALS AND METHODS

Following assessing instruments were used:-(a) Sixteen Personality Factor Text [-3]. It is an

objectively scorable test that gives a fairly com-plete coverage of personality in a brief time.Form D of the test was used as it was shorterthan Form A or B. Additionally it had itemsrelated to Motivation Distortion (MD). Its lan-


guage dernand on the subject was less com-pared to Forms A and B.

(b) Raven's standard Progressive Matrices (DPRadaptation): The test had five sets A-E. Thedifficulty level increased from set to set as theconceptual complexity of each set of problemsincreased progressively. The test was givenwith a time limit of 20 minutes as the aim wasto assess the cognitive efficiency rather thecognitive sufficiency. The test assesses clarityof thinking under stress. Higher the score betterthe performance.

Thirty two young and healthy volunteer nursingtrainee officers who were at various stages of train-ing progress were administered the tests. l6 PF wasadministered without any time limit. Subjects were.familiarised with the test by examples. The impera-tiveness of answering frankly was emphasised be-fore the administration of the test. Standard scoringprocedure was followed [2,3]. ln cases where highmotivation, distortion scores were seen, appropriateconection was applied to the raw scores.

RESULTS

The mean score of progressive matrices wasfound to be 39.

Results of the l6 PF test are given in Table I and2. ln 16 PF the polarity of factors had been deter-mined on the basis of a graded scale continuum. Fordetermining high and low scores, normal significantlevel ofstandard l0 scores had been taken i.e. threeand below for low scores and eight and above forhigh scores. An averaging ofthe scores ofall sub-jects on all factors would have rendered the resultssomewhat meaningless as for most of the signifi-cantly high scores almost equal number of lowscores also were seen. In a factor-wise averaging.high scores and low scores were calculated sepa-rately. Table I shows these average scores of highand low scores and the number of individuals whohave scored in the respective category i.e. high, lowand mid level. Table l depicts the average high andlow score for all the l6 factors i.e. from A-Q4. Here,only those factors that have some high score and lowscore frequency have been taken into consideration.Thus, for high score, factors A, E, N Q2 and Q4become noticeable. For low scores. factors B. C. I.M, and factor Q2 have shown some increased fie-quency ofoccurrence.

2 7

* B

C

E

r

G

H

I

L

M

N

oQrQ2Q3Q4

9.0

8 .08 .38 .09.09.0

8 0

:

8.28.09.2

o

2t 22z

t)

6

t 2

2.62.42.43.03.03.02.02.63.02.52.03.0z - )

1 . 8J .U

t . 6

t)

t 8l 022^8t 2A

22^

o

t 2l 026

5 .55.01 . 3

4.85 .46 . 16 .04.6o . J

A '

5.25 .54.94 .75 .45 .8

20t 420l 82822l 82022l 0l 62620t 626l 8

TABLE I

Mean values of significant (high and low) and non signifi-cant scores for all primary factors (16 PF)

Factors Significant scores Non significant scoresHieh N Low N Scores N

a time limit. For general clinical purposes, this te)^s-ris given without any timing. For such purpose, theaim is to assess the mental capacity. However, sinceno clinicality was imputed here and mental effi-ciency was preferred to capacity, a time limit wasgiven so as to get information on efficiency. Com-paratively the group taken for the study was a lowefficiency one as suggested by the scores. Whetherthis low efficiency is adequate enough for successfulperformance of nursing duties by members of MNSis a point that needs to be debated.

Table I shows that six trainees ever warrn-hearted, outgoing and like the company of people.Not only that they wished to be in company, but theirvitality level seems to be at optimum in groups. l2of the subjects taken for the study were of dominantqpe. They linked to assert in a group. This aspect inone way is positive and, in another, negative. Attimes their independent nature might get the betterof themselves and they were likely to become arbi-trarily independent and authoritarian. Again, amongthe high scorers, l2 subjects showed themselves tobe sophisticated and polished, having the subtlenuances of how to get along with people, and quiteshrewd. They detested uncouthness. Six subjectswere quite self reliant having confidence in them-selves whereas eight of them i.e. one fourth of totalnumber of subjects, nursed a type of free-floatinganxiety. They had their own tensions. A certainamount of tension is a positive trait as without suchtensions possibly one might not be able to achieveanything further. There was no evidence that thetension level of these eight subjects was anywaydebilitating. However, further proof of this was tobe ascertained from the second order factors.

l8 subjects were low in abstract thinking ability.This is somewhat surprising as the items for thisparticular factor were apparently well within thecapability of this selected group. Here, low factor Bmay be taken with a little bit of caution; a few itemspossibly might not reflect the cognitive efficiency ofthe individual although it has been the experience ofthe researchers that a very low score in this particularfactor was indicative of some functional deteriora-tion/deficiency. To get a complete picture of thecognitive efficiency, only standard progressive ma-trices was given to the subjects, for cognitive factorconstitutes an important element of the total person-

Jour. Marine Medical Society, Jan-Jun 1999, Vol. l, No. l

6A

8

*Mean of Ravens Progressive Matrices : 39

Table2 shows generalised averaged results (as inTable l) of all subjects in terms of low and highscores obtained in the second order factors. Thefactors taken were low anxiety vs high anxiety,introversion vs extraversion, emotionality vs alertpoise and subduedness vs independence.

TABLE 2Mean values of significant (high and low) and non signifi-cant scores for all second order frctors

Significant scores Non significant scoresHigh N Low N Scores N

Anxiety 9.2

Extra- 9.0version

Aler t 8.5poise

Indepen -

dence

MD 8 .0

6)

L

L

1 . 51 . 6

z .o

2.6

5 .65 . 7

6 .1

5 .2

4 .8

2428

t 0

24

DISCUSSION

The mean was found to be 39 from a possiblemaximum of 60. lt was expected that a selectedgroup like Military Nursing Service (NINS) traineeswould show higher scores. The test was given with

28

ality structure of the individual. Here again, as wasmenioned earlier they scored comparatively low.Ten i.e. one third of the total subjects were low inemotional stability. This is a finding that is to betaken seriously as this particular factor in a way isthe key one for anyone's stress tolerance and egostrength. For nursing profession, emotional labilityis contra-indicative. Further, since it concerns withego strength and also frustration tolerance, theirability to withstand stresses and strains becomessuspect. A military nurse's profession is replete withvarious kinds ofstresses. In the context ofsituationsof was it becomes all the more so. Perhaps a betterscreening device at the initial stage would haveprecluded such elgments that were possibly low inthis particular factor. A sizable number ofsubjectsi.e. 22 were of conservative type. One quality valuedfor all jobs is self confidence and the ability totranslate this confidence into selfreliant nature. Tensubjects were low in this factor. As time goes on theymay pick up the modality and methodology ofequipping themselves to be self reliant. A majorityi.e.22 of the subjects were quite practical, not givento any imaginative creativity.

From Table 2 it is evident that most of the sub-jects were neither extroverts nor introverts. From apriori hypothesis it was seen that the nurses prefer-rably should be extroverted. However, the role ofthis particular factor to nursing profession is stillunclear. While discussing Q4 it was said that secondorder factor I would give some corroborative mean-ing to it. Although six subjects (out of eight Q4 high)showed high anxiety, thereby indicating some ad-justment problems. Again some ofthe subjects werefound to be quite unassertive and 'colourless'. In the

primary factor structure some were found quite as-sertive. These personnel did not show any low scorein this sphere. Eight of the subjects were quickdecision makers, and almost impulsive at that.

Since the study was an exploratory one, valida-tional discussions with the trainins authorities werenot carried out.

CONCLUSIONS

Findings of the study suggest that at least onefourth of the subjects were low in emotional stabil-ity. This aspect is likely to interfere with their suc-cessful adaptability to the profession, although highmotivation for a job is likely to prompt them tosucceed in training.' Overall, the group was somewhat low in cogni-tive efficiency. Whether it was sufficient for suc-cessful performance in Nursing profession is a pointto be pondered.

RECOMMENDATION

Both the above cited factors i.e. cognitive effi-ciency, and emotional stability may be paid moreattention at the time of selection.

REFERENCES

l. Cattell RB. Personality, a systematic and factual study.McGrav, Hill 1950.

2. Cattell RB, Herbert W Eber. l6 Personality questionnaire,

Manual for forms, A,B,C, and D, IPAT lllinois. 1962.

3. Cattell RB. Handbook for the 16 PF questionnaire tabularsupplement No. 2IPAT. 1972.

4. Matarazzn JD. (1980) Behavioural Health and BehavioralMedicine. Frontiers for a new Health psychology. Cited in

Zimbardo PG. Psychology of life. Health, Stresses, Coping.

Scoft Fresman and Company, London. | 988.

Jour. Marine Medical Sociery, Jan-Jun 1999, Vol. I, No. l 29

PROFICIENCY IN DIVING :ROLE OF PERSONALITY FACTORS

P JAYACHANDER*. S SUBRAMONY*. KJ UTHAMAN*

ABSTRACT

In order to have a better understanding ofthe personality make up ofthe prospective divers ofthe Indian Navy,a personality study was carried out at the diving school, Naval Base Cochin. The sample consisted of 48 divingtrainees. NPRU's 6 Personality Factor Test and Eysenck's Personality Inventory were administered to the sample.The results revealed that sociability, emotional stability, objectivity and genera! activity level of the trainees (asmeasured by 6 Personality Factor Test) had significant positive correlation with the Instructor's/supervisorsperformance rating which was the criterion for the study. Neuroticism factor as measured by Eysenck'sPersonality Inventory had a significant negative correlation and Extraversion/Introversion factor showed signifi-cant positive correlation with performance rating. In short, it was found that a successfully trained diver is likelyto be somewhat extraverted and sociable, is emotionally stable and free from nuerotic tendencies. He is also foundto be energetic, enthusiastic, objective and not hypersensitive. The paper discusses the result in detail. Suitablerecommendations are also made.

KEY WORDS : Personalitv factors. Diver

INTRODUCTION

A diver can be defined as a person trained to

A p".forrn underwater tasks. The naval diversl- lcan divided into two types: viz. ship's diverand clearance diver. The ships diver is the basiccourse after which they graduate into clearancediver IIl, II and I.

The ship's diver is required to descend to depthsupto 35 metres and carry out tasks ofrepair, salvageand rescue beneath the surface. He has to carry outinspection in near darkness, due to mud and waterconditions. He is also expected to finish the giventasks within the allotted time which depends on thedepth he has descended. Usually he is alone andrelies on his own efficiency and judgement. How-ever, he is connected to the surface by a breast ropeand air pipe and sometimes a telephone. While doingthejob he is exposed to the pressure ofwater aroundhim which hampers his movements and workingefficiency.

