i

lMARINE MEDICAL SOCIETY(Regd F-3611)

PresidentSurg VAdm PUNITA ARORA SM VSM

DGMS (NAVY)

Vice PresidentsSurg RAdm JM BORCAR VSM

Surg RAdm VS DIXIT VSM

Executive Committee

Surg Cmde VK SAXENA VSM Surg Cmde SK MOHANTY SM VSM

Surg Cmde BS RATHORE VSM Surg Cmde MJ JOHN

Surg Cmde R MITTAL Surg Cmde SK SATSANGI

Surg Capt S NANGPAL Surg Cdr K CHATTERJEE

SecretarySurg Cdr R CHOPRA

TreasurerSurg Cdr VK GOYLE

Addres s for Corre spondenceSecretary

MARINE MEDICAL SOCIETYInstitute of Naval Medicine,

INHS Asvini CampusColaba, Mumbai 400 005.INDIA

Website : http ://www.mmsindia.net

'IIt

' l,l

JOARNALOFMARINEMEDICAL

SOCIETYDEC 2OO5

Published Biannuallv

Editor-in-ChiefSUTgRAdmJMBORCAR VSM

EditorSurg CdTIKII\DRA.IIT

Assistant EditorSuTgLtCdTKAMALMISHRA

Address for Correspondence' EditorJOI.JRNAL OF MARINE MEDICAL SOCIETY

Institute of Naval Medicine,INHS Asvini Campus,

Colaba. Mumbai 400 005.

hinted and Published and.owned by DirectorGeneral of Medical Services (Navy),Sena Bhavan, New Delhi 110 011. Printed on his behalf atlpo Graphics, Mumbai400 103. Editor : Surg Cdr IK Indrajit, C/o Institute of Naval Medicine, Mumbai 400005.

?//cca

Seal

Oottcpt "nzrclo

/nite

>K

Prashant Medical and Surgicals

Mumbai

r lL - -

Joun Marinc Medical Society,2005, Vol.7, No.2

CONCLUI

We areparticipatirwriting, prSet withinethical przcertain exlJ in an edigiarism arindividualdisrepute"a burgeonin scientilthis editor

In actrthors [24]owners of,bers and 1take a disissues, aspotentiall

Asaf i rthe core tling and rnurturinging origin

REFERENl . R Ho r

and fr

2. FlanaPaceand gJAMI

3. Not icAvai lNEJN

4. Whit (f raud2005

5. McCaThe I

6 . Sox l

?003MJ, (5. Av8t702

7. WhatgervaAcce

Jour. Man

r L l

, J

II

I|.. l r

94

JOURNAL OF MARII\E MBDICAL SOCIETY

CONTENTSt mrronral

Ethical Issues in Scientific Writing, Publishing and Editing Biomedical Journals:ABurgeoning Need forAwareness 97Surg Cdr IK Indrajit, Surg Cdr Katnal Mishra

ORIGINALARTICLESHeat Stress Onboard A Ship in Refit l0lSurg Cdr Kaustuv Chatterjee, Surg Cdr Kaushik Chatterjee

Evaluation of the Accuracy and Reliability of Glucometer to Ascenain its Suitability for Monitoring Glucose 107Homeostasis in Hyperbaric ChamberSurg Is Cdr CS Mohanty, Maj Rajeev Bajaj, Surg It Cdr P Gokulakrisluan, Surg Capt S Nangpal, lt Col Ajay Malik

Personality Profile of Submarine Volunteers and Trainees: Can We Predict Motivation for Submarine Service? I 13Surg Lt Cdr P Gokulakrishnan, Surg Cmde MJ John, Surg Cdr DK Ghosh, Ms Jyoti Rathod, Surg Cdr K Chatterjee,Maj Rajeev Bajaj

Acute Skin Failure l2lSurg Cdr J Sridhar Sury Capt PLK Desylva

Psychosocial Aspects of Individuals with HIV/AIDS 125Mrs Padmini V, Surg Cdr Sunil Goyal, Surg Capt RN Misra, Surg Cdr Asutosh Tripathi

I A Prospective Study of32 Operated Patients ofHead Injury 130' Srrg Cdr KI Mathai, Surg Cdr S Ganguly, Sury Capt B Fanthome

, RationalPrescribing 134

. .Surg Capt Girish Gupta

REYIEWARflCI,ETooth Mobility - A Dental Challenge 136Surg Cdr (D) B MuHterjee

CASEREFORTSDecompression Sickness - Three Unexpected Cases L4lSurg Is Cdr Wvek Verma, Surg Lt Cdr K Mishra, Major R Bajaj, Surg Capt B Sudarshan, Surg Capt S Nangpal

Congenital Vallecular Cyst in A Neonate : A Case Report 144Surg Capt Emmanuel James, Surg Cdr Shanlar Narayan, Surg Cdr Joy Chatterjee, Col SS Gill

Mullerian Adenosarcoma of the Uterus Presenting as a Cervical Polyp - A Case Report 146Surg Is Cdr G Panhasarathy, Surg Cdr Naveen Chawla, It Col (Antc) R Duraiswani, Surg Cdr A KapurSurg Cdr R Panicker Surg lt Cdr R Sivasanlur

Gastroschisis- A Case Report l4gSurg lt Cdr RK Patel, Surg Is Cdr AK Pillai, Surg Capt YP Monga

Nickel Titanium Palatal Expander - A Case Report l5lSurg lt Cdr (D) SS Chopra, Surg Cdr (D) SS Pandey

PATHOLOGYQIJIZ 153

: Sr,rg L,t Cdr Ramesh Rao, Lt Col A Malik, Surg Cdr S Deb, Surg Capt RN Misra, Surg Capt B Fanthome

RADIOI,OGICALQTJIZ 156Surg Capt J D'Souza Surg Cdr IK Indrajit, Surg Cdr AS Naidu, Surg ls Cdr SN Singh

i nooKRpvrEwHyperbaric Oxygen Therapy in Otorhinolaryngology 159Surg lt Cdr S Narayan

INSTRUCTIONS TO AUTHORS 160

- - - - - - - l- l

l - t

Wdtl

Seat

eaf*nncto

/tue

- -(.4,r/t

A E Y

-at -

, Prabhat Medical and Surgicals

Mumbai

, I

!

t

% Jour. Marilu Medical Society,2N5, Vol.7, No.2

EditorialETHICAL ISSUES IN SCIENTIFIC WRITING PUBLISHING ANDEDITING BIOMEDICAL JOURNALS : A BURGEOMNG NEED FORAWARENESS

Surg Cdr IK Indrajit', Surg Cdr Kamal Mishra-

INTRODUCTION

J-\uring the last few decades, there has been aItf steady progress in medical academics, with anever increasing number of scientific articles and ci-tations published in medical journals across theglobe. Much of this progress has been largely at-tributed to the widespread use of computers andinternet technologies. What's more, there is a "con-venience factor" of easy accessibility to onlinebiomedical databases, directly at home, office andhospitals, that has clearly played a role of a majorfacilitator.

However, few disreputable and vexed issues re-lated to unethical scientific writing have struckrecently at the foundations of biomedical publish-ing, tainting is pristine form and structure.

ISSUES IN UNETHICAL SCIENTIFIC WRITING

Getting to the point, leading biomedical joumalshave periodically reported instances of unethicalpractices that directly compromise intellectual hon-esty []. Some of these ethical issues range fromplagiarism, wrong authorship issues [2] , incompletemanuscript review, duplicate submission, false sig-natures on submitted documents [3], conflict ofinterest of reviewer to presenting false, fabricatedand manipulated data [4,5] which are messy situa-tions that often compel a notice of retraction [3,6].

In particular, plagiarism ([Latin] plagiare: to steal),as defined by a Georgetown University Council docu-ment is "the act of passing off as one's own theideas or writings of another." [7]. It simply denotesliterary theft. Common deviations that constituteplagiarism includes " a) downloading a free research

paper; b) copying an article from the web or an onlineelectronic database; c) copying material from a localsource; d) cutting and pasting to create a paper fromseveral sources ; e) quoting less than all the wordscopied; and g) faking a citation "[8].

At the outset, three aspects of the disturbingscenario challenging scientific writing and creativ-ity, need a closer analysis.

Firstly, unethical issues in writing and creativeskills are not strictly restricted to medicine, but con-front other disciplines like arts, science, history [9],economics, music, movies and even basic areas likeschool education too [0], time and again.

Secondly, a large and significant majority of es-tablished cases of unethical scientific writing areattributable to lack ofawareness, naivety and inex-perience on part ofthe authors I l], reviewers andeditors. Nevertheless, both unintentional as well asintentional forms of unethical scientific writing prac-tices are violations.

Thirdly, the current tribulations in scientific writ-ing can be attributed to a great extent, to the "cutand paste" tool of word processing software. Thisconvenient and immensely popular tool, encouragesany naTve person,hot fully aware ofthe key princi-ples of authorship as well as rules of ethical scientificwriting, to stray into unscrupulous and unethicalpractices. As a matter of fact, Eyesenbach G editorof Joumal of Medical Internet Research, suggests asimple but cleverly effective solution. He proposesa ramp up of the infamous "cut and paste" featureinto an ethically correct and easily executable "cut,paste and attribute" concept [2].

'Editor: "Associate Editor. Journal of Marine Medicine Societv

Jour. Marine Medical Society, 2005, Vol.7, No. 2 97

DETECTION OF TJNETHICAL SCIENTIFICWRITING

Editors of leading journals world over, presentlyface ponderous questions on issues ofdetection ofunethical scientific writing. How does the editorialboard know if the submitted manuscript/citation orarticle contains copied material? How can unethicaltechniques in writing be detected by reviewers? Canethical deviations in academic writing be identifiedaccurately, reliably and quickly by scientific meth-ods including computer software?

Robert Harris, a reputed educator recommendsfour broad detection strategies [8]. Thefirsr strat-egy involves looking for intemal clues within articleslike "mixed citation styles, lack ofreferences or quo-tations, unusual formatting, off topic content, signsof datedness, anachronisms of long-past events ascurrent, anomalies of diction and style". The sec-ond strategy in detection is based on "knowledgeof the sources of citations". When it comes to con-temporary medical writing, the mostcommon sourceof scientific content is Pubmed. However it must beremembered that numerous biomedical databases,joumal databases, search engines, web pages etc,can be comprise sources too. The third strategy ofdetection apparently is to !'search for the paperonline" using exact phrase or searching a string ofappropriate keywords. Andytzally, commercial "pla-giarism detector" software programmes likePlagiarism Finder, Turnitin and iThenticate are avail-ablefordetection [l3].

PREVENTING I.JNETHICAL SCIENTIFICWRITING

Currently, there are few leading bodies involvedin evaluating, formulating and propounding guide-lines on ethical scientific writing.These includeInternational Committee of Medical Journal(ICMJE) [4], World Association of Medical Edi-tors.(WAME) [5], Committee on Publication Ethics(COPE) [16], Council of Science Editors [17] and Of-fice of Research Integrity (ORI) tl8l .

Largely, these international agencies meticulouslydeliberate and focus hard on a many ethical areaslike authorship, contributorship, editorship and edi-torial freedom, peer review, conflicts of interest,obligation to publish negative studies, corrections,retractions, expressions of concern, copyright, over-

98

lapping, redundant and acceptable secondary pub-l icat ions, dupl icate submiss ion, compet ingmanuscripts based on the same study or database,differences in analysis, interpretation, in reportedmethods or results, correspondence and electronicpublishing.

Furthermore, most journals at regular intervals,offerdetailed guidelines and instructions to authors.However, there is a glaring lacunae in "instructionsto authors", in that the guidelines for ethical writingas well as steps to prevent unintentional plagiarism,is dealt with rather superficially and sketchily.

Conversely, to steer clear of unethical scientificwriting, a small but valuable set of guidelines com-prises the following:

a) At all times acknowledge the contribution oforiginal authors, even if their written ideas areparaphrased. Remember paraphrase involvesrestating author's ideas, in yourown words [191.

b) Cite the source of material written, as fittinglyand as correctly as possible, when preparing awritten document or a slide presentation.

c) Use inverted quotes suitably, if material fromcitation or article is inserted unchanged.Furthermore, inverted quotes should be usedmandatorily for all direct quotations, includingoccasional phrases.

d) Be aware of Ingelfinger rule, (named after FranzJ. Ingelfinger, editor of New England Journal ofMedicine in 1969)l20l, which denotes a "policyof considering a manuscript for publication onlyif its substance has not been submitted orreported elsewhere" [21], essentially "to protectthe Journal from publishing material that hadalready been published and thus had lost itsoriginality"[21]. Rarely at times, for reasons ofdissemination of vital information for improvinghealth care, this rule has been relaxed.

e) Exercise caution while referring, analyzing andincorporating scientific material available on theInternet . There are several instances ofincomplete, misleading, inaccurate, disparatemedical in format ion avai lable on theInternet [22].

D Always encourage yourself to think and writeon original and new ideas.

Jour. Marine Medical Society, 2405, Vol.7, No.2

CONCLUSION

We are witnessing an era of increased interest,participation and overwhelming progress in academicwriting, publishing and editing biomedical journals.

Set within this trend, there are few instances of un-ethical practices that sully the overall picture, to acertain extent. Drawing attention to this, MayberryJ in an editorial, fittingly states that "fraud and pla-giarism are the death knell ofresearch. They bringindividuals, institutions, and academic journals intodisrepute"[23]. These recurring concerns emphasizea burgeoning need for awareness of ethical issuesin scientific writing, which indeed is the focus ofthis editorial.

In actual fact, the time has arrived for au-thors [24], reviewers [25], readers [26], subscribers,owners ofjournals, editors [27], editorial board mem-bers and publishers ofbiomedicaljournals [28], totake a dispassionate but resolute look at the aboveissues, as well as dwell on strategies to overcomepotentially damaging deviations.

As a final point, it can be repeated endlessly, thatthe core theme in ethical scientific writing, publish-ing and editing biomedical journals, is one ofnunuring intellectual honesty and sincerely promot-ing original scientific work.

REFERENCESl. R Horton. 21st-century biomedical journals: failures

and f u tu res . The Lance t 362 :9395 .1510 -1512

2. Flanagin A, Carey LA, Fontanarosa PB, Philips SGPace BP. Prevalence of articles with honorary authorsand ghost authors in peer-reviewed medical journals.

JAMA 1998t280:222-224

3. Notice of Retraction published on October 24,2002.Avai lable at ht tp: / /content .nejm.org/cgi / repr int /NEJMe0300l5vl .pdf ; Accessed on 02 Nov 2005

4. White C. Educat ion and debate: Suspected researchf raud : d i f f i cu l t i e s o f ge t t i ng a t t he t r u th . BMJ2 0 0 5 ; 3 3 I : 2 8 l - 2 8 8

5. McCarthy M. Lies, damn lies, and scientific research.The Lancet 20O4t364: 1657-1658

6. Sox HC. "Not ice of retract ion," Ann Intern Med,20O3:139:7O2,. Retraction of: Poehlman ET, TothMJ, Gardner AW Ann Intern Med. 1995 l;123(9):673-5. Available at http://www.annals.org/cgilreprint/139/8l7o2.pdt; Accessed on 03 Nov 2005

7. What Is Plagiar ism? Avai lab, le at ht tp: l lgervaseprograms. georgetown.edu/hc/plagiarism.html ;Accessed on 03 Nov 2005

Joun Maine Medical Society, 2005, Vol.7, No. 2

Harris R. In Anti-Plagiarism Strategies for ResearchPapers Veision Date: November 17, 2004. Availableat http://www.virlualsalt.com/antiplag.htm g Accessedon 0l Nov 2005

History News Network Index: What Is Plagiar ism?Available at http://hnn.us/articles/5l4.html; Accessedon 02 Nov 2005

McKenz ie J . F rom Now On : The Educa t i ona lTechnology Journal The New Plagiar ism: SevenAnr idotes to Prevent Highway Robbery in anElectronic Age : Available at http://fno.org/may98/cov9Smay.html; Accessed on 20 Oct 2005

Jdnes R et al. Letters: The scandal of poor medicalresearch: Sloppy use of literaturc often to blame. BMJI 994 :308 :59 I

Eysenbach G Report of a case of cyberplagiarism andref lect ions on detect ing and prevent ing academicmisconduct using the internet . J Med Internet Res2OOO 2:e 4. Avai lable at http : //w ww jrn ft .or gl 2OO0 | | |e4; Accessed on 03 Nov 2@5

Plagiar ism Detect ion Tools. Compi led by SharonStoerger. Avai lable at ht tp: / /www.web-miner.com/plagiarismlftools; Accessed on 0l Nov 2005.

International Comminee of Medical Journal Editors :Uniform requirements for manuscripts submitted tobiomedical journals: writing and editing for biomedicalpubl icat ion : Avai lable at ht tp: / /www.icmje.org/ :Accessed on 03 Nov 2005

World Association of Medical Editors: Web Resourceson Publicatibh and Research Ethics. Available at http://www.wame.org/ethicsrsource.htm; Accessed on 20 Oct2005

Committee on Publication Ethics. Available at http://www.publ icat ionethics.org.uk; Accessed on 0l Nov200sCounc i l o f Sc ience Ed i t o r s Ava i l ab l e a t h t t ps : / /www.councilscienceeditors.org; Accessed on 03 Nov2005

18. Off ice of Research Integr i ty . Avai lable at ht tp: / /www.ori.dhhs.gov; Accessed on 03 Nov 2005

Avoiding Plagiarism : Mastering the art of scholarship.From The Office of Student Judicial Affairs (SJA), UCDavis, The Regents of the Univers i ty of Cal i fornia.Available at http://sja.ucdavis.edu/avoid.htm; Accessedon 03 Nov 2005

Troy J. The Ingelfinger Rule: Franz lngelfinger at theNew England Journal of Medicine 196'l-77. ScienceEd i t o r : 20O2 ;25 :6 ;195 -198 . Ava i l ab l e a t h t t p : / /w w w . c o u n c i l s c i e n c e e d i t o r s . o r g / m e m b e r s /securedDocuments/v25n6p195-l98.pdfl Accessed on03 Nov 2005

Ingelfinger Rule from MedicineNet. Available at http:// w w w . m e d t e r m s . c o m / s c r i p t / m a i n /art.asp?articlekey=13488: Accessed on 04 Nov 2005

Silberg WM, Lundberg GD, Musacchio RA. Assessing,con t ro l l i ng , and assu r i ng t he qua l i t y o f med i ca l

8 .

9 .

12.

1 3 .

1 4 .

l 5

,}I

a'

r ' a

1 9 .

2 2 .

No.2 99

2 3 .

in format ion on the Internet : caveant lector et

viewor-let the reader and viewer beware. JAMA

1997: '277 :1244-1245.

Mayberry J. Edi tor ia l . Plagiar ism and f raud.

Postgraduate M edical Journal 2003;79:605. Available

at http ://www.pmj.bmjjournals.com/cgi/content/full/'79193'1-1605t Accessed on 12 Nov 2005

Perneger TV Hudelson PM. In Editorial: Writing a

research article: advice to beginners. International

Journal for Quality in Health Care 2004;16:3:l9L-

192 Available at http://intqhc.oxfordjournals.orglcgil,content / fu l l /16/3/191: Accessed on l2 Nov 2005

Hoppin FG Jr. How I Review an Original Scientific

Article. Ara J Respir Crit Care Med 20O2;166:.1019-

1023. Available at http://ajrccm.atsjournal.org/cgi/content/full/168/8/l0l ; Accessed on 12 Nov 2005

Lange JH. In Letter. Editors and their priorities about

libel and fratd. BMJ 2004;328:230.

Smith R. Edi tor ia l : Edi tor ia l misconduct . Medical

edi tors need ef fect ive sel f regulat ion. BMJ

2003.326:.1224-1225. Available at http://

bmj journals.com/c gi lcontent I fu l l l 32617 4O I I 1224 ;Accessed on 12 Nov 2005

The Longman Exercise Zone and avoiding plagiarism

from Pearson Educat ion. Avai lable at ht tp: / /

occawlonl ine .pearsoned.com/bookbind/pubbooks/long- longman-uopleazap- l /medial ib/splash.html IAccessed on 12 Nov 2005

Original I

HEAT S'

SurgCdrK

ABSTRACT

Sailors, in t

in ref i t as

spaces wher

TemPeraturselected het

discomfortObservatio

ManY sai lo

heart rate

for continr

Heat strest

of sailors I

to determi

KeY Word

INTROD'

\TavalL \ J u r v

spaces lil

areas wh

tions exmaintairdoning I

shiPs orried outexposed

The zvonditicval shiloPerati(

Anefunctioture atand thetion, ra

PrinciPrKalYani

Jour. M

) 1

28.

24

2 5

.lry

sRax8Metropolitian Drugs and Chemicals

A;ZASeat et*lttnezto

Mumbai

t r

100 Jour. Marine Medical Society, 2M5, Vol.7, No.2

trnal.otglcgi/2 Nov 2005

iorities about

r c t . Med i ca lr t r on . BMJa r h r rp : / /7 40u 1224:

g plagiar isnra t h t r p : / /

L/pu bbook s/p l a s h . h t m l ;

7, No.2

Ortginal AfticleHEAT STRESS ONBOARD A SHIP IN REFIT

Surg Cdr Kaustuv Chatterjee, Surg Cdr Kaushik Chatterjee

ABSTRACT

Sai lors, in the course of their dut ies are of ten at great r isk of st ress due to heat . This increases when ships arei n r e f i t as a i r - cond i t i on i ng shu t s down resu l t i ng i n i nc reased t empe ra tu re and hum id i t y w i t h i n con f i nedspaces where work has to go on,

Temperatures in var ious compartments of a ship in ref i t were recorded. Physio logic measurements of randomlyselected heal thy indiv iduals involved in l ight work were taken and they were evaluated for symptoms of heatd i scomfo r t . We t Bu lb G lobe Tempera tu re i ndex and Phys io l og i ca l Hea t Exposu re L im i t s we re ca l cu l a ted .Observat ions were repeated af ter the ai r condi t ioning was restored.

Many sai lors exper ienced heat re lated discomfort . There was a stat is t ical ly s igni f icant increase observed inheart rate when air -condi t ioning was non-operat ional . The durat ion of permit ted physio logical heat exposurefor cont inuous l ight work was found to less than hal f that in a i r condi t ioned environment.

Heat st ress condi t ions were found to exist on the ship which needs to be moni tored f requent ly. Work scheduleof sai lors needs to be modi{ ied to l imi t exposure and provide adequate rest per iods. Further s ludies are requiredto determine the heat exposure l imi ts to formulate ef fect ive heat st ress prevent ion programmes on board.

Key Words : Heat st ress, Heat balance, Heat re lated discomfort

INTRODUCTION

\Javal personnel are continually at risk of expoI \ sure to heat stress onboard ships. Machineryspaces l ike engine rooms, galleys and laundries areareas where high temperature and humidity condi-tions exist. The temperatures onboard ships aremaintained within the comfort zone by air-condi-tioning systems. However, during dry-docking ofships or when major maintenance routines are car-ried out on air-conditioning systems, personnel areexposed to heat stress for prolonged periods.

The aim ofthis study is to quantify the heat stress

"onditions experienced by personnel onboard na-val ships when the air-conditioning system is notoperational.

An essential requirement to maintain normal bodyfunction is the maintenance of core body tempera-ture at 37+1"C. Heat exchange between the bodyand the environment takes place mainly by convec-tion, radiation and evaporation of sweat. Heat may

also be transferred by conduction when the body isin contact with a hot surface. The basic heat bal-ance equation for the body is I I ,2]:

A S = M - W + C + R r E

where:AS - Change in body heat content.M = Metabolic heat generated by the body.W = Extemal workperformed.C = Convective heat exchange.R = Radiativeheatexchange.E = Evaporative heat loss.

A number of heat stress indices have been de-veloped to estimate the quantum of heat strainexperienced by the body and to establish safe l imitsfor acceptable heat strain. These indices attempt tointegrate the basic parameters (i.e. air temperature"radiant temperature, humidity, air movement, cloth-i ng and ac t i v i t y ) t ha t i n f l uence humanthermoregulation. Heat stress indices are conven-iently categorized into Rational, Empirical and Direct.

Principal Medical Off icer , INS Darshak, C/o Fleet Mai l Of f ice,Visakhapatnam. Classi f ied Special is t in Psychiatry, INHSKalyani , Visakhapatnam.

Jour. Maine Medical Sociery, 2N5, Vol.7, No. 2 t0 I

Rational indices are based on the heat balance equa-tion (e.g. Heat Stress Index (HSI),Index of ThermalStress (ITS) and Required Sweat Rate); empiricalindices are based on physiological responses ofhuman subjects like sweat loss (e.g. Effective andCorrected Effective Temperature (ET, CET), Pre-dicted 4-Hour Sweat Rate (PaSR)); direct indices arebased on measurement of temperatures (e.g. WetBulb Globe Temperature (WBGT), Wet Globe Tem-perature (WGT), Oxford Index).

The Predicted 4 - Hour Sweat Rate (P4SR) indexwas formulated by McArdle et. al. in 1947 in thenaval context. It is the amount of sweat producedby fit, acclimatized young men exposed to the envi-ronment for 4 hours, while loading guns withammunition during a naval engagement. They pro-posed a P4SR o f 4 .5 l as a l im i t , when noincapacitation of any fit, acclimatized young menoccuned [3].

The WBGT index is the most common and con-ven ien t i ndex used fo r sc reen ing i n ho tenvironments. The International Standards Organi-sation (ISO 7243)recommends its use as a screeningtool for establishing thermal stress. The referencevalues for acclimatized and non-acclimatized indi-viduals for various levels of activity are given inTable l. These values have been established forallowing a maximum core (rectal) temperature of38'C [4](Table l).

Physiological Heat Exposure Limits (PHEL) weredeveloped by the US Navy in 1973 [5]. The criteria

TABLE IWBGT reference values from ISO 7243 (f 989)

for determining safe physiological exposure to heatstress were based on a composite of cardiovascularand respiratory functions and core body and skintemperatures.

METHODOLOGY

The study was carried out on a Naval ship in dry-dock in the month of September at Visakhapatnam.The air-conditioning system of the ship was notoperational. The ambient outdoor temperature inshade at the time of the study was 32 t 5oC. Theoutdoor WBGT index in shade ranged from 26.ll"Cto 32.24" C (men = 29.17 " C).

Temperatures were measured in compartmentsusing a sling psychrometer. Psychrometric dry-bulband wet-bulb temperatures were measured in vari-ous compartments in the No2 Deck of the ship.which houses offices, messes, galleys, pantries, din-ing halls and ward room. Galleys were non-functionalduring the period ofstudy and thus personnel work-ing there were not exposed to any additional radiantheat from equipment like hot plates and heaters oradditional humidity from steam generated duringboiling/cooking.

Physiologic measurements of height, weight, oraltemperature and heart rate were taken of 14 randomlyselected healthy individuals involved in l ight work(M < l30Wm-2) on No2 Deck for five days. All indi-viduals were in medical category S I A I and not obese(Mean BMI =22.01Kgm-t, SD = 1.57). In addition,the individuals were queried for the presence or ab-sence of seven symptoms of heat related discomfort

namelleye iniaches.

