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MARINE MEDICAL SOCIETY(Regd F-361 1)
PresiclentSuTg VADM CD SASIKUMAR
PHS DGMS (NAVY)
Vice PresidentSuTg RADM INDRU KARNANICommanding Officer INHS Asvini
Executive CommitteeSurg Cmde HP MUKHERJEB VSM
EXO,INHS Asvini
Surg Cmde SN GADEDMS (P&M) Naval Headquafters
Surg Cmde SP MALHOTRADirector. InstitLrte of Naval Medicine
Surg Cdr S NANGPALOfficer-in-Charge,School of Naval Medicine
Surg Cmde NR RAHA VSMCMO, Southern Naval Command
Surg Cmde WP THBRGAONKARCMO, Eastern Naval Comrnand
Surg Cdr AM JOGLBKARBMO, COMSUB (West)
SecrelarySurg Cdr MJ JOHN
TreasurerSurg Cdr KK DUTTA GUPTA
Addres s for Corres ondenceSecretury
MARINE MEDICAL SOCIETYInst i tute of Naval Medicine, INHS Asvini Campus,
Colaba, Bornbay 400 005.
Published and owned by f) irector Ceneral Medical Services (Navy) Surg VADM SASIKUIVIAR PIIS,Medical Dircctorate. Sena Bhavan. New Delhi - 110 011 ano
printecl on his behalf at TYPO GRAPHICS, Bombay 400 103.I ldi tor- in-Chicl ' : Surg Cdr PS LAMBA, INI ' lS Asvini, Colaba, Bornbay 400 005.
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VOLUME 3
NavalWestetEastetSouth
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IERGAONKAR:l Comrnancl
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VOLUME 3
JOURNAL OFMARINE MEDICAL
SOCIETYNUMBER I
Published Biannually
. EditorSurg Cdr PS LAMBA
Co EditorSurg Cdr AC PRAVEEN KUMAR
Sub EditorsNaval Headquarters Surg Cdr A AHUJA NMWestern Naval Command Surg LT Cdr VRG PATNAIKEastern Naval Command Surg Cdr D D'COSTASouthern Naval Command Surg Cdr DK WASUNKAR
Editorial Advisory BoardSuTg RADM INDRU KARNANI
Surg Capt CR PAINCoI DINESH PRASADCol BN BORGOHAIN
Surg Cdr PP BELLUBMMSurg Cdr S NANGPAL
Surg Cdr A BEHL, VSM
Address for CoruespondenceEditor
JOURNAL OF MARINE MEDICAL SOCIETYInstitute of Naval Medicine, INHS Asvini Campus,
Colaba. Bombav 400 005.
t996
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YPASEFLPMS TH E, R
" Genotropin
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d product. Pharmacia's seruice-
programme is belping us in the
management of growth bormone
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JOU
From the Editor's DeskSurg Cdr PS LAMBA
OPINIONLegislations for Diving CSurg Cdr PP BELLUBI \Surg LCdr VRG PATNA
CONTEMPORARY ISITransplantation of Humar
Transplantation of HumarSurg LCdr MSN MURTIi
ACADEMIC RUMINA]Taking a Teaching Ward ISurg CdT.ARLIN BEHL V
ORIGINAL ARTICLESEnvironmental PhysiologlSurg LCdr VRG PATNAISurg Cdr AM JOCLEKAI
Unconsciousness During SSurg Cdr B SUDARSHAI
Reproductive Hormone RtSurg Cdr PS LAMBA, Sul
Religion Differentials in ASurg Cdr KK DUTTA GUSurg Cdr MJ JOHN, Surg
Non Hodgkin's LymphomSurg LCdr S RANJAN, Sr
Subacute Hepatic FailureSurg Cdr AC PRAVEEN I
Antibiotic Resistance PatttLt Col S BHATTACHAR'
DRUG THERAPYConcurrent ChemoendothtSurg Cdr B Fanthome, Sur
Abbreviated Prescribing Information: Genotropin'(re(ombinant somatropin) 5ee local pres(ribing information forfull d€tails. Indications may vary from (ountry to country.Indications, Dosage and Administration: Ihe weekly doseshould be divided into 7 s ( injedions. Growth disturban(e dueto insutfi( ienl secretion of growth hormone in (hildren: 0.5 to0.7 lu/kg/wk or l4 to 20 lu/m:/wk [ven hiqher dose5 havebeen used.6rowth disturbance due to gonadal dysgenesis(Iurner's syndrome): 1.0 lU/kg/wk!r 28 lU/mriwk. GroMh dis-turbance in oreoubenal children with chronic renalinsufficieno:30 lU/mr/wk (approx. 1.0 lUikglwk). Higher dosesmay b€ needed il groMh velocq too low. Consider doseadjustments after 6 months. Reola(ement theraov in adultswith prmounced growth hormone deficiencv (defined as peak