The main tasks of the ship's diver are: inspectionof the ship's fittings, bulkhead plates and damagecontrol; freeing offouled cables, anchors etc., recov-ery ofvaluables lost overboard. Clearance divers do

not descend to greater depths but may be required toremain under water for longer time. They use selfcontained equipment and are therefore more mobileand independent. Their main utility in wartime ismine clearance and bomb disposal and they areresponsible for searching the ship's bottom for lim-pet mines etc. They clear underwater obstacles be-fore amphibious landing and do underwater attackon enemy ships and installations. They have to begood swimmers and capable of swift and silentmovements underwater. They are exposed to allunderwater hazards and underwater explosions.

The nature ofjob performed by the diver, as wehave seen above, is very complicated vis-a-vis hisnormal duties as a sailor, and involving a lot ofrisks.The diver has not only to be intelligent, but alsorequires to possess certain personality charac-teristics in order to successfully accomplish histasks.

Available literature on the studies conducted ondivers was perused in detail. A study conducted byNPRU emphasised the job description, hazards ofdiving and physical and psychological requirementsof divers. Recommendations were made to improvethe service conditions, training methods and food

*Scientists (Psychologists) in Naval Psychologidal Research Unit, Defence Research and Development Organisation, Naval Base, Kochi- 682 004.


t 1

I activitiesifbacticidestudy will

ings ofthis

thuringiensis6 1 6 1 . ? 5 - q

unlight on the

thuringiensiss 1996:'28.2'.

ltion of Bacil-

;quito control.

JD. Fieldtrialr the control of

Vol. l, No. I

t)

requirements [1].

In another study by NPRU a set of five testsmeasuring verbal ability, non-verbal ability, me-chanical comprehension, numerical reasoning andtools knowledge were administered to a sample ofdivers and there was no significant correlation withthe course results. However, this study evolved apredictor test battery of nine subtests which were tobe administered with the help of an apparatus.

The study however, identified a few psychologi-cal variables which are pre-requisites ofa successfuldiver. They are: Achievement motivation, panic af-finity, practical ability, speed of perception, alert-ness in decision, speed and sffess endurance.

In some ofthe foreign studies as well, importanceofpersonality variables has been stressed. In a studyat the 'Underwater research Centre' at Boston(Beirsner and Lorocco, 1983) it was found thatsensation and thrill seeking, high stake gamblingnature and an over enveloping carefree nature wouldgo with success in a diver's training as also in theirtrade [2].

AIM

The main aim of the study was to identiff thepersonality factors which are necessary for a diverto successfully accomplish his tasks.

METHOD

l. Subjects :The subjects for the study were taken from the

sailors who were undergoing different divingcourses in the Diving School, INS Venduruthy, Co-chin. Owing to the long duration of the courses onlya limited number (n:49) were available for thestudy.

2. Tests and Variables

(i) The 6 PF test : Developed by NPRU, it is anadaptation of the Guilford Zimmerman Tem-perament Survey and measures the followingsix personality factors. It has 120 items [3].

a. General Activity general drive for activity,energy, enthuslasm.

b. Restraint

c. Sociability

being self controlled, careful, nothappy-go-lucky, thinkingbefore acting

mixing with people, beingin limelight, organising clubs.willing to do extra work,easily conversing.

Jour. Marine Medical Societv, Jan-Jun 1999, Vol. l, No. I

Emotional Stability

Objectivity

Friendliness

composure. calmness, not beingnervous, impulsive or depressed

unbiascd, feelings not easilyhurt, not disturbed by criticism

agreeableness, not hostile,enjoying fiiendship, notsusprcrous

(ii) The Eysenck's Personality Inventory : This testis developed by Eysenck (1953). lt measuresthe following factors and has 48 items [4].

a. Neuroticism - hypersensitivity, irritability, feel-ings easily huft, nervousness, anxiety, inferior-ity feelings, guilty feelings, sleeplessness andlack ofselfconfidence

b. Extraversion/lntroversion - being sociable, ex-cited, enjoying social gatherings, easily mixingwith people as against being seclusive, prefer-ring to work alone, not liking company.

As the criterion measure, instructor officers andsailors who conducted the training were asked torate the divers on seven factors viz. intelligence,stress tolerance, self-confidence, willingness forhardwork, social adjustment, sense of responsibil-ity, readiness to bear privation and overall rating.The rating was done on a five point scale rangingfrom HIGH to LOW. Detailed instructions regard-ing the definitions and meaning of each trait, theprobable behavioural indicants ofthese traits and themethod of rating was given to the instructors/super-visors.

RESULTS AND DISCUSSION

The results are given in Tables l-3.

TABLE IMean and standard deviations ofthe scores obtained by di-vers in the different scales of6PF

Statistics S E G A Res

M

SD

7.8 10.24 .48 I .5 l

6 .4 9 .8 l t .42 . 1 4 l . l 9 | 7 4

I t . 42.24

n = 4 9S = Sociability; F = Friendliness; E = Emotional Stability; Ob= Objectivity; GA = General Activit-v; Res: Restraint

From Table I it is seen that the divers as a groupscore comparatively high in restraint and generalactivity, and comparatively low in friendliness, withthe other scores fall ing in the middle range. This is

3 l

Cone 0.500 0.657lat ion r ** *r

SD r 0.108 0.079

0.431 -0.263 0.631 0.26'.1* * i i

0.1 l7 0 .135 0 .087 0 .134

TABLE 2Correlation coelficieilts of various scales in 6PF with overallperformance rating

be a little unrelated to a diver's work as he oftenworks alone. It is possible that because of their outgoing nature and initiative and willing ness to put inextra work, divers who are high in this trait mighthave been perceived as more efficient by the super-visors.

It is only natural that divers who are high inemotional stability are better divers. Because oftheir composure, lack ofnervousness and selfcon-trol they become more successful in their job. Andin a job like diving, which is highly stressful, emo-tional stability is very relevant. This is the case withgeneral activity also. The diver who is more ener-getic, dynamic and enthusiastic is likely to be moresuccessful.

Objectivity is the opposite of hypersensitivity. Ahypersensitive person has his feelings easily hurt, isdisturbed badly by criticism and worries over hu-miliating experiences. Such negative qualities,needless to say, will be a handicap to a diver, whois working in a stressful environment.

Refening to Table 3, we find that, the findingsmore or less corroborate the findings explained in'the previous paragraphs. The scores on the EPIsuggest that there is a strong negative correlationbetween neuroticism and supervisor rating. A mal-adjusted person is a misfit here. His nervous nature,his inferiority feelings, anxiety, initability and emo-tional immaturity will have a negative impact on hisjob performance, and the supervisors will naturallyrate such a person very low. We have also found inthe previous paragraphs that emotional stability hashigh positive correlation with supervisor rating.These two findings are supportive ofeach other.

It is also found that extraversion is positivelycorrelated with supervisor rating. A diver, who isoutgoing, sociable, who takes social initiative andnot reticent has been rated high by the supervisors.It is also in agreement with the previous finding thatsociable divers are rated high by the supervisors.Similar results were also obtained in the BostonStudy [2].

In short, it can be stated that a successfullytrained diver is likely to be somewhat extravertedand sociable, is emotionally stable and free fromireurotic tendencies, is energetic, enthusiastic objec-tive and not hypersensitive.

Jour. Marine Medical Society, Jan-Jun 1999, Vol. 1, No. I

SUIT{MARY

Forty nine rpersonality tersonality Invencorrelated witlby instructon/there was a pctween sociabiand general actperformanceNeuroticism hwith the perforpositive and sance rating.

Jour. Marine Mea

**significant at .01 level; * significant at .05 levelS = Sociability; F = Friendliness; E = Emotional Stability; Ob =

Objectivity; GA = General Activity; Res: Restraint

TABLE 3Correlation coe{Iicient of neuroticism rnd extrrversion withoverall performance rating

Neuroticism Extraversion

Overall performance rating -0.580** 0.314*

n--49; significance level as in Table 2.

rather in the expected direction, as divers can bereasonably expected to be self controlled, seriousand not carefree and happy-go-lucky, due to thepeculiar nature of their job. Their general activitylevel, energy and enthusiasm also is likely to behigh. At the same time a diver, who works ratheralone and not in a group, mostly finds himself insituations where he has to do his own planning andtake his own decisons and to do the work in his ownway. Therefore, though not hostile or rebellious, hemay be less agreeable and group dependent.

From Table 2, we find that scores on sociability,emotional stability, general activity and objectivityhave high positive correlation with supervisor/in-structor rating. Here, one aspect may look a littleintriguing. While it was found that divers as a groupare less in friendliness, sociability is highly cone-lated with supervisor rating. Also, friendliness haseven a negative, though not significant correlationwith supervisor rating. Here we have to understandthat friendliness is not synonymous with sociability.Friendliness, here is conceived as agreeableness ina group, not being ofhostile and suspicious and notbeing contemptuous of others. Opposite of friendli-ness is hostility [5]. On the otherhand sociabilityconnotes mainly social initiative and is charac-terised by behaviours like making friends, organis-ing clubs, easily eonversing with others and doingextra work when necessary. The trait may seem to

32

I

,-"fr outrut innightryer-

Sdi{MARY

Forty nine diving trainees were administered twopersonality tests viz. 6PF test, and Eysenck's Per-sonality Inventory. The personality test scores werecorrelated with a five point performance rating doneby instructors/supervisors. The results revealed thatthere was a positive and significant correlation be-tween sociability, emotional stability, objectivityand general activity, as measured by the 6PF test andperformance rating by supervisors/instructors.Neuroticism had a significant negative correlationwith the performance rating and extraversion had apositive and significant correlation with perform-ance rating.


RECOMMENDATION

The facton that were found to be significantlyrelated with haining success as indicated by theperformance rating of the supervisors may be given

adequate weightage at the time of screening of vol-

unteers for diving branch.

REFERENCES

L Note PRW. Diving in Indian Navy. PRW Note No: 182. NewDelhi:Psychological Research Wing. 1958.

2. Biersner RI, Larocco JM. Personality Characteristics of USNavy Divers. J Oc capational Psycholog 1983: 56 : 329-34 .

3. Guilford JP. Zimmerman WS. The Guilford ZimmermanTemperament Survey : Manual for Instructions and Interpre-tations Califomia: Beverly Hills. Sheridan Supply Co. 1949.