Aireter, inThe nadition'tempel

Tnwb

wheretTnwbTdbTpwb

Thconfir(Tg) tture ('

the fo

wBcwhenTnwtTg

PIwere

PHExWl

whet-M

wB(C

the tparlcalcand

RES

1Noltheeralthefen

mawa

Jor'

Metabolic rate (M) inWatts per squoremetre (Wm'2\

WBGT reference value (oC)Person accl imatised to heat Person not accl imatised

Resting, M<65

Light work 65<M< l30

Moderate workI 30<M <200

Heavy work200<M<260

Very heavywork M>260

3 0

2 8No sensibleair movement

) \

) a

Sensibleal f movemenl

2 6

, <

29

2 6No sensibleair movement

l 8

Sensibleair movement

2 5

2 0

) LJ J

102 Jour. Marine Medical Socieil,2N1 Vol.7, No.2

re to heat,vascular

and skin

p in dry-patnam.was notature In"C. The26.1 | "c

rtmentslry-bulbin var i -re ship.ies, d in-nctional:l work-radiantaters orduring

;ht, oralndomlyrt workr l l ind i -rt obeseldit ion,: or ab-omfort

No.2

namely, fatigue, itching, decreased concentration,eye irritation, nose irrjtgtion, idc tlrrolt ed bcod.aches.

Air movement, measured using a digital anemom-eter, in the compartments was negligible (< 0.3 ms-').The natural wet bulb temperature for the above con-dition was derived from the psychrometric wet bulbtemperature using the formula: [6]

Tnwb = Tdb - 0.8 (tdb -Tpwb)

where:Tnwb = Natural wet bulb temperature (oC).Tdb = Dry bulb temperature (oC).Tpwb = Psychrometric wet bulb temperature (oC).

There being negligible radiant heat within theconfines of the compartments, globe temperature(Tg) was assumed to be equal to dry bulb tempera-ture (Tdb). The WBGT index was calculated usingthe formula for indoor WBGT: [4]

WBGT=O.7Tnwb+03T9

where:Tnwb = Natural wet bulb temperature (oC).Tg = Globe temperature (oC).

Physiological heat exposure limits (PHEL) in hourswere calculated using the formula: [5]PHEL = (17.25x108 - 12.97Mx105+18.61M2x103)xWBGT-5.36

where:"M = Metabolic power(Wm-2)WBGT = WBGTindex('C)

Observations were repeated for two days afterthe air conditioning system w?s restored, for com-parison. Two tailed, paired t test was used tocalculate the significance ofdifference for heart rateand oral temperature.

I(ESULTS

The mean WBGT index inside the ship in deckNo2 was observed to be 30.86'C (SD = L07) duringthe period when the air-conditioning was non op-erational as compared to26.26"C (SD = 0.46) whenthe air-conditioning system was operational, a dif-ference of 4.6oC.

The experience of heat related discomfort is sum-marised in Thble 2. When the air-conditioning systemwas non opeftrtional, a large proportion expedenced

Jour Marine Medical Society, 2005, WL.7, No.2

discomfort. The most common symptoms were tired-ness (39%), sore throat (39Vo\, eye irritation (29Vo),headaches (27Vo) atd sleepiness (23Vo) (Table2).

The mean heart rate and oral temperature re-corded during both phases is shown in (Table 3),(Figs. 1,2).

The Physiological Heat Exposure Limits calcu-lated for light work (M = 130 Wm-2) are shown in(Table4).

DISCUSSION

Within the PrescriptiveZone (PZ), as heat stressincreases, the human body maintains core tempera-ture at 37oC by increased sweating. Herein, the heartrate gradually increases with increasing heat stress.

TABLE 2Symptoms of heat-re lated dlscomfort

Sympaoms No Affected (%)

Air conditioning Air condiaioningNon operatlonal Operational

Tiredness

I t ch i ng" !Conccntrat ion

Eye I r r i tat ion

Nose l r r i tat ion

Sore throat

Sleepiness

Headachcs

z'r (39%)8 ( l l % )t 2 ( t 7 % )20 (29%8 ( l l t / o )27 (39%)t 6 ( 2 3 % )t 9 ( 2 7 % )

0 (0%)

0 (07o)

0 (07o)

0 (07o)

O (07o)

8 ( l l 7 o )

O (0o/o)

3 (4Vo\

TABLE 3Mean heart rate and oral temperalure

Air conditioning Air conditioningNon operational Operational

Heart Rate(m in ' r )

Temperature('c)

7 5 . 6 7(SD = 6 .17)3 6 . 6 3(SD = 0.30)

7 2 . 9 3(sD = 4.02)

3 6 . 6 0(SD = 0.30t

TABLE 4Phys io log ica l heat exposure l im i ts

Air conditioning Air conditioning

Non operational Op€rationalWBGT = 30.86'C WBGT = 26.26'C

Light Work(M = 130 Wm' ' ) 3.67 Hours 8.73 Hours

103

___-l

(.)

EI

II6

Eo

IctIr

Fig. I : Box plot ofobserved heart rate.

As heat stress increases further, the sweat rate stopsrising. In this zone called the Environmentally DrivenZone (EDZ), core body temperature starts to rise asdoes the rate of increase in heart rate. The transitionfrom IZ to EDZ is known as the Upper Limit of Pre-scriptive Zone (ULPZ). Beyond the ULPZ thethermal drift of heart rate is unable to maintain suffi-cient cardiac output and manifests as heat exhaustionand collapse even in otherwise healthy individu-als [3,7]. While there is considerable variation inthe amount of increase in heart rate in relation toincrease in core temperature, the heart rate increasesby - 15 b.min-r for rise in core temperature by I "C ina supine resting individual.(ISO 1992) t8l.

In this study, in the absence of air-conditioningthe WBGT index inside the ship was in excess of thelimit prescribed for light work in ISO 7243, indicativeof the requirement for modified work routines andfurther monitoring of heat stress conditions.

A large proportion of sailors experienced symp-toms of heat related discomfort. There was astatistically significant increase observed in theheart rate (difference in mean heart rate = 2.74b.min-r, p<0.05) of subjects when the air-condition-ing system was non-operational. There was nochange in oral temperatures which can be explainedby effective thermoregulation achieved by the bodyin the prescriptive zone. The time limit for permitted

1U

Fig. 2 : Box plot of oral temperature.

physiological heat exposure for continuous lightwork was calculated to be 3.67 hours in non-ACenvironment, which was less than half that in airconditioned environment.

The results indicate that while the sailors did ex-perience discomfort, the physiological strain in termsofincrease in heart rate though significant (p<0.05)was not high. The physiological heat strain how-ever would be greater in individuals involved ingreater amount of physical activity.

CONCLUSIONS

Thermal stress is a special problem on ships es-pecially on weather decks and flight decks duringoperations in the tropical seas. More so it is a com-mon problem below decks in high heat and humidityareas like engine rooms, galleys, laundries especiallywhen the air conditioning systems are ineffective ornon operational. The onset of symptoms of thermalstress are insidious and if ignored can rapidly dete-r iorate leading to ser ious condi t ions of heatexhaustion and heat stroke.

Protection against thermal stress requires limit-ing exposure. to hot environments, reduction ofphysical activity, and engineering control using aircirculators, adequate ventilation and spot coolingof heat generating areas, appropriate clothing andreplacement of fluid loss due to sweating.

Joun Marine Medical Society, 2005, Vol.7, No. 2

Heat stress conditions need to be monitored fre-quently. Work schedule of sailors needs to bemodified to limit exposure and provide adequate restperiods. Adequate intake of fluids and loose cottonclothing needs to be ensured. In harbour, provisionof air conditioning through external chilling plantswill go a long way in preventing heat related mor-bidity in ships with non operational airconditioningsystems.

The problem of heat stress is compounded dur-ing conditions like fire fighting and flight operationswhere personnel are exposed to excessive heat whilewearing clothing which compromises heat loss bypreventing evaporation of sweat. Introduction ofice vests worn by fire fighters under the fire proxim-ity suits and by fl ight deck crew will help inpreventing heat related disorders.

The study concludes that heat stress conditionsexisted on this ship in refit. Further studies are re-quired to assess the physiological heat strain onsailors involved in various specific activit iesonboard ships during operational and refit periods.A need has been felt for revision of reference valuesof WBGT index and physiological heat exposurelimits to suit subject populations acclimatised tohigher ambient temperatures of tropical environ-ments [9]. Studies are therefore required to determinethe physiological heat exposure limits applicablespecific to the population exposed so as to formu-late effective heat stress prevention programmes.

Jour. Marine Medical Society,2005, VoL7, No.2

REFERENCES

l. Climate and Health, Chapter II, Manual of Health forthe Armed Forces, Vol l,2OO2,

2. NIOSH. Cr i ter ia for a Recommended Standard:Occupat ional Exposure to Hot Environments.Published by the National Institute for OccupationalSafety and Health. 1986.

3. KC Parsons, Assessment of Heat Stress and Heat StressIndices, http://www.ilo.orglencyclopaedia/

4. Parsons KC. Internat ional Standards for rheAssessment of the Risk of Thermal Strain on ClothedWorkers in Hot Environments. Ann Occup Hyg 1999:43 (5) : 297-308.

5. Dasler AR. Ventilation and thermal stress, ashore andaf loat . In Chapter 3, Manual of Naval Prevent iveMedicine. Washington, DC: Navy Department, Bureauof Medicine and Surgery. 1974.

6. Michael Donoghue A, Murray J Sinclair and Graham PBates. Heat Exhaust ion in a deep undergroundmetalliferous mine. Occup Environ Med 2000: 57 :r65 -74 .

7. Bethia D, Parsons K. The development of a practicalheat stress assessment methodology for use in UKindustry, Published by Department of Human Sciences,Loughbo rough Un i ve rs i t y , Le i ces te r sh i r e , Un i r edKingdom.

8. Nigel AS. Taylor and Denys Amos, Insulated SkinTemperature and Cardiac Frequency as Indices ofThermal Stra in dur ing Work in. Hot Environmenrs,Publ ished by Combatant Protect ion and Nutr i t ionB ranch , Ae ronau t i ca l and Mar i t ime Resea rchLaboratory, Defence Science and TechnologyOrganisation, Department of Defence, Australia.

9. Sr ivastava A, Kumar R, Joseph E, Kumar A. HeatExposure Study in the Workplace in a GlassManufacturing Unit in India. Ann Occup Hyg 2OO0.,44 (6\ : 449-53.

t05

I

r. it

W,in

?eat

eoa*tt"netcto

/tn&

fK

PAR€L CH€MsT14UIYIBAI

]oin lldttte l}edical Society,2N5, Vol.7, No' 2

;ure to heatiovasculary and skin

hip in dry-hapatnam.p was noterature in5"C. The

n 26. I l 'C

partments; dry-bulb:d in vari-the ship.

Itries, din-functionalnel work-ral radiantleaters or:d during

:ight, oralrandomlyight work. All indi-not obeseaddition,rce or ab-scomfort

1.7 , No.2

EVALUATION OF THE ACCURACY AND RELIABILITY OFGLUCOMETER TO ASCERTAIN IT'S SUITABILITY FORMONITORING GLUCOSE HOMEOSTASIS IN HYPERBARICCHAMBER

Surg Lt Cdr CS Mohanty', Maj Rajeev Bajajf, Surg Lt Cdr P Gokulakrishnan*,

Surg Capt S Nangpal", Lt ColAjay Malik*

ABSTRACT

Oxygen may affect glucose meler and reference analyzer measurements. Fluctuations in whole blood glucose(WBG) levels while receiving hyperbaric oxygen therapy (HBO) result ing in seizure-l ike activi ty. Therefore,hyperbaric medical attendants rnust accurately monitor the WBG levels of these patients during HBOTT. lnaddressing this concern, this study evaluated the effect of change in oxygen tension (POr) in blood and in theambien t a tmosphere and thus accuracy and re l iab i l i t y o f commerc ia l l y ava i lab le g lucometers (G lucometerSure Step 'M/S Johnson & Johnson pro fess iona l p roduc t , Ind is ' ) in the hyperbar ic env i ronment . l0 b loodsamples were prepared from a healthy volunteer, ranging from 25 to 380 mg/dl by spiking and di lut ing, fortest ing Glucometers at I and at 2.8 atmospheres absolute (ATA). I t was noted that at 2.8 ATA, glucose values inSure Step Glucometer decreased in hyperglycemic range (>250 mg 7o) despite being high part ial pressure ofoxygen. The WBG moni to r i s p rec ised bo th in hypog lycemic and hyperg lycemic range up to 250 mgvo. V , /erecommend that Sure Step Glucometer can be used inside hyperbaric chamber for monitoring blood glucose ofpa t ien t undergo ing HBOTT.

Key Words : Hyperbaric chamber, Glucometer, Blood glucose,

INTRODUCTION

I ccurate glucose measurements are needed for6point-of,-care testing in crit ically i l l patients in.side the hyperbaric chamber. With the constraintsof space and fire hazards most of the life savingequipments are contraindicated for use even in caseof emergencies inside the chamber inside the hyper-

- baric chamber.

The fluctuation of blood glucose level underhyperbaric condition is well documented and thusthe most common cause of hypoglycemia especiallyin diabetic patient during HBOrT I I ].

seizure like activity due to oxygen toxicity in highPaO, commonly propose a difficulty to differentiatefrom the earlier condition. Thus the right diagnosisat right time is essential to save the life of a seri-ously ill patient and a portable glucose meter inside

the chamber can help to differentiate between twoconditions.

Oxygen, a confounding variable, can affect glu-cose meters measurements especially in hyperbarichyperoxic condition [2]. Most of the Glucometeravailable commercially use glucose oxidase enzymeto catalyze the oxidation ofglucose in blood by oxy-gen in atmosphere. The end product is HrOr. In OneTouch Glucometer (M/S Life scan - Johnson&Johnson professional product, India), HrO, pro-duced as a result of glucose oxidase action onglucose, reacts with a colorless benzothiazolinonedye to produce a blue coloration. While usingglucometer inside hyperbaric chamber, the ambientoxygen partial pressures are in excess of the normal0.2 ATA. Product brochures provided wi thglcometers acknowledge the fact the accuracy ofmeasurement is significantly affected by change in

'PG Trainee (Marine Medicine), Institute of Naval Medicine, Mumbai. rGraded Specialist (Physiology), Institute of Naval

Medicine, Mumbai. *Graded Specialist (Marine Medicine), INS Virbahu, Visakhapatnam. '* Senior Advisor (Marine Medicine),Institute of Naval Medicine, Mumbai. "Classified specialist (Pathology), INHS Asvini, Mumbai.

Jour. Marine Medical Society, 2405, VoI.7, No. 2 107

atmospheric pressure and oxygen partial pressure.Zero conection for use in high altitude is also rec-ommended by the manufacturer [3], no such zerocorrection is stated for use in hyperbaric chamber.The aim of the study is to evaluate the suitability ofGlucometer for monitoring the blood glucose levelin hyperbaric chamberby studying linearity of bloodglucose estimation and to suggest the correctionfactor, ifany, for such use.

MATERIALANDMETHODS

The study was conducted at Institute of NavalMedicine and INHS Asvini, Mumbai. Blood sam-ples were drawn fiom healthy volunteers only.Samples were collected in Lithium Heparin and NaFVacutainer. One Touch Sure Step Glucose neter wasused for blood glucose measurement. Blood glu-cose was also measured by RA 50 biochemistryanalyzer, which was used for Laboratory referencevalues.

Pre-study calibration

Calibration of RA 50 and Glucometer was doneby using respective standard control solution (glu-cose solut ion of 100 mg/dl ) suppl ied by thei rrespective firms, before commencement of the study.

Test Module

The study was carried out in two steps.

Step l:

20 venous blood samples were collected in l0each Lithium Heparin and NaF Vacutainers. Forstandardizing the glucometer in both, hyperglycemicand hypoglycemic ranges, appropriate dilution andspiking was done with calculated amount of normalsaline and 25 Vo dextrose solution.

Samples were tested by glucometer and RA 50 atnormal atmospheric or surface conditions. All 20samples were tested together by both glucotneterand RA 50 simultaneously. Standardization ofGlucometer was done by cornparing with referencelaboratory method (RA50) in both heparin and NaFvacutainers, done under normal atrnospheric condi-tions ofambient pressure and oxygen concentration.

Preparation of samples

DILUTION: Three diluted samples were pre-

108

pared, for hypoglycemic range ofblood glucose, bydiluting the blood samples with Normal saline in thefollowing amounts :

Sample No Who le B lood Norma l Sa l i ne

I

23

l m l2 m l3 m l

3 m l2 m ll m l

SPIKING: Blood sample no.4 was taken as isolatedwhole blood for estimation of blood glucose level.The next successive samples were spiked, forhyperglycemic range of blood glucose, with 25 VoDextrose solution. The amount of 25 Vo Der.trosesolution was calculated for each sample, to be suchthat a difference of 50 mg of glucose was achievedin successive samples, as given in details below.

Samp le No Who le B lood 257o G lucose So ln .

A

)6'l

89l 0

5 m l

5 m l

5 m l

5 m l

5 m l

5 m l

5 m l

l0 pt l20 pl30 pl40 pl50 pl60 pl

Calculation

The mathematical calculation done to get theamount of 25 Vo dextrose for increasing 5O mg Vo ofglucose in 5 ml of blood sample and calculated asfollow

50 mg can rise 50 mgolo if put in 100 ml blood

So to rise 5O mg%o in 5 ml of blood - amount to bedivided by a factor of 20

ThusX=50 /20=2 .5m9

25 ml of dextrose contain 25 7o of dextrose vol-ume /weight

25 gm of dextrose - 100 ml of solution

25000 mg of dextrose - 100000 microliters

2.5 mgof dextrose is contained in 100000/25000X2.5 = l0 micro liters

Thus six spiked samples of 50 rng difference insuccessive samples were prepared by adding 10, 20,30. 40. 50 and 60 microliters of 25 Vo dextrose solu-

Jour Marine Medical Society,2005, Vol.7. No. 2

50s 4 5o 4 0€ s sO T

f , nv t q

a l nga

tion.

Step

0nomductdiffepresstep,stepHen,plestestfthey

t .

2.

-2345t)

789

IJot,

Fig.

TAB

Resra s f

S a nNo.

lucose, byrline in the

r a l Sa l i ne

tion. The samples were marked 5 to 10.

Step 2:

Once the glucometer was standardized undernorrnal atmospheric conditions, evaluation was con-ducted by testing the same blood samples underdifferent conditions of pressure and oxygen partialpressures, inside hyperbaric chamber, in the secondstep. Samples collected in Nalr vacutainer duringstep I showed erratic reading in the glucometer.Hence, only heparin vacutainer collected blood sam-ples were studied in step 2. The blood samples weretested in four different atmospheric conditions, andthey are as follows.

l . At I ATA pressure wi th ambient oxygenconcentrations.

2. At 2.8 ATA pressure us ing a i r , ins ide thehype rba r i c chamber , immed ia te l y on

Glucose Values By RA50 & Glucomct€r h l lepsrinized

1 2 3 4 5 6 7 8 9 1 0ssmPlc No +RAso +Gk,*ter

Fig. I : Comparison of blood glucose value in RA 50 andGlucometer in samples using heparin anticoagu-lant.

TABLE Inisults of STEP l: Comparison of blood glucose valuesas found in heparin vacutainers

pressurization.

3. At 2.8 ATA pressure using air, inside thehyperbar ic chamber, af ter l5 minutes ofpressurization. During this time actual clinicalcases were continuing on HBOTT. Theirexhaledoxygen was enriching the atmosphere insidethe chamber. This test was done at peak oxygenconcentration just before ventilation of thechamber.

4. At 2.8 AIA pressure, inside the hyperbaricchamber, using 1007o O, under a paediatricbreathing hood.

RESULTS

All twenty samples, l0 samples each with lithiumheparin or NaF as anticoagulant, blood glucose wasevaluated in glucometer as well as in RA 50 bio-chemistry analyzer in laboratory.

First it was measured with blood samples withheparin anticoagulant. The results are shown in Ta-ble I and Fig. I, which depicts the blood glucoselevel in One Touch Sure Step Glucometer and labo-ratory RA 50 biochemistry analy zer.

The blood glucose values measured in RA 50and Glucometer of blood samples using NaF as an-ticoagulant are shown in Table 2 andFig.2.

Then blood glucose samples tested during stepI by both the estimation techniques were comparedas shown in Table 3 and Fig. 3.

The above data indicates that the values in

TABLE 2Resu l l s o f STEP l : Compar i son o f b l ood g l ucosevalues as found in Sodium Fluor ide vacutainers

S a m p l e W h o l e D i l u t i n g /No . B lood Sp i k i ng

RA 50 Glucorneter(Avgl

3 m l

2 m l

l m l

ts isolated:ose level.riked, forvith 25 VoDer.trose

lo be suchr achieved;below.

cose So ln .

, r,r) trlJ p l) trl) p l) lrl

.o get the) mg%o of;ulated as

blood

ount to be

trose vol-

rS

r0/25000

erence lnrg 10,20,ose solu-

i l.7, No.2

500s 4s0o 4O0€ ssog 3o03 250; 200; 1503 1006 5 0

0

S a m p l e W h o l e D i l u t i n g /No . B lood Sp i k i ng

RA 50 Glucometer(Avc.)

I23

56789l 0

l m l

2 m l

3 m l

5 m l

5 m l

5 m l

5 m l

5 m l

5 m l

5 m l

2 2A 1

' t9

8 01 2 81 8 6241l t t

4 t 4442

2 55 26 88 7t371 8 32513093994 3 0

I

2J

A

56789l 0

3 m l

2 m l

l m l

5 m l

5 m l

5 m l

5 m l

5 m l

5 m l

5 m l

I 8{ J

5 89 l1 4 52ro2 5 1320392448

l o

3 34 76 8I l 6t641 8 5) ) A

29032r

3 m l N S

2 m l N S

l m l N S

050 mg/dl100 mg/dl150 mg/dl200 mg/dl250 mg/dl300 mg/dl

l m l N S2ml NS3ml NS

05 01 0 01 5 02002503 0 0

Jour. Marine Medical Society, 2405, Vol.7, No.2 109

heparin samples in RA50 and Glucometer shows thelinearity and precision. However the values evalu-ated with samples collected in NaF as anticoagulantdemonstrated great variation between RA 50 andglucometer. Hence in step 2 (inside hyperbaric cham-ber) the NaF vacutainers were discarded andcollected only in heparin vacutainers.

The blood glucose values measured during step2 in different conditions are as shown in Table 4 andFig. 4. Tabulated are the blood glucose level in hy-perbaric (2.8 ATA) conditions using air, lNVo O,and air with enriched Oxygen as breathing medium.

The results indicate that there is a linearity ofblood glucose estimation of glucose values up 250mg/dl. Blood glucose estimation was precise in allsamples < 250 mg/dl in the differing hyperbaric con-dition and the values are significantly lower in the

TABLE 3Shows blood glucose value of both heparin and NaFsamp les

Sample Heparin blood samples NaF blood sampleNo. RA 50 Glucometer RA 50 Glucometer

range of blood glucose above 250 mg/dl. Aboveblood glucose of 250 mg/dl, the values were alsodiffering in the different conditions of the test. Hence,

Compar is ion o fRA 50 andGlucometer in NaF samples

3500€40o3 300:-200:100€o

1 2 3 4 5 6Srmplc No

7 I910';RAsa)+Glucometer

Fig. 2 : Comparison of blood glucose value in RA 50 andGlucometer in samples using NaF anticoagulant.

Compar is ion o f RA 50 and Glucometer

500

1 2 3 4 5 6 7 8 9 1 0stilebs No , --8i#*113?fl1""n"

, -Ei*,if,5,"*

Fig.3: Comparison of blood glucose value of bothhepar ln and NaF samples in RA50 andGlucometer.

500

? 400

I aooi zoo3 100

! +oo! 300i zoo; 100

0

Fig.4:

no corglucon

DISCI

Moon themethouct H

(

Thblue tthe ancose i

I

2J

A

56789l 0

) )427 98 0128r 8 62413124 t 4442

? {

7 '

6 88 7r371 8 3251309399430

l 84 35 89 l1 4 52t0251320392448

l 63 34 76 8l l 6t641 8 5226290321

TABLE 4Blood Glucose measured in Step 2 in different conditions

Sample No. Whole Blood Dilut ing /Spiklng IATA 2.8 ATA Aif 2.8 ATA O, 2.8 ATA

I234)6'7

89l 0

l m l2ml3ml5ml5 m l5ml5ml5 m l5ml5ml

3 m l N S

2 m l N S

l m l N S

050100150200250300

4 l

501', '

8 81 3 81 9 823s3083 5 5385

3 74 75 77 01 3 51 8 6221247357366

3 94 26 38 8t26l 7 l230244307325

3 94 76'l8 2t21t82222228243334

TIthe pInsidtial pl'he Ibarirrtsc

cduriA S S

dia6Thuoul

Jou1 t 0 Jour Martne Medical Society,2(N5, Vol.7, No.2

y'dl. Aboves were alsotest. Hence,

L d

e s

t t

"'-- 1

8 9 1 0.RA 50-Glucometer

n RA 50 andticoagulant.

l e t e r

9 1 0Hqpa4nl:rfl

nsperinnetor NaF

re of bothL A 5 0 a n d

2.8 ATA

3 9A 1

o /

8 2127t822 2 2) ) 9

243334

tL.7, No. 2

500G! 400

! soo: 200

; 100

0

Glucometer in var ious cond i t ions

1 2 3 4 5S a m p b N o

Fig.4: Blood glucose values in hyperbaric chamber invarious conditions.

no correction value could be estimated for use ofglucometer inside the chamber during HBOTT.

DISCUSSION

Most commercially available Glucometers workon the principle of Glucose oxidase (GOD) enzymemethod, which catalyses glucose to the end prod-uct H2O2 as shown in the equation below.

GOD

Glucose + 2H,O -+Gluconic acid + 2 HrO,

The H"O, thus formed reacts with a dye formingblue coloration and the amount of color indicatesthe amount of HrO, thus indirectly indicate the glu-cose amount in the blood.

peroxidase

Benzothiazolinone + HrO, --toxidised

benzothiazolinone (Blue) + HrO

.-.. This reaction could possibly be influenced bythe partial pressure of oxygen in the atmosphere.Inside hyperbaric chamber, the ambient oxygen par-tial pressures are in excess of the normal 0.2 ATA.'l

he fluctuation ofblood glucose level under hyper-baric condition is seen in various studies durinerBorT.

CNS oxygen toxicity is also a common problemduring hyperbaric oxygen therapy, which manifestas seizure during HBO2T both conditions possessdiagnostic dilemma to marine medicine specialist.Thus reliability of Glucometer is essential in hyper-baric chamber.

There have been a few studies conducted in dif-

Jour Marine Medical Society, 2405, Vol.7, No.2

ferent centers around the world. One study pub-l i shed i n M i l Med . i n 1995 conduc ted themeasurement of blood glucose in hyperbaric condi-tion using four different glucometers. They foundthat using the One Touch II Glucometer, the bloodglucose values were decreased in the hyperglycemicranges (> 150 mg/dl) when compared with normalatmospheric conditions [4].

Second study titled "Oxygen effects on glucosemeter measurements with glucose dehydrogenase-and oxidase-based test strips" found that increasein oxygen tension lowered glucose values meas-ured wi th Glucose Oxidase (GOD) based teststrips [5].

Our study shows blood glucose estimation wasprecise in all samples <250 mgldl in hyperbaric con-dition, linearity of glucose value up 250 mg/dl wasseen and the values are significantly lower in therange of blood glucose above 250 mg/dl.