Genotrooirfrecombinant somatropin-f
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GH response <3 !g/t (<9 mlu/t) in insulin tolerame test): How Supplied: Genotropin powder for injection (l+ll) is provi-Init ially, for about four weeks, 0.125 lU/kg/wk. The dose should ded as in single or multi-dose packages in a two companmentthen be titrated based on side effens and effed on serum cartridge (2, 3,4, 16, 32 or 36 lU), or a vial (4 or 12 tU), wilhlevels of insulin-l ike growth fa(tor' l ( lGf' l). solvent. Multi-dose canridges and vials contains preseryative.Precautions: Genotropin should be avoided when active Devices for re(onstitution and injection are available.tumour is present. Insulin dose may require adjustment in dia- For funher information, plea-betics. l\y'onitor thyriod function while patient is on Genotropin se contact Pharmacra AB, ekeatment .spe( ia lp recaut ionsapp l ies inpat ien tswi th in t racra- 11287sto(kho lm,Sweden l t - rnial lesions. Additional precautions applies. or your local Pharmacra offr- _. ly-
ffiilil :i,"#1;:'fiillxl i, iJllJ*'3,':J,i,i[11;.li,, ;:;:ffi['i il:,',:llg' Pharmaciaprimaiily related to symptoms of fluid retention. Incidence and The produ( is known as 1T8 100 tet Road. ,prevaleice is reduced over time. Inroieni local skin reaciions Genotonorm'in Betnu-^ llgrllalail!1!9a]o'9l56ooo8attheinjectionsite. Franreandspain. "' I1tttJJ,t193?ffi"*tt
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ERAPY
Genotropin
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.doJe canridges and vials (onlains preservative.oflst'tution and injection are available.mation, plea-fmacia AB, e
i*:H:ifii Qr,l:*'#:H" Pharmacia
4008. 100 Fet R€d.- ;-;-, Indiranaqar. Banoalores6o 008rrutrgruilr'
Tet:(090J525580gs26s807Fd: (080) 5273809
JOURNAL OF MARINE MBDICAL SOCIBTY
CONTENTS
From the Editor's DeskSurg Cdr PS LAMBA
OPINIONLegislations for Diving Operations in IndiaSurg Cdr PP BELLUBI VSM, Surg Cdr G VERGHESE, Surg Cdr J MATHEW,Surg LCdr VRG PATNAIK
CONTEMPORARY ISSUETransplantation of Human Organ Act
Transplantation of Human Organ Act - A Critical AppraisalSurg LCdr MSN MURTHY, Surg Cdr RK MALIK, Lt ColA RAJVANSHI
ACADEMIC RUMINATIONSTaking a Teaching Ward RoundSurg Cdr ARUN BEHL VSM
ORIGINAL ARTICLESEnvironmental Physiology of Submarine (Microclimate Requirements of Confined Spaces)Surg LCdr VRG PATNAIK, Surg Cdr P BELLUBI VSM, Surg Cdr c VERGHESE,Surg Cdr AM JOGLEKAR, Surg Cdr PS LAMBA, Surg Cdr KMR NAIR. Surg Lt CS SAXENA
Unconsciousness During Submarine Escape TrainingSurg Cdr B SUDARSHAN
Reproductive Hormone Responses During Simulated Normal and Saturation DivesSurg Cdr PS LAMBA, Surg Capt AM MADHWAL, Surg Cdr MJ JOHN, POMA BS RAWAT
Religion Differentials in Acceptor Charateristics of Female Sterilisation at Kochi (Kerala)Surg Cdr KK DUTTA GUPTA, SM NAIR, Dr (Mrs) NATRAJAN, Surg Cdr S NANGPAL,Surg Cdr MJ JOHN, Surg LCdr K PAARI, Surg LCdr A CHATERJEE
Non Hodgkin's Lymphoma - The INHS Asvini ExperienceSurg LCdr S RANJAN, Surg Cdr A BEHL VSM, Surg Cdr B FANTHOME