4. Eysenck HJ. The Structure of Personality. New York:Wiley.1953.

5. Cuilford JP. Personality. New York: Mc Craw Hill. 1959.

$ inse ofcon-Andemo-r withener-more

ity. ALutt, iser hu-ilities,:, who

rdingsned iilB EPI:lation{, mal-nature,demo-ton hisrturallyrund inlity hasrating.lher.

sitivelywho isive andrvisors.ing thatrvisors.Boston

essfullyaverted:e fromc objec-

I , N o . 1

I

I. . I

33

MEDICAL MANAGEMENT OF ECTOPIC PREGNANCY -INHS ASVINI E)GERIENCE

Surg Cdr SUSHIL KUMAR*, Surg Capt RT AWASTHI+,Surg Capt P TARNEJA#, Surg Cdr S CHATTERJEE**

ABSTRACT

Five cases of unruptured ectopic pregnancies managed by injection methotrexate are reported in the ensuingarticle. In all these cases a single injection of methotrexate was used as primary mode of treatment. Four patientsresponded favourably. Only one patient developed the complication ofruptured ectopic pregnancy after initialtreatm ent with m ethotrexate.

KEY WORDS : Ectopic Pregnancy, Medical Management.

INTRODUCTION Criteria for patients selection-1. Haemodynamically stable.

2. Ultrasonographic (USG) exclusion of intrauter-ine pregnancy.

3. Ectopic pregnancy 4 cm or less in its greatestdiameter.

4. No evidence of rupture of ectopic pregnancy.

5. HCG titre less than 10,000 iu/|.

Treatment protocol:Day-l Baseline Hb, TLC, DLC, platelet count, serum

creatinine, liver function test, injectionmethotrexate 50 mg/M2 IM.

Day-4 hCG titre.Day-7 hCG titre, complete blood count, platelet count,

serum creatinine, liver function test.Weekly hCG titre till it became negative.

Case I

25 years old lady reported with history of prolonged period

of l2 days duration. She was manied for one year and the couplewas not using any contraceptive. There was no history ofamenor-rhoea or pain abdomen. On per vaginal examination uterus wasofnormal size and there was mild tendemess in right fomix. Urinebeta heG was positive (less than 2500 ir/l). TVS confirmed a

unruptured right tubal pregnancy with a diameter of 4 cm. Patientwas treated with methotrexate as per protocol mentioned earlier.Beta hCG levels started decreasing one week after commence-ment of featment and became negative after three weeks. Fol-lowup after two months revealed a small persistent mass, but thepatient was otherwise asymptomatic.

Case 2

32 yeus old lady reported with complaints of six weeks

IFig. I

odern management of ectopic pregnancyis one of the medicines greatest successstories. Before the first successful opera-

tive treatment of tubal pregnancy reported byLawson Tait in 1884, patients suffering from ectopicpregnancies were managed expectantly by observa-tion only, carrying 70%o mortality [l]. Thereaftersurgery became the main stay of treatment. How-ever in past few years the management has changeddramatically. With the availability of high resolu-tion trans vaginal sonography (TVS) and highlysensitive human chorionic gonadotrophin (hCG) as-say, it has now become possible to detect ectopicpregnancies at avery early stage. The diagnosis ofunruptured ectopic pregnancy offers a number oftherapeutic options such as conservative surgery bylaparoscopy or medical management.

Medical treatment of ectopic pregnancies is ap-pealing for several reasons: less tubal damage, lesscost and hopefully enhanced potential for futurefertility. Methotrexate, a folic acid antagonist hasbeen used for quite some time against gestationaltrophoblastic disease with remarkable success. Itwas first used for ectopic pregnancy by Tanaka inte82 l2l.

Five cases ofectopic pregnancies managed con-servatively by single dose methotrexate as primarytreabnent are presented here.

deve

ossel

REFI

t . cn

Jour. ,

*Classified specialist Obstetrics and Gynaecology; +Senior Adviser Obstetrics and Gynaecology INHS Asvini; #Senior AdvisetObstetrics and Gynaecology INHS Sanjivini; **Classified specialist Obstetrics and Gynaecology, INHS Kalyani.

Jour. Marine Medical Societv, Jan-Jun 1999, Vol. I, No. I34

'ahrenorrhoea, Iower abdominal pain and spotting per vagina of

five days duration. Patient was manied for twelve years with nolive issue. Her only previous pregnancy was tubal pregnancywhere right salpingectomy was done. On abdominal examinationthere was tenderness over left iliac fossa. Per vaginal examinationrevealed marked tendemess on cervical movement. On basis ofhistory and examination, clinical diagnosis ofectopic pregnancy

was made. Urine beta hCG was 4000 iu/|. TVS confirmed acomplex lefl adenexal mass of about 3 cm diameter. There wasno evidence of rupture. Patient was treated with single dosemethotrexate as per standard protocol. She became asymptomaticafter three days, beta hCG started declining after four days andbecame negative aftcr four weeks. This patient became pregnantagain ten months after the treatment and delivered normally

Case 3

29 years old lady ieported with history of40 days amenor-rhoea and pain lower abdomen. She was paratwo and had alreadyundergone tubal ligation. On abdominal examination there wastenderness over right iliac fossa. Pelvic examination revealedmarked pain on cervical movement. Beta hCG was positive inl :10 di lut ion and negat ive in l :100 di lut ion (sensi t iv i ty 25-50in/l). TVS showed right adenexal mass about 2.5 cm in diametersuggestive ofectopic pregnancy. She was treated with single dosemethotrexate. She became asymptomatic after one week, betahCC became negative after three weeks and adenexal massdisappeared after three months.

Case 4

22 years old patient, para one, reported with complaint offiveweeks amenorrhoea and lower abdominal pain. Abdominal ex-amination was inconclusive. Per vaginal examination revealedtendemess in the left fomix. Urine pregnancy test was positive

up to l:10 dilution only. TVS failed to demonstrate intrauterinepregnancy or any adenexal mass. Diagnostic laparoscopy re-vealed a tubal pregnancy at comual end of left tube.

Patient was treated conservatively with methotrexate. How-ever she developed haemoperitoneum due to ruplured ectopicpregnancy. Laparotomy was done and proximal two cm oftubecontaining ectopic pregnancy was removed.

Case 5

27 yeus old para one reported with history of six weeksamenorrhoea, bleedin! and pain abdomen. Abdominal examina-tion was normal. On vaginal examination cervical movementswere found to be tender. Urinary beta hCG was positive (3500

ir.r/l). TVS revealed a right ectopic pregnancy of four cm diameter.She was treated with single dose methotrexate following whichshe became asymptomatic after three days and beta hCG becamenegative after four weeks but adenexal mass persisted for threemonths and then started reducing and completely subsided aftersix months.

DISCUSSION

In this article five cases oftubal ectopic pregnan-cies are presented. In all these cases single dosemethotrexate was used as primary mode of treat-

Jour. Marine Medical Sociev, Jan-Jun 1999, Vol. 1, No. I

ment instead of conventional surgery. In some casesquantitative assay ofurinary hCG could not be done.In these patients dilution method was used as a roughguide. Clinical presentation was different in eachcase. Diagnosis was based on highly sensitive hCGassay (detection limit 25-50 iu/l) and TVS.

Ultrasound or laparoscopic directed instillationof drugs such as potassium chloride, methotrexate,hypertonic saline in to the gestational sac ofectopicpregnancy have been described for quite some time.However use of sy$temic chemo-threpeutic agentsas primary mode of treatment for ectopic pregnancyhas been a fairly recent phenomenon. Followingearlier reports on use of methotrexate in unrupturedectopic pregnancy by Miyazakietal. (1983), Stovdl(1991) reported 100 cases of ectopic pregnanciestreated with single dose methotrexate [3,4]. Boththese studies concluded that methotrexate treatmentis safe, effective and helps in preservation ofrepro-ductive potential. Stoval reportedg}yo success raieif strict criteria were followed [a]. In our study offive cases, one patient had ruiltured ectopic folloli,-ing methotrexate, requiring laparotomy. All otherpatients responded to the treatment.

Possibility of rupture in medically treated casesofectopic pregnancies is variously reported between3-10% [5] .

Beta hCG titre usually starts declining after sevendays but fullresolution may take 3-6 weeks [6]. Inour study hCG titre became negative with-in fourweeks in all cases. The ultrasonic picture of massmay persist after hCG titre becomes negative. Thetime for resolution of mass is variable and it oftentakes several months to disappear [7]. In our studyectopic mass persisted for 2-6 months. Howeverpersistence of mass should not be taken as a failure.No systemic side effects ofmethotrexate were notedin any ofour cases.

CONCLUSION

Significant improvement in means of diagnosis,such as sensitive beta hCG assay and TVS haschanged the clinical picture of ectopic pregnancyfrom an emergency condition to relatively morebenign and milder condition. It is largely due to earlydiagnosis that many forms of treatment modalitieshave been evolved. Medical management with sin-gle dose methotrexate is by farthe simplest and most

35

effective.

REFERENCES

I . Tait RL. Five cases ofextra uterine pregnancy operated uponat the time of rupture. BMJ 1984; | :250.

2. Tanaka T, Hayashi H, Kutsuzawa T, Ichinoe K. Treatmentof interstitial ectopic pregnancy with methotrexate: report ofa successful case, Fertil Steril. 1982;37 : 851.

3. Miyajaki Y, Shinnay, Wake N. Studies on non surgicaltherapy oftubal pregnancy. Acta Obstet Gynecol Jpn 1983;35 :489.

4. Stoval TG, Ling FW, Cray LA. Single dose methotrexate for

treatrnent ofectopic pregnancy. Obs Gyn l99l: l'17 :754.

5. SperoffL, Robert GH, Nathan G. Ectopic Pregnancy. In LSperoff, 5th edition. Clinical Gynaecological Endocrinologyand lnfertility, Williams and Wilkins. 1994;947-64.

6. Brown DL, Felkar RE, Stoval TG, Emerson DS, Ling YW.Serial endovaginal sonography of ectopic pregnanciestreated with methotrexate. Obs Gyn l99l',77 :406.

7. Stoval TG, Ling FW, Gray LA, Carson SA, Buster JE.Methotrexate treatment of unruptured ectopic pregnancy : areport of 100 cases. Obs Gyn 1991; 77 : 491.