CONCLUSION

During HBO2T, in hyperbaric condition, espe-cially in diabetic cases [6-8] blood glucose valuesare known to fall and hence are possibly be in lorverrange. In the normal and lower blood glucose range,the glucometer was found to be estimating bloodglucose within -5 Vo of the values as compared to thenormal atmospheric conditions. So it is recom-mended that One touch Sure step Glucometer canbe used inside the hyperbaric chamber during HRO,Tfor estimation of blood slucose.

REFERENCES| . Dr Viren J Ruparel , Surg Cdr MJ John, Surg Cdr S

Nangpal, Surg Lt CS Saxena. Astudy of blood glucoselevel changes during hyperbaric oxygen therapy. lourMar ine Medical Society 1996, Vol .3. No l , 3 l -311.

2. Edge CJ, Grieve AP, Gibbins N, O'Sullivan F, Bryson P.E f f ec t s o f p ressu re on who le b l ood s l ucose

J .

measurements using the Bayer Glucometer 4 b loodglucose meter. Und.erseu Hyperb Med 1996l' 23(4):221-

Fink KS, Christensen DB, Ellsworth A. Effect of highaltitude on blood glucose meter performance. DiabetesTechnol The r 2002t4(5):627 -35.

Price ME Jr, Hammett-Stabler C, Kemper GB, DavisMG, P iepme ie r EH J r . Eva lua t i on o f g l ucosemoni tor ing devices in the hyperbar ic chamber. Ml lMed 1995: 160(3): 143-6.

Tang Z, Louie RF, Lee JH, Lee DM, Miller EE, Kost) .

6 7 8 9 1 0+2.8ATA oir. . . . - . .2.84T4 r009a 02- -- . - 2.8 ATA b€do€ Entil6llo

/

IIi

A

1 1 1

8 .6 .

GJ. Oxygen effects on glucose meter measurementswith glucose dehydrogenase- and oxidase-based test

str ips for point-of-care test ing. Cr i t Care Med2OOl;29(5): r062-7O.

Longoni C, Camporesi EM, Buizza M, et al. Reductionin insul in requirements dur ing hyperbar ic Oxygen

therapy. UBR 1988; l5(suppl) :16-17.

Kakhnovskii IM. Efuni SN. Khodas MY, Bolshakova

TD, Gitel EP. The mechanism of hypoglycemic effectof hyperbaric oxygenation in diabetes mellitus patient.

KIln Med (Mosk) l98l; 59(9):83-88 HBO Rev 1983Ju l ; 4 (3 ) : 143 .

Takahashi H, Kobayashi 3, Sakakibara K. Effect of

hyperbar ic oxygen on the endocr ine system and

metabolism of diabetic patients. Undersea Biom Res

1990; l7(suppl) :52.

PERSO]TRAII{ISERVI(

SurgltCtIlkJYotiX

ABSTRAC

SubmarintsubmNrineNavY. A ctSubmarinunstructulevels duridentifiedsufficientexpectedminimalPsYchoti(conserval

Key. Wor

INTROI

Tn 162(-lcian CmergedarmoryNavY ht

Subtstress, tlonged

Peculia(a) Nt

cohu

(c) Dwbt

sl

'Gd Sp(Marin,INHS

Joun I

AcZLSeat eo**nztato

/ttirrtc

>KIay Chemist

Mumbai(b) Isr

ni

I12 Jour Murine Medical Society,2N5, Vol. 7, No. 2

emic effecttus pat ient .Rev 1983

Effect of, s t em andBionr Res

t, No.2

PERSONALITY PROFILE OF SUBMARINE VOLUNTEERS ANDTRAINEES: CAN WE PREDICT MOTIVATION FOR SUBMARINESERVICE?

Surg Lt Cdr P Gokulakrishnan', Surg Cmde I\4I John*, Surg Cdr DK Ghoshr,Ms Jyoti Rathod", Surg Cdr K Chatterjee*, Maj Rajeev Bqiaj#

ABSTRACT

Submarine operations demand capacity to sustain physical isolat ion and resistsnce to hardships, The job of asubmariner is different from that of a surfacc mariner, However their traits bave trot been quantified in IndianNavy. A computerised psychological asscssment protocol was drawn out and tcsted on 61 volunteers of BasicSubmarine Course, before, during and after training. These quali t ies were also assessed by conventionalunslructured interviews. Submariners indicate a high degree of satisfact ion in respect to food and energylevels during sailing but were dissatisfied in relation to job satisfaction and recreetion. l6 Personality Factoridenti f ied a few traits common to submarine volunteers, They were reserved (A'), conservative (Q,) and self-sufficient (Qr'). They were also tense (O') and apprehensive (Qn') during the time of medical examination as isexpected natural ly and these lraits were not reproduced subsequently. Results of tbe study indicate an easy,minimal staff involving but t ime consuming way to identi fy traits desirable in submariners, viz, absence ofpsychoticism, phobic-anxiety, substance abuse potential snd somatisation and presence of self control,conservative and conscientious traits. Provision of the inventory in Hindi wi l l augment the val idity.

Key Words: Psychometry, l6 PF, personali ty tests, Submarine voluntcers, Motivation

INTRODUCTION

Jn 1620, a manned craft made by the Dutch physi-lcian Cornelius van Drebel which remained sub-merged for 4 hours, heralded an addition to thearmory of a naval fleet - the Submarines. IndianNavy has been operating submarines since 1960's.

Submariners are likely to be exposed to morestress, because the confined microclimate under pro-loqged submergence presents a number ofpeculiarities, like:

(a) Need to adapt to changing environmentalcondi t ions - pressure, temperature andhumidity.

(b) Isolation from familiar world. Absence of day/night cues and sunlight.

(c) Differing work and rest routine which interferewith innate biological clock. lnadequdte restbecause of intermingled working and livingspace.

(d) Poor habitability condirions: Cramped space.Persistently increased ambient temperature.I nsu f f i c i en t space fo r re laxed phys i ca lmovements.

(e) Lack of diversion and entertainment.

(D Severe drinking and washing water restriction.

(g) Lackofprivacy.

(h) Separation from family and friends and

0 Constant threat to life while deployed, not onlyfrom enemy action but also from the vast abyssof the ocean.

The physical manifestations of a submariner un-der stress include autonomic instability, lethargy,emotional lability and hypodynamia leading to de-c reased work ing capab i l i t i es and i nc reasedaccidents [].

Essentially a person employed in an isolated en-vironment should be emotionally stable, free from

'Gd Specialist (Marine Medicine), INS Virbahu, Visakhapatnam, 'Director, Institute of Naval Medicine, Mumbai, rCl Spr:cialisr

(Marine Medicine), INS Satavahana, Visakhapatnam, "Clinical Psychologist, INHS Asvini, Mumbai, .tl Specialist (Psychiarry),INHS Kalyani, Visakhapatnam, "Gd Speciatist (Physiology), Institute of Naval Medicine, Mumbai.

Jour. Maine Medical Society, 2005, Vol.7, No.2 1 t 3

psychoticism and phobias, conscientious, objectiveand not hypersensitive [2]. Desirable qualities insubmariners include achievement motivation, prac-tical ability, enthusiasm, perceptual speed, alertness,quick decision making and stress endurance [3].However these traits have not been quantified inIndian Naval Submariners.

A battery of computerized psychological testswas selected to assess the personality of submarin-ers. Since 'reliability' and 'validity' of psychometryare complicated, validation of these tests has beenattempted against unstructured interview [4]. Stand-ard biostatistics methods were used for analyses [5].

AIM

l. To identify consistent personality traits insubmarine volunteers and compare them withgeneral population norms.

Z To study the behavioural pattern of submarinevolunteers and trainees so as to identify theirmotivation for submarining.

3. To identify factors desirable for positivemotivation towards submarine service. whichcan be used as predictive factors in submarineentry-level screening.

MATERIALSANDMETHOD

Subjects

The subjects for the study were the 6l subma-rine volunteers who reported to INS Virbahu for FinalSubmarine Medical Fitness examination in early 2000.On selection and medical fitness. the successfuluoiiht"".t proceeded to the Submarine school, INSSatavahana forthe 12 months long Basic SubmarineCourse (BSC). The relative uniformity of their age,educational and socioeconomic background andcommonality of basic naval training and years ofservice made them a homogenous group. Thesecommon factors also ensured that they belonged tosimilar pay scale (monetary standard of living), aremostly unmarried and have few family commitments,owing to their young age and most of them beingbachelors.

Test Material

The Following computerised psychometric testswere administered. The tests were in the form of

I14

questionnaires in English language.

(i) Custom - made symptoms checklist (CSCL).

(ii) Cauell's l6 Personality Factor (l6PF).

(iii) Satisfaction Scale.

( iv) Car lsson Chemical abuse potent ia l test .(ccAPT)

The tests were administered 4 times:

(i) Initially - at volunteering.

(ii) After 3 months - During escape training.

(iii) After I year - During sea service on boardoperational submarines.

(iv) After 2 years.

Initial tests were spread over 2 days to ensure

(a) Absence of attrition due to medical unfitness.

(b) Follow up of findings of the previous day:Verifying records from Service Documents.

On day one, the subjects were individually inter-v iewed, in formed consent obta ined and thedemographic data sheet completed. On day two, thevarious tests and scales were administered.

cscLCSCL has an inventory of 45 psychiatric symp-

toms grouped under 9 factors that provides dataregarding various psychiatric ailments. The subjectis instructed to read the statements/ questions care-fully and answer by selecting their choice.

16 PF

The Cattell l6PF model, with 105 questions, isprobably the most-widely used system for catego-rising personality [6]. The result sheet providesgraphically on a ten-point scale l5 personality fac-tors and lmental abil ity factor. Each factor ismeasured on a bipolar scale.

Satisfaction Scale

This is a subjective self-rating scale of 0 to 9. Theareas covered are: Appearance, Food, Energy lev-els, Family love, Money, Job comfort, Recreationand Self-sufficiency. The scales were administeredthrice during this study, once at entry level and twiceafter qualifying for submarine service: once at har-bou r and once du r i ng a submar ine sa i l i ng .Instructions are also given to decide quickly and to

Jour Marine Medical Sociery, 2005, Vol.7, No.2

4

rg/dl. Abovees were alsor test. Hence,

n dr l e s

8 9 1 0-RA50+ Glucometer

in RA 50 and

Lnt icoagulant .

' n l e l e r

I 1 050 Hep€fin:omoter hoDarin50 NsF)omelgr NaF

r lue of borhR A 5 0 a n d

2.8 ATA

3 9A 1

6 78 2t271 8 22 2 22282 4 3334

VoL7. No.2

,/

enter the response at the first instance.

CCAPT

This inventory has 50 questions and is useful inassessment of substance abuse potential. The testis classified into l8 different categories assessingon chemical abuse, thought disorder, antisocial ten-dencies etc.

Interview Assessment

The subjects were subjected to unstructured in-terviews at init ial entry, during Escape training,during sea service on board operational submarinesand after 2 years of volunteering for submarine arm(l year after completing submarine service). Anysubject who had significant features necessitatingfollow up was interviewed again.

RESI.II.JT

Age distribution : Mean age of this sample atentry to the study was 22 yrs and 84 days with arange of l9yrs and 02 days to27 yrs and 348 days.

Naval service : The sample had mean 38.07months of Naval service with a range of 23 to 6lmonths.

Educational status i The minimum educationalqualification was Class lO.8.l9%o were graduates ordiplomates, 52.47 Vo held pre-university qualifica-tions and 39.34 Vo were matriculates.

Marital status | | | .47 7o of the sample was mar-ried. All had arranged marriage and mean durationof marriage was22 months.3 subjects (4.9Vo)had

. , children.

Smoking habit : 3l .14 Vo of the sample gave his-tory of cigarette smoking. Mean quantify of cigarettesmoking was 4.2 pack years.

Alcohol conswnption :39.34 70 reported com-plete abstinence from alcohol consumption. Meanweekly quantity of consumption for the rest was300 ml of spirits. None of the subjects gave historyof binge drinking, relief drinking, prenoon drinkingor drunken brawl leading to punishments. Serviceand medical records verified this.

Experience with substances of abuse potential :None of the subjects reported any experience withany substance of abuse. There were no clinical signssuggestive of substance abuse noticed during the

Jour Maine Medical Society, 2005, Vol.7, No.2

interactions.

Major illnesses in the past: None of the subjectssurveyed had a history of hospitalization with majorillnesses. They were all in Medical category S I A I .There was no history of head injuries in the past. Nosubject sustained any diving accident during Es-cape Training other than trivial otitic barotrauma.

Order of birth:26.22 Vo weft the eldest sibling,37.70 Vo were the youngest and the rest were ofmiddle birth order.

Family history of mental illness : Two subjectsreported history suggestive of Alcohol Dependencein their Fathers, and one, in his elder brother. Noneof the others reported a history of mental illness inthe family.

Diving qualif ication : Two subjects also hadShip's Diver's qualification with a mean diving serv-ice of 20.5 months. Thev had no historv of divinsaccidents.

Success in taining : All the 6l subjects whowere inducted in the study completed Escape train-ing. 60 of them completed BSC successfully at theend of I year. I sailor has failed in the qualifyingexamination at the end of training. 59 of them(92.72Vo) were on active submarine service 2 yearsafter induction, thereby completing the study. I sailorwas removed from submarine cadre on disciplinarygrounds.

16 PF factors : Mean and standard deviationsfor the 15 Personality factors in submarine volun-teers is shown in Table l. The scoring for all 16factors at various times is shown in Tables 2 to 4.

CSCL : The scoring for each factor at varioustimes is shown in Table 5.

Satisfaction scale : Average scoring in Satisfac-tion scale is shown in Table 6.

Relative positions of the various factors in satis-faction scale are shown in Table 7.

CCAPT: None of the subjects showed any ten-dency for substance abuse.

St ructure d int e rv iew s : Most subjects confessedthat the most important reason for them volunteer-ing for submarine service were:

a. Urge to see enemy action/ contribute to navaloperations &'victories' (52.45Vo)

1 1 5

b. Extrapay (4O9Vo)

Parental/brotherly counseling (father/brotheris/was a submariner) (4.9lEo).

The comparison in scoring pattern in 16 PF and

TABLE IScoring of submarine volunteers in 16 PF

Factor

CSCL of the 2 subjects who failed to qualify as sub-mariners is shown in Tables 8 and 9 respectively.

DISCUSSION

The nature of the job performed by a submarineris very complicated compared to the normal dutiesof a sailor. It is but natural that one with an aptitudevolunteers for it. Certain personality characteristicsshould naturally help him to be successful in fulfill-ing his role. This is all the more important sincesubmarining is a life-long career; by volunteeringfor submarine arm, the sailor is committed tosubmarining for the entire duration of his career.How well he performs as a submariner, decides howhis naval career shapes up. The duration of trainingfor submarine arm is also the longest amongst allbranches in the Indian Navy. The topic of selectionis especially important in military applications fortwb reasons: the physical and emotional demandson military personnel are considerable, and the costof failure, in training or in actual duty, is very great.

There is very little literature on selection ofsub-mar ine rs , ma in l y because submar in ing i s aclandestine profession, especially key to the bal-ance of power in the cold war era. A few reports onthe personality characteristics of Russian, NATO

TABLE 4Scores in fa

Factor: PsYl

Submarine volunteers( n = 6 1 )

M e a n S D

G e n e r a lpopu la t ion

m e a n

Low = Scores

Medium = Sc

High = Scorer

+ 2 Test Find

TABLE 5Average sco

Factor: Al l

Low = Score

Medium = S

High = Scor

+ 2 Test Fin

TABLE 6Average sc

Average S

A

cE

F

G

H

I

L

M

N

oQ lQ 2Q 3Q4

4.495 . 0 25 . 6 65 . 0 85 . 2 15 . l 05 . 5 25 . 3 55 . 7 56 .036.204 . 8 16 . 1 64 . 8 96 . 2 0

l . 3 lt . 3 71 . 3 9l . l 00 . 9 61 . 4 01 . 0 01 . 5 31 . 2 00 . 8 80.93l . 3 31 . 4 4t . 2 2t . r 8

5 . 55 . 55 . 55 . 55 . 5) . )5 . 55 . 55 . 55 . 55 . 55 . 5) - )5 . 55 . 5

TABLE 2Scores in factor G

Factor: G - Rule Consciousness I n i t i a l( n = 61 )

3 Months(n = 6 l )

12 Months(n = 60)

24 Months(n = 59)

Appearance

Food

Energy Lev

Fami ly Lov

Money

Job Comfot

Recreat ion

Self-sufficit

All Factors

Low = Scores I to 4: Expedient

Medium = Scores 4.5 to 6

High = Scores 6.5 to l0: Conscientious

+ 2 Test Findings

64 69

54 88

N o tSignif icant

4

4 5

l l

No tSigni f icant

z

4 6

l l

S i gn i f i can t( P = 0 . 1 5 2 7 )

TABLE 3Scores in factor Ql

TABLE 7Relative p

Order of I

Factor: Ql - Openness to Change I n i t i a l( n = 6 l )

3 Months(n = 6 l )

l2 Months(n = 60)

24 Months(n = 59)

Low = Scores I to 4: Conservative

Medium = Scores 4.5 to 6

High = Scores 6.5 to l0: Radical

+ 2 Test Findings

l 83 76

2 03 65

N o tSignificant

2 829J

Signi f icant(P = 0 .0124 )

2 73 0

High l ySigni f icant

(p = 0 .0018 )

I23A

6

7

8

1 1 6 Jour Maine Medical Socieo, 2005, Vol.7, No.2 Jour lrtlai

TABLE 4Scores in factor 'Psychoticism'

Factor: Psychot ic ism In i t i a l(n = 6l )

3 Months(n = 61)

12 Months(n = 60)

24 Months(n = 59)

Low = Scores 0 or I

Medium = Score 2

High = Scores 3 or 4

+ 2 Test Findings

5 8J

0

5 830

NotSignificant

5 820

NotSignificant

5 8I0

Significant(P = 0.0455)

TABLE 5Average scores in all factors in CSCL

Factor: All In i t ia l(N = 6l)

3 Months(N = 6l)

l2 Months(N = 60)

24 Months(N = 59)

as sub-ively.

narinerI dutiesptitudeeristicsfulfill-t sinceteeringtted tocareer.es howraininglgst alllectionons for:mandshe costI great.

of sub-g i s ate bal-orts onNATO

nthss9)

Low = Scores 0 To 60Medium = Score 6l To 120High = Scores l2l To 180+ 2 Test Findings

5 830

5 830

Not

Significant

5 8)0

Not

Significant

5 8I0

Significant(P = 0.0455)

TABLE 6Average scoring in Satisfact ion scale.

Average Scores For Factor Initial (N = 61) AFAfter 12 Months(At Harbour) (N = 60)

After 12 Months(During Sail ing) (N = 59)

Appearance

Food

Energy Levels

Family Love

Money

Job Comfort

Recreation

Self-sufficiency

All Fb'ctors

6.846.566.596.64< 1 )

6 .056.756 . 6 16.47

6.956.666.736.686 . t 46 . r 76 .866.766.62

6 . 7 36 . 8 36 . 86 .696 . 4 25 . 8 56 . 3 26 . 5 16 . 5 2

cantt527)

TABLE 7Relative positions of the various fsctors in satisfaction scale

Order of Merit Init ial (N = 6l) After 12 Months(At llarbour) (N = 60)

After 12 Months(During Sail ing) (N = 59)

nthsr9) I

23456

8

Appearance P

Recreation

Family Love

Self Sufficiency

Energy Levels

Food

Job Comfort

Money

Appearance

Recreation

Self Sufficiency

Energy Levels

Family Love

Food

Job Comfort

Money

Food 1Energy Levels 1Appearance JFamily Love 1Self Sufficiency JMoney ?Recreation JJob Comfort J

e

e4I

I

J

I

e

e

ly)ant0 l 8 )

', No.2 Joun Marine Medical Society, 2N5, VoL7, No.2 i l7

TABLE 8The comparison in scoring pattern in l6 PF of the 2 subjects who fai led to qual i fy as submariners with theaverage scoring for the volunteers

Sub jec ts A C E M Q r Q 2 Q 3 Q 4

Average 4.45(N = 59 )

Subject 6.5

N o 1 4

Subject 5

No 44

4 . O 4 2 4 . 9 9 5 . 6 3

6.5 6 .5 ' l

2 5 6

5 . 1 9 5 . 1 0 5 . 5

5 5 . 5 6 5

6 . 5 4 . 5 6

5

2

^

4 . 8 9

4 . 5

5

t 4 5 . 3 7 5 . 7

s . 5 6

4 7

6.05 6.22

6 5 . 5

5 6

4 . 8 1

3 . 5

6

6 . 1 5

6 . 5

6 . 5

6 . 2 0

6

6 . 5

TABLE 9The comparison in scoring pattern in CSCL of the 2 subjects who fai led to qual i fy as submariners with theaverage scoring for the volunteers

Sub jec ts Somat i - Obsess ive- In te rper - Depress-z a t i o n c o m p u s o n a l i o n

s t ve

A n x i e t y A n g e r -h o s t i l -i t y

Phob i c Pa rano id Psycho - To ta lA n x i e t v I d e a t i o n t i c i s m

S e n s i t i -v i ty

Average 0.644(n = 59 )

Subject 2N o 1 4

Subject 2No 44

0 . 9 6 6

I

I

0.847

2

2

0 . 5 7 6

z

2

|.23'7

I

I

0 .847

I

)

34.22

7 4

1 i

I

2

2

0 . 3 5 6 0 . 5 7 6

t 2

t 2

S Qualities in successfulNo. trainees

Qualities in unsuccessfultraine€s

TABLE TOcomparison of Psychological traits of successfuland unsuccessful trainees

features. Indian Submarines are bought from West-ern Nat ions, most ly of f the shel f wi th l i t t lemodifications to existing designs.

l6 PF evaluation ofour subjects identified a fewtraits common to submarine volunteers. They werereserved. conservative and self-sufficient. Thd hnd-ings compare favourably with a similar study doneby van Wijk C, Waters AH on South African subma-riners [7]. An extroverted person will feel out of placein the close confines of the submarines with smallcrew. Conservative personnel are more focused towithstand long hardships and deprivation of crea-ture comforts. The study conducted at Departmentof Psychology, Institute for Marit ime Medicine,South Africa, on Personality characteristics of 85submariners aimed to determine the extent to whichI 6 PF can be used to describe successful submarin-ers [7]. Although no significant factors were foundin their study, the results indicate that four person-ality factors appeared to be most descriptive of thesample. They were adventurousness, confidence,group orientation, and self-sentiment.

Jour. Maine Medical Society, 2005, Vol.7, No.2

Highhas beergroup ittency - agroup 0to teamthe subtstrong Ishown I"buddyFactor I

Thelish ancwithouovercoor pre!comfotMJ an<of Matalso fein Indidifficu

I n afu lNaand JtUSAseniorusingPersottraitswere rcritericial, <thesemodi:to en\voun,larity,

IntrainrPsycAfrite tytrainredusugEattri'

Jour

I Reserved

2 Humble

3 Sober

4 Tough minded

5 Pract ical

6 Absence ofpsycho t i c i sm

7 Self assured

Outgoing

Assert ive

Happy go lucky

Tender minded

Imaginat ive

Presence ofpsychot ic ism

Apprehensive

and US Navy (USN) submariners and divers wereavailable. The Indian submariner essentially differsin psychological make up from this group, due todifferences in social structure, ethics, family values,economic status and tough job profile prevalent inhis society compared to his western counterparts.In addition, all the above countries build their ownsubmarines, taking into consideration their operat-ing conditions, built for their men and oceanographic

n8

l ? i lh the

Q 3 Q 4

1 . 8 9 6 . 2 0

r . 5 6

6 . 5

w i t h t he

o. TotalI

34.22

1 A

1 4

'rom west-v i t h I i t t l e

ified a fewThey were. The find-;tudy doneran subma-rut of placewith smallfocused torn of crea-epanmentMedic ine,;t ics of 85rt to whichsubmarin-rere foundur person-tive of thelnfidence,

Vol.7. No.2

High scores on Q2 is difficult to describe since ithas been expected that submariners due to their closegroup interaction would score low on group depend-ency - a 'Joiner" and a sound follower [8]. A positivegroup orientation is expected to assist in adjustingto teamwork approach to submarining and the waythe submariners see themselves as an elite unit, withstrong loyalty code. However studies [9,10] haveshown that even combat divers with a strong inbuilt"buddy system" also scored inexplicably high onFactor Q2.

The statements made on the screen were in Eng-lish and at times, subjects pressed the keys randomlywithout comprehending the question. One way toovercome this draw back is either to explain to himor present the questions in a language he is mostcomfortable with. In AFMRC hoject No 2 I 30/96 JohnMJ and RyaliVSSR studied the personality factorsof Marine Commandos of Indian Navy I l]. Theyalso felt the need for computerized questionnairesin Indian languages familiar to the sailors who haddiff i culty in understanding English.

In a study, Personality characteristics ofsuccess-ful Navy submarine personnel, by Moes GS, Lall Rand Johnson WB of Submarine Squadron Seven,USA evaluated the personality characteristics ofsenior and occupationally successful submarinersusing the Schedule for Non-adaptive and AdaptivePersonality (SNAP) [2]. Results indicated that thetraits of detachment, propriety, and workaholismwere most descriptive of the sample. 377o met SNAPcriteria for a personality disorder, typically antiso-cial, obsessive-compulsive or avoidant.. Howevert'liese are a result of initial inherent traits after beingmodified over the years of remaining and adaptingto environmental demands aboard submarines. Theyoung trainees in our study did not reveal any simi-larity.

In a study tit led Submarine escape: the effect oftraining on anxiety, van Wijk C at Department ofPsychology, Institute of Marit ime Medicine, SouthAfrica. evaluated submariners with the IPAT Anxi-ety Scale before and af ter submar ine escapetraining I I 3]. He hypothesized that training shouldreduce the anxiety of submarine escape. Resultssuggested a decrease in overt and covert anxiety,attributable to the effect of training. In our study no

Jour Marine Medical Society, 2005, Vol.7, No.2

trainee revealed any anxiety during Escape training.

Some studies [4,15] describe the relationshipbetween personality factors and stress disorders,including cardiovascular disease risk in submarin-ers. This remains to be seen in the long run.

Thirst for action and monetary perks were foundto be the most important factors motivating the vol-unteers to opt for submarine arm.

Satisfaction scale is appropriate to single out thesatisfaction levels in submariners, especially whencompared to pre-selection levels, since its showswhether the expectations of the clientele are met.Submariners indicate a high degree of satisfactionin respect to food and energy levels (during sail-ing). This is probably because the extra 'sailing' rationprovided to a submariner not only makes the diettasty but also betters the nutritional status improv-ing energy levels.

Submariners were relatively dissatisfied with jobcomfort and recreation while at sea. The boredom ofmonotonous life, absence of natural and social stimu-lus, cramped spaces, lack of entertainment and theneed to remain focused on job constantly make thesetwo factors relatively difficult to adjust to.

In the CSCL the successful submarine volunteersconsistently scored less in somatisation, phobicanxiety and psychoticism. These factors appearedappropriate when discussed from an environmentaldemand perspect ive. Absence of phobias andpsychoticism has always been recognized as char-acteristics of a submariner. This studv confirms thatfact.

An analysis of the profile of the volunteers whocould not qualify for the submarine cadre indicatesthat their traits were different from the rest of thesuccessful volunteers. Their very low incidence pre-cludes statistical confidence. The differences aretabulated in Table 10.

Results of the study indicate an easy, minirnalstaff involving but t ime consuming way to identifydesirable traits in submariners, namely absence ol'psychot ic ism, phobic-anxiety and somat isat ion:absence of substance abuse potential and presenccof se l f contro l , conservat ive and conscient ioustraits.