Subacute Hepatic Fai lureSurg Cdr AC PRAVEEN KUMAR, Surg LCdr H MANI, Col DINESH PRASAD
Antibiotic Resistance Pattem in Common Isolates, A Six Year Study - Asvini ExperienceLt Col S BHATTACHARYA, Surg LCdr D BAJPAYEE, Col AK HUKKOO
DRUG THERAPYConcunent Chemoendotherapy in the Management of Locally Advanced Breast CancerSurg Cdr B Fanthome, Surg Cdr A BEHL VSM, Surg LCdr S RANJAN
6
l Al +
16
l 9
28
J )
3 8
43
46
50
CASE REPORTSTransient Hemiplegia Following a Single Clinical Hyperbaric Oxygen (HBO) Exposure at 2.5 ATASurg Cdr MJ JOHN, Surg cdr s NANGPAL, Dr vJ RUPAREL, Surg cdr A BANERJEE,Surg Cdr KK DUTTA GUPTA
Air Embolism complicating Haemodialysis for chronic Renal Failure Treatmentwith Hyperbaric OxygenSurg Cdr S NANGPAL, Surg Cdr MJ JOHN, Surg Cdr KK DUTTA GUPTA,Surg Lt CS SAXENA, Surg Cdr RK MALIK
Urticaria PigmentosaSurg LCdr S NARAYAN, Lt Col P RAMADASAN, Surg Cdr MK GUPTA
Acute Renal Failure in a case of Necrotising Granulomatous vasculitisLt Col S BHATTACHARYA, Surg LCdr S MANI, CoIAK HUKKOO
Case of Chronic Recurrent Volvulus of the StomachMaJ SUBHAS CHAWLA
Mal ignant HistiocytosisSurg LCdr S RANJAN, Surg Cdr A BEHL VSM, Surg Cdr B FANTHOME
SU BMARINER'S VIEWPOINTSubmariner's Body ClockCdr ASPI CAWASJI NM, Surg Cdr PP BELLUBI VSM
U ltrasonographic DiagnosisSurg LCdr M GOEL, Surg LCdr lK INDRAJIT, Lt col sp MITTAL, surs cmde NR RAHA
Electrocardiographic DiagnosisSurg LCdTJP LAZARUS, Col DINESH PRASAD
News from the Deep
54
fFROM THE EDJ]
We are now into tbe
strength to strength, tiil
tions from our co-editor
more case reports in thr
India's medical legislati
Surg LCdr MSN Mud
exploited lot, especiall5
there is an crying need
country.Surg Cdr PP B
antibiotic policy is mrotl
resistance patterns and
detailed by LT Col S Ql
smaller hospitals. Resur
benefits of such a surv'e)I
familiar disease in InCe
disease treatment @ntn
tions" by Surg Cdr A B
post graduates. "Circad
NM, e/ ai in their artic
afticles, ECG diagnosis
due in November'96 :
enthusiasm is requested
Jour. Marine Medical Societ
56
58
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7 1
72
) Exposure at 2.5 ATABANERJEE,
nent
mde NR RAHA
54
EFROM TFM EDITOR'S DESK
We are now into the third year of publication. Marine Medical Society has been growing from
strength to strength, with the help of its enthusiastic members. This issue has significant contribu-
tions from our co-editors in Vishakhapatnam and Kochi. To encourage this trend, we have included
more case reports in this issue. Human organ transplant act1994, was a significant milestone in
India's medical legislation. We discuss this in our contemporary issue, with incisive remarks from
Surg LCdr MSN Murthy et al. Continuing on the topic of legislation, our divers are really an
exploited lot, especially in the civilian setting. With increasing offshore and shipping activities,
there is an crying need for legislation on this issue to protect the interests of divers all over the
country.Surg Cdr PP Bellubi VSM el a/ discuss this subject in depth. Antibiotic resistance and
antibiotic policy is another current and relevant issue. Each hospital has to evaluate its own bacterial
resistance patterns and evolve their own antibiotic policy. The experienie at INHS ASVINI is
detailed by LT Col S Bhattacharya et al. This may act as a guideline for MI Rooms, sick bays and