Jour. Marine Medical SocieM, Jan-Jun 1999, Vol. I, No. I36

DROWNING ACCIDENTS IN CHILDREN

Surg Lt Cdr S DAS*, Surg Lt Cdr BG PAWAR+,Surg Lt Cdr SS Mr{TI{AJ**, Surg Capt KS BAWA#,Surg Cdr G GUPTA++

INTRODUCTION

T\ rowning is the third most common cause of

I I accidental deaths with around 1,40,000 per--4-7 sons dying annually across the globe [1,2].At least half of these victims are children. The peakage ofsubmersion accidents being I to 4 years dueto indoor accidents in bath tubs. buckets etc. Theadventurous adolescents are also vulnerable due toaccidents at sea, river, swimming pools etc. Appro-priate management can minimise the morbidity insurvivors.. Majority of paediatric immersion acci-dents are preventable.

TERMINOLOGY

Various terms have been defined to distinguishdifferent submersion accidents and injuries. Theterm "drowning" means a submersion accident lead-ing to death during or within 24 hours of the acci-dent. "Near drowning" is submersion accident inwhich the victims survive for first 24 hours irrespec-tive of eventual outcome. In "typical" or "wet"drowning there is aspiration of fluid in air passageswhile in "atypical" or "dry" drowning there is verylittle or no aspiration of fluid. lUYo to 20%o of allsubmersion victims are cases of 'Dry Drowning'.Secondary drowning are the cases which die after24 hrs due to secondary effects of submersion vizAdult Respiratory Distress Syndrome, Pneumonia,.Pulmonary oedema etc. 'Immersion Syndrome' issudden death probably due to vagally mediated car-diac arrest after contact with cold water. SubmersionInjury is any subr4ersion effect resulting in hospital-isation or death e.g. drowning, near drowning, cra-niospinal injuries etc. "Save" is the individual whowas perceived to be a potential victim of submersionand subsequently rescued. For every case ofdrown-ing there are three to five cases ofne4r drowning andten cases of"Save".

PATHOPTTYSIOLOGY

The pathophysiology of submersion accident iscomplex. This involves interplay of various factorscausing multiple organ dysfunction and death. Thesignificant factors are (i) Hypoxia (ii) Acidosis (iii)Pulmonary oedema(iv) Alteration in blood volume(v) Dyselectrolaemia (vi) Haematological Dysfunc-tion and DIC (vii) Injuries to brain, spinal cord andother vital structures.

Pulmonary oedema is one ofthe common effectsof both fresh and sea water drowning. However themechanism is different (Figs. 1,2). Profound hy-poxia may occur with aspiration of as little as 2.2mVkg of water. Damage to central nervous systemeither due to hypoxia causing raised intracranialtension (ICT) leading to herniation of the brain stemor due to craniospinal injuries during submersionaccident results in 30 to 40% deaths and residualneurological deficit in l0oh of survivors. Brady-cardia, ventricular fibrillation and asystole are theeffects of hypoxia. Likewise other organs may alsosuffer with hypoxic insult.

HOW LONG CAN HYPOXIA BE TOLER-ATED

This depends on multiple factors, knowledge ofwhich is crucial for the resuscitator.(a) Age : A young child has better survival because

ofrapid surface and core cooling consequent tocontract with cold water and ingestion or aspi-ration of cold water respectively resulting indecreased cerebral metabolism. It has been sug-gested that man has a vestigeal diving reflex,which is more marked in children and is initi-ated by cold and fear. This reflex improvessurvival by selectively perfusing vital organslike brain and heart, while in grown ups, thebody temperature of less than 34oC adversely

*PostGraduateTrainee;+PostGraduateTrainee; **ClassifiedSpecialistinPaediatrics:#Sr.AdviserPaediatrics;++ClassifiedSpecialist

in Paediatrics and Neonatologist, Department of Paediatrics, INHS Asvini, Colaba, Mumbai - 400 005.

Jour. Marine Medical Societv, Jan-Jun 1999, Vol. I, No. I 3 7

Il r" yo cardial -]

I permeability dysfunction -

Ir_

Altered SurfactantIIt

AtelectesisV/Q Mismatch

Chemical irritation ofalveolar membrane

1 Peripheral airwayI Resistance

II

Region'al Hypoxiaand intra PulmonaryShunt V/Q Mismatch

Absorption intocirculation

III

l ,l Blood HaemolysisI volume

IlrI *Hyperkalemia

Ventricularfibrillation

Pulmonary edema* However the hyperkalaemic effect of haemolysis may get negated by kaliuretic effect ofcortisol secretion.

Fig. I : Pathophysiological change in lungs due to aspiration offresh water.

Hypertonic fluidinside alveoli

Cold water

IFace

IrrigeJinat nerve stimulation

ICNS (inedulla)StimulationHypertension

If CerebralI perfusion

JJonrJ,*ooo'In drawing of fluid plasma protein to alveoli

Pulmonary edema Loss of surfactant Hypovolemia(*lnhalation of more than 1l ml/kg of sea water, reduces bloodvolume to 56%)

Fig. 2 : Pathophysiological change in the lungs due to sea wateraspiration.

affects the outcome as it inhibits swimming

movements even in accomplished swimmersand further causes vagus mediated cardiac ar-rhythmias and coma. (Fig. 3).

b) Water temperature : Victims submerged in coldwater have better chances ofsurvival even afterprolonged submersion (Table l).

c) Previous health and drug administration

Fig.3: Divingreflex

TABLE I

Correlation of water tcmperuture and period of submer-sion permissible for better survival

Maximum period of submersion Temperature range

skin and viscera

If CororlaryI circulation

3 Minutes

l0 Minutes

55 Minutes

At l50C

l 0 t o l 5 0 C

0 t o l 0 0 c

38 Jour. Marine Medical Society, Jan-Jun 1999, VoL I, No. I

Systemic Hypoxia

Salt Water Aspiration*

$ea Water = 37o Saline)

tAbr-e zClinical Manifestations

System Respiratory CentralNervous

CardioVascular

GastroIntestinal

Renal

Manifestation Cyanosis pinkfroth frommouth and noseapnoea/tach-ypnoeaPulmonaryoedema

Infection

Alteredsesorium

Raised ICT

Decorticate

Decerebrateposturing

anhythmias

ischaemia

Ventricularfibrillation

Abdominaldistension

GIbleeding

Acute tubularnecrosls

RenaldysfunctionUrinaryabnormalities

MANAGEMENT

Rescue and Resuscitation

Rescue and resuscitation are two pivotal actionsin management of submersion victims. Rescueshould be prompt, effective and safe. The rescueteam should be accompanied by or immediatelyfollowed by, a medical resuscitation team. Resusci-tation should be started as soon as the head ofthevictim is taken out of water. All victims. must begiven the benefit of skilled resuscitation, despiteapparent hopelessness of the situation. Some ofthem will survive and only 5% ofsurvivors willhavemajor brain damage [3]. Children with hypothermiaor cold water immersion may appear dead withoutpulse, respiration and even may have dilated pupilsbut they should be given prolonged resuscitation tillthe body becomes euthermic. The aim of resuscita-tion is to correct hypoxia urgently. The standardABC of resuscitation should be followed.

i) Airway Maintenance; - Suction and clearanceoforopharyngeal secretions and foreign bodiesif any, correct position of face and neck (mildextension of neck with shoulder elevation andtuming of face to one side) are important. At-tempts to drain the water from lower respiratorytract will only waste valuable time, howeversub diaphragmatic abdominal thrust, Heim-lich's maneuver may be attempted in cases ofsuspected foreign body inhalation [3-4]. Cri-coid pressure may be applied to prevent vomit-ing.

ii) Breathing ; Establish ventilation (Mouth tomouth or bag and mask or bag and tube) with

Jour. Marine Medical Society, Jan-Jun 1999, Vol, I, No. l

. oxygen ifavailable.

iii) Circulatio,ra .' Start extemal cardiac compres-sions if no carotid pulses are felt. Establishintravenous or intraosseous line. Treat venfficu-lar fibrillation with intravenous lidocaine or bydefibrillation and cardiac stand still by Injadrenalin (0.1 mg/kg l:1000 for intratracheal)and (l:10,000 for inhavenous/intracardiao.Repeat if necessary.

Supportive Management : Nasogastric intuba-tion and intravenous sodabicarb infusion 1.2 ml/kgin l:l dilution once adequate ventilation is estab-lished are necessary.

Transportat ion .' The cardiopulmonary resuscita-tion must be continued by the medical or paramedi-cal team during transportation.

Documentation: Following information must beobtained and documented by doctors on arrival ofpatient at the hospital.

a. Time of accident

b. Probable duration of submersion

c. Temperature of the water

d. Type of submersion; salt or fresh water anddegree of contamination

e. Time of first spontaneous gasp after apnoeaf. Any vomiting during CPR (indication of aspi-

ration)

g. Seizures or any abnormal posturing viz decere-brate or decorticate

h. Resuscitation attempt and time lapse if anybetween rescue and resuscitation

j. Details ofpreceding illness like seizures, usage

39

of drugs like sedatives, alcohol consumptionetc.

Hospilal Management: Immediately on arrivalat the Paediatric Intensive Care Unit (PICU) all vitalsigns i.e. heart rate, respiration rate, capillary fillingtime, blood pressure, Glasgow coma score etc.should be recorded as base line record and patientshould be hooked on to multi system monitoringsystem. Immediately aggressive organ specific re-suscitation must be instituted, along with simultane-ous investigations.

Irwestigationsa. Radiology : X-ray chest to detect pneumonia or

pneumothorax and craniospinal x-ray to detectinjuries.

b. Biochemical : Blood sugar, haematocrit, serumelectrolytes and serum osmolarity.

c. ECG for evidence of myocardial ischaemia

d. Microbiology : Urine analysis and throat/tra-cheal swabs for culture

Organ Specific Resuscitation

Respiration

a) Airway maintenance

b) Oxygen therapy under transcutaneous oxygensaturation (SICO2) monitoring

c) Ventilatory support. Continuous Positive Air-way Pressure (C PAP) Continuous MandatoryVentilation (CMV) t4l.Early CPAP in most of the cases is desirable.Arterial blood gases and StCOz abnormalitiesindicate need of ventilation.

d) Loop diuretics in pulmonary oedema

e) Hyperbaric oxygen has been tried with incon-sistent results [5]

f) Extra corporeal membrane oxygenation in se-vere lung injuries [6]

Brain Oriented Resuscitation :

It plays the most crucial role in the salvage ofsubmersion patients. Its objective is to maintainICT. ICT of < 20 torr and cerebral perfusion pressure(CPP) of > 50 ton [7].