1 t 9

ACKNOWLEDGEMENT

This paper is based on Armed Forces Research CommitteePrcject 2258199 titled "In depth analysis of bchaviouralpattern of submarine volunteers and trainees to predictmotivation for submarine service"

REFEREI\CT^S

l. Thomas TL, Parker AL, Horn WG et aI. Accidenrsand injuries among U.S. Navy crdwmembers duringextended submarine patrols, 1997 to 1999, Mil Med2001; 166(6): 534-40.

2. Rosnet E, l,e Scanff C, Sagal MS. How self-image andpersonali ty inf luence performance in an isolatedenvironment. Environ Behav 2OOO; 32(l): l8-31.

3. Weybrew BB, Molish HB. Attitude changes during andafter long submarine missions. IJndersea Biomed Res1979: 6 Suppl 5: 175-89.

4. Kaplan H, Sadock B. Comprehensivc textbook ofPsychiatry. 6,h ed. Williams & Wilkins, 1995.

5. Swinscow TDV, Campbell MJ. Stastistics at square one.l0ti ed. London: BMJ Books, 2003.

6. Cattell RB, Eber HW, Tatsuoka MM. Handbook forthe l6PF. Champaign, IL: Institute of personaliryand Aptitude Tesring, 1992.

7. van Wijk C, Waters AH. Personality characteristicsof South African Navy Submarine Personnel. Mit Mcd2000; 165(9):656-8.

120

Hampson S. Personality. Psychologist 1999: 12 :284-8.

Biersner RI, La Rocco JM. Personality characterisricsof US Navy divers. J Occup psychol 1983; 56: 329-34.

Beckman TJ, Johnson WB. Lall R. Salient personalitycharacteristics among navat personnel. MiI Med 1996;16l:717-9.

John MI, Ryali VSSR. Computcrised psychometricevaluation of personali ty prof i le of MarineCommandos. Institute of Naval Medicine, Mumbai:1996. AFMRC Project report 2130196.Moes GS, Lal l R, Johnson WB. personalirvcharacteristics of succcssful Navy submarine p"rronn"i.Mil Med 1996: 16l(4): 239-42.van Wijk C. Submarine csclpe: the effect of trainingon anxiety. Mil Med 1998;163(2):68-70.

Tappan DV, Weybrcw BB. Relationship of personalityfactors and some social habits to cardiovascular risk insubmariners. Aviat Space Environ Med 1982;53(4):383-9 .

Thomas TL, Hooper TI, Camarca M et al. A methodfor monitoring the health of US Navy submarinecrewmcmbers during periods of isolation. Aviat SpaceEnviron Med 2000;71(7): 699-7O5.

Jour Marine Medical Society, 2005, Vol.7, No. 2

8 .

9 .

10 .

t2.

13 .

t4.

1 5 .

-

ACUTE SKIN FAILURE

Surg CdrJ Sridhar', Surg Capt PLKDesylva*

ABSTRACT

Widespread skin disease could cause severe disruption of skin function, leading to the potentially fatal conditioncalled acute skin failure. This occurs due to an inability to maintain core lemperalure, breakdown of the skinas a mechanical barrier, and loss of electrolytes, lluid and protein. Acute skin failure commonly occurs in toxicepidermal necrolysis, pemphigus, erythroderma and bl istering viral infect ions. Five cases of impending acuteskin fai lure encountered at the departm€nts of Dermatology at INHS Asvini and INHS Kalyani between 2001and 2005 are discussed. Maintenance of haemodynamic, electrolyte and thermal equi l ibr ium, nutr i t ionalsupplementation, antimicrobial therapy and treatment of the underlying csuse are the key principles ofmanagement .

INTRODUCTION

fhe skin is the largest organ in the body. In theI adult it extends over 1.7 m2 in area and weighs

in excess of 3 kg. It receives 307o of the circulatingblood volume and has a wide range of anatomicalvariation in terms of thickness and locally adaptivestructure. It is immunologically active, protects thebody from water and electrolyte loss, and is a barrierto infection. noxious chemicals and ultra violet ra-diation. It has metabcilic, sensory, and sociosexualfunctions.

In widespread skin disease, these functions maybe disrupted to varying degrees. Severe disruptionof skin function results in a rapidly evolving andpotentially fatal dermatologic crisis referred to asacute skin failure ll,2l.

MITNNHT,INDMETHODS

Five cases of impending acute skin failure man-aged at the departments of Dermatology at INHSAsvini and INHS Kalyani between 2001 and 2005were studied. The patients were analysed with re-spect to age, percentage body surface areainvolvement, management protocols and incidenceof complications.

OBSERVATIONS AND RESULTS

The age group of patients ranged from 2.5 yearsto 50 years. The percentage of skin involvement

ranged from2o-90%o. The mean duration of admis-sion was 22.3 days. All patients except one (Patient4 - Stevens-Johnson syndrome) received prophy-lact ic ant imicrobia l therapy. In fect ion andsepticaemia, hypoproteinemia, high output cardiacfailure and renal failure were the complications ob-served. Details of patient profile, clinical features,diagnostic investigations, complications and man-agement outcome are placed at Table l.

DISCUSSION

Acute skin failure is a heterogeneous entity char-acter ised by an inabi l i ty to mainta in coretemperature, breakdown of the skin as a barrier andloss of electrolytes, fluid and protein [3]. Physiologicand metabolic derangements in acute skin failureare listed in Table 2. A variety of dermatological con-ditions could precipitate acute skin failure (Table 3).Toxic epidermal necrolysis, pemphigus, erythro-derma and blistering viral infections are commoncauses of skin failure in dermatological practice [4].

The management principles of early diagnosis,intensive care (maintenance of haemodynamic, elec-t ro ly te and thermal equi l ibr ium, nutr i t ionalsupplementation and antimicrobial therapy), as wellas aggrissive treatment ofthe underlying cause werestrictly adhered to in all the five cases described.

An array of functional derangements were ob-served in Patient 3, who had Toxic Epidermal

'Graded Specialist (Dermatology & Venereology), INHS Kalyni, Gandhigram, Vsakhapatnam - 530 005, .Classified Specialist(Dermatology & Venereology), INHS Asvini, Colaba, Mumbai - 400 005.

loun Marine Medical Society, 2005, Vol.7, No.2 t21

TABLE 1Overview of cases of acute skin failure treated at the Dermatology department

S DiagnoslsNo.

Setq

Age

Cllnicalfeatures DlrSnostlcinvestigrtlons

Complicatlons DeflnitiveMenrgcment

Outcom€

l . Psoriat ic M.50ervthroderma

2. Pemphigus M,3lvulgaris

Toxic M,2Vzepidermalnecrolysis

Stevens- F,08Johnsonsyndrome

5. SLE F. I8

Redness,

desquamation,

skin th ickening-90%

BSA'

Flaccid bullae

over normal-

looking skin,

Nikolsky sign

posi t ive;

Mucosal

involvement-

45% BSA

Sheet-like

denudation of

skin, wi th

mucosal

involvement-

65% BSA

Crusted, circular

plaques with

tendency to

confluence and

muco-cutaneous

involvement-

20% BSA

Erythematous,

scaly plaques,

predominant ly

over sun-

exposed areas,

with malar

rash -30% BSA

HPE-epidermalnecrolysis

Septicaemia,

dyselectrolytemia

renal failure

Antibiotic cover.early, parenteralcorticosteroids

HPE-confirmed High outputpsoriasis cardiac failure,

hypoproteinemia

Direct Infect ionimmunofluorescence-IgG alongepidermalkeratinocytes

Inotropic support, Recovered

starch baths.

Infliximab 5mg/kg

as loading dose

infusion at wk 0,3,6

Antibiotic cover, Recovered

Dexamethasone

Cyclophosphamide

Pulse therapy

3 . Fatal case

4 . HPE-epidermal Infectionnecrolysis

ANA, dsDNApositive in hightitre; HPEconfirmatory

Oral corticosteroids Recovered

Hypoproteinemia Pulsed, IV Recovered

methyl-predni solone,

oral corticosteroids.

chloroquin,

c yc lophosph ami de

*Body Surface Area

Necrolysis (TEN) with 857o skin involvement (Fig.l). He was managed in the burn unit with strictreverse isolation, temperature and humidity control,in accordance with standard recommendations [5,6].On the fifth day of hospitalization, the patient de-veloped features of renal failure and hypothermia.Blood culture grew E.coli, and the patient succumbedon the sixth day of admission. Sepsis due to break-down of barrier function of the skin in TEN was themost likely cause of death. Further, corticosteroids,administered to halt the immunolological damage inTEN may have contributed to sepsis [7,8], despite

122

Fig. I : Acute skin fai lure due to toxic epidermalnecrolysis

Jour Marine Medical Society, 2005, Vol.7, No. 2

's with theTABLE 2Physiologic and metabolic derangements in acuteskin failure

Cutaneous derangements EffectQ 3 Q 4

4.89 6 .20

4 . 5 6

's with the

:ho- Totalm

34.22

7 4

7 4

t from West-wirh l i t r le

ntified a few;. They werent. The find-r study done'ican subma-I out ofplaces with small: focused toion of crea-Department: Medicine,'istics of 85)nt to whichlsubmarin-were foundour person-ptive of the:onfidence,

Vol.7, No.2

6 . 5

Loss of protein, fluid andelectro lytes

Infect ion

Impaired thermoregulation

Increased Cutaneous blood flow

Metabolic derangements

Immunologic derangements

Increased skin penetrationof medicaments

Renal failure,dyselectrolytemia

Septicaemia

Hypothermia

High outputcardiac failure

Ketoacidosis

Early sepsis

Systemic toxic i ty

TABLE 3Causes of acute skin fai lure

Acute HemorrhagicFevers

Erythrodermas

General ized BullousEruptions

Condit ions Inducinghigh output heartfal lureCondit ions associatedwith vasculopathies

Envenomations

Meningococcemia

Rocky mountain spotted fever

Ebola virus infection

Acute septic emboli

Necrotizing fasciitis

Periorbital cellulitis

Cutaneous T Cell lymphoma

Psor iasis

Atopic dermat i t is

Drug eruption

Seborrheic dermatitis

Pityriasis rubra pilaris

Streptococcal scalded

skin syndrome

Pemphigus (vulgaris, foliaceous,

erythematosus)

Pemphigoid (bullous, cicatricial)

Epidermal necrotic diseases:

Kaposi's varicelliform eruption

Toxic epidermal necrolysis

Stevens-Johnson syndrome.

Erythrodermas

A-V malformations

Giant haemangiomas

Klippel-Trenauney syndromePolyarteritis nodosa

Protein C and S deficiencies

Lupus erythematosus

Brown recluse spider bite

Jellyfish stings

parenteral antibiotics. In contrast, the remaining fourpatients had lesser degrees of compromise of bar-rier function, and therefore, fewer chances of

Joun Marine Medical Society, 2005, Vol.7, No. 2

Fig. 3 : Pedal oedema in psoriatic erythroderma

infection, fluid, electrolyte loss and thermal derange-ment. This could explain theirfavourable outcomes.

Patient l, with psoriatic erythroderma (Fig. 2) de-veloped pedal oedema and ascites during the firstweek of admission. Extensive desquamation in r:ryth-roderma causes hypoproteinemia and generalisedanasarca [9]. Further, cutaneous hyperemia in eryth-roderma results in a high output cardiac state, whichcould manifest as pedal oedema and ascites [0](Fig. 3). He was successfully managed with ino-tropic support, nutritional supplements, starch baths(to reduce desquamation) and definitive therapy forpsoriasis.

CONCLUSION

Acute skin failure is not a diagnosis but a de-scriptive entity that encompasses the myriad ofsystemic derangements that occur in widespread,acute skin disease. Prompt recognition and diagno-sis ofthe underlying cause could prove life-saving.Skin failure should rate alongside heart failure, res-

123

Fig. 2 : Skin failure due to psoriatic erythrderma

piratory failure and liver failure as worthy of inten-sive care. Indeed, intensive care is axiomatic to asuccessful outcome in acute skin failure. Such casesare therefore best managed in the burn unit of thehospital.

REFERENCES

l. Burd A. New skin. Transplantat ion 2000; 70(11):r 5 5 I - 2 .

2. Roujeau JC. How skin diseases can threaten life. J EurAcad of Dermatol and Venereol 1995;5(l): 55.

3. Irvine C. Skin failure-a real entity: discussion paper. "/Roy Soc Med l99l:84 : 412.

4. Ducic I, Shalom A, Rising W Nagamoto K, MunsterAM. Outcome of patients with toxic epidermalnecrolysis syndrome revisited. Plast Reconstr Surg2002; l l0 (3 ) :768-73.

Hettiaratchy S, Moloney D, Clarke J. Patients withacute skin Ioss: arb they best managed in a burns unit?Ann R Coll Surg Engl 2001 Jan; 83(l):26-9.

Palmieri TL, Greenhalgh DG Saffle JR, Spence RJ,Peck MD, Jeng JC, et al. A multicenter review of toxicepidermal necrolysis treated in U.S. burrt centers atthe end of the twentieth century. J Burn Care Rehabil2002 Mar-Apr 23(2) :87 -9 6.

Roujeau JC. Toxic epidermal necrolys is (Lyel lsyndrome): more than "acute skin failure". IntensiveCare Med 1992;18( l ) :4-5.

Majumdar S. Mockenhaupt M, Roujeau J, TownshendA. Intervent ions for toxic epidermal necrolys is.Cochrane Database Syst Rev 002;(4):CD001435.

Balasubramaniam P, Berth-Jones J. Erythroderma: 90%skin faifure. Hosp Med 2004 Feb;65(2):100-2.

Sehgal VN, Srivastava G Sardana K. Erythroderma/exfoliative dermatitis: a synopsis. Int J Dermatol 2004Jan ;43 ( I ) : 39 -47 .

Jour. Marine Medical Society,2005, Vol.7, No.2

5 .

6 .

PSl

Mrs\Surg

ABSI

Thls rproblFactotestlnPstielawarlLack

Key \

7 .

8 .

9 .

10 .

INTX

LII IHIVevOkrthe cresrceproc(-"Nt

gainiand I-"Ye

tion,sevetisola

Hsoci:distnAIDthatHIV

Tprevpati(lemserv

'vc'Dept

Jout124

t i en t s w i t hburns uni t?-9.

ipence RJ.ew of toxicceDters at

tre Rehabil

s i s ( L y e l l

. Intensiyc

IownshendL e c r o l y s i s .) 0 1 4 3 5 .

e rma :90% 'r0-2.

throderma/matol 2004

t .7 , No.2

PSYCHOSOCIAL ASPECTS OF INDIVIDUALS WITH HIV/AIDS

Mrs V Padmini',Surg CdrSunil Goyal#,SurgCapt RN Misra.,Surg CdrAsutosh Tlipathi"

ABSTRACT

This study' conducted at Voluntary Counsell ing and Testing Centre INHS Asvini evslultes the psychosocialproblems of HIV/AIDS patients. The study group included 35 HIV posit ive patients of al l ages and both sexes.Factors in data col lect ion Included Age, sex, socio.economic status, education, source of Infect ion, reasontesting was done, emotional reactions, family acceptance and condit ion of patients ot the t ime of test ing. Al lPatients experienced strong emotional reactions like Anxiety, Sadness, Insecurity, regret and anger to becomingaware of their HIV stetus. Patients who informed their famit ies received ful l emotional support from them.Lack of awareness regarding HMAIDS was common among the patients.

Key Words : HIV/AIDS, Psychosocial Aspects, HMAIDS Counsell ing

INTRODUCTION

TJV/AIDS is a stigmatized disease that results inI lmultiple psychosocial problems. Diagnosis ofHIV infection in an otherwise healthy individualevokes a series of psychological reactions of whichthe common ones are anxiety, depression, low self-esteem, suicidal thoughts and anger []. The thoughtprocess of the patient often is Denial and Isolation- "No, not me"; Anger and Rage - "Why me?" Bar-gaining, Survivor guilt - "Yes, me, but. . ." Depressionand Wthdrawal -"Yes, me" and finally, Acceptance-"Yes, me" [2]. Apart from the psychological reac-tion, an individual with HIV/AIDS often undergoesseveral social stressors in form of social withdrawal.isolation and rejection.

HIV/AIDS counselling aims at providing psycho-social support at times of crises and preventingdistressing psychosocial reactions. In addition, HIV/AIDS counselling provides support to the family sothat they, in turn, can help and care for people withHIV infection [3].

The aim of this study has been to delineate theprevalence of psychosocial problems in HI\A AIDSpatients. Knowledge of the magnitude of the prob-lem will help in planning psychosocial supportservices for the patients.

MATERIALANDMETHODS

INHS Asvini is a recognized Immunodeficrencycentre with Voluntary Counselling and Testing Cen-tre facility, which has been established since Jan2004. It offers Pre test and Post -test counselling forall individuals undergoing HIV testing. The studygroup was successive patients identified as HIVpositive and treated in INHS Asvini from Jan 2004toOctober2004.

Each patient was administered a semi - struc-tured proforma to collect demographic data and theirpsychosocial response to HIV/AIDS. Different fac-tors taken into account while doing the study wereAge, Sex, Socioeconomic status, Education, Sourceof Infection, Reason testing was done, Condition ofpatient at time of testing, AIDS defining criteria,Family Acceptance, Emotional Reactions, Queriesasked by patients and Medication taken/Planned.

The study group included individuals with var-ied educational, occupational and economic status.The study group comprised 35 HIV positive pa-tients, including 3l males and 4 females, in the agerange of 28 to 54 yrs.

RESULTS

The majority (69Vo)were in the age group of 2l -

'VCTC Counsellor, Immunodeficiency Centre; rClassified Specialist and Head. Department of Psychiaery: .Senior Adviser,

Depanment of Pathology; "Classified Specialist, Department of Psychiatry, INHS Asvini Colaba, Mumbai 400 005.

Jour. Marine Medical Society, 2N5, VoI.7, No.2 t25

40 yrs as compared to 3lVo in the age group be-tween 4l-60 yrs. Our study clearly indicates that itis the productive age group, between 2l-40 yrs

which has predominantly been affected due to HIV/AIDS, as shown in (Fig. l). Educational status ofthe patients showed 02 (6%) patients were illiterate,M(llVo)wereless than Matric,05 (147o) had passed

their twelfth but majority of the patients 24 (697o)

have studied up to Matric. Majority of the patients,

25 (7lVo) were from the middle-income group. Nonewere from the upper income group, whereas l0 (29Vo)

were from the lower income group.

Forty percent underwent testing for skin prob-

lem,34Vo for fever, weight loss pneumonia and 267o

underwent testing for various reasons includingvoluntary testing. At the time of testing 2OVo were

asymptomatic whereas the majority 807o were symp-tomatic. Only 4OVo gave history of infection throughCommercial Sex Workers/ amateurs. 367o could not

identify the source. 97o gave history ofblood trans-fusion. 9Vo blamed their spouse for their statuswhereas 67o gave history ofsexual exposure as well

as blood transfusion (Table 1).

Currentl y 5 87o patients are asymptom atic, 42Vo

are symptomatic with AIDS defining condition with

CD4 count less than 200. Maximumpatients (42qo)

were treated for skin problems.26Vo were treated for

TB, fever, wt loss. lTVo patientstreated forTB were

on HAART. 6Vo werc tregted for other infections.Only 9Vo were asymptomatic with no illness.

The patients were asked to comment on family

acceptance to gauge the social impact of the illness.In the study population, the families of 25 patients

l}20yrr 2f-a0tn 41-6OFr

Fig. l: Sample distribution Age/ Sex.

126

TABLE IPercentage distribution of various factors

S. No. Factors

TABLE 3Correlatfamily a

Socio Ecstatus

Upper ingrouPMiddle it

Total

Familysample(07) patheir Hthe Lot(20V0)(Table!

positiv26Vo rfuture.were asible remoti(4).

DISC

Inctive tresigrthesecludirnotifidiagnAIDS

Padowna lonthe timiltirprobl

Jour

a. Reason test ing was done:Skin problemFever, weight loss, pneumoniaOthersAt the t ime of test ing:SymptomaticAsymptomaticSource of Infection:C.S.W amateursBlood TransfusionUnknownSpouseB.T. and C.S.WAIDS delining criteria:Symptomatic with AIDS definingcondition CD4 counts < 200Currently asymptomaticMedication taken / planned:

Treatment for skin problemTreatment for TBFever /weight lossTreatment for TB and on HAARTOthersNone

14 (40%)12 (34%)09 (26%)

28 (80%)o7 (2O%\

14 (4O%)O3 (94o)13 (369o)O3 (99o)02 (6%)

15 (42Eo)20 (589o1

rs (42%)06 ( r7c lo l03 Qqo)06 (177o)O2 6qo\Oi (97o)

grouPLower irgroup

d.

Alltional

TABLE 2Correlat ion betweenacceptances

education and family

Education Family TotalAware. Aware, Not Not

support ive suPPort ive eware

I I l i terateLess thanMatricMatricl 2 rh

o202 04

o202

l 80 3

0 5o2 0 5

Total

(ll%o) were aware of the patients HIV status andwere supportive. Nine patients (26Vo) had not re-vealed their HIV status to the family members. In 0l

case (3Vo) the family was aware but not supportive.Correlation between Education and family accept-ance did not reveal any specific trend, probably dueto small population size (Table 2).

{ r

Correlation between Socio-economic status and

Jour. Marine Medical Society,2005, Vol.7, No.2

3 s090 l25

4l{{lyn

14 (40Vo)t2 (34%,)09 (26V0)

28 (807o)07 (20Vo\

14 (409o)03 oqa)13 (36qo)03 oqo)07 (60/o)

15 (429o)20 (580/o)

15 (42%,)06 ( l7o/o\03 9qo)06 ( t1Eo)02 (6%)03 (99o)

TABLE 3Correlat ion between socio economic status andfamily acceptance

TABLE 4Emotional reactions (self reported)

Emot i ona l Anx ie t y / Sadness / Ange r

reect ions insecur i ty regret

N = 3 5 09 (26%) 03 (9%) or (3%) 22 (62Vo l

went for voluntary testing for any other reason. Thisshows that voluntary testing for people with high-risk behaviour must be encouraged by education,counselling and other means.

In a majority of the cases (4OVo) infection wascaused by an exposure to commercial sex workers.The commonest reported source of infection wasexposure to a CSW / amateur. In some cases, thesource of infection was unknown. However, the pa-tients had been diagnosed with Sexually TransmittedDisease (STD), indicating that they had probablybeen exposed to a CSW but were unwilling to dis-close it.

Patients who had been infected due to exposureto CSW mentioned a change in their behaviour. Theyregretted their behaviour and stated that after dis-c losure of thei r s tatus they had become veryshort-tempered, restless and were always tense.36Vofelt that there was no need to disclose to othersabout their past life for fear of rejection and dis-crimination and guilt that they had infected theirwives (Table I ). This constant fear of negative reac-tions prevented them from taking help and emotionalsupport from others. All the patients felt strong feel-ings of guilt and anger.

In some cases, (97o) infection had been causedby their male spouse. Our sample consisted of de-fence personnel posted away from home for longperiods of time. Many of them, infected by risk be-haviour, had infected their spouses as well. Othersimplicated blood transfusion as the cause of theirinfection. In both these cases, the reaction of pa-tients were shock, and anger at being in this situationfor no fault of theirs.

During the evolution of HIV infection, a progres-sive loss of CD4 lymphocytes predicts subsequentdevelopment of AIDS. Most patients have less thanl5-2OVo(2N) of the normal number of these cells atthe time AIDS is diagnosed [7]. Fifteen (42%o) pa-

127

Socio Economics te tus Fami ly

Aware, Aware, Not Notsupport ive support ive rware

Totsl

Upper incomegroupMiddle incomegroupLower incomegroup

t'l

Total

Family acceptance could not be done due to thesample size. However, in the Middle income group(07) patients out of a total of 25 (28Vo) did not revealtheir HIV status to the family. On the other hand inthe Lower Income group only (02) patients out of l0(20Vo) did not reveal their HIV status to the family(Table3).

All the patients were asked to describe their emo-tional reaction to becoming aware of their HIVpositive status. Only a subjective report was sought.26Vo reported Anxiety and Insecurity about theirfuture, 97o sadness and regretted their actions, 37owere angry as they did not hold themselves respon-sibfe and the majority (62Vo), rqported a mixedemotional response of all the above factors (Table4).

DISCUSSION

Individual reactions to awareness ofa seroposi-tive test result ranges from intense emotion toresignation or shock [4,5]. Research suggests thatthese reactions depend on a number of factors in-cluding test result expectations, whether the initialnotification occurred simultaneously with an AIDSdiagnosis or with the experiencing of significantAIDS related symptoms [6].

Patients reported shock, disbelief, some brokedown, while others mentioned being depressed fora long time on receiving their positive results. Atthe time of testingS0%o of the patients were sympto-matic and they underwent testing due to skinproblems, fever and weight loss. Very few patients

Jour Marine Medical Sociery, 2405, VoL7, No.2

25

t 0

01

02

0 l

0 8

3 5090 l25

I fami ly

tre

. A

0 5

tatus andrd not re-rers. In 0lpportive.y accept-rably due

l r

tatus and

t\.7, No.2

Total

n')

04

3 5

tients were symptomatic with severe loose motions,fever and weight loss with CD4 count less than 200,whereas majority of the patients 2O (58Vo) patientswere asymptomatic.

An analysis of treatment given reveals that pa-tients were treated for TB, skin problems, fever/weight loss and were on HAART (Table l). Maxi-mum (42Vo) were being treated for skin problems atthe time of testing. This shows that STD/ dermato-logical conditions are the commonest reason for anindividual to undergo HIV testing, which is reflec-tion of high-risk behaviour.

Deciding whom to tell about one's HIV statusentails efforts to protect oneself from discrimina-tion, assess one's fear of rejection and refuse pityfrom others while avoiding making them suffer orfeel sorry [8]. Patients mentioned feeling very un-easy, anxious, and confused aboutdisclosure oftheirHIV status to family. They found it very disturbingand felt fear about discrimination, hostility andchange in attitude of their families towards them.Our results indicate that maximum patients initiallyhad problem but later on family became supportivetowards them. Non-acceptance by family was verylow. 267o patients decided not to disclose their sta-tus to their families (lhble 2). The findings in ourstudy are in agreement with the reviews of Fineburg

[9] based on the various psychosocial problemsfaced by persons with HIV/AIDS where maximumpatients claimed that they had not faced any prob-lems related to family.

It was seen that patients who had family supportwere able to cope better in life and had a more posi-tive outlook than patients with no family supportwho still felt very anxious and insecure. Patientsmentioned reduced feelings ofanger, hatred, resent-ment, and anxiety for themselves because of strongsupport from family.

This reveals a trend that patients need not hidetheir HIV status from the family. After a period ofinitial shock, the family is supportive. Though a cor-relation between education and family acceptancewas not possible due to small sample size, it is note-worthy that even individuals with lowereducationallevel of l2'h standard and below have not hiddentheir HIV status from their families and are gettingsupportfrom them (Table 2).

128

Correlation between socio-economic status andfamily acceptance though not statistically feasibledue to small size , did reveal a trend amongst themiddle class individuals to hide their HIV status fromthefamily (Table 3).

Bernard Lapointe's Model [0] of reaction tosituational distress has four phases. Initial crisisstarts when a person makes an appointment for test-ing. During the transitional phase, once leaming thatthey are HIV Positive, they feel anger, guilt, self-pity, anxiety, sadness, confusion and distress.During the phase of acceptance, grief about loss offriends, social status, independence and physicalwholeness is felt. The final phase, which is the long-est, is the preparation for death.

In our study, a majority (62Vo) (Table 4) of thepatients experienced a fairly strong emotional reac-tion on becoming aware of their HIV status. Theyhad a sense ofanxiety, insecurity about their future,and felt vulnerable. Some regretted their past be-haviour, such as visiting CSW. The majority ofindividuals had mixed emotional response compris-ing of anxiety, anger and sadness. However theyhave accepted their positive status and are trying tocope with life.

All 35 patients were inquisitive about their ill-ness. They had queries related to HIV/AIDS,medication, modes of transmission, how long willthey livg etc, which revealed several underlying mis-conceptions about the disease. This shows thatalmost all the patients had very less informationabout HIV/AIDS. During counselling sessions, maxi-mum patients mentioned that lack of awareness andknowledge about HIV/AIDS had resulted in high-risk behaviour.

A common problem in individuals with HIV/AIDSis loss of interest in future goals and aspirations.Counselling helps in providing necessary motiva-tion for helping the individual set short-term goals.This helps in providing a direction and meaning totheir lives and helps in eliminating their feeling ofworthlessness. Effective counselling helps motivatean individual living with HIV handle life in a easierway, provide a positive direction to cope and lead abetter life. In a study I l] conducted on HIV posi-tive individuals it was found that persons who ratedthemselves as having achieved a sense of meaning

Jour Marine Medical Society,2005, Vol.7, No.2

and purpose in their lives reported higher self-es-teem and less anxiety.

CONCLUSIONIn our study group, following the disclosure of

the seropositive status nearly all the patients hadintense emotional reactions like anxiety, sadness,regret and anger. Fear of discrimination from familymade tlem hesitate and delay disclosure. However,the majority of families, initially shocked, graduallyaccepted and became supportive. This reveals atrend that patients need not hide their HIV statusfrom theirfamilies. The small sample sizeof this studyprecludes statistical analysis of the data, but eventhis modest beginning emphasizes the vital role ofcounselling in helping patients deal with theirphysical and emotional stress.

REFERENCES

l. Holland, JC, Tross S. 'The Psychosocial andNeuropsychiatr ic Sequelae of AIDS and relateddisorders'. Annals of Internal Medicine 1985; 103:760-4 .

2. Kubler-Ross E. 'On death and dying'In; Ahmed PI:Living and dying with AIDS: Plenum 1992

Jour Mainc Medical Society, 2N5, Vol.7, No. 2

National Aids Control Organization. 'HMAIDS

counselling', Training manual for trainers. pg 38.

Bor R, Miller R, Goldman E, Scher L The meaning ofbad news in HIV disease: counselling about dreadedissues revisited. Counselling Psychology 1993; 6:69

Roncone R, Core L, Casacchia M. Counselling andpsycho educational interventions in HIV infection.New Trends in Experimental and Clinical Psychiatry1 9 9 3 ; 9 : 1 3 7 .

Doll LS, Kennedy MB. HIV counselling and testing:what is it and how well does it u6rk? In: Schochetman.G George JR, Eds. AIDS testing, 2d Ed. New York:Springer-Verlag 1994: 302.

Redfield, RR, Burke DS. HMnfection: The clinicalpicture, Scientfic American 19881 259: 90-8.

Siegel and Krauss. Living with HIV infection: Adaptivetasks of seropositivc gay men. Iourndl of Health andSocial Behavior l99l: 32(3'): 17-32.

Fineberg HV. The Social dimensions of AIDS. ScientificAmerican 1988; 259 : 128-34.

Lapointe B. 'L'Approche psychosociale du patientsero positif au VIH. In: Pollak 1992. AIDS: A problemfor sociological research, Sage Publication.

Linn JG Lewis FM, Cain VA, Kimbrough GA. HIV -i l lness, social support, sense of coherence, andpsychosocial well being in a sample of help seekingadufts. A/DS Educ Prev 1993:5 :254.

3 .

4 .

5 .

6 .

7 .

8 .

9 .

10 .

l l .

129

I

A PROSPECTTVE STTJDY OF 32 OPERATED PATIENTSOF HEAD INJURY

Surg Cdr KI Mathai', Surg Cdr S Ganguly" Surg Capt B Fanthome*

ABSTRACT

Over a period of 2 ll2 years 32 operated Head lnJury patients were prospectively evrluated. The made of injury,

the post resuscitatlon GCS, CT Scan flndings.and operrtlve procedures performed were correlated with age.

Thelargest number of casuatties (E) occurred in the 20 to 30 year sge group. Six of these were due to 2 wheeler

accidents. The commonest csuse in the under l0 group was falls from heights (4 pstlerts) and in the over 50

group were due to pedestr ians being hlt by motor vehicles. Extra dural hematomas were commonest in the

paediatric group and compound injuries in the 30 - 40 year sge group. The outcomes of these patienls were

correlated with post resuscitation GCS, the mass lesion present and the age of the victim. 14 patients in this

group expired after surgery. At 3 months follow up E were functionally independent, 6 required assistance for

activities or daily living and 4 were vegetative.

Key Words : Head Injury, Outcome correlstions

INTRODUCTION

fhaumatic brain injuries are a major concern for

I the armed forces. Even after surgical evaluation

of mass lesions the prognosis with major head

trauma remains guarded Il]. The mode of injury pro-

duction and the mass lesions commonly encounteredvary in different age groups [2,3]. The outcome is

affected by the age of the victim and also the

Glassgow Coma Scale scores at admission.

A prospective study of Head Injuries was catried

out to evaluate, in respect to the various age groups,

the modes of injury production, the post resuscita-

tion Glassgow Coma Scale, the mass lesions

encountered and the outcomes.

MATERIALANDMETIIODS

This is an ongoing prospective study by the au-

thor, where all cases managed in totality by him wereprospectively evaluated for the following variables:

l. The age ofpatient

Z The mode of injury

3. The GCS score - post resuscitation

4. The CT Scan picture

5. The operative findings

6. The outcome at discharge and at three months

Only patients who merited surgery for mass le-sions or compound injuries were included in thestudy. The indication for surgery in mass lesionswas clinical and radiological evidence of progres-sive or significant compression. Conservativelymanaged head injuries were not included in the study.Outcome was evaluated by the criteria of theGlassgow Outcome Scale (GOS) and level of con-sciousness by the Glassgow Coma Scale (GCS). Asthe management protocols were by standard inter-nationally accepted guidelines, no specific consentwas considered mandated.

RESULTS

Over a period of 2 ll2 years a total number of 32patients were prospectively evaluated.

(a) Age and Sex distribution:

The age and sex distribution is elaborated inTable l. These were 4 children under l0 yearsofage. 3 patients in the 10 - 20 years group, 8casualties in the 20 - 30 age group, 6 in the 30 -

40 age group, 7 in the 40 - 50 age group and 4 inthe > 50 year group. The sex distribution showed

'Classified Specialist (Surgery) & Neurosurgeon; *Classified Specialist (Anaesthesiology) & Cardiac Anaesthesia; *'Senior

Adviser & HOD (Surgery) and Oncosurgery, INHS Asvini, Colaba, Mumbai - 400 0O5'

Jour Marine Medical Society, 2005, W.7, No. 2r30

TABLE IAge and sex distr ibution

Age group (yrs) Male Fema le

< 1 0l 0 - 2 02 0 - 3 03 0 - 4 04 0 - 5 0> 5 0

,6542

2t2I

3)

a male predominance which was most markedbetween 20to4O yearof age.

O) TheModeof\iury

The mode of injury in these patients, correlatedto age is given in Table 2. In the less than l0year age group, falls from heights were thepredominant cause of injury. In the 2O - 30 agegroup two wheeler accidents constituted thecommonest cause of head injury (6 cases), whilein the older age groups pedestrian accidentsand four wheeler accidents were equallycommon.

(c) TheTimelag

The time Lag between injury and definitivesurgery is given in Table 3. This was correlatedwith the outcome. Correlation of the time lagwith outcome is given in Table 4. Of the tenpatients operated within 4 hours of injury 3 werefunctionally normal at 3 months, and 4 werefunctionally independent. l5 patients wereoperated after24 hours ofthe injury and ofthesewe had 8 mortalit ies, 2 patients were in avegetative state after 3 months and 3 weredependent, at least partly on caretakers for

TABLE 2Mode of injury

Time lag in hours(Trauma to definitive surgery)

TABLE 3The t ime lag

No. of patients

| (409o\

| ( 34%)t (26Va)

i (807o)' ( 2 0 1 o \

. (40%)(9%a)(369o)

Qq")(6nk)

(42Va)I ( 5870 )

(4ZVo )t ( i 7 9 o l(e%)

t ( 179o )(6Vo\(9Vo)

family

Total

0 204

A A

(r)

< 44 - 2 4> 2 4

l 00'll 5

(o

(e)

activit ies of daily l iving. The difference inoutcomes between the patients operated inwithin 4 hours and those operated after 24 hrsis statistically significant (P < 0.05). One of themain reasons for a higher mortality rate in theser ies was hence the delay in def in i t ivetreatment, which was due to the referral patternand outstation referrals.

The GCS scores at admission have been givenin Thble 5. The majority of patients in this serieshad GCS scores between 6 and 12.

The CT Scan findings of these patients aregiven in Table 6. Extradural heamatomas werecommonest in the under l0 age group. Intracerebral heamatomas occurred in the older agegroups. The commonest lesion in this serieswas an acute SDH. The commonest site of SDHwas fronto-parietal (8 of l2cases) and of EDHwas Temporal (3 of 5 cases).

The outcome of these patients age wise is givenin Table 7. Statistical significance was evaluatedby the Mann Whitney U test. 14 patients instudy group expired after surgery. The mortalityrate was high in the above 50 age group (3 of 4patients) and lowest in the < l0 years group (lof 4). The difference was statistically significant.

(D

35

Age Grouplyrs)

Rta with injury to

2 Wheelers 4 Wheelers

Fsl lsFromHt.

A IH o m e A s s a u l tPediastr ian

tus andnot re-s. In 0 l)ortive.accept-bly due

tus and

7, No.2

< 1 0l 0 - 2 02 0 - 3 03 0 - 4 04 0 - 5 0> 5 0

0I6)00

0I

332

I

000)2

000000

3I

00I

0

000II0

Jour. Maine Medical Society, 2005, Vol.7, No. 2 I3I

TABLE 4Time lag correlated to outcome

Time lag in hours(Trrumat todefinit lve surgery)

Vegetat iveOutcome

DependentDead Independent Norma l

< 4^ a ^

> 2 4

,)4

8

NILNIL

3I

l

I35

4NIL

NIL

TABLE 5Gcs scores (post reuscitaion)

Age groupyrs

6 - E 9 - t 2 > t 2

< 1 0l 0 - 2 02 0 - 3 03 0 - 4 04 0 - 5 0> 5 0

2I3222

II

J

J

)0

0It

I

II

G) The outcome of patients in relation to their GCSis given in Table 8. All patients with GCS < 6 inthis series expired. In patients with GCS > 12,50Vo achieved apparent normalcy. This wasstatistically si gnifi cant.

TABLE 7O u t c o m e ( a t 3 m o n t h s )

TABLE 6CT scan f indings

Age groupyeans

SDH Contusions ICH Compoundinjuries

< 1 0r 0 - 2 02 0 - 3 03 0 - 4 04 0 - 5 0> 5 0

3I

I

000

I

I

3232

00J

24

0

000002

00Iz

00

EDH - Extra Dural Haemaioma; SDH - Sub DuralHaematoma: ICH - Intra Cranial Haematoma

DISCUSSION

This study was prospective. It was done to evalu-ate the various factors of consequence in operatedhead injuries. While much of current literature has

I0002I

focused oology ofttiming, stwritten [{dures likrevolved iever colPharmacfacil itatperfusioras expedMoleculrinjuries tepsilon 4outcomeadmissiraccurate

The eoutcomewith incongoinga baselitevaluati

REFEREl . S te i

NeuPovPP

2. DolNeu

Age groupyears

Dead Vegetat ive Dependent Independent Normal

< 1 0l 0 - 2 02 0 - 3 03 0 - 4 04 0 - 5 0> 5 0

I

0334

3

00I00I

0I

220

J

I

I

000

TABLE 8GCS scores correlated with outcome

G C S Dead Vegetat ive Dependent Independent Normal

< 66 - 88 - 1 2> 1 2

463I

025

2

0,,

0

0200

00.,

J

t32 Joun Marine Medical Society, 2005, Vol.7, No.2 loun M'

focused on intensive monitoring and the pathophysi-ology of neural trauma [4, 5], the final chapter in thetiming, surgical approach and outcome is yet to bewritten [6]. Radical Surgical decompressive proce-dures like decompressive craniectomies have beenevolved and tried with gratifying results [7]. How-ever conventional management sti l l comprisesPharmacologic and Physiologic manipulations tofac i l i ta te opt imal cerebral b lood f low andperfusion [8,9], with evacuation of mass lesions [9]as expeditiously as possible [0]. The invasion ofMolecular biology has touched the field of headinjuries too, with studies showing the value of E -

epsilon 4 Genotype correlating with a poor neuologicoutcome I l]. At a more mandane level the GCS atadmission and the age of the patient remain the mostaccurate of outcome predictors [2].

The epidemiological data with radiological andoutcome correlations would be of benefit, especiallywith increasing numbers being added on to thisongoing study. It is hoped that the data will providea baseline or a spring boured for specific protocolevaluations in the future.

REFERENCE.Sl . Stein SC. Classif icat ion of Head Injury. In

Neurotrauma, Narayan RK, Wilberger JE andPovlishock J T (eds). McGraw - Hill, New York. 1996:P P 3 t - 4 1 .

2. Dous BR, Lind B, Christensen H, et al. The Role ofNeuro imaging in the Initial Management of patients

toun Maine Medical Society, 2005, Vol. 7, No. 2

with minor Head Injury. Ann Emerg Med 1994: 23 :t279-83.Bullock R, Chestnut RM, Clifton G et al. Guidelinesfor the management of Severe Head Injury The BrainTrauma Foundat ion (Ncw York) . The AmericanAssociat ion of Neurological Surgeons (Park Ridge,Illinous), and the Joint Session of Neurotrauma andCritical Care, 1995.

Findlay JM. Cunent Management of Cerebral Vasospas.Contemp Neurosurg 1997; 19 (24): l-6.

Unterberg AW, Kienning KL, Hart R, et al. Multimodalmonitoring in Patients with Head Injury. "/ Traunra1991; 42 (Suppl 5) : 532-7.

Bullock R. Clasurut RM. Clifton G et al. Guidelinesfor the management of Severe Head In jury.Neurotrauma 19961 13 :639-734.

Pol in RS, Shaff rey ME, Bogaer CA, et a l .Decompressive Bi f rontal Craniotomy in themanagement of Severe Refractory Post t rar .mat icCerebraf Edema. Neurosurgery 19971'41 :84-94.

Tatagi H, Saito T, Kitahara T, et al. The mechanismof ICP Reducing Effect of Manitol. In ICP Y Ishii S,Nagar H and Brock M (eds) Springer - Verlag, Berlin.1993 : PP729 -33 .

Marion DW, Letarte PB. Management of IntracranialHypertension. Contemp Neurosurg 1997; 19 (3) : 16.

Wilberger JE, Harris M, Diamond DL. Acute SubduralHematoma Morbidity. Mortaliry and Operatice Timing.J Neurosurg l99l:74 : 2L2-8.

Friedman G Froom P. Sazbon L, et al. ApolipoprotienE - E 4 Genoty le predicts a poor outcome inSurvivours of Traumatic lnjrury. Neurclogy L9991 52 :244-8.

Alberico Am, Ward JD, Choi SC, er al. Outcome afterSevere Head Injury. ./ Neurcsurg 1987:' 67 : 648-56.

3 .

4 .

5 .

6 .Compound

injuries

00I200

Sub Dura l

re to evalu-n operatederature has

1.7. No.2

9 .

10 .

l l .

12.

1 3 3

RATIONAL PRESCRIBING

Surg Capt Girish Gupta.

I prescription is the most important document in./1ttre hands of people who practice medicine. Itis the singular determinant of doctor's knowledge,experience and skill in alleviating the sufferings ofthe patients. Therefore, it is imperative that the doc-tor should rationalise his prescription writing. Theprocess of rational prescribing as a whole consistsof seven steps as outl ined in Table I . For this a pro-totype, a case of cough has been discussed.

Step 1: Define the patient's problem

The patient's problem can be described as a per-sistent dry cough and a sore throat. These are thesymptoms that matter to the patient, but from thedoctor's viewpoint there might be other dangers andconcerns. The patient's problem could be translatedinto a working diagnosis of persistent dry cough fortwo weeks after a cold. There are at least four possi-ble causes. The most I ikely is that the mucousmembrane of the airway is affected by the cold andtherefore easily gets irritated. More so, at presentstate of environmental pollution, allergic diseasewould be a fair possibility. A secondary bacterialinfection is possible but unlikely (no fever, no greenor yellowish sputum). It is even less probable thatthe cough is caused by tuberculosis or lung tumour,although these should be considered if the coughpersists.

Step 2: Specify the therapeutic objective

Continuous irritation of the mucous membranesis the most likely cause of the cough. The first thera-peutic objective is therefore to stop this irritationby suppressing the cough, to enable the membranesto recover.

Step 3: Verify whether your treatment is suitablefor this patient

You have alreadv determined vour treatment. the

TABLE ISteps of prescribing

Step l : Def ine the pat ient 's problem

Step 2: Speci fy the therapeut ic object ive

What do you want to achieve with the treatment?

Step 3: Ver i fy the sui tabi l i ty of your t reatment

Check ef fect iveness and safety

Step 4: Star t the t reatment

Step 5: Give informat ion, instruct ions and warnings

S tep 6 : Mon i t o r

Step 7: l f no response, analyse al l the steps. Star t a l lover again. Pay specia l at tent ion tocommun i ca t i on .

most effective, safe, suitable and cheap treatmentfor dry cough, in general. But now you have to verifywhether your treatment is also suitable for this par-ticular patient? Is the treatrnent also effective andsafe in this case?

Codeine is effective, and it is not inconvenient totake a few tablets every day. However, there is aproblem with safety because the patient is a studentand codeine has a sedative effect. For this reason itwould be preferable to look for a cough depressantwhich is not sedative. Other two alternatives withinthe group ofopiates (noscapine, pholcodine) sharethe same side effect. The antihistamines are evenmore sedative. But newer class of nonsedating anti-histamines are now freely available e.g. Fexofenadine.We must therefore conclude that it is probably berter not to prescribe any drug at all. If we still considerthat a drug is needed, Fexofenadine remains a pos-sible best choice but in as low a dosage as possible,and for a few days only.

Step 4: Start the treatment

The advice should be given first, with an expla-nation of why it is important. Be brief and use wordsthe patient can understand. Then, Fexofenadine can

be presctimes drdetails vdiagnosdose harfor thedren, be

Step 5:warninl

Thewillredmay caadvisec5 days,he shotand wtthroat.his owtis cleat

Step 6:

If tlter. Hressentltion.

Step 7

I f tcome

l . T

L I rh

ali

3 . 7u

4. 1if

'Senior Advisor and Head of Department (Paediatrics and Neonatology), INHS Asvini Colaba, Mumbai - 400 005

Jour. Marine Medical Society,2N1 VoL7, No.2134 Jour

treatment?

nt

l rn i ngs

Star l a l l

.reatment: to verify' th is par-:t ive and

/entent tohere is aa studentreason it)pressantes wi th inne) shareare eventing anti-fenadine.ably bet-considerns a pos-possible,

rn expla-se wordsrdine can

'1.7, No. 2

be prescribed: Tab Fexofenadine 60 mgs, I tablet 2times daily; date; signature and other necessarydetails viz. name, address and age ofthe patient anddiagnosis are written clearly. In paediatric patientdose has to be adjusted to body weight. Also checkfor the established safety of a given drug in chil-dren, before prescribing.

Step 5: Give information, instructions andwarnings

The patient should be informed that Fexofenadinewill reduce the cough. It works within 3-4 hours andmay cause occasionally palpitations. He should beadvised to come back ifthe cough does not go in 3-5 days, or if unacceptable side effects occur. Finallyhe should be advised to follow the dosage scheduleand wamed not to take any thing that can irritatethroat. It's a good idea to ask him to summarise inhis own words the key information, to be sure that itis clearly understood.

Step 6: Monitor (stop) the treatment

If the patient does not return, he is probably bet-ter. However, monitoring the patient progress isessential to assess the effectivity of the prescrip-tion.

Step 7: Introspection

If there is no improvement and the patient doescome back; there are five possible reasons:

l. The treatment was not effective.

L Incomplete prescription was followed andhence less effect. Therefore, need of properexplanation of full prescription to patient andattendant at the time of prescription writing andlater at dispensary has to be understood.

3. The treatment was not safe, e.g. because ofunacceptable side effects.

4. The treatment was not convenient, e.g. thedosage schedule was hard to follow or the tasteof the tablets was unpleasant.

Jour. Maine Medical Sociery, 2N5, Vol.7, No.2

5. Combinations are also possible, which may haveotherdrugs along with primary drug; dispensingof such combination is undesired, as otherdrugs may be unnecessary and may precludebenefit to the patient.

If the patient's symptoms continue, you will needto consider whether the diagnosis, treatment, ad-herence to treatment and the monitoring procedurewere all correct. In fact the whole process startsagain. Remember you have done communication toperfection, as it is integral part of a prescription,else even the best prescription is left desiring. Some-times there may be no end solution to the problem.For example, in chronic diseases such as hyperten-sion, careful monitoring and improving patientadherence to the treatment may be all that you cando. In some cases you will change a treatmeut be-cause the therapeutic focus switches from curativeto palliative care, as in terminal cancer or AIDS.

CONCLUSION

So, what at first seems just a simple consultationof only a few minutes, in fact requires a quite com-plex process of professional analysis. What youshould not do is copy the other doctor and memo-rise that dry cough should be treated with 60 mgFexofenadine 2 times daily for seven days - which isnot always true. Instead, build yourclinical practiceon the core principles ofchoosing and giving a treat-ment, which has been outlined in table below. Thekey in making your prescription successful lies moreon verbal communication and listening to patientand attendants in addition to effective prescriptionwriting. Prescription of more number of drugs in agiven case is a sign of weakness of this instrument,unless there is sufficient reason to do so. Theendpoints of good prescription includes early ef-fective cure of malady and appropriate completenessof prescription with resultant absolute satisfactionboth to the patient and the prescribeq irrespectiveof good or bad outcome.

t 3 5

I

Review ArticleTOOTH MOBILITY - A DENTAL CHALLENGE

Surg Cdr @) B Mukherjee

INTRODUCTION

fleservation of the natural dentition in a state of-f comfort, health and function is the primary goalof the dental profession. "Mouth is the mouthpieceof Mind". Healthy teeth and gums are essential forthe power of speech and beautiful smile.

Mobile teeth are an area of concern not only forthe patient, but also to the Dental Surgeon becauseit represents a critical state when the tooth lies be-tween the two'S'. whether to be saved or sacrificed.

Tooth mobility is the most commonly used pa-rameter to evaluate the status of the periodontiumand is considered a important clinical feature in peri-odontal disease. Teeth extracted due to periodontaldiseases far exceed those lost due to caries or otherreasons [].

Assessment of tooth mobility is considered tobe of paramount significance in the establishmentof diagnosis, prognosis and treatment plan.

The mobility of tooth results from loss of all or aportion of its periodontal attachment and alveolarbone and is a consequence of varied etiology, theprinciple causes being, periodontitis, occlusal trau-matisation and periodontosis. This provides for achallenging treatment modality selection in peri-odontal therapy. The saving of the mobile teethrequires a critical diagnosis and application ofsuit-able management criteria befitting the prognosis ofa particular case. The procedure in use to save mo-bile teeth from early demise could either be bysplinting, periodontal surgery grafting, guided tis-sue regeneration etc. or in combination.

It is prudent to acknowledge that while consider-ing to saving a mobile teeth adequate diagnostictechniques in oral diagnosis, periodontal analysisand occlusal analysis needs mandatory considera-tion before a treatment procedure is applied.

THE CAUS$ OF TOOTII MOBILITY

Tooth mobility could result from Local and Sys'temic factors.(A) Local Factors:-

I Loss of tooth support (Bone loss).

a) Bone destruction due to uncontrolledperiodontitis (from plaque inducedgingivitis)

b) The amount of mobility will depend on BoneLoss. The severity and distribution atindividual root surface, the length and shapeof root surface, the root size compared withcrown.

Traumafrom Occlusion: - (i.e. injury producedby excessive occlusal force or due to abnormalhabits such as Bruxism & clenching). Mobilityoccurring due to trauma from occlusion is aresult ofresorption ofthe cortical layer ofbone,leading to reduced periodontal fibre support.

Tooth Hypo funct ion:- A tooth withoutantagonist causes widening of periodontalligament initially due to reduced stress.

Periapical Pathology:- The extension ofinflammation from an acute periapical abscessmay increase tooth mobility in absence ofperiodontal disease.

Periodontal Surgery:- After periodontal surgerya temporary increase in tooth mobility isobserved.

Pathologic lesions ofjaws that destroy alveolarbone and/orthe root of teeth eg. Osteomyelitis,tumors, cysts etc.

Traumatic injury to the dento- alveolar unit.

Overjet and over bite are directly proportionaltotooth mobility.

6.

7.

8.

Classified Specialist (Oral Surgery), Naval lnstitutc of Dental Sciences, INHS Asvini, Colaba, Mumbai'

136 Jour. Marine Medical Society,2U5,W|.7, No.2

(B) Systemic Causes:-

l. Age:- Mobility is positively related to age ofthe individual.(increased mobility with age) [2]

Z Sex & Race:- Slightly higher incidence is seenin females and negroes [2].

3. Menstrual Cycle: - Slight increase in toothmobility is observed in 4'h week of menstrualcycle [3].

4. Pregnancy:- Mobility of tooth increases duringpregnancy and is attributed to certain physico-chemical changes in the periodontium [4].

5. Systemic Disease:- Certain systemic diseasesaggravate periodontal disease and increasedtooth mobility is observed.

Eg :- Downs Syndrome, Neutropenia,Hypophosphatesia,

Acute Leukemia, Hyper Parathyroidism, Pagetsdisease etc.

6. Bone factor concept of Glickman:- The bonefactor concept developed by Irving Glickmanin early 1950's, attributed that certain individualsmanifest a greater magnitude of alveolar boneloss/ resorption to any periodontal lesion.

NACTORS AFFECTING DEVELOPMENT OFTOOTHMOBILITY

l. Magnitude, frequency and character ofmasticatory stress.

Z Physical resistance of the periodontitium.

3. Direction of the masticatory stress.

4. The amount of fibre bundle in the periodontium.

5. The strength of the alveolar bone.

6. Periodontal ligament can tolerate tension muchbetter than pressure.

7. Para functional habits and forces.

8. Physiological and systemic factors whichinfluence metabolic process of cells such asblood circulation in periodontitium, age,nutrition and general health.

PATTERNS IN TOOTH MOBILITYl. Physiologic Tooth Mobility:- All teeth exhibit a

slight degree of physiologic mobility whichvaries for different teeth and different times ofthe day. Greatest in arising in the morning and

Jour. Marine Medical Society, 2005, Vol.7, No.2

progressively reduce in the day.