Convulsive abdominal contractions followed byirregular gasping respiration and appearance ofthepain response within six hours of accident are fa-vourable prognostic markers.

40

L Management of increased ICT:-a) Positioning ofhead at 30 degree elevationb) Hyper-ventilation to attain PaCOz of 25 torrc) Diuretics (loop and osmotic)d) Steroids and barbiturate

It has been observed that short acting barbituratesand hypothermia, both produce leucocyte dysfunc-tion and increase the risk of infection.

Cardio Vascular Resuscitation

i) Treatment of shocka. Establish euvolumia with central venous pres-

sure (CVP) controlb. Use of inotropes like dopamine and dobutamine

.ii) Treatment of anhythmia

Gastro-Intestinal Resuscitation

a. Gastric decompression to prevent respiratoryembanassment

b. Prophylactic H2 receptorblockers and injectionvit K to prevent GI bleeding.

Supportive Management

Acidosis correction: By judicious use of Sodabi-carb under periodic ABG monitoring.

l(arming; Slow warming of the body over 6-9hrs by using surface warming with radiant warmeror humidified warm blower. However in severehypothermia, internal warming should also be at-tempted.

Follow up : All children with near drowninghaving neurological involvement should be fol-lowed up with fundoscopy, motor assessment, CTscan, Brain Evoked Response Auditory (BERA)EEG and IQ assessment in follow up clinics peri-odicaly.

Prognosis : 20%o of submersion victim die ofsecondary drowning and up to 25o/o survivors maydevelop neurological deficits. The poor prognosticindicators are [8].

a . A g e < 3 y r sb. Submersion period > 5 minutesc. Severe metabolic acidosis pH < 7.1d. Asystole on arrival in PICUe. Glasgow coma score < 5

Jour. Marine Medical Societv, Jan-Jun t999, Vol. l, No. t

Prevention

A whole hearted effort must be put at individual,family, society, seruice and national levels, to pre-vent occurr€nce of submersion accidents. Parenteducation on water safety measures will play pivotalrole in preventing.paediatric submersion [9].REFERENCES

l. Kallas HI. Drowning and Near drorvning in Nclson Textbook of pcdiarics, l5th cditlon. &litors - Nclson WE,Bchrdn RE, Klcigmm Rl4 Awin AM Baulotc, hismgook. 1996:264-70.

2. L,evin DL, Toro LD Tumer G& Drovming md ner drown-hg PCNA. Apr. 1993;321-35.

3. Black JA. Paediatic cmergenciq. 1987;4 : 4247 .

4. Disforgm JF, Drovming-lf &rg J Med 1993;32t:253-54.


5. Narayanan S, Nrayanu L Drowning and ncr Drowning inMedical crncrgencies in chil&en 2nd edition by Sirgh M.193;3t3-90.

6. Heacn BS, Fdado JFG, et al. E>fta corporeal nrmbrancoxygenation in prcdiatric patients. Fourth Armual Childr€nHospital Natiorul lvtedical Cenffe ECMO symposium. FcbI9EE.

7. Deat JM Mo Comb JG. Inta cranial pressure monitoring inseverc pdidic ner drowning. Neuro &rger l98l;9 :07-30.

8. Kibel Nagcl FO, Beafry SM DW. Childhood near drowningfacton associatedwith poorout come. SAtrica MedJ 19901,78:4X2-25.

9. Coftnm SP. Parent education for drowning prevention. JPred Health Cme l9l : 5 : 14146.

4l

OuizX-RAY DIAGNOSIS

Surg Cdr PS TAMPI*, Brig DINESH PR.ASAD**

ABSTRACT

ATV a ll year old female presented with complaints of excessive menstrual blood loss since onset of menarche 6months prior to admission. She gave a history of being treated with several courses of antihelminthics andhematinics in the past. Clinical eramination revealed severe pallor, no fever, icterus, bony tenderness, petechiae,ecchymosis, bleeding from any site or lymphadenopathy. Per abdominal examination showed firm non tendermoderate hepatosplenomegaly. Investigations: Hb-4.5gmohTLCtDLC/Plateletcountswere normal, PCY =l8oh,reticulocyte count = 1.9%o, urine RE-NAD, urine Hb, hemosiderin, urobilinogen negative/not increased. G6-PDnot deficient. Metabolic and renal parameters were normal. Direct Coomb's test and sickling test was negative,HBsAg Negative. Urine Inorganic Phosphorou s = 14 mgTo and 0.40 gm | 24 hours. Urine Calcium 14 mgo/o and0.36 gm /24 hours, BT' CT' PT normal. LFT-S Bilirubin 2.0 mg% (direct=0.5 mg7o, ID= 1.5 mgTo) Total Protein= 5.0 gmYo, A:G = 1.8:1, AST = 24 IU/L, ALT = l0 IU/L, serum Alkaline phospatase = 2323lUlL.

Serum calcium = 8.3 mg7o, Inorganic Poa = 3.5 mg%. Serum acid phospatase = 4.5 mgo/o. Peripheral blood smearshowed anisopoikilocytosis with macrocytes and late normoblasts. No target cells or micropherocytes. No evidenceof hemolysis' WBC's / platelets were normal. No hemoparasites. USG abdomen showed hepatosplenomegaly. PFTwas normal. Fig. I and 2 (X-ray skull and Pelvis were diagnostic).

DIAGNOSIS : OSTEOPETROSIS

7lhere is marked increase in density of all

I bones with bluning ofendosteal margins andI- loss of cortico medullary differentiation

(obliteration of medullary cavity). Coarsening oftrabeculae is seen. No definite modelling deformityis present. Bone age appears - normal.

*Classified Specialist in Medicine and Pulmonologist: **Con-sultant (Medicine); INI{S Asvini, Colab4 Mumbai - 400 005.

/ 1

DISCUSSION

There are a number of disordeis having in com-mon an increase in the mass ofbone perunit volume(hyperostoses). These conditions are rare, often fa-milial and may be grouped together as theosteopetroses.

Osteopetroses - (Albers schonberg or Marblebone disease).

There are two main genetically distinct types

l. Recessivelv inherited and severe fonn

l r i g . 2 : (X - rayPc l v i s ) .

Jour. Marine ll,ledical Society, Jan-Jun 1999, Vol. l, No. I

F i g . l : (X+aySku l l ) .

2. Dominantly inherited and mild formsHowever intermediate forms appear to exist. In-

fantile osteopetrosis is autosomal recessive trait thatis manifested in utero and progresses after birth withanaemia, hepatosplenomegaly, hydrocephalus, cra-nial nerve involvement and death often due to infec-tion. The radiographic appearances are remarkableand diagnostic. Bone density is generally increased,and defects in modelling occur which produce a clubshaped appearance in the metaphyses. In the verte-brae and phalanges these may produce an appear-ance of one bone within another ("endobones").When bone marrow is involved there is leuco-erythroblastic anemia and cranial nerve compres-sion with optic ahophy.

In the severe infantile form, there is proptosis,overgrowth of the frontal bones, loss of hearing,poor gowth mental retardation and hepa-tosplenomegaly. The bones fracture easily.Osteomyelitis may occur. Death from hemorrhageor infection in early childhood is common. Bio-chemically, plasma acid phosphatase is increasedwhilst plasma alkaline phosphatase remains normal.

There is probably an inherited defect of osteo-clasts with defective resorption of bone.

Mild Ostropetrosis : In this dominantly inheriteddisorder which varies its expression, the only detect-able abnormality may be radiographic, but fractures,osteomyelitis, nerve compression and aneamia mayoccur.

Other osteopetroses i These are all excessivelyrare, craniometaphyseal dysplasia is significant anddisfiguring. In osteopathia striata, the only signifi-cant abnormality is radiographic. The generalisedfrom of diaphyseal dysplasia (Comaruti - Engel-mann disease) is associated with frontal bossing,proptosis, deafiress, blindness, bone pain, extensivehyperostsis, difficulty in walking wasting and weak-ness of the muscles, skeletal disproportion and de-layed puberty.

REFERENCES

1. Beighton P, Honan F, Hammersma H. A review of theOsteopetroses. Postgrad Med J 197,7 : 53 : 507.

2. Coui F, Krivit W, et a/. Successful bone marrow transplan-tation for infantile malignant Osteopetrosis. Nev EnglJ Med1980;302 : 701.

3. Smith R. Walton RJ. et al. Clinical and biochemical studiesin Engelmann's disease (Progressive diaphyseal dysplasia),Qr J Med 1977:46 :273.

Jour. Marine Medical Society, Jan-Jun 1999, Vol. I, No. I 43

Case ReportsATYPICAL PRESENTATION OFA CASE OF LUPUS-VULGARIS

Surg Cdr R DHIR*, Surg Capt KM SHAH#

KEY WORDS: Lupus Vulgaris, Atypical

INTRODUCTION

1. upus wlgaris is the most common qpe ofI cutaneous tuberculosis. It also has the most

Izlvaried presentation. While most of the casesfrom European studies have revealed a preponder-ance of lesions on the face with frequent mucousmembrane involvement, studies from India haverevealed that buttocks, thighs and legs are the morecommon sites of involvement.[,2]. We are report-ing a case ofundiagnosed, long standing lupus vul-garis with certain unusual features.

CASE REPORT

A 69 yean old housewife resident of UP reported to thedermatology department in November 1997 with complaints ofrecurent abscess of the left palm of six years duration andweakness and numbness ofthe left hand offive years duration.She first noticed multiple small painful soft reddish swellings, onthe le ft palm. At this stage she was diagnosed as a case of palmarabscess and subjected to incision and drainage (l and D) by asurgeon. Due to recurrent episodes ofpalmar abscess I and D wasrepeated four times in a span of one year.

ln early 1982 she developed numbness and weakness oftheleft hand. Since then each episode ofpalmar abscess was treatedwith a course of antibiotics. Besides, she was on homeopathictreatment for one year in | 996. There was no history of low gradefever, recunent cough with expectoration, haemoptysis or loss ofweight. There was no history of contact with a patient of tuber-culosis.

Clinical cxamination at the time ofpresentation revealed anaveragely built elderly lady of 42 kg with no pallor or icterus.Clinical examination revealed (Figs. I and 2) multiple welldefined reddish brown atrophic plagues on the left palm andforearm. There were multiple soft semifluctuant skin colouredpapular and nodular lesions among these patches. Some oftheselesions had evolved to form an abscess. The left hand and leftforearm showed impaired sensation and atrophy of the hy-pothenar eminence and the palmar interossei.