Z Single rooted teeth have more mobility thanmulti-looted teeth. It is observed when a 500!bforce is applied on the crown of teeth; it elicittooth mobility in horizontal direction [5]a) 100 -200 pm for incisors

b) 5G90pmforcanines

c) 8G100 pm forp'remolars

d) 4G80pmforrnolars

3. Tooth mobility occurs in 2 stages:-

a) Initial orlntra socket stage- the tooth moveswithin the confines of periodontal ligament.This occurs with forces of about l00lb andisabout5Gl00pm.

b) Secondary stage - this movement is gradualand causes elastic deformation of the ah,eolarbone in response to increase horizontalforces.

4. The return of tooth to original position whenthe force appl ied on occluding teeth isdiscontinued (rccurs in 2 stages.

a) First Stage- It is an immediate spring likeelastic recoil.

b) Second Stage- This is an asymptomaticrecovery movement. This is pulsating andsimilar to the normal pulsation of theperiodontal vessels, which occurs insynchrony with the cardiac cycle.

5. Reduced tooth mobility occurs in some cases(e.g. Ankylosed tooth due to fai led re-implantation and in autogenous bone graftplaced in contact with detached root surface).

6. Increased/Static tooth mobility occurs as astabilising mobility.(e.g. Trauma from occlusionand controlled periodontal disaease).

7 . Hyper mobility: - This form of mobility is refenedto as "residual mobility" and occurs aftercompletition of periodontal surgery. This occursin two phases, a developing phase and apermanent phase [6].

EXAMINATION & MEASUREMENT OF TOOTHMOBILITY

The examination and measurement of tooth mo-bility is important in clinical diagnosis of the

t37

condition of teeth, the prognosis and in treatmentplanning.

The importance of the clinical parameter of toothmobility, can be appreciated from the fact, that toothmobility Indices and tooth mobility measuring de-vices (mobilometers) have been continuouslyresearched from as early as 1938.

Tooth mobility is evaluated by placing an instru-ment on the facial & lingual surface of the tooth andapplying pressure. The readings signify:-

Class0A.{ormaltooth - Mobiliwlessthen0.2mm

Class I mobility

Class 2 mobility

Class 3 mobility

- Movement horizontal/mesiodistal 0.2to lmm

- Horizontal/mesiodistalmobility I to2mm

- Horizontal/mesiodistalmobility exceeding 2mmorVertical mobility

Errors in mobility measurement may be due to

a) Variation in direction offorce.

b) Pointof application ofpressure.

c) Mode and manner of application.

d) Duration and time of forces.

e) Instabilityvariation.

0 Slippageofdevice.

Mobilometers instruments [7] have been in useto measure mobility in clinical research from year1939, many devices have been introduced since then.The latest device and one of the current Assays isPeriotest (Siemens AG Germany). Periotest utilizesdynamic forces of short duration of low millisecondrange. It evaluates the damping characteristic ofteeth.

PROGNOSIS IN TOOH MOBILITY CASES

This depends on:-

a) Amount of bone loss.

b) Malocclusion.

c) Traumafromocclusion.

d) Para functional/ adverse habits.

e) Numbers of root in teeth.

0 Position of tooth in arch.

g) A 8 year duration study Flezzar et al (1980).

138

Mobile teeth with pockets respond less toperiodontal therapy than firm ones.

h) Restarting tooth stability in mobile tooth isinversely proportional to degree of bone loss.

MANAGEMENT OF TOOTH MOBILITY

In the treatment of tooth mobility the correctionof the etiology and proper management of systemicbackground is the prime concern. Occlusal conec-tion, splinting of teeth, use of bone graft inaterial,sectioning of multi- rooted tooth etc. are the varioustreatment modalities in use.

OCCLUSAL CORRECTION

Occlusal correction /adjustments is the estab-lishment of functional relationships favorable to theperiodontium by one or more of the following pro-cedures.

a) Reshaping of the(Coronoplasty).

b) Dentalrestorations.

c) Tooth movement.

d) Tooth removal

e) Orthognathicsurgery.

t ee th by g r i nd ing

Coronoplasty which may be required in toothmobility cases means the selective reduction of oc-clusal areas with the primary purpose of influencingthe mechanical contact conditions and the neuralpattern of sensory input, with an important purposeto eliminate occlusal forces injurious to the preser-vation of periodontal health.

Comprehensive therapeutic occlusal alterationusually includes stabilization of the retruded con-tact position (RCP) and smooth coordination ofcontacts between the RCP and intercuspal position(ICP). In addition, smooth interference - free lateralprotrusive excursions from the ICP are achieved.Disturbing retrusive supra contacts along lateralborder paths are usually lessened or removed.

In Bruxism and TMJ disorder cases a removablefull arch stabilization appliance is used (mainly max-illary stabilization appliance), to alleviate toothmobility symptoms.

SPLINTINGOFTEETH

When teeth are seriously loosened by acute

Jour Marine Medical Society, 2005, Vol.7, No.2

II

III

III

I

trauma or periodontal disturbance, stabilization bysplinting can become a valuable adjunct, before,during and after corrective therapy.

Historically splinting of weakened teeth by hu-mans is found in a Phoenix human mandible from500 B.C. Egyptian mummies also show similargoldwiring. Splinting of teeth continued being modifiedwith the availability of new materials.

Splinting in Dentistry

The term Splinting means " joining of two or moreteeth into a rigid unit by means of facial or remov-able restorations or device".

Two terms of importance is:-

Splintee : Tooth that need support.

Splinters : Adjacent teeth that provide support.

The Indications of Teeth Splinting are:-

a) Stabilize moderate to advance tooth mobility.

b) Stabilize teeth in secondary occlusal trauma.

c) To facilitate scaling and surgical procedures.

d) Stabilize teeth after orthodontic treatment.

e) Stabi l ize teeth af ter acute denta l t rauma.ie.subluxation, avulsion etc.

I Prevent tripping and drifting ofteeth.

g) Prevent extrusion of un opposed teeth.

The Classification (Types) of splints used in den-tistry is essentially based in accordance with theperiod of stabilization.

(a) Temporary Stabilization

Worn for less than 6 months

These could be: - Removable eg. Occlusal splintwith wire OR Fixed eg. Intra coronal like amalgam,amalgam and wire, composite, resin and wire or Ex-tra coronal like stainless steel wire with resins, enameletching & composite resin etc.

(b) Provisional Stabilization

To be used for months upto several years eg.Acrylic splints, metal band.

(c) Permanent Splints

Used indefinitely eg. Full orpartial veener crownsoldered together, inlay/on lay soldered together.

J our. M arine M edic al S o c ie ty, 2005, VoL. 7, N o. 2

l .

The Advantages (strength) of Splinting are:-

May establish final stabil ity and comfort forpatient with occusal trauma.

Helpful to decrease mobil ity and acceleratehealing following acute trauma of the teeth.

A l l ow remode l i ng o f a l veo la r bone andpe r i odon ta l l i gamen t f o r o r thodon t i ca l l ysplinted teeth.

4 . He lps i n dec reas ing mob i l i t y f avo r i ngregenerative therapy.

5. Distribute occlusal forces over a wider area.

The disadvantages of splinting are that it ham-pers patient oral hygiene practice, this could lead tofurther periodontal breakdown in a patient with al-ready compromised pe r i odon ta l suppo r t .Furthermore occlusal forces on an improper advicedand cons t ruc ted sp l i n t cou ld i n j u re t heperiodontit ium of all teeth within the splint.

Use of Bone Grafts

Bone grafting is one of the common form of re-generative therapy applied to restore periodontalt issue.

All grafting techniques require pre-surgical scal-ing, necessary occlusal adjustments and exposureof the defect with a full thickness flap. The use ofantibiotic during the procedure is generally recom-mended.

Several types of natural bone and bone substi-tutes are used in periodontal regenerative therapy.

(a) Bone Grafts:-

Autogenous Grafts:- Bone from intra oral siteseg. edentulous ridges, tori, maxillary tuberosity, ex-traction sites, etc. are used as coagulum or boneblend. Bone from extra-oral site is taken from illiaccrest.

Allografts: - e.g. Uncalcified Freeze- Dried BoneAllograft (FDBA) and Decalcified Freeze- DriedBone Graft (DFDBA).

(b) Bone Substitutes:-

Xenografts - They are mainly two types-

i) Bovine derived hydroxyapatite, eg. Osteograf& Bio-oss

r39

2.

J.

treatment?

nt

t rn ings

Start a l l

reatmentI to verifythis par-:trve and

'enient tohere is aa studentreason it)pressantrs wi th inte) shareare eveniing anti-fenadine.rbly bet-considerrs a pos-lossible,

n expla-;e wordsJine can

.7, No.2

ii) Coralline Calcium Carbonate. eg. Bio Coral.

AlloplastsBio- ceramics: - These are primarily composed of

calcium phosphate. example : Hydroxyapatite bothreversible & non reversible and tri-calcium phos-phate.

Bioactive Glasses:- Two types are in use,PerioGlas (Bioglass synthetic bone graft particulate)& Biogran (resorbable synthetic bone graft).

Sectioning of Multi rooted TeethThe treatment of certain mobility cases in molar

teeth with furcation involvement provides an op-portunity for retention of their healthy portion bythe aid of root resection and hemi section or bisec-tion. The removal of a root without removal of anyportion of the crown is termed as root resection pro-cedure.

When one root and its corresponding crownportion is removed the procedure is called a hemi-section. [n case of bisection a molar is sectionedinto two separate portions i.e. Mesial and distal.

All teeth sectioning cases require Endodontictreatment and a suitable Crown and Bridge work.

CONCLUSIONPeriodontal disease can affect any individual at

any age and at any point of time. The severity anddeleter ious ef fect of the d isease on theperiodontitium causing mobility of teeth and its ulti-mate sacrifice can be encountered and minimised byeducating the patient, early diagnosis and the se-lection of a suitable treatment modality by thePeriodontist.

REFERENCES| . Kel ly JE, Harvey CR. Basic Dental Examinat ion.

Findings of Persons I - 74 years, United Stares l97l-74, publication No. 79- 662, Series II, No. 214, MD,US . Pub l i c Hea l t h Se rv i ce , US Dep t o f Hea l t hEducation, and Welfare. National Center for HealthStatistics

2 . Pe r l i t esh MJ . A Sys tema t i c app roach t o t hein te rp re ta t i on o f t oo th mob i l i t y and c l i n i ca limpl icat ions. Dental Cl in ic Mortar Ant1980:24 : 177.

3. Lawrence A Friedman. Horizontal tooth mobility andmenstrual cycle. J Periodottt Res 1972;7 : 125-30.

4 . Ra te r i t s chak KH . Too th mob i l i t y changes i npregnancy. J Periodont Res 1967;2 : 199.

5. Mubdleman HR. Ten ycars of tooth mobi l i rymeasurements. J Periodont 1960; 3l : ll0.

6. Ramfjord SP, Major Ash Jr . The s igni f icance ofocclusion in the et io logy and t reatment of ear lymoderate and advanced periodontitis. J Periodontoll 98 l : 52 : 510 -5 .

7. Pameijer CH, Stallard RE. A Method for quantitativemeasurement of tooth mobilitv. J Periodontal 1973..44,6 : 339-45.

.loun Marine Medical Society, 2005, Vol. 7, No. 2IA

DEC(

SurgLSurgC

Key Wt

INTRO

I l 9 !

v c a

ries oufrom slcal Satf o r a pDecontralianSchedrschedtDCS ittered ttwo ofthe thiing co

CASEA quall5 0 M uduratioraccordipresentboth thdive. Cand sydiagnolwas imdiver bthe botNavy Iand thr

CASE

A qualSalvagwas aascent

. .Senir

MedicINHS,

Joun I

severity andse on thel and its ulti-ilnimised byand the se-rl ity by the

Examina t i on .I States l97l-No . 214 , MD.p t o f Hea l t h.er for Health

:ach t o t heand c l i n i ca l,lortar Ant

mobi l i ty and7 : 125 -30 .

changes i n99.

r t h mob i l i t yr 10.;n i f icance ofnent of ear lyI Periodontol

)r quantitativetdontal 1973',

VoL7, No.2

DECOMPRESSION SICKNESS . THREE TJNEXPECTED CASES

Surg Lt Cdr Vivek Verma', Surg Lt Cdr K Mishra', Maj R Bajaj r,

Surg Capt B Sudarshan", Surg Capt S Nangpal*

Key Words : Decompression sickness (DCS), Bui l t in breathing system (BIBS).

INTRODUCTION

f-\ecompression sickness (DCS) is a unique disItf ease encountered by divers. Indian Navy car-ries out various types ofdiving operations rangingfrom shallow water Scuba Diving to highly techni-cal Saturation Diving. If decompression is requiredfor a particular dive, it is carried out using variousDecompression Schedules such as British, US, Aus-tralian etc. In the Navy we use British DecompressionSchedules, which are quite safe .In addition, theseschedules are followed strictly, so the incidence ofDCS is very rare in our divers. However, we encoun-tered three unexpected cases of DCS in our divers,two of them were qualified clearance divers whilethe third one was a undertrainee for clearance div-ing course.

CASE REPORT IA qualified experienced Clearance Diver dived to a depth of50 M using air in a Recompression Chamber (RCC). Theduration of the dive was 30 Min. The dive was carried outaccording to Table l l of Br i i ish Navy Div ing Manual . Hepresented immediately after surfacing with severe pain inboth the f lanks. He did not have any problem dur ing thedive. On examinat ion his v i ta ls were normal and generaland sys tem ic exam ina t i on was un remarkab le . He r vasdiagnosed as a case of Type I (musculoskeletal) DCS andwas immediately recompressed to l8 M using oxygen. Thediver became asymptomatic within five min after reachingthe bottom. He was decompressed using Table 6l of BritishNavy Div ing Manual . He was asymptomat ic on surfacingand there was no recurrence afterwards.

CASE REPORT 2

A qualified Clearance Diver dived to a depth of 47 M in aSalvage Operation carried out by the Indian Navy. The divewas a difficult dive because of poor visibility and multipleascents dur ing the dive. He was asymptomat ic af ter the

dive. He presented 12 hrs after the dive with rashes all overthe body specially concentrated on the chest, abdomen andarms [Fig. l]. The lesions were associated with severe itching.Allergic reaction due to any contact with a marine animal /material was ruled out by taking history carefully. Therewere no o the r symp toms . On exam ina t i on he hadmaculopapular rashes of s ize ranging f rom lmm-7mm insize associated with intense erythema. He was diagnosed asa case of Type I (Skin only) DCS and was immediatelycompressed to a depth of l8 M using Oxygen. He had 80-85% rel ief af ter reaching l8 M. The i tching completelyreso l ved , t hough t he sk i n l es i ons rema ined . He wasdecompressed using oxygen Table 6lof British Navy DivingManual. He had fresh lesions on left forearm the followingday. He was again given Recompression Therapy (RCT)

and became asymptomatic within five min at l8 M. Therewere no fresh lesions afterward. The skin rashes completelyresolved within five days. [Fig. 2]

CASE REPORT 3

A undertra inee diver presented immediately fo l lowing aopen sea dive to a depth of 35 M wi th pain in the r ightshoulder and inability to lift his arm above shoulder. He wasusing divator 324 air set and had sp€nt less than one min at35 M. There was no history of t rauma / unaccustomedphysical work following the dive. There was no localizedtende rness . H i s gene ra l and sys tem ic exam ina t i on wasunremarkable. He was immediately g iven recompressiontherapy using oxygen Table 6l and became asymptomatic.w i t h i n l 0 M in o f r each ing t he bo t t om. The re was nofecurrence on surfacing.

DISCUSSION

Decompression sickness is a disease as well as aaccident. In the Navy we use British Decompres-sion Tables which are quite safe. Occasionally weencounter cases of DCS in No Decompression divesand dives in which the decompression stops havebeen followed strictly. In these cases there is noobvious reason for developing DCS. The factors

*'Senior Advisor, (Marine Medicine), Institute of Naval Medicinel 'PG

Trainee, (Marine Medicine); *PG Trainee, (MarineMedic ine) l 'Graded Special is t (Physio logy), Inst i tute of Mar ine Medic ine, Mumbai . "Senior Advisor, (Mar ine Medic ine),INHS, Kalyani , Visakhapatnam.

Joun Marine Medical Society,2N5, Vol.7, No.2 141

Fig. I : A qualifiedClearance Diverpresented 12hrs af-ter the dive with rashes all over the body speciallyconcentrated on the chest, abdomen and arms.The lesions were associated with severe itching.

which increase the susceptibility towards develop-ing DCS are divided into those related to the Diveand those related to the Diver []. The factors re-lated to the diver which increase the susceptibilityextra-ordinarily towards developing DCS are pul-monary barotrauma, Patent foramen ovale,Immunological sensitivity to bubbles and poorphysical fitness [2,3]. The factors related to dive aredepth, duration, multilevel diving, decompressionschedule used etc [4]. Whenever a diver presentswith symptoms of DCS, he should be immediatelygiven Recompression Therapy (RCT) at the earliest,even ifthe dive profile doesnot favour developmentof DCS.If a Recompression ChamberComplex (RCC)

is available it should be used. If p RCC is not avail-able-even In Water Recompression (IWR) can begiven using British, COMEX, DCIEM orAustralianTables [5]. If Oxygen is available it should be pre-fened over air as the time required for decompressionis shorter and also the bublile resolution is fasrcr.Built in Breathing (BIBS) System should be used todeliverpxygen. If BIBS is not available oxygen canbe delivered at pressure using Oxyger-57 set in anernerg€ncy. It should be our endeivor that at leastone RCC fitted with BIBS is available at every sta-tion for such kind of exigencies. Once the RCT hasbeen completed and the diver is comfortable an X-Ray Chest, PFT and an ECG should be done at the

142

Fig.2 : Following immediate compression to a depth of'18 M using Oxygen, the itching completely re-solved, though the skin lesions remained. With arepeat Recompression Therapy (RCT) he wasasymptomatic within five min at l8 M. The skinrashes completely resolved within five days.

earliest possible opportunity to rule out cardiac andpulmonary damage [6]. An echocardiography canbe done to confirm the diagnosis and in follow ups.A all joint X-Ray can be taken after one year to seeif there are any changes of Dysbaric Osteonecrosis.Newer investigative modalities such as MRI and CTscan can be done to detect changes due to DysbaricOsteonecrosis (DON) but they have a high falsenegative rate in cases of neurological DCS [7]. Insevere cases of DCS with incomplete recovery, thediver should be admitted in hospital and managedby Marine Medicine Specialist in consultation withvarious specialist. A diver who suffers from DCSshould be given restrictions following the incident.In case of mild DCS like Musculoskeletal DCS, heshould be excused from diving for a period cf oneweek. In a severe DCS like Neurological / CardiacDCS with complete resolution of symptoms a divershould not be allowed to dive for a period of onemonth and reviewed thereafter. If symptoms haveresolyed completely and there is no residual dis-ability, he should be allowed to dive. In a case ofsevere DCS with incomplete resolution or in caseswhereTable 62,7l,72have been used the divershould be downgraded for a period of three monthsand reviewed thereafter [8,9]. If the symptoms / signshave completely resolved, he should be dealt asdescribed earlier. A restriction on the diving depth

Joun Marine Medical Srciety,2005, Vot.7, No.2

preslmincsyml

REFI|.

can Isymlnentdeveandvelo'been

Joun

I

can be placed if considered necessary. In case thesymptoms/signs persist, he should be made perma-nently unfit for diving. In the end it is clear thatdevelopment of DCS depends on the dive, the diverand the decompression schedule used. It can de-velop in dives where decompression schedule hasbeen carried out strictly and also where no decom-pression is rcquired. One must always keep DCS inmind when dealing with a diver lnesenting with vaguesymptoms post-dive.

REFERENCES

|. Cook SR Environmental factors affoctingdecompression sickness. Part III. Role of exercise,temperature, drugs and water balance in dccompressionsickness. In Fulton JR ed. Decompression sickness.Philadclphia: WB Saunders: 195l:223-41.

2. Cross SJ. Evans SA. Thomson LF, et al. Safety ofsubaqua diving with patent foramen ovale. BR Med J1992.3O4:481-2.

3. Dunford R, Hayward J. Venous gas bubbles production

.loun Marbte Medical Society,2U5, UoL7, No.2

folloring cold Etre$ dring a no decompression dive.Undersea Biomed Rcs l98l:8:41-9.

James T, Francis R, Mitchell J. Pathophysiology ofDCS, In: Bennet PB, Elliot DH, eds. The physiologyand medicinc of diving. 4t edition. London: WBSaunders; 1993:433-53.

Edmonds C, Underwater oxygen treatment of DCS. In: Moon RF. Sheffield PJ, eds. Treatment of DCIKensinlon MD: Undersca and Hyperbaric MedicalSocietj{ 1996 : 255-65.

Koch GH, Weisbrod GL, Lepawsky M, er al. Chestradiograph can assist in diagnosis of PulmonaryBarotrauma. Undersea Biomed Res l99l:18 (Suppl):100

Moon RE, Masscy EN, Debatin IF, et al. RadiographicImaging in Ncurological Decomprcssion i l lness.Undersea Biomed Res 19 (Suppl):42-45.

Article 5501. Section 5. Therapeutic Recompression.British Navy Diving Manual ll2-114.

Navy Department: US Navy Diving Manual. Vol 5.Revision 4. Diving medicine and Recompressionchamber operation. 145-147.

4 .

5 .

6 .

7 .

8 .

9 .

143

I

CONGENTTAL VALLECULAR CYST IN A NEONATE : A CASE REPORT

Surg Capt Emmanuel James', Surg Cdr Shankar Narayan*,Surg CdrJoy Chatterjee', Col SS Gilf'

Key Words : Vallecular cyst; Neonate 11

INTRODUCTION

(longenital vallecular cysts are rare [l,2] and\-,though benign, their anatomical location pre-disposes to upper aerodigestive tract obstructionand can even result in neonatal death [2-5]. We re-port a 25-day male neonate, who was managedsuccessfully.

CASE REPORT,

A 25-day male infant was transferred from a peripheral

hospital. Born at term by normal delivery to a 28 years

second gravida with no significant contributory history,birth weight was 2700 g and the infant did not need anyresuscitation at birth.

Parents not iced the infant to have intermit tentregurgitation of feeds and a hoarse voice since day 3 of life.He was brought to the hospi ta l on day 23 of l i fe wi thcomplaints of total refusal of feeds, excessive crying andan at tack of cyanosis. Examinat ion revealed a massprotruding from the posterior tongue. The infant was startedon parenteral fluids and antibiotics and transferred to ourcenter.

On admission to our center, the infant was pink andactive. All his vital parameters were normal. Oral cavityexamination revealed a large cystic mass arising from theposterior part of the tongue. No other congenital anomalywas detected.

Surgery was performed the next morning. On dircctmicrolaryngoscopy, a cyst measuring 3 x 3 cm, arisingfrom the left vallecula and crossing the midline was noted.The epiglottis and glottis could only be visualized afteraspiration of the cyst. The cyst was excised in-toto usingthe pediatric suspension laryngoscope and microscope. TWobits of tissue measuring I x 1.5 cm and 0.7 x 0.5 cm weresent for histopathology which revealed fibrocollagenoustissue lined by stratified squamous epithelium. The infantmade an uneventful recovery and was discharged on theterm postoperative day, by which time he was on exclusivebreast feeds and his voice was no longer hoarse.

DISCUSSIONCongenital vallecular cysts are rare and only 40

such cases have been reported in world literature.These benign cysts result in a variety of symptomsthat include feeding difficulties, failure to thrive, stri-dor, hoarseness of voice and attacks ofcyanosis [,3-8].Alarge numberof infants with con-genital vallecular cysts also have associatedlaryngomalacia that has been reported to spontane-ously resolve following removal of the cyst t1,4,51.Our patient had feeding difficulties, hoarseness ofvoice and a solitary attack of cyanosis.

These cysts may be visible in the oral cavity asin our patient. The degree of compromise of the res-piratory tract can be assessed by obtaining plainradiographs of the neck [6,8,9]. However, directlaryngoscopy, preferably fibroendoscopy, is essen-t ial to conf irm the diagnosis as wel l as forfollow-up [4-7].

It is of interest to note that there is a recent re-port of antenatal diagnosis of vallecular cyst usingantenatal ultrasonography and magnetic resonanceimaging [2]. These cysts can cause anesthetic diffi-culty and our patient could only be intubated afterthe contents of the cyst were aspirated and the epi-glottis and the area below visualized clearly. Suchanesthetic difficulties are known and need skilledmanagement [10].

The symptoms in our patient coupled with thevisible cystic mass arising from the posterior part ofthe tongue were enough to suggest the diagnosis.Direct visualization by microlaryngoscopy and com-plete removal of the cyst was resorted to following

'Additional Advisor (ENT); *Classified Specialist (Pediatrics) & Nconatologist; rClassified Specialist (Anesthesiology) &Pediaric Anesthesiologist; "Classified Specialist (Pathology & Oncopathology), AFMC, Pune.

Jow Marine Medical Society, 2005, Vol.7, No.2I4

which the patient recovered fully.

The aim of presenting this rare condition is toincrease awareness about congenital vallecular cystsso that, given the mix of symptoms as in this patient,early diagrosis and appropriate management is pro-vided to reduce neonatal morbidity and mortality.

ACKNOWLEDGEMENT

Wc are grateful to Surg Vice Admiral VK Singh, AVSM,VSM, DGMS (Navy), tbe then Commanding Officer, INHSAsvini, for his guidance in thc managcment of this patient,

REFERENCES

l. Ku AS. Vallecular cyst: report of four cases - one withco-existing laryngomalacia. J Laryngol Otol 20OO:ll4:. 224-6.

2. Cuillier R Testud R, Sampcriz S, Fossati P. Prcnataldiagnosis at 25 wceks gestation and nconatalmanagement of a vallecular cyst. Ann OtolaryngolChir Cemicofac 20O2 ; ll9:293-5. (Article in French,abstractcd for Pubmed).

3. Guiterrez JR Berkowitz RG Robertson SF. Vallecularcysts in newborns and young infants. Pediatr Pulmonol

Joun Marbu Medical Society,2m5,til.7, No.2

1999;27: 282-5.

Liu HC, Lcc KS, Hsu CH, Hung HY. Nconatal vallecularcyst: r€port of elevcn cws. Clutrggcng Yi Xue 7a Vti1999;22:615-20. (Article in Chinese; abstracted forPubmed).

Hsieh WS, Yang PH, Wong KS, U HY Wang EC, YehTF. Vallecular cyst: 8n uncommon cause of stridor ininfants. Err J Pediatr 2ffi0; 159: 79-81.

Oluwole M. Congenital vallecular cyst: a causc of failureto thrive. Br J CIin Pract 1996;50:170.

Gtuckman PG Chu TW. Hasselt CA. sNeonatalvallccular cysts and failurc to thrive. J l-aryngol Otol1992; 106:448-9.

Tunccr U, Aydogan LB, Soylu L. Vallecular cyst: Acause of failurc to thrive in an infant. Int J PediatOto rhinolaryngol 2OO2: 65: 133-5.

Liang CD, Huang CB. Laryngcal vallecular cyst in ancwborn: report of onc case. Vtonghua Min Guo XiaoEr Ke Yi Xue Hui 7a 7.hi l99l;32: 6G9. (Article inChinese; abstractcd for Pubmed).

Cheng KS, Ng JM, Li HY Hartigan PM. Vallecularcyst rnd laryngomalacia in infants: rcport of six cascsand airway management. Anesth Analg 2OO2;95:1248-50.

4 .

5 .

6 .

7 .

9 .

10.

145

I -

MULLEzuAN ADENOSARCOMA OF THE UTERUS PRESENTING ASA CERVICAL POLYP _ A CASE REPORT

Surg Lt Cdr G Parthasarathy', Surg Cdr Naveen Chawla', Lt Col (AMC) R Duraiswamit,Surg CdrA Kapur", Surg CdrR Panicker*, Surg Lt Cdr R Sivasankar#

ABSTRACT

Mullerian adenosarcoma is a rare variant of mixed mullerian tumors of the uterus. Typically, it is composed ofben ign , occas iona l l y m i l d l y a t yp i ca l g l andu la r ep i t he l i a l e l emen ts adm ixed w i t h a ma l i gnan t , sa r coma tousstroma. This tumor accounts for only aboutT-8Vo of all uterine sarcomss. Usually, the tumor originates in the

endometr ium and grows as a polypoid mass wi th in the endometr ia l cavi ty. The most common present ing

complaint is abnormal uter ine bleeding and on examinat ion, a polypoid mass protruding through the cerv icalos. We present the case of a 52 year o ld lady, who presented wi th post-menopausal b leeding. On per vaginam

examination, a polypoid mass was seen protruding through a dilated cervical canal. A polypectomy was carriedout, which revealed a Mullerian adenosarcoma. A pan-hysterectomy was then performed, which showed evidenceof residual d isease in lhe uter ine cavi ty, not invading the myometr ium. One year fo l lowing the surgery, thepat i€nt is symptom free.

Key Words: Mul ler ian, Adenosarcoma, Phyl lo ides, MMMT, Adenof ibroma, Sarcoma.

INTRODUCTION

l\ fullerian adenosarcoma is a distinctive type ofIYlmullerian tumor and is usually low grade ascompared to the malignant mixed mullerian tumor,the high grade vdhant. Usually, it presenis in one oftwo modes, either as a bulky, polypoid growth in theendometrial cavity, at times distending the cervicalcanal and protruding through the cervical os, or lesscommonly as an intramural nodule within the uter-ine corpus [l-3]. Microscopically, it is composed ofepithelial and stromal elements, the distinguishingfeature being the presence of cytologically benignglands in a malignant stroma. The stroma resemblesendometr ia l s t roma by l ight and e lect ronmicroscopy [4,5]. Adenosarcoma, like is malignantcounterpart, the malignant mixed mullerian tumor, isfar more common in the post-menopausal age group,where the presentation is that of post-menopausalbleeding. However, the overall age of onset mayrange from peri-pubertal girls to women in the ninthdecade [3]. The importance in recognizing this tumorlies in the fact that it has a much better prognosis

than the malignant mixed mullerian tumor, from whichit has to be distinguished because of the latter'spoorer prognosis and aggressive treatment. Thistumor also has to be distinguished from the benignendometrial polyp, adenofi broma and adenomyoma,since this distinction is important from the aspect ofmanagement [2].

CASE REPORTA 52 yea r o l d l ady p resen ted w i t h i r r egu la r pos t -

menopausal bleeding for 3 months, not associated with anysymptoms of pelv ic inf lammat ion. On examinat ion, shewas found to have a polypoid, friable, dirty gray white massprotruding from the external os, bleeding on manipulation.A polypectomy was performed at the same time and thet i s sue subm i t t ed f o r HPE . Fo l l ow ing t he d i agnos i s o fadenosarcoma, the pat ient was subjected to a pan-hysterectomy soon thereafter.

Histopathological f indings

A 2.5 cm diameter, grayish white, ovoid tissue specimenwas initially received which had numerous hemorrhagic areason the surface as well as on cut section. The cut section alsorevealed 's l i t l ike ' spaces (Fig. l ) . Microscopy showed anadm ix tu re o f ep i t he l i a l and s t r oma l e l emen ts . The

'Graded Specialist (Pathology); *Classified Specialist (Pathology), INHS Sanjivani. Naval Base, Kochi 682 004; {Classified

Specialist (Pathology), 159 GH C/o 56 APO; "Classified Specialist (Obs & Gyn); *Classified Specialist (Obs & Gyn); rrGraded

Specialist (Radiodiagnosis), INHS Sanjivani, Naval Base, Kochi 682 004.

Jour Marine Medical Society, 2405, Vol.7, No.2t46

n to a depth ofiompletely re-rained. With aRCT) he was8 M, The skinr five days.

t cardiac andography cant follow ups.e year to seeiteonecrosis.MRIandCT:to Dysbarica high falseDCS [7]. Inecovery, thend managedultation withs from DCSthe incident.xal DCS, heeriod cf one:al / Cardiactoms a diver:riod of onerptoms haveesidual dis-In a case ofr or in casesd the diverrree monthsfoms / signsbe dealt asiving depth

, Vol.7, No. 2

t ' t

Fig. I : Cut surface of the polypoid specimen showingnumerous ' s l i t l i ke ' spaces and foc i o fhemorrhage.

Fig.2 : Benign looking proliferative endometrial glandwith pinkish intraluminal secretions set in a ma-lignant stroma. H&E stain, 100X.

epithel ium elements were composed predominantly ofendometrial type of glands. These glands wcre mostlyproliferative in nature with a benign appearance (Fig. 2)and forming irregular complex patterns and at placesappeared 'sl i t l ikc' , The stroma was cel lular withperiglandular condensation (cuffing) of the stromal cells.The stromal cells at places showed a moderate degree ofnuclear pleomorphism (Figs. 3,4) with mitosis exceeding 2per l0 HPF in the ccllular areas. Foci of necrosis were seen.There was no obvious heterologous differentiation notcd.

The hysterectomy specimen receivcd showed presenceof residual tumor in the endometrial cavity. Howevcr, thebasc of the tumor was not extending into the myometrium.The rest of the endometrium showed cystic hyperplasia

Joun Maine Medical Society, 2005, Vol.7, No.2

Fig.3 : Highly pleomorphic, plump and Uizarre stiomalcells. H&E stain, 4(X)X.

Fig.4 : Bizarre stromal cells with a mitotic figure in thecentre. H&E suin.4fi)X.

and was otherwise unremarkable. The cervix, ovaries andtubes were all found to be histologically normal with noevidence of disease.

DISCUSSION

Mullerian adenosarcoma is an uncommon butimportant neoplasm of the uterus initially describedin 1974 by Clement and Scully [6]. This tumor is avariant of the mixed mullerian neoplasm in which theglandular or epithelial component is benign and thesfromal component is maligrant. The malignant mixedmullerian tumor, on the otherhand, displays a malig-nant epithelial as well as stromal element. Thespectrum of mixed mullerian neoplasm ranges fromthe adenofibroma and adenomyorha at the benignend, mullerian adenosarcoma, which has an inter-mediate prognosis, to the malignant mixed mulleriantumor, an aggressive tumor that often rapidly

t l

147

progresses to fatality [2,3].Microscopically, mullerian adenosarcoma is com-

posed of epithelial and stromal elements, with theepithelial component varying from pseudo-stratifiedendometrial to ciliated to hobnailed patterns resem-bling reactive endocervical epithelium. The stromais typically highly cellular, with a characteristic peri-glandular cuffing of the stromal cells, a feature whichdistinguishes the adenosarcoma from endometrialor adenomyomatous polyps. Further, the stromalcells show mild to marked atypia with mitotic countsusually exceeding 2 or more per l0 high powerfields [,3]. The stromal component usually resem-bles the endometrial stroma by light and electronmicroscopy [4,5]. However, in about 2OVo of thecases, multinucleated giant cells and heterologousdifferentiation may be noted. The heterologous ele-ments are most frequently skeletal muscle [7],a l though angiosarcomatous [8] , adipose andcartilaginous [9] elements have been documented.Tumors with predominantly tubular structures havebeen described by Clement and Scully [0], whosub classified them as uterine tumors resemblingovarian sex cord tumors. However, tumors with be-nign glands and sarcomatous stroma, especially withcystically dilated glands and peri-glandular stromalcondensations should be classified as mullerianadenosarcomas.

Mullerian adenosarcomas have a distinctly bet-ter prognosis that the malignant mixed mulleriantumors. Distant metastases are quite rare and seemto occur only when associated with tumors pos-sessing a highly malignant sarcomatous componentor in tumors with a heterologous differentiation[2,7].In Clement and Scully's hallmark series of a 100 cases,only 23 cases developed local recurence followinghysterectomy, of which about one third occurredafter 5 years of initial diagnosis. In almost all cases,the recurrence was restricted to the vagina, pelviso r abdomen , w i t h on l y two cases show inghematogenous spread. They also found that the mainassociation for increased risk ofrecunence was thepresence of myometrial invasion. In this study, theyalso specified the criteria for distinction ofadenosa-rcoma from adenofibroma as the presence of, aloneor in combination,2 or more stromal mitoses per 10high power fields, marked stromal cellularity, andsignificant stromal cell atypia []. This liberal diag-

148

nostic strategy is based on their vast experiencewith this tumor, thus making the diagnosis of ad-enofi broma relatively rare.

The treatment of mullerian adenosarcomas is byhysterectomy with bilateral salpingo-oophorectomy.Post-operative irradiation has been found to be un-necessary except in those cases where wide invasionis noted or in those tumors that have been incom-pletely excised [3]. The purpose of presenting thiscase is to highlight this rare uterine neoplasm andthe importance of distinguishing this tumor from abenign adenofi broma, adenomyoma or endometri alpolyp to avoid drastic surgery and also to distin-guish it from the highly aggressive malignant rnixedmullerian tumor, which requires a more aggressivemanagement and invariably has a poorer outcome.

REFERENCES1. Clement PB, Scul ly RE. Mul ler ian Adenoarcomas ol '

t he U te rus . A C l i n i co -pa tho log i ca l Ana l ys i s o f 100cases wi th a Review of the Li terature. Hum Pathol1 9 9 0 ; 2 l : 3 6 3 - 8 1 .

2. Mutter GL, Crum CP. Tumors of the female geni ta lt r ac t (Pa r t C - Tumors o f t he Endome t r i un r ) . I n :Fletcher CDM, Editor. Diagnostic Histopathology ofTumois, 2"d Ed. London: Harcourt Publishers Ltd 2000:(Vol . l ) : 648-68.

3. Kempson RL, Hendrickson MR. Mixed Epithelial andMesenchymal Neoplasms: Mixed Mullerian Neoplasia.In Bennington JL, Editor. Surgical Pathology of theU te r i ne Co rpus . Vo lume 12 . Ma jo r P rob lems i nPa tho logy . Ph i l ade lph ia . WB Saunde rs Co . 1980 :4 1 8 - 3 8 .

4. Gloor E. Mullerian Adenosarcoma of the Uterus. Anr JSurg Pathol 1979;3 : 203-9.

5. Katzenstein AA, Askin FB. Feldman PS. Mul ler ianAdenosarcoma of the Uterus. An Ultrastructural studyof four cases. Cancer l9'l7i 40: 223342.

6. Clement PB, Scul ly RE. Mul ler ian Adenoarcornas ol 'the Uterus. A Clinico-pathological Analysis of ren caseso f a D i s t i nc t i ve Type o f Mu l l e r i an M ixed Tumor .Cancer 19'14:34 : l138-49.

7 . Chen KTK . Rhabdomyoma tous U te r i neAdenosarcoma. Int J Cynecol Pathol 1985' , 4:146 -52 .

8 . Lack EE , B i t t e rman P , Sundeen JT . Mu l l e r r anAdenoarcoma of the Uterus with pure angiosarcoma.A case report . Hum Pat ln l l99l1 '22: 1289-91.

9 . Ro th LM, P r i de GL , Sha rma HM. Mu l l e r ranAdenoa rcomas o f t he U te r i ne Ce rv i x w i t hHeterologous Elements. Cancer 19'16: 3 '7: l '72.5-36.

10. Clement PB, Scul ly RE. Uter ine Tumors Resembl ingOvar ian Sex-cord Tumors - A Cl in ico-pathologicalAnalysis of 14 Cases. Am J Cl in Pathol 1976:66:5 t 2 - 2 5 .

Jour. Marine Medical Society, 2005, Vol.7, No.2

GASl

SurgLt

Key Wot

INTROI

' I A S T

\ t t T e

nal walintact untate olfloatingany co\presentsonogrl

CASE RA 2 4

a ntenatage st at l ointrautelc l rcumtcbowel lcloops or

Ax iafloatinga small r

the umbiloops.anthe herrlocation.ascltesIn v iewmade. Pthe gestand emfoet us.fo l lowifallopiathe smaumbilicseen.

DISC

Ga

'Grade

(Surge

Jour. I\

experiencelosis of ad-

)omas is byhorectomy.rd to be un-Ce invasion:en incom-enting this,plasm andnor from atdometrialto distin-

lant rnixedrggressiveoutcome.

rarcomas ofys i s o f 100Ium Puthol

ra le geni ta lt f lunl ) . In:rthology ofs Ltd 2000;

ithelial andNeoplasia.

ogy of theob lems i nCo . 1980 :

erus. Am ./

Mul ler iantural study

rcornas ofI ten casesd T'umor.

U te r i ne1 9 8 5 ; 4 :

l u l l e r i ansarcoma.-91 .

u I ler i anx w i t h' t25-36.

embl ingr logical76: 66:

7, No.2

GASTROSCHISIS- A CASE REPORT

Surg Lt Cdr RK Patel', Surg Lt Cdr AK Pillai#, Surg Capt YP Monga.

Key Words : Ultrasound; Gastroschisis; Antenatal diagnosis

INTRODUCTION

1-l astroschisis is a condition, which is character\fizea by a small defect (2 to 4 cm) in the aMomi-nal wall, lateral (usually on the right side) to theintact umbilical cord. The abdominal contents her-niate out through this small defect in-utero andfloating freely with in.the amniotic cavity, withoutany covering membrane unlike Omphalocele. Wepresent a case ofwhich was diagnosed on antenatalsonography.

CASE REPORTA 24 yrs o ld pr imigravida pat ient came for rout ine

antenatal sonography. The pregnancy was of 24 weeksgestat ional age. The ul t rasonography revealed that theintrauter ine gestat ion was of 20 weeks. The abdominalcircumference was corresponding to l8 weeks. Very fewbowel loops were seen in the abdominal cavity. No bowelloops or cyst ic areas seen in thorax.

Axia l scanning of the foetal abdomen showed f reelyfloating bowel loops outside the abdominal cavity througha small defect (Fig. l). This defect was on the right side ofthe umbilical cord. No membrane was seen around the bowelloops and cord attachment was pushed towards left side bythe herniat ing bowel loops. Foetal heart was normal inlocation. There was no pleural, pericardial effusion or foetalascites. Kidneys, spine, and brain parenchyma was normal.In view of the above findings diagnosis of Gastroschisis wasmade. Patient was advised admission for antenatal care. Atthe gestational age of 36 weeks, foetus developed distressand emergency caesarean operation was done to save thefoetus. A female neonate was born and found to havefol lowing defects-Complete smal l in test ine, uterus, andfallopian tubes along with ovaries has herniated out throughthe small defect in the abdominal wall on right side of theumbilical cord (Fig. 2). Thick Meconium stained liquor wasseen.

DISCUSSION

Gastroschisis is derived from a Greek word mean-

Fig. I : Ultrasound scan showing free floating. GIT loopsoutside the abdomen.

Fig.2: Herniated intestinal loops seen outside theabdomen.

'Graded Specialist (Radiodiagnosis); rGraded Specialist (Obstetrics and Gynecology); tommanding Officer and Senior Advisor

(Surgery and Reconstructive Surgery), INHS Kalyani Gandhi gram visakhapatnam s30 005.

Jour. Maine Medical Society, 2A05, VoL7, No.2 149

ing "belly cleft". This is a relatively small defect (2to 4 cm) in the aMominal wall lateral (usually on theright side) to the intact umbilical cord [-3]. The ab-dominal contents herniated out through this smalldefect in utero and are freely floating with in theamnion without any covering membrane unlikeOmphalocele [2,3]. Most commonly it's the smallbowel, which eviscerates often accompanied by thelarge bowel and sometimes stomach but liver andother solid organs are rarely involved I l-3]. Almostall the patient with gastroschisis demonstrates ei-ther bowel malrotation or non-rotation. Intestinalischemia or stenosis may be present in l/3d of cases.This ischemia may lead to bowel wall gangrene per-foration or mecorium peritonitis [2,3J]. The umbilicalcord is normally inserted in the anterior abdominalwall, In Omphalocele the cord is inserted into thesac which distinguish it from the gastroschisis [5].Foetus having gastroschisis are more often associ-ated with pre maturity and intrauterine growthretardation.

Gastroschisis is generally sporadic with inci-dence of I in 10,000 live births but its occurrencewith other anomalies is rare [2]. Various theories re-

garding this defect have been recommended, likeabnormal involution of the right umbilical vein ordisruption of the Omphalo-mesentric artery withischemia or umbilical coelom fails to form rvhichforces the elongated gut to rupture into amnioticcavity. This riefect differs from the pathogenesis ofthe Omphalocele, which is failure of closure of theprimary body fold [6].

RDFERENCES

l. Asharaft KW, Sharp RJ, Sigalet DL. Synder CL.Paediatric Surgery, W.B Saunders company, Edi III:640-644.

2. Rumak CM, Wilson SR. Charboneau JW. DiagnosticUltrasound, Mosby, Edi II, Vol II: 1162- 1166, 1193.1224-t225.

3. Callen PW. Ultrasonography in Obstetr ics andGynaecology, WB Saunders Company, Edi IV 20fi):492-500.

4. Neill JA, Rowe MI, Grosgrld JC, Forkalseud EW CaranAG. Paediatr ics surgery, Mosby. Edi V, Vol I I ,1998:1052.

5. Buyse Ml. Birth defects Encyclopaedia CambridgeEngland, Blackwell scicntific publications, 1990.

6. Klein MD, Hertzler JH. Congenital defects of theaMominal wall. Sarg Gynaecology Obstetrics l98l;152 (6) : 805-E.

Jow Marine Medical Society,2W5,W.7, No.2150

NICK

SurgLt

ABSTRI

The slotturn, practivaterapplianrwork.

Key Wo

INTRO

A N

conttnrrequirework Imore pThis inity and

CASE IA l .

present ib i t e . C lmaxillarMolar tNiTi exphasec orrec ta l ignme

TheA 0 .01 ton theAt thedebondci rcu m

DISC

Ancan b(Classdistaliers st

'Grade

INHS

Jour. I

NICKELTITANIT]M PALATAL EXPANDER -A CASE REPORT

SurgLt Cdr(D) SS Chopra', SurgCdr(D) SS Pandef

ABSTRACT

The slow expansion appliances enables more physiologic adjustment to mldpalatal sutural separation. This inturn, produces greater stability and less relapse potential. The prefabrlcatcd Nickel titanlum (NiTi), temperature-sctivated palatal expander hss the abtlity to produce light, continuous pressure on the midpalatal suture. Thisappliance is also capable of correcting rnolar rothtion and requires little patient cooperation and laboratorywork .

Key Words : Nickle Titanium Palatal Expander, Crossbite.

INTRODUCTION

I Nickel titanium (NiTi) temperature-activated-l-l,palatal expansion appliance produces light,continuous pressure on the midpalatal suture andrequires little patient cooperation or laboratorywork I I ]. The slow expansion appliances allow formore physiologic adjustment to sutural separation.This in tum, produces greater post treatment stabil-ity and less relapse potential.

CASE REPORTA l4 year-old male patient in the permanent dentition

present ing wi th Class I malocclusion in poster ior cross-bi te. Cl in ical ly , he also presented wi th palata l ly p lacedmaxillary lateral incisors and highly placed cuspids (Fig. l).Molar bands were fitted on the maxillary first molars. ANiTi expansion appliance (size 30) was used (Fig. 2). First-phase t reatment object ives of expanded archform,correct ion of poster ior crossbi te and space for cuspidalignment were achieved in four months.

The appliance was left in place for 3 months as a retainer.A 0.018" Roth Pre-adjusted Edgewise Appliance was bondedon the maxillary arch and the teeth were aligned (Fig. 3).At the end of 12 months of treatment, the appliance wasdebonded / debanded and the patient was placed on removablecircumferent ia l reta iners.

DISCUSSION

An estimated 25-3OVo of all orthodontic patientscan benefit from maxillary expansion , and 95Vo ofClass II cases can be improved by molar rotation,distalization and expansion [2]. Rapid palatal expand-ers such as the Haas [3] and the Hyrax [4] have

Fig. I : Pre treatment intra oral maxi l lary occlusalphotograph.

Fig.2: Nickel titanium palatal expander at the start oftreatment.

'Graded Specialist (Orthodontics); tClassified Specialist (Oral & Maxillofacial Surgery), Naval Institute of Dental Sciences,

INHS Asvini. Colaba. Mumbai - 400 005.

Jour Marinc Medical Society, 2005, Vol.7, Na 2 I 5l

f-

Fig.3 : End treatment intra oral maxi l lary occlusalphotograph.

traditionally been used for treating transverse max-illary discrepancies. Rapid palatal expansion hasbeen shown to produce forces ranging from 3 to 20pounds. Studies have documented free-floatingbone fragments, bleeding, micro fractures, cyst for-mation, vascular disorganization and connectivetissue inflammation in suture sites during rapid ex-pansion [5].

Application of light, continuous forces in areasof periosteal growth allows normal arch dimensionsto develop at any age without undue tipping of theabutment teeth. Increased fibroblastic, osteoclasticand osteoblastic activify seems to occur when themaxilla is widened slowly. Slower expansion has alsobeen associated with more physiologic stability andless potential forrelapse than with rapid expansion.The neuromuscular adaptation of the mandible tothe maxilla in slow expansion allows a normal verti-cal closure [6].

Nickel titanium palatal expander (NPE) delivers auniform, slow, continuous force for maxillary expan-sion, molar rotation and distalization and also archdevelopment. This appliance expands at a rate thatmaintains tissue integrity during repositioning ofteeth and remodeling of bone. In other words, as thepalate expands, regeneration matches the rate ofexpansion.

The action ofthe nickel titanium palatal expanderis made possible by harnessing nickel titanium'sproperties of shape memory and transition tempera:

r52

ture. Shape memory is the ability to constantly re-turn to a set shape after deformation. Nickel titaniumcan be alloyed to produce a metal with a specificthermal transition temperature-in the case of theNPE, 94"F. At temperatures higher than the transi-tion temperature, interatomic forces bind the atomsmore tightly, producing a stiffer metal. At lower tem-peratures, the forces weaken, making the metal quiteflexible.

Another group ofpatients that can be benefittedfrom this type ofappliance is the cleft lip and palatepatients [7]. Early surgical soft tissue repair of thepalate often creates constriction of the maxillary archand contributes to posterior cross-bite. Maxillaryexpansion is needed around mixed dentition periodto approximate the anterior and posterior alveolarsegments in preparation for the alveolar bone graft.Due to the presence ofan alveolar and palatal cleft,low level of force is agtually desirable for maxillaryexpansion so as not to tear the repaired soft palate.

The nickel titanium palatal expander is self-acti-vated by body temperature; automatically expandsto its predetermined shape; requires little manipula-tion by the clinician; produces a light, constantpressure on the teeth and midpalatal suture; has aredundant safety system; and permits the patient tomitigate the pressure response.

REFERENCESl. Arndt WV. Nickel titanium palatal expander. J Clin

Orthod 1993; 27 :129-37.2. McNamara JA Jr. Brudon WL. Orthodontic and

Orthopedic Treatment in rhe Mixed Denrit ion,Needham Press, Ann Arbor. MI. 1995.

3. Haas AJ. Rapid expansion of the maxillary dental archand nasal cavity by opening the mid-palatal surure,Angle Orthod. 196l; 3l : 73-90.

4. Bishara SE, Stanlcy RN. Maxillary expansion: Clinicalimplications, Am J Orthod 1987; 9l : 3-14.

5. Hicks EP. Slow maxillary expansion: A clinical studyof the skeletal vs. dental response to low magnitudeforce. Am J Orthod 1978: 73 : l2l-41.

6. Henry Rl. Slow maxillary expansion: A review ofquad-hclix thcrapy during the transitional dentition, J. Dent.Child., November-Decembcr 1993, pp. 408-13.

7. Abdoney MO. Usc of the Arndt nickel titanium palatalcxpandcr in clcft palatc cases. J Clin Orrhod 195:29: 496-9.

Jom Marine Medicd Society, 2ns,lbL 7, No. 2

I

PATHOLOGY QUIZ

Surg Lt Cdr Ramesh Rao', Lt CoI A Malik", Surg Cdr S Deb*,Surg Capt RN Misra*, Surg Capt B Fanthome*

(2years old male presented with pain in abdomenLfand mass epigastrium of 01 year duration.CTScan showed a mass lesion adherent to stomachand body of pancreas. The tumourwith cuff of stom-ach was sent for histopathological examination.

What is your diagnosis?

Graded Specialist( Pathology), "Classified Specialist(Pathology) & Oncopathologist, €lassified Specialist (Pathology),'senior Advisor (Pathology &Microbiology), *senior Advisor (Surgery &oncosurgery), INHS Asvini

Joun Marhc Medical Society 2m5,WL7, No.2 t53

ANSWERTOQUIZ

GASTROINTESTINAL STROMAL TTJMOUR(GIST)

DISCUSSION

Histopathological examination of tumour showsinterlascing fascicles of spindle cells. Minimal cel-lular pleomorphism is seen. Mitotic activity is low( I /50 hp0.Immunohistochemistry reveals weak C-kit expression, CD-34 is negative.

GISTs are rare neoplasms which account for 0. I -

l7o of gastrointestinal malignancies. These tumourshave unique histological, imunophenotypic andmolecular genetic features that set them apart fromtypical smooth muscle tumours andschwannomas [,2].

GISTs are thought to arise from neural cells ofgastrointestinal walls known as the interstitial cellsof Cajal or 'pacemaker cells' [31. They are character-ized by a remarkable cellular variability in theirdifferentiation potential. Their common denomina-tor is an immature proliferation of epithelioid orspindle cells often showing partial or incompletemyoid, neural or mixed features of differentiation.Some GISTs are primary in the omentum, mesenteryor retroperitoneum, and are unrelated to the tubularGl tract [,4,5].

Immunohistochemically most GISTs are positivefor CD34 and c-kit protein CDI l7; the latter is quitespecific for GISTs among mesenchymal tumours.Genetically GISTs commonly show DNA losses inthe long arm of chromosome 14, and c-kit gene mu-tations occur at least in some cases [6].

Evaluation of malignancy of GISTs is based onmitotic count, tumour size and extra-gastrointestinalspread. Miettinen et al. suggested that tumours withthe mitotic rate higher than 5 per l0 HPFs or the sizelarger than l0 cm have significant risks of recur-rence and metastas is , and are h is to logical lyconsidered malignant [ 1,7].

The specific identification of GIST has becomeincreasingly important because a Kit-selective tyro-sine kinase inhibitor, imatinib (Glivec, formerlyknown as STI57 I, Novartis Pharma AG Basel, Swit-zerland). has shown promise as an effective adjuvanttherapy treatment [8].