Regional lymph nodes were not enlarged. Systemic examina-tion did not reveal any abnormality. Investigations revealed araised ESR 45, Mantoux 8 mm, x-ray chest revealed bilateral

pleural angle blunting while ultrasonogaphy ofthe chest showeda small amount of fluid in the left pleural space. The initial skinbiopsy showed a granuloma with features suggestive of BTleprosy. However, a careful revaluation ofthe initial slide and arepeat skin biopsy showed features oflupus vulgaris. The patientwas put on ATT (isoniazid, rifampicin, pyrazinamide) to whichshc showed a very good response.

DISCUSSIONThe initial clinical diagnosis was cutaneou's tu-

berculosis. The presence of impaired sensation on

Fig l

rClassified Specialist Dermatology & Venereology. #Sr. Adviser Dermatology & Venereology INHS Asvini, Colaba, Mumbai 400 005


Fig.

44

,.?}

thb affected area accompanied with paralysis ofthesmall muscles of the left hand did point towards thepossibility of Hansen's disease. Being reasonablysure of cutaneous tuberculosis, we kept the possibil-ity, though remote, of a dual pathologl i.e. cutane-ous tuberculosis and Hansen's disease. However, acareful evaluation of the history, clinical featuresand histopatholory excluded the possibility ofHan-sens disease. The cause of impaired sensation andweakness of small muscles of the left hand simulat-ing Hansen's disease is debatable and could be dueto nerve damage or duq to repeated incisions and

drainage or chronic long standing disease producingatrophy and contraction ofthe affected area. Thiscase report coraborates the absence ofany reportedcases in the literature ofcutaneous tuberculosis andHansen's disease at the same site.

REFERENCES

l. Satyanaraym BV. Tuberculoderma" A briefreviewtogetherwith statistical analysis and observations. Itx J DermatolI/ercreol 1963; 29 : 25-30.

2. Singh G. Lup-us Vulgris in India IJ Denat Yerc Lep 197 4;40:'257-60.

Jour. Marine Medical Society, Jan-Jun 1999, Vol. I, No. I 45

OSSIFYING FIBROMA OF THE MANDIBLEASSOCIATED WITH SOLITARY BONE CYST(A Case Report)

Surg Lt Cdr (D) SS PANDEY*

^1n. ssifuing fibromas are a type of fibro osseous

I f lesions of the jaws which comprise a di-\-t verse, interesting and challenging group of

conditions that pose difficulties in classification andtreatment []. Common to all is the replacement ofnormal bone by a tissue composed of collagen fibresand fibroblasts that contain varying amounts ofmin-eralised tissues which may be bony or cement likein appearance. Uncertainty associated with theetiopathogenesis of these lesions make them themost controversial lesion in terms of diagnosis.

Ossif,ing fibromas of the jaws are well circum-scribed, generally.slow growing lesions, which en-large in an expansile manner. WHO and someauthors consider ossiffing fibromas to be non-odon-togenic neoplasms which are benign in nature [2].

CASE REPORTA 2l years old apprentice reported with a bony swelling in

the molar region on the right side of mandible. There was nohistory of trauma to the jaw. Clinical examination showed aswelling 2 cm x 2.5 cm in the body of mandible (Rt) with neitherany signs of inflammation nor any impairement of labial sensa-tions. There was no lymph node enlargement. Intra oral exami-nation revealed expansion of both lingual and buccal corticalplates in premolar and molar region ofthe right side of mandible.Bimanual palpation oflingual vestibule revealed a cystic consis-tency and a bony defect. However the over lying mucosa wasnormal in colour and non tender on palpation. The premolar andmolar teeth were vital and percussion produced no pain.

Radiologically a fairly large well defined radio lucent lesionwas seen in the body of the right mandible (Fig. l). The lesion

extended from first molar to the third molar. The cortex ofthelower border ofthe lesion was intenupted. The apices ofthe teethwere not involved in the lesion. CT scan of mandible showedthinning of buccal cortex with marked thinning and erosion withground glass appearance. The mandibular canal was seen cours-ing through the lesion. With a clinical diagnosis of bone cyst,enucleation ofthe cyst extra-orally through submandibular lower

border continuiry was planned.

Raising of the muco-periosteal flap revealed a cavity linedwith soft tissue and filled with lieht amber coloured serous fluid.

There was no lingual cortex and the lesion appeared to be infil-trating into the surrounding tissues. Apices ofthe adjacent teethwere not involved. Paper thin buccal cortex, perforated at placeswas removed along with bony tissue from the margin. lnferroralveolar neuro-vascular bundle was pushed towards the supenoraspect ofthe lesion and was not coursing through the lesion assuggested in CT imaging. Lesion was enculeated and curetted outfrom the cavity. Inferior border of mandibular continuity wasmaintained using iliac crest graft retained with stainless steelwiies and the cavity was filled with gel foam and wound wasclosed in layers. A drain was placed before suturing. Histo-pathologically, a diagnosis of ossifing fibroma was confirmed.

Post operative extra-oral lateral oblique radiograph of rightmandible taken after 2 l/2 months showed a well taken iliac crestgraft and regression in the bony cavity (Fig. 2).

DISCUSSION

Ossifuing fibromas represent well circum-scribed, slow growing lesions which enlarge in anexpansile manner and at times may invade surround-ing tissues. Larger mandibular lesions cause charac-teristic thinning and bowing of inferior border butinterruption is very rare. The lesions may be dis-placed in the involved area but root resorption is notassociated with the tumour [3].

Although in this case per operative findings of acavity filled with serous fluid were suggestive of abone cyst, histopathology confirmed diagnosis ofossifying fibroma. Moreover, contrary to CT find-ings, the neuro vascular bundle was seen at thesuperior aspect ofthe lesion.

A cortico-cancellous iliac crest bone graft wasused to fill the bone defect. This is important toprevent pathological fracture.

It is not clear whether the so called solitary bonecyst and the cystic cavity involved in ossiffingfibroma are pathogenetically related. Though theexact etiology ofcystic cavity developing in ossify-ing fibroma is not known in the present case thecystic cavify appeared to have formed because of

*Oral and Maxillofacial Surgeon. Naval Institute of Dental Sciences, c/o INHS Asvini Mumbai 400 005.

Jour. Marine Medical Society, Jan-Jun 1999, Vol. I, No. I46

n

he ensuingur patientsrfter initial

fintrauter-

ts greatest

egnancy.

,t count,

onged period

nd the couple

ryof amenor-)n uterus wasfomix. Urineconfirmed a

'4 cm. Patient

.ioned earlier.f commence-: weeks. Fol-mass, but the

of six weeks

enior Adviser

Vol. I, No. I

Fig. | : Pre op ossilyrng libroma.

developmental aberration or degeneration of fibro-osseous tissue.

REFERENCES

I . Charles A Waldron. Fibro osseous lesions of the Jaws.J oralmaxillofac Surg 1985:4 : 249-62.

Jour. Marine Medical Society, Jan-Jun 1999, Vol. 1, No.

liig. 2 : Radiograph taken after surgery.

2. Hiroko Wara, Musamichi Ohishi, Yoshinori Higuchi. Fi-brous dysplasia ofthe mandible associated with large soli-tary bone cyst. J Oral maxilofac Surg I 990; 48 : 88-9 I .

3. Willam G Shafer, et al. Atext book oloral pathology. WBSaunders company. 1983 237.

47

P ersonal CommunicationHAND WASHING :AN ESSENTIAL COMPONENT OF NICU CARE

Surg Cdr G GUPTA*, Surg Cdr SS MATHAI+, Surg Capt KS BAWA#

epsis is one ofthe commonest cause ofneona-tal morbidity and mortality in India. Incidenceis variably reported with high of l0%o in some

units with sigrificant mortality. Therefore, preven-tion of infection is the single most important vari-able in improving the NICU statistics. Bacteria onthe skin stay either as transient flora or permanentcommensals. These micro organisms are transmit-ted to the neonates on coming in contact with con-taminated hands. Hand washing is therefore themost effective modality to prevent such propagationof infection. However, one must constantly exercisecomprehensive infection prevention protocol in theunit. For an effective hand wash, following stepsshould be strictly adhered to [1].

l. All entrants to the unit, without exception mustwash their hands thoroughly, before enteringthe patient care area. NICU staffshould ensurethat their finger nails are clipped and adequateattention is paid to their cleaning.

2. Sleeves should be rolled up above the elbows.Remove all articles worn on the hands andforearms viz bangles, watch, rings etc. Suchitems should not be worn by the NICU staffduring the duty tenure inside the unit.

3. Wash hands with detergent soap, antiseptic andclean running water. Detailed procedure hasbeen depicted in Figs. 1 and 2 [2]. Ensure clean-ing of nails, hands and forearm up to elbow.Repeat at least five times all the six movementsshown in Fig. l. Total scrub time should not beless than two minutes. This is the time requiredto effectively reduce the population of poten-tially pathogenic permanent inhabitant bacteriaon the hand skin. Do not touch the tap afterscrubbing. One may consider using foot or el-bow operated or autotaps.

!!!

nov? t ts5I0

Fig. I : Areas of hands most frequently missed during hand-washing.

4. Rinse thoroughly under running water

5. Keep both hands up in front ofyour chest so thatwater drains down towards the elbows.

6. Hands should be dried with sterile towels. Paperautoclavedtowels can be made from print paperor from old EEG tracings without incurring anyexpenditure. Hand electric automatic drier maybe used instead or along with paper towels,effectively. Now a days, such driers are avail-able along with bacterial filters thus increasing

1

I

1I

IPalnr to palnr

5

rlw 1,.mltl

I

l[)alm to palm.

\_\

5

Rotational rutvcrsa.

Fig. 2 : Effect

Jour. Marin

* Classified Specialist in Paediatrics & Neonatologist, + Classified Specialist in Paediabics, # Sr. Adviser Paediatrics, Departrnent ofPaediatrics. INHS Asvini. Colaba- Mumbai - 400 005.

Jour. Marine Medical Societv, Jan-Jun 1999, Vol. I, No. I48

FIG:2r

. i6 i lsstD

I rut' l r

Iwl-EI

,ttlL[Nl i t t : rn

r lrto

1Gr.l'}

+JZ

w

Palnr to palnr

Palm to palm. lingers interlaced.

Rotational rubbing ofright thumb clasped in lefi palm and viceversa.

Fig. 2 : Effective hand hygiene.


Right palm over lcll dorsunt and lcli palm ovcr right dorsurn.

t*

Backs of fingers to opposing palnrs rvith lingers intcrlocked

Rotational rubbing backwards and forwards with claspedfingers ofright hand.

h

luring hand-

)r

restso that/s.

'els. Papernintpaperuninganydriermayer towels,are avail-increasing

)cpafinent of

'ol. l, No. I 49

their efficacy.7. Do not touch any objects such as doors. hair.

nose, case sheets, x-ray, ECG etc. after scrub_bing.

8. After touching each patient and or equipment,to remove possible transient flora so acquired,one must wash the hands for at least 30 seconds.One may also use 70o/o alcohol for scrubbingthe hands and letting them dry before touchin!the next patient or equipment. Do not blow airfrom your mouth to dry your hands. Antisepticsolution of choice is Chlorhexidine. Otheragents may be used depending upon the sensi_tivity of existing NICU flora [l]. Use of anti_septics is desirable but if this is not feasible,then one must resort to meticulous hand wash_ing with soap and water. However, use of ap_propriate antiseptic handwash is mandatorv incase of an epidemic in the unit.

In our unit with meticulous handwash policya.long with other comprehensive infection pi.u"n-tion measures, incidence of sepsis has been con_tained-below one percent. Nursing personnel playkey role in ensuring hand washing. A whole hearted

effort must go in to ensuring implementation Sexisting_infection prevention policies and incorpo_ration of newer facilities like use of bacterial filters,air curtains, ultra violet light and laminar flow sys_tems etc. The entire'effort ofNICU care will becomefutile if hand washing is inadequate. Therefore, theunit must have ongoing education cum training pro-grammes for new entrants involved in patieni carewith emphasis on the importance of hand washingin particular and infection prevention in general. Itis recommended that effective handwashlechniquedescribed above should be used in all intensive andhigh risk areas ofthe hospital vizNICU, ICU, CCU,RCU, Chemotherapy ward etc. This will huu" udistinct posive effect on the vital statistics of thehospital.

REFERENCES

l. Georges P, William JC. Infections acquired in the Nursery.Epidemiology and control in: Infectious disease ofthe fetusand the newbom infant, 3rd edn Eds Remington JS, KleinJO, WB Saunders philadelphia. 1990; l0l l-12.

2. Protocol from departmentofpharmaceutal sciences, Univer_sity of Nottingham. 1992.

r ' '--

L-

' 1

--f

OtherAt

12. DisrCairoxyt56

13. Nev

nessAug

14. MaeRou,cultt

Pleasel. The2. The,

case'3. Edit(4. BothIfthe r

number (s

Tables (ft

Tablesafter on rnumber isin arabic rshould spe

Horizotween a c(avoided. Sumns shou

coM]PrrnaHcHe

10. MrHuhurCusea(St'bio

l l . Ag,RarpitaNalpubstat

Shaunlccure

50 Jour. Marine Medicat Society, Jan-Jun 1999, Vol. I. No. 1

S-

BOOK REVIEWS

STEREOSCOPIC ATLAS OF MACULAR DISEASE : DIAGNOSIS AND TREATMENT

4th Edition. Edited by JDM Gass ST Louis: Mosby-year Booklnc. 1997; l and2: 1060. Price $325.00, ISDN : 0-8151-3416-9

;\ phthalmology is a science of vision. Contrary to othert I speciatities ofmedicine, examination techniques such as\-/ palpation and auscultation are rarely employed in oph-

thalmology. It is more dependent on seeing the eye with variousinstruments and aniving at a diagnosis. This is especially true incase of posterior segment disease. The myriad variants of thefundus oculi warrant an excellent guide. The "Stereoscopic Atlasof Macular Disease" is one such worthy guide.

This explicit edition in two volumes contains 2,866illustrations with 124 stereoscopic pairs in colour. Thestereoscopic pictures are printed sets of colour photo-graphs which can be viewed with the viewer provided withthe book or any stereoscopic glasses. This I 060 pages, twovolume edition provides a comprehensive overview of

concepts of macular disorders and their management.Newer developments including curent concepts in macu-lar hole pathogenesis, and classification ofchoroidal ne-ovascular membrane have been included. Advances intherapy as in acyclovirtherapy for serpiginious choroiditisand other macular disorders have also been elucidated.The backbone ofthe book is its plethora ofpictures whichreflect the author's vast experience.

This book is recommended as a must for any teachinghospital as a valuable source ofreference.

Surg Lt Cdr R Vasanth KumarDepartment of Ophthalmology, INHS Asvini, Colaba, Mumbai400 00s.

INTERVENTIONAL RADIOLOGY

Third edition, Edited by Wilfrido R Castaneda-Zuniga. Publishedby Williams and Wilkins, Maryland, USA 1997;2 : 1816. PriceRs. 6800/- ISBN 0-683-181 I | 7-3.

flthis is a highly exhaustive and comprehensive book on

I Interventional Radiology. The presentation and text areI- clear and lucid. The text is interspersed with numerous

high quality diagrams and photographs which give an in depthunderstanding of human anatomy as related to interventionalprocedures and also to the various steps involved. The firstvolume has sixteen cliapters ofwhich thirteen are dedicated tovascular intervention and include details of vascular embolec-tomy, atherectomy, angioplasty and vascular stenting. The impor-tance of good sedation in the success of any interventionalprocedure has been recognised by the authors and a completechapter has been dedicatedto Sedation by Nonanaesthesiologists.The second volume has ten chaoters and covers interventional

procedures in the uro-genital, gastro-intestinal and biliary sys-tems. All procedures are described in detail with relevant indica-tions as also the possible complications and their management.The authors have also included the relatively new field ofFocussed Ultrasound thermal surgery guided and monitored byMagnetic Resonance Imaging as a separate chapter.

This text book is one of the most authoritative bookson Interventional Radiology and is recommended to notonly Radiologists but also to Urologists, Gastroenterolo-gists, Cardiologists and Vascular surgeons. It will serve tobe an excellent reference book for anv institution.

Lt Col SS AnandClassified Specialist Radiation Medicine and Radiologist, INHSAsvini. Colaba- Mumbai 400 005.

LEVER'S HISTOPATHOLOGY OF THE SKIN

Edited by David Elder; published by Lippincott - Raven, Phila-delphia-New York, Eighth edition, hard bound. 1997; I 073. PriceRs. 3,000 Appr.

f f Talter F Lever, MD (1909-1992) was a pioneer in

l/|/ dermatopathology, who introduced generations ofV Y physicians to the subject and whose work lives on in

this volume. This book is a classic work which gives an excellentaccount on the relevant clinical features, pathogenesis, ultrastruc-tural studies histogenesis and elaborate histopathologic features.A cadre ofexpert contributors has been recruited. Emphasis ondiscussion of immunochemistrv and immunofluorescence as ad-

juncts to diagnosis have been expanded. An introductory algo-rithmic classification for differential diagnosis of skin diseaseshas been added to provide a paftern-based classification. Refer-ences have been updated. This book is recommended for all thedermatologists, pathologists and post graduate students ofderma-tology.

Surg iapt KK SHAHSr. Adv. (Dermatology and Venereology) INHS, Asvini.

Jour. Marine Medical Society, Jan-Jun 1999, VoL 1, No. I 5 l

Letter to the Editor

PSYCHOLOGICAL ASPECTS OF UNDERWATER ENDEAVORS

Dear Sir,

7Tlh. above article published in Joumal of Marine

I Medical Society, issue of July 1997,4 : I was veryL interesting. In addition to describing the problems

faced by divers and submariners, it also raises, a fewquestions in my mind like:

l. Whether aviation and marine specialities can becompared.

2. Use of submarines for exploring depth of sea formaritime utilities in addition to developing the attackpower of our Navy.

I am a little hesitant to say that the problems (physi-ological and psychological) faced by divers are muchmore strenuous compared to the astronauts. Also about

robust and healthy physique required ofthe divers com-pared to astronauts.

Although the authors have highlighted the problemsfaced by submariners and divers, till now we have not beenable to give good and effective counter measures for thesame.

I sincerely hope that this article will inspire the medicalfratemity to find effeitive means to decrease the hazardsof sea explorers and more and more volunteers will opt forsuch exciting but hazardous endevours to help mankind tolive better.

SurgLtVMKVERMASchool ofNaval Medicine, Colaba Mumbai 400 005.

INTERNET NEWS

For the initiated: Go to any search engine such as:

AOL

Yahoo

Infoseek

Lykos

Search the following topics/sites

i Virtual Hospital

Virtual patients

Internet grateful Medline

Priory. Com

Journals on line

National Medical Library

Lots of scientific and medical information is to be gained from these sites.

- EDITOR

52 Jour. Marine Medical Society, Jan-Jun 1999, Vol. l, No. I

buropuNEs FoR AUTHoRS

L Joumal of Marine Medical Society (JMSS) publish-es original articles, case reports, topical reviews, editori-als. special articles, letters to the Editor, book reviews, andother scientific information in all disciolines of medicalsciences.

2. Contents of the JMSS are covered copy right. Arti-cles are accepted for publication with the understandingthat their contents, all or in part, have not been publishedand witl not be published elsewhere except in an abstractform of with the consent of the Editor, JMSS does notaccept the responsibility for statements made by theauthors. The Editorial Board has the right to introducesuch changes as may be considered necessary.

3. Authorship

Only those who have rnaterially participated in thepreparation of the article, should be selected for author-ship. The final typescript must be read and approved byall the authors and a statement to that effect signed by eachauthor must accompany the article. If more than fourauthors contribute to the article; an accompanying state-ment must specify briefly the work done by each author.

4. Manuscripts must be neatly typed, in double spacethroughout, on one side ofthe sheet ofgood quality whitebond paper of the size 28 x 22 cm with 3 cm margin onboth sides. Words should not be hvohenated at the end ofa l ine .

Three copies. including the original, ofthe typescriptshould be submitted along with two sets of illustrations.Authors must retain a copy of all the above material, asthe Journal cannot be held responsible fbr its mutilationor loss in transit or due to any other reason.

5. The typescripts should be enclosed in a large enve-lope, superscribed 'Article for Publication', preferably notfolded and sent under registered cover to:Editor,Journal of Marine Medical SocietyINHS ASVINIColaba, Mumbai - 400 005.

6. Acknowledgement / Decision: Material receivedfor publication will be acknowledged immediately.

Besides being evaluated for scientific value and accu-racy, the typescript is edited for the contents and precise-ness as also for the style of expression and presentation.Each article must not only high-light a new aspect ofthesub.iect, but must also make enjoyable reading.