154

REFERENCES

l . M ie t t i nen M , Laso ta J . Gas t ro i n tes t i na l s t r oma lt umors -de f i n i t i on , c l i n i ca l , h i s t o l og i ca l .immunohistochemical , and molecular genet ic featuresand differential diagnosis. Vrchows Arch 2OOl:.438(l\:t - t2

2. Berman J, O'Leary TJ. Gastrointestinal stromal tumorworkshop. Hum Pathol 20011 32(6): 578-82

3. Sircar K, Hewlet t BR, Huiz inga ID, et a l . Interst i t ia lcells of Cajal as precursors of gastrointestinal stromaltumors. Arn J Surg Pathol 1999:23(4): 377-89

4. Duffaud F, Blay JY. Gastro intest inal st romal ' tumors:bio logy and t reatment. Oncology 2003; 65(3): 187-9 7

5. Joensuu H, Kindblom LG. Gastro intest inal st romaltumors-a review. Acta Orthop Scand Suppl 20O4'.75(3l l ) : 62-71

6. Tazawa K, Tsukada K, Makuuchi H, Tsutsumi Y. Animmunohistochemical and c l in icopathological study

Jour Maine Medical Society, 2005, Vol.7, No.2

F i g . 3 :

rcnded, likelical vein orartery withform rvhichto amnioticogenesis ofrsure of the

Synder CL.any, Edi I I I :

/. Diagnostici l66, 1193,

i tet r ics anddi IV 20(X):

d EW, CaranV, Vol Il,

Cambridger, 1990.

bcts of rhe?tr ics l98l :

,1.7, No.2

!

of gastrointestinal stromal tumors. pathol Inr 1999:49(9): 786-98

7. Pidhorecky I, Cheney RT, Kraybill WG, Gibbs JF.Gastrointestinal stromal tumors: current diagnosis,biologic behavior, and management. Ann Surg Onco!

Joun Marirc Medical Society, 2nj Uol.7, No.2

2000t 7(9\: 705-t2

Sawaki A, Yamao K. Imat in ib mesylate acts inmetastat ic or unresectable gastro intest inal st romaltumor by targeting KIT receptors-a review. Cancer.Chemother Pharmacol 2004; 54: 554-9

r55

RADIOLOGICAL QUTZ

Surg Capt J D'Souza', Surg Cdr IK Indrajit", Surg CdrAS Naidu, Surg Lt Cdr SN Singh'

A 23 year old adult male, son of serving person

flnel, presented with gradual onset headache of

six weeks duration. There was no associated vomit-

ing. Clinical examination did not show any focal

neurological deficit.

Lateral radiograph of skull is shown in Fig' I'

What is the diagnosis?

F i g . l :

ImalP

largtdispselkteric

I\defiriorT2,axitblotaquthemusagharwhi n ian(dilrpitflo

.Senior Advisor & HOD (Radiodiagnosis & Imaging), "Classified specialist (Radiodiagnosis & Imaging)'.Post graduate Resident'

INHS Asvini. Mumbai

Joun Marbte Medical Society, 2005' Vol. 7' No- 2

' yi(

FI]

coex

Di

156

Imaging Findings

Plain lateral radiograph of the skull shows en_larged sella with erosion of the floor. The sellarfloordisplays a "double-floor" appearance. The dorsumsella is thinned with features of erosion of the pos_terior clinoid process.

MR brain was performed which showed a welldefined, circumscribed lesion involving the supe_rior vermis of the cerebellum. Fig. 2 depicting axialT2 weighted, coronal FLAIR and posigadoliniu,axial Tl weighted images shows the leiion (whiteblock arrows) compressing the fourth venri;le &aqueduct of Sylvius, with consequent dilatation ofthe lateral & third ventricle, suggestive of non_com_municating hydrocephalus. pre and postcontrastsagittal images (fig. 3) shows heterogenous en_hancement of the leslon which is depicted-by verticalwhite arrow. The lesion measured 4.91 x 5.ix 4.5 cmin its maximum dimensions. The sella is enlargedand filled with CSF, continuous superiorly wiih adilated 3d ventricle (horizontal white anow). Thepituitary gland appears flattened against the sellarfloor.

The patient was subsequently operated upon,yielding a histopathological diagnosis.

FINALDIAGNOSIS

Medulloblastoma at cerebellar vermis with non-communicating hydrocephalus causing sellarexpansion.

Discussion

Medu l l ob las roma i s a h igh l y ma l i gnan t

intraepithelial tumor of the posterior fossa that ispredominantly seen in children but may also occuryin adults [1,2]. lt accounts for 6%o_gVo of al I centralnervous system tumors. Cerebellum is the most com-mon location for medulloblastomas and almostTl%oof these arise in the midline cerebellar vermis [ 1,2].

Clinically, the condition manifests in nea"rly (75Vo)patients with symptoms less than 3 months i3i. Heua_ache can be generalized or localizet to thesuboccipital. Besides persistent vomiting is a comTmon symptom. Merastasis by leptomenin$hiseeding is seen often, since there is un ilh"r"ntt"n_dency to metastasize to CSF. Extraneural spread toIiver, lung and muscle (2%o),thepancreas (4To,;,kid_ney,s (ZVo), testes (2Zo), ureters (lvo),ovaies (l%o),and breast (l7o) is rare [3,5].

IMAGING STI]DIES IN MEDULLOBLASTOMASkull radiograph may show erosion & thinning

ofdorsum sella & posteriorclinoid process [4,5], asdemonstrated in this case. In cases of M"dullobtur_toma, CT scans reveals hyperdense, so l id ,well-defined vermian cerebellar mass with surround_ing vasogenic edema & hydrocephatus. Calcificationis seen in lO-2OVo of the cases. Contrast studiesshows heterogeneous enhancement of the le_sion [4,5]. The presence of falcine calcification inchildren with medulloblastomamay be a marker fornevoid basal cell carcinoma [6].

. On MR imaging, the lesions appear iso to

hypointense relative to white rnutt", oi TIW im_ages [7]. Postcontrast studies shows heterogeneousenhancement [7]. MR spectroscopy in cases of

'aduate Resident.

i, Vol.7, No.2

Fig. 2 :

Jour Maine Medical Society, 2005, Vol.7, No.2157

medulloblastoma typically shows elevated cholinepeaks, reduced N-acetyl aspartate and creatinepeaks [4]. The World Health Organization classifiesmedulloblastoma asa grade IV lesion [4].

The differential diagnosis comprises of pilocyticastrocytoma, ependymoma and brainstem glioma.Pilocytic astrocytoma is charecterised by a cysticmass with an enhancing mural nodule [5]. Ependy-moma are "plastic" tumors arising within fourthventricle that often extend through the foramen ofLuschka into the adjacent cerebellopontine cis-tern [5]. They are typically calcified. Brainstemglioma are dorsally exophytic brainstem mass lesionthat displaces fourth ventricle posteriorly. It showsminimal or no enhancement [7].

Surgical resection is the mainstay of treatmentaugmented with radiotherapy. The 5 year survivalrate ranges fromSO-1OVo 13,57.

REFERENCESt . Giangaspero F, Bigner SH, Kle ihues P, Pietsch T,

Trojanowski JQ. Medul loblastoma. In: Kle ihues P,Cavenee W eds. Pathology and genetics of tumoursof the centra l -6,ervous system. Lyon, France:International Agency for Research on Cancer, 2000;129-t37.

2 . S tav rou T , B rom ley CM, N i cho l son HS , e l a l .Prognost ic factors and secondary mal ignancies inchildhood medulloblastoma. J Pediatr Hematol Oncol2OOl:, 23:431-436.

3 . Koe l l e r KK , Rush ing EJ . Medu l l ob l as toma : AComprehensive Review wi th Radiologic-PathologicCorrelat i t ,n. Radio g raphi c s 2003 t23: I 6 I 3- I 637.

4. El l ison D. Classi fy ing the medul loblastoma: ins ightsfrom morphology and molecular genetics. NeuropatholAppl Neurobiol 2OO2:. 28:257 -282

5 . Koe l l e r KK . Cen t ra l ne r vous sys tem neop lasms :i n t r aax ia l . I n : Sm i rn i o topou los JG , Koe l l e r KK ,Mathews VB Provenzale JM, Hudgins PA, eds. 2002Syllabus: categorical course in diagnostic radiology:neuroradiology. Oak Brook, lll: Radiological Societyof North America, 2000;97-102.

6. Stavrou T, Dubovsky EC, Reaman GH, Goldstein AM,Vezina G Intracrania l calc i f icat ions in chi ldhoodmedu l l ob l as toma : r e l a t i on t o nevo id basa l ce l lcarcinoma syndrome. AJNR Am J Neuroradiol 2OOO:.2l :79O-194

7 . Ba rkov i ch AJ . Ped ia t r i c neu ro imag ing 3 rd ed .Ph i l ade lph ia . Pa : L i pp inco t t W i l l i ams & W i l k i ns .2000.

8. Abacioglu U, Uzel O, Sengoz M, Turkan S, Ober A.Medulloblastoma in adults: treatment results andprognostic factors. In, J Radiat Oncol Biol Phys 2002:

e 54 :855-860.

Joun Martne Medical Society, 2005, Vol. 7, No. 2

BOO

HYP]

ByNY

Ac tof Otortables.

Secand H

Secin the

Sec

Sec

Secand isr

Se<treatr

Ser

Ser

Se'Yanal

LaOveriogy aassoc

Contt

Surg

,58 Jour.

BOOK REVIEW

HypERBARTc oxycEN THERApy rN oroRHINoLARyNcor.ody

By N Yanagita and T Nakashima, Published by lhrgerAG (Switzerland)

A comprehensive book that covers new scientific data on Hyperbaric Oxygen Therapy (HBOT) in the fieldof Otorhinolaryngology and head and neck surgery. The book has 129 pages, 9 sections, 44 figures and 12tables.

Section L Deals with the new indications for Hyperbaric Oxygen Therapy and its complications by Takahashiand H Kobayashi.

Section 2. Brown DH ,Evans AW and GKB Sandor describes the usefulness of Hyperbaric Oxygen Therapyin the management of Osteoradionecrosis of the Mandible.

Section 3. Here Granston G discusses the role of HBOT as a stimulator of Osseointegration.

Section 4. Hyperbaric Oxygen Therapy for Necrotizing Cervical Infections by Scher RL.

Section 5. Effect of Isobaric Oxygen versus Hyperbaric Oxygen on the normal and Noise-Damaged hypoxicand ischemic Guinea Pig inner ear.

Section 6. Effect of Hyperbaric Oxygen Therapy in comparison to conventional or placebo therapy or notreatment in Idiopathic Sudden Hearing [oss, Acoustic Trauma, Noise-Induced Hearing [,oss and Tinnitus.

Section 7. Hyperbaric Oxygen Therapy for Sudden Deafness by Nakashima T

Section 8. Hyperbaric Oxygen as aTreatment for Facial Palsy by Makishima K,Yoshida M and Kuroda Y.Section 9. Otologicalcomplications of Hyperbaric OxygenTherapy by Ueda H, Shied CW MiyazawaTand

YanagitaN.

Lastly the book offers a vast Subject index, which makes it easier to search for the relevant topic quickly.Overall this book, though small and brief gives all the latest information regarding the indications methodol-ogy as well as complication of HBOT in the field of Otorhinolaryngology. A valuable possession for all thoseassociated with the field of Marine medicine as well as Otorhinolaryngology.

Contributed by

Surg Lt Cdr S Narayan, PG Trainee Marine Medicine, INM, Mumbai.

Joun Maine Medical Society, 2il)5, Vol.7, No. 2 159

(Authors are advised to go through these latest guidelines carefully)

I. JOT.JRNAL OF MARINE MEDICAL SOCIETY(JMMS) publishes original articles, case reports,review articles, editorials, contemporary issues, let-ters to editor. book reviews and other scientificinformation in all disciplines of medical sciencesconcerned with the health of mariners.

2. Contents of the JMMS are covered by copyright.Articles are accepted for publication with the un-derstanding that their contents, all or in part, havenot been published and will not be published else-where, except in the abstract form or with the consentof the Editor. JMMS does not accept any responsi-bility for the statements made by the authors. TheEditorial Board has the right to introduce suchchanges in the articles as may be considered neces-sary for effectiveness of communication.

3. Following CERTIFICATES (single copy) mustaccompany the articles :

(a) Certificate from Authors

(i) Certif ied that I/we have not used anyinformat ion or mater ia l f rom of f ic ia ldocuments graded 'restricted' and above orany 'classified' information obtained in my/our official capacity in the preparation ofthe article titled . .

(ii) Certified that this manuscript contains nomat te r t ha t i s l i be l l ous o r o the rw iseunlawful, or invades individual privacy orinfringes on any proprietary rights.

(iii)All authors certify that they have madesubstantive and intellectual contributions tothe article and assume public responsibilityfor its content.

It is also certified that none of the material inthis manuscript has been published previously or iscurrently under consideration for publication else-where.

First authorDate

tfl

Second authorDate

Authors

lnstructions to Authors

OtherDate

(b) Certificate from Officer Commanding/Headof the Institution where study has been carriedout. (Refer to NO 24195)

(i) For Original Articles, Case Reports andMethods in Medicine

Certif ied that I have no objection to thepublication ofthe article titled ".

" in Journal of MarineMedical Societv written bv ". . .. . . . . ." for which studv has been carried out inthis institution.

Station :

Date: (Head of the Institution)Signature with Official Stamp

(ii) For Review Articles, Update Articles andContemporary lssue :

Certified that I have no objection to the publicationof the Review/Update/Contemporary Issue titled ".

. . . . . " in Journal ofMarine Medical Society written by ". . . . . .

. . . . " w h o i s p o s t e d a s . . . .( appo in tmen t ) . . . . . ( dep t ) .. . (name of institution).

Station :

Date: (Head of the Institution)Signature with Official Stamp

4. MANUSCRIPT must be typed, in double spacethroughout, on one side of good quality white bondpaper of size 22 x28 cm or A4 size with 3 cm mar-gin on both sides. Font size should be of l2 pointsminimum. Words should not be hyphenated at theend of a l ine. Two copies, including the original, ofthe typescript strould be submitted along with 2 setsof illustrations. The typescript should also be sentin electronic media (floppy or CD) in .doc (Word)format. Authors must retain a copy of all the abovematerial, as the Journal cannot be held responsiblefor its loss due to any reason. The material shouldbe enclosed in a large envelope, superscribed 'Ar-

ticle for publication --- Not to be Folded', and sent

Joun Marbte Medical Society,2005, Vol.7, No.2

under registered cover to Editor, Journal of MarineMedical Society, Institute of Naval Medicine,Colaba, Mumbai 400 005.

5. PROCESSING : Material received for publica-tion will be acknowledged. When required, onecopy of the typescript, suitably modified, will besent to the principal author for revision andresubmission in duplicate. Accepted articles willbe published in their turn. Reprints l0 of each arti-cle will be sent free of cost to the FIRST author.Articles not accepted for publication will be returnedby ORDINARY post.

6. AUTHORSHIP should be restricted to personswho have sufficient contributions to (a) conceptionand design or analysis and interpretatj-on of data;(b) drafting the article or revising critically; (c) fi-nal approval of the article to be published. Allconditions must be ideally met. The order of au-thorship should be a jo int decis ion of a l l theco-authors.

7. TYPESCRIPT : The typescript comprises (a)title page, (b) abstract and key words, (c) text, (d)

'references, (e) tables, (f legends for illustrationsand (g) illustrations. All these must start on sepa-rate pages and in the above order. Pages should benumbered consecutively beginning with the tit lepage.

(a) Title page - gives the title of the article, a shorttitle for page heading, type of article (originalar t ic le , case repor t etc) , name(s) of theauthor(s), affi l iations. of author(s), place ofwork, names and addresses of the authors(including PIN code and FAX) and word count(excluding abstract and references).

Ideal ly , the t i t le should be of about 60characters. It should have no abbreviations.Names of all the authors with highest academicdegree must be typed one below the other withproper footnote marks af ter the name.Affi l iations (with corresponding footnotemarks at the begining) and addresses ofauthorsshould be typed as footnotes only. Thefollowing footnote marks should be used in theorder given *,+,#,**,++,##.

(b) Abstract and Keywords - The abstract is asynopsis of the main article in about 200 wordsand gives an opportunity to the author to induce

Joun Marine Medical Society, 2005, Vol.7, No.2

the reader to go through the article. It shouldbe structured in to the headings: Background,Methods, Result and Conclusion, giving factsand not descriptions. Speculative surmises, andreferences to other works on the subject shouldnot be included. Avoid abbreviations. Noabstract is required for case reports. Below theabstract give not more than 5 key words usingterms from Medical Subject Headings list ofIndex Medicus.

Text - The text should be divided into sections.e.g. Introduction, Material and Methods,Results and Discussion. Each should have itsindividuality and must not be mixed withothers. Ensure that all references, tables andfigures are cited in the text.

(d) Abbreviat ions - Only author ised,internationally accepted abbreviations shouldbe used. First time use of abbreviation mustalways be preceded by its full form exceptfor s tandard uni ts of measurement .Abbreviations are to be avoided in title. abstractand keywords.

(e) References - Responsibility of accuracy of thereferences l ies entirely with the authors.References should be listed in the order inwhich they are cited in the text. Only relevantand recent references are encouraged. Theyshould be indicated in the text by Arabicnumerals enclosed in square brackets, forexample [2], on the line of the text and notabove the line. Ensure that all the referencescited in the text are included in the list, andvice versa. List all authors when 6 or lesslwhen 7 or more, give only first 3 and ldd elcl. One-word names ofjournals, and names ofun-indexed journals, should be given in full.e.g. Cancer, Gastroenterology, Surgery. Forcorrect abbreviations of the journals refer tothe latest Index Medicus. Do not use full stopsin abbreviations ofjournal names. Representrveexamples are given below. Please note thatinitials of names have no periods; the yearfollows the periodical's or publisher's name:Editorial, Abstract, etc appears in parenthesis;both begining and ending page numbers aregiven.

(c)

l 6 I

Journals

i) Standard Journal Articles - You CH, Lee KY,Chey RY, Menguy R. Electrogastrographicstudy of patients with unexplained nausea,bloating and vomiting. Gastroenterology 1980;79 :3 l l - 4 .

ii) Organization as Author - The Royal MarsdenHospital Bone-Marrow Transplantation Team.Failure of synegeneric bone-marrow graftwi thout precondi t ion ing in post-hepat i t ismarrow aplasia. Lancet 1977:2 :242-4.

iii) No Author Given - Coffee drinking and cancerof rhe pancreas [editorial]. BMJ l98l; 283 :628.

iv) Volume with Supplement - Magni F, RossoniG, Berti F. BN-52021 protects guinea-pig fromheart anaphylaxis. Pharmacol Res Commun1988; 20 Suppl 5 : 75-8.

v) Issue with supplement - Gardis G, Cole JO,Haskell D, Marby D, Paine SS, Moore P. Thenatural history of tradive dyskinesia. J ClinPsychopharmacol I 988; 8 (4 Suppl) : 3 I S-37S.

vi) Type of article indicated as needed - SpargoPM, Manners JM. DDAVP and open heartsurgery ileaerl. Anaesthesia 1989:44 :363-4.

vii) Journal Paginated by Issre - Seaman WB. Thecase of the pancreatic pseudocyst. Hosp Practl98l ; 16 [Sep] :24-5.

Books and Other Monographs

viii)Personal Authors - Eisen HN. Immunology :an introduction to molecular and cellularprinciples of the immune response. 5'h ed. NewYork : Harper and Row, 1974.

ix) Editor(s), compiler as Author - Dausset J,Colombani J, editors. Histocompatibil i tytesting 1972. Copenhagen : Munksgaard,1973.

x) Chapter in a Book - Weinstein L, Swartz MN.Pathogenic propert ies of invadingmicroorganisms. In : Sodeman WA Jr ,Sodeman WA, editors. Pathologic physiology: mechanisms of disease. 3d ed. Philadelphia :WB Saunders, 1974; 457-72.

xi) Conference Papers - Harley NH. Comparingradon daughter dosimetric and risk models. In:Gammage RB, Kaye SV, editors. Indoor air and

162

human health. Proceedings of the Seventh LifeSc iences Sympos ium; 1984 Oc t 29 -31 ;Knoxvil le (TN). Chelsea: lrwis, 1985 :69-78.

xii) Conference proceedings - Vivian VL, editor.Child abuse and neglect : a medical communityresponse. Proceedings of the First AMANational Conference on Child Abuse andNeglect; 1984 Mar 30-31; Chicago. Chicago :American Medical Association. 1985.

xiii)Scientific or technical report - Akutsu T. Totalheart replacement device. Bethesda (MD) :National Institute of Health, National Heart andLung Institute: 1974 Apr. Report No. : NIH-NHLI-69-2185-4.

xiv) Monograph in series - Hunnighake GW, GakekJE, Azapiel SY, et al. The human alveolarmacrophage. In : Harris CC, editor. Culturedhuman cells and tissues in biomedical research.New York : Academic Press, 1980; 54-56.(Stoner GD, editors. Methods and perspectivein cell biology; vol l).

Other Articles

xv) Dissertation or Thesis - Cairns RB. Infraredspectroscopic s tudies of so l id oxygen

[dissertation]. Berkeley, Univ. of California :1965.

xvl) Newspaper Anicles - Rensberger B, Specter B,CFCs may be destroyed by natural process. TheWashington Post 1989 Aug 7; Sect. A : 2 (col.5).

xvii) Magazine Articles - Roueche B. Annals ofmedicine : the Santa Claus Culture. The NewYorker l97l Sep 4; 66-81.

(f) Tables - are to be typed on separate pages. Theyshould be serially numbered in rabic numerals

CIABLE I, TABLE 2) and a short title shouldspecify the contents. Horizontal lines in thebody of the table except between a columnheading and i ts sub-headings should beavoided. The vertical l ines separating thecolumns should be totally omitted. A tableshould not exceed two pages in length, andshould not contain less than four lines ofdata.All abbreviations should be defined in anexplanatory note. Tables should be self-explanatory and should not duplicate the data

Jour. Marine Medbal Societv,2005, Vol.7, No.2

I

HS, er a l .nanc ies inntol Oncol

rstoma: APathologict-1637.

La: insightsteuropathol

eoplasms:el ler KK,eds. 2002radiology:ral Society

lstcin AM,chi ldhoodrasal cel ldiol 20{J,0;

3rd ed.Wi lk ins ,

i, Ober A.sults and'hys 2002;

' ,Na2

I

i

in the text.(g) Legends - to illustrations should be brief (rarely

exceeding 40 words), but must explain thesalient features of the illustrations.

(h) Illustrations - should be presented only if theydepict something new or unusual. They shouldbe serially numbered in the order of theirmention in the text, irrespective of theirnature,viz. Photograph, drawing or chart, using onlythe word 'figure' and not diagram, graph, etc.Type a label indicating the top 1t ;, the shorttitle of the article, and the figure number on apiece of paper and paste it on the back of theillustration.

Photogaphs : Unmounted preferably colour,:glossy (not matt) prints of excellent clarity andcontrast should be selected. Their size ideallyshould be post card size. Whenever a surgicalcorroction/work up ls undertaken, it shouldbe backed by a prcoperatlve, peroperatlveand postoperative photograph/results ofother imaging techniques used. Do not writeanything on the photograph, either on the backor on the front. Do not use pins, staples or evenpaper clips to put the photographs together.Enclose the photos in thin cards, so that theydo not get mutilated. Avoid identifiablephotographs, unless you have obtained thepatient's permission to reproduce them (a copyof which must accompany the article). lrgendsto photographs should b€ typed and stuck onthe back alongwith an arrow mark depictingthe vertical contour.

Diagrans and Charts : These should be drawnon thin, white, smooth or glazed card in blackink, and not in any other colour.

8. MISCELLANEOUS : Use metric measurements- cm, m, g, kg, ml, l. No periods, no plural form(eg. '10 cm' not '10 cms.'). Use 'radiograph', 'ra-

diographic ' and'radiographical ' not 'X-ray' ,'skiagram' and'roentgenogram'.'Significant'should be reserved for use in the statistical sens€.Avoid names and initials of the patients and dates.Avoid small articles on single individual aspect ofthe subject, when one larger article discussing allthe aspects would carry more weight. Avoid unfo.mlllsr s55Derlr,lons, mcdlcal Jaryon and pasdve

Joun Marbu Medical Sociery,2m5,Uol.7, No.2

voice. Avoid duplication and repetition of materialin Results and Discussion, in Tables and Text, andin Text and I:gends.

9. Rejected Articles: Articles once rcjected willnot be entertained for reconsideration. Two copiesof the article along with photographVfigures/tableswill be sent back to the author. One copy will bekept with MJAFI office for record.

10. Manuscript for various types of articles :(a) Original Articles : These are scientific

communications from research workersengaged in the field of medicine. The articlespertaining to the field of military medicine andthose of general interest are published onpriority.

Format - Abstract (See 7 (b) above).Introduction should describe the importanceand aim of the study. Methods should describethe researcb plan, the subject and the methdused in thatorderexplaining in detail the modusoperandi for confirmation of disease andcontrol of subjectivity. Data in tables or figuresshould not be duplicated in text; however,important observations may be highlighted.Inferences should be based on relevantstatistical analysis. Discussion should includethe limitations of the research plan, materialand methods, considering both the purpose andthe outcome of the study. Discrepancies fromprevious studies should be explained.

(b) Case Reports : A case report shouldcommunicate a message that transcends theindividual patient and should describe rareinteresting facets of a particular disease or anunusual entity. The introductory paragraphshould give general background and thespecific interest of the case. In a series onlyone case should be described in detail and onlysalient features in other cases should be

--mentioned. Discussion should highlight9unusual features ofthe case report and shouldnot be a review of literature.

(c) Revicw Artlcle and Updote Artlcle : Theseare invied from experts in the field. Authorsare requested to consult the Editor-in-Chief forprior approval of the topic.

r63

(d) Methods in Medicine (including Drug andEquipment update): These are briefdescriptions of a specific technique orprocedure, modification of a technique, orequipment of interest and should be supportedby relevant diagrams and results of clinical and/or field trials.

(e) 'Letter to the Editor, and replies : Theseshould be brief offering objective andconstructive criticism of published articles.These should be written on a non-letter headpaper without greeting, salutation or signature.The name and affiliation should appear at theend of the letter. A short and pertinent titleshould be given. These should be accompaniedby a covering letter.

IT. SIZE OF TEXT :

The Table below provides guidelines regardingmaximum permissible size of text as well as numberoftables, figures and references.

12. Articles not adhering to the above specifica-tions are likely to be rejected.

13. BIBLIOGRAPHY

(a) International Committee of Medical JournalEdi tors. Uniform requirements for manuscriDts

t&

TableUpper Llmit of Tex! Tables, Figurcs and References

Tlpe of Article Text Table References(in and

words) Figures

Is

tt \l ,I t

I .,

fr l

a l

Original ArticleReview rupdate ArticleContemporary IssueMethods in MedicineCase ReportLetterEdirorialEmergency Medicine

25003m020001000100050015002000

8I444233

3030l 05

l 0

l 0l 0

o)(c)

(d)

(e)

submitted to biomedicaljournals. N Engl J Medlq 4.7;33:6:3cf.-15.

Anonymous. Information for readers andauthors. Ann Intern Med 1989; I l0: 1.4-1.7.Dudley H. The presentation of original workin medicine and biology. l " ed. London:Churchill Livingstone, 1977.King LS. Why not say it clearly : A guide toscientific writing. I't ed. Boston: Little Brownand Company, 1978.Ohri VC. Points to ponder for writing an article.MedicalJournal Armed Forces India 1994:50:l6t-2.

Jour Marine Medical Society,2A05, Vol.7, No.2

DECEMBER 2OO5 Registered with Registrar of news paperfor India Res. No. 69828/99