The article may further be reviewed by a referee .

The Editorial Board has the right to introduce suchchanges as may be considered necessary. When necessary,

one copy of the typescript, suitably modified, will be sentto the author for revision and resubmission.

All the material pertaining to an article will be sent fiecof cost to the author whose name is given on the title pagefor that purpose.

Extra reprints will not be supplied.

8. Author's and OC certificates as per SAO l518/81must accompany the article in duplicate, as per the pro-forma given below:

Author's certificate: Certified that I have not used anyclassified information obtained in my official capacity.

I have checked the article for grammar and spellin-es.

Principal Author

Certificate from OC

Certified that I have no objection to the publication ofthe article entitled

written by

OC

The Vancouver style

In keeping with the current trends in Medical Journal-ism and for the sake of ensuring intemational unilbrmitythe "Vancouver Style" of publication is to be followed.Detailed information regarding the pattern to be followedfor articles is given below. Contributors are eamesttyrequested to note and'strictly follow them.

Classification and Length of Articles

|. Original art iclesThe subject should decide the length of the article.

However, the text should not exceed eight typed pages(double space) or about 4,000 words, excluding title pageabstract page, references, tables and legends. The numberoftables, illustrations and ref'erences should be kept to theminimum.

2. Case reportsCase reports are accepted only ifthey describe inter-

esting facets ofa particular disease, an unusual/rare entityor finding. As a rule, Case Reports are given low priority.

The text should not exceed 1500 words. There is noneed to give a comprehensive review of literature.

3. Review articles

Review articles are accepted only by invitation.

4. Miscel laneous art iclesTechnical notes. letters to the Editor. briefnotes. etc.

will be accepted only on their merit.

The Editorial Board may reduce the number of tables.references and illustrations.

The Typescript

The typescript comprises: a) Title page, b) Abstractand key words, c) Text, d) References, e) Tables and f)Legends. AII these must start on separate pages and intheabove order.

a) Title page gives the title of the article, full names ofthe author(s), affiliations of authors, place of work, andname and address of the author for correspondence andrequest for reprints. Give respective PIN.

Ideally, the title should be of about 60 characters. Itshould have no abbreviations. Give full first names of theauthors, middle initials and last name(s). No degree willbe printed. Names of all the authors must be typed onebelow the other with proper footnote marks after the name.

Other items, viz..affiliations (with corresponding foot-note marks at the beginning), name and address ofauthorsfor correspondence and request for reprints, should betyped as footnotes. The following marks are available, andshould be used in the same order.*.+,#,**.++.##

b) Abstract (p. 2) should be typed on a separate sheet.It is a synopsis of the main article and gives an oppor-

tunity to the author to induce the reader to go through thearticle in its original form. In about 200 words, (100 forcase reports), divided into a few sentences, it must givebriefly the history and nature ofthe disease / subjects; themethods, results, diagnosis and conclusion, giving factsand not description.

Speculative surmises, and references to otherworks onthe sub.iect should not figure in the abstract.

Remember - An abstract is mini-article.

Key words : Not more than five important words whichwil l help the indexer.

The text

The text should be divided into sections, e.g. introduc-tion, material/subject/patients and methods, results, anddiscussion. Each should have its individuality and mustnot be mixed with others.

References

Responsibility of accuracy of the references lies en-tirely with the authors. It must be ensured that the namesofthe authors cited are conectly typed both in the text andin the Reference list.

References should be listed in the order in which thcyare cited in the text, and not in the alphabetical order ofthe author's name.They should be indicated in the text byarabic numerals enclosed in square brackets (e.g. [2]), onthe line ofthe text and no as superior numbers.

Ensure that all the references cited in the text arcincluded in the list, and vice versa. Underline the name of

book/journal in the list ofreferences. :. r

Journals

Standard Joumal Article (List all authors when six orless; when seven or more, give only first three and add etal).

One-word names of Joumals should be given in full,e.g. Cancer, Gastroenterology, Surgery.

For conect abbreviations ofJournals refer to the latestIndex Medicus.

Names of Journal not indexed must be given in full.No full point in abbreviations of the Joumal's name

(e.g. N EnglJ Med).l. You CY, Lee KY, Chey RY, Menguy R. Electrogas-

trographic study of patients with unexplained nauseabloating and vomiting. Gastroenterology | 980; 79 :3 i l - 1 4 .

2. Corporate Author.

The Royal Marsden Hospital Bone-Marrow Trans-plantation Team. Failure of syngeneric bone-marrowgraft without preconditioning in post-hepatitis mar-row aplasia. Lancet 1977 : 2 : 242-44.

3. No Author GivenAnonymous. Coffee drinking and cancer ofthe pan-creas (Editorial). Br Med J l9gl; 293 : 629.

4. Journal SupplementMastri AR. Neuropathy of diabetic neurogenic blad-

der. Ann Intern Med 1980: 92 (2 Pt 2\ : 3 l 6- I 8.Frumin AM, Nussbaum J, Esposito M. Functional

asplenia: demonstration of splenic activity by bone mar-row scan (Abstract). Blood 1979;,54 (Suppl l) : 20a.

5. Joumal Paginated by lssueSeaman WH. The case of the pancreatic pseudocyst.Hosp Pract l98l; l6 (Sep) : 24-5.

Books and other Mo.nograph

6. Personal Author(s)

Eisen HN. Immunology : an introduction to molecu-lar and cellular principles of the immune response.5th ed., New York: Harper and Row. 1974: 406.

7. Editor, Complier, Chairman as AuthorDausset J, Colombani J, eds. Histocompatibility test-ing 1971. Copenhagen Munksgaard. 1973 l2-8.

8. Chapter in a book

Weinstein L, Swartz MN. Pathogenic properties ofinvading microorganisms. In L Sodeman WA .lr,Sodeman WA, eds. Pathologic physiology mecha-nisms of disease. Philadelphia WB Saunders. 1974;457-72.

9. Published Proceedings PaperDupont B. Bone marrow transplantation in severe

$on ororpo-ilters,v sys-comee, theg pro-t careshingral. Itnique'e andCCU,ave alf the

lursery.re fetusI, Klein

Univer-

I combined impunodeficiency with an unrelatedMLC compatible donor. In: White HJ, Smith R, eds.Proceedings ofthe third annual meeting ofthe Inter-national Society for Experimental hematology.l-louston : International Society for ExperimentalFlematology. 1974; 44-6.

10. Monograph in a Series

Hunnighake GW, Gadek JE, Szapiel SV, et a/. Thehuman alveolar marcophage. In : Harris CC, ed.Cultured human cells and tissues in biomedical re-search. New York: Academic Press. 1980; 54-56.(Stoner GD, ed. Methods and perspective in cellbiology; vol l) .

I l. Agency Publication

Ranofsky AL. Surgical operations in shortstay hos-pitals: United Stated - 1975. Hyattsville, Maryland :National Centre for Health Statistics, 1978; DHEWpublication no (PHS) 78 1785, (Vital and healthstatistics; series l3; no. 34).

Other Arlicles

12. Dissertation or thesis

Cairns RB. Infrared spectroscopic studies of solidoxygen (Dissertation). Berkeley, Califomia: 1965;l 56.

1 3. Newspaper Article

Shaffer RA. Advances in chemistry are starting tounlock mysteries ofthe brain: Discoveries could helpcure alcoholism and insomnia. explain mental ill-ness. How the messengers work. WallStreet Journal.Aug.1977; l2 : I (vo l . l ) , l0 (vo l . l ) .

14. Magazine Article

Roueche B. Annals of medicine: the Santa Clausculture. The New Yorke r l97l; Sep 4 : 66-8 l.

Please note thatl. The initials have no periods;

2. The year follows the periodical/publisher's name (incase of Books);

, 3. Editorial, Abstract, etc. appear in parenthesis;

4. Both beginning and ending pages are given. -lfthe reference is ofonly one page, underline the page

number (see 3 above).

Tables (follow references)

Tables may be typed in between text matter, preferablyafter on near about the paragraph in which the tablenumber is mentioned. They should be serially numberedin arabic numerals (Table I, Table 2) and a short titleshould specify the contents.

Horizontal lines in the body ofthe table, except be-tween a column heading and its subheadings, should beavoided. Similarly, the vertical lines separating the col-umns should be totally omitted.

Legends (follow tables)

Legends should be brief(rarely exceeding 40 words),but must explain the salient fbatures of the illustration.

Illustrations

Illustrations should be presented only if they depictsomething new or unusual. They should be serially num-bered in the order oftheir mention in the text, irrespectiveoftheir nature, viz. photograph, drawing or chart, usingonly the word Figure and not diagram, graph, etc.

Figures should be numbered to correspond to the casenumbers, e.g. Fig. lA, Fig. lB, Fig. 24, Fig. 28, etc.

Illustrations are of the following kinds:

l. Photograph, 2. Transparency, 3. Diagram or lincdrawing, and 4. Chart.

l. Photographs: Unmounted glossy prints - not matfin-ish - ofexcellent clarity should be selected. Their size

. ideal ly should be 13 x 18 cm (5" x 7").

Do not write anything on the photograph, either onthe back or on the front. I

Do not mount the photographs.

Do not use pins, staples or even paper clips to put thephotographs together. Enclose the photos in thincards, so that they do not get mutilatcd.

Avoid identifiable photographs. unless you have ob-tained the patient's permission to reproduce them.

2. Transparencies and coloured photographs are notaccepted.

3. Diagrams should be drawn on thin, white, smooth orglazed card in Indian black ink, and not in any other

. . colour.

4. Charts shouldte drawn in the same way as diagrams.Type a label indicating on the top principal author

name, short title of the article and the figure number. andpaste it on the back of the illustration.

Units

Use metric measurements, cm, g, kg, ml (not cc). Noperiods, no plural form (e.g. 30 cm, 48 kg, l5 ml etc.).

Use radiograph, radiographic and radiographical notX-ray, skiagram, roentgenogram, roentgenographic androentgenologic.

Man/woman instead of male/female oatient etc. Patientinstead of case.

'Significant' should be reserved for use in statisticalsense.

Spell ings

British spellings are preferred to American spellings.(e.g. colour, tumour and not colour, tumour).

In words with diphthongs (ae, oe) retain only e anddelete o, (e.g. etiology (aetiology), hemo (haemo), cecum

No. I

vol. 1 no. i jan-jun 1999 · marine medical society (regd f-361 i ) president surg vadm jc sharma...

Documents