smaller hospitals. Resurgence of chloromycetin therapy for enteric fever is an important pointer of
benefits of such a survey. In "Drug Therapy" we discuss locally advanced breast cancer, a peculiarly
farniliar disease in India. Surg Cdr B Fanthome el ai discuss the protocol evolved at the malignant
disease treatment centre at INHS ASVINI. In para clinical subjects we have "Academic Rumina-
tions" by Surg Cdr A BehlVSM, who emplrasizes the importance of a ward round in teaching of
post graduates. "Circadian Rhythms" are discussed by our executive colleague Cdr Aspi Cawasji
NM, e/ al in their article "Submariners Body Clock". In addition we contirrue with our original
articles, ECG diagnosis and a new addition - Ultrasonograplric diagnosis. Our next publication is
due in November '96 along with the Marine Medical Conference. Your continued support and
enthusiasm is requested. -1->| --dt / - I
f<w-____,_:xr
PS LAMBA
Surg Cdr
Editor
Jour. Marine Medical SocieN, June 1996, tr/ol. 3, No. l
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>
ANNOUNCEMENT
XV NATIONAL CONFERENCEON
MARINE AND ALLIED MEDICINE
XV National Conference on Marine and Allied Medicine will be held on23rd and 24th Nov 96 at Air India Auditorium, Nariman Point, Mumbai, underthe Presidentship of Surg VADM CD Sasikumar, PHS.
Papers for presentation are invited by l5th Oct 96. Papers are to be forwardedin triplicate, with Commanding Officers' Certificate and necessary securityclearance, to The Secretarr-, Marine Medical Society, INM, INHS AsviniCampus, Mumbai 400 005.
OpinionLEGISLATIONSDIVING OPERA
Surg Cdr PP BELLUBSurg Cdr J MATHEW
ABSTRACT
Since the 1950's. Indian Nrmeeting the requirementswith total disregard for thmorbidity and mortality.legislation is considered vfirms which would in turn
KEY WORDS: Diving le1
INTRODUCTION
fflhe Indian Navy ha
I f ield of diving anI I950's . Unt i l recer
activit ies in India was thethe service requirements,and commercial requirerhas in the last two decadeto nleet the requirementnatural gas industries, uincreasing urgency to Inrother commercial industrdcrnanding and sustainedoff shore industry.
In the last twenty yearto ensure that oil, gas an(continue to be extracted fio f the oceans. The d iv ingof the shore operationalreduce the inherent risks iing barometric pressuresengincer ing and d iv ing rcrease in present operatsafety. Within the broad sdiv ing is a re lat ive ly snand demanding d isc ip l i t
* ,^ddi t ionir l Adviscr . Mar ine iI ly 'pcrbar ic Medic ine.
.lour. illurinc lt4edical Soce
OYS.CA[CALCIUM SUPPLIMENT
OYS'CALFORTE
HIGH CALCIUM SUPPLIM ENT
MEZOLINE,
I T INIDAZOLE + CLOTRIMAZOLE E
PENETRATE,S IIII} ERAD ICATESTHE ONLY COMBINATION OF ITS OWN TYPE
HAB PHARMACEUTICAL LTD.D. & S. lndustriol Complex, Woliv Photo,Vosoi (Eost), 401 2OB (Mohoroshtro )
eOpinionLEGISLATIONS FORDIVING OPERATIONS IN INDIA
Surg Cdr PP BELLUBBI VSM*, Surg Cdr G VERGHESE**,Surg Cdr J MATHEW**, Surg LCdr VRG PATNAIK***
ABSTRACT
Since the 1950's, Indian Navy has made rapid progress in the field ofdiving and rescue operations and is currentlymeeting the requirements of both governmental and commercial industry. The incidence of exploitation of diverswith total disregard for their safety underwater, is on the increase, leading to avoidable but a definite increase inmorbidity and mortality. The evolution of a code of conduct for diving operations and enactment of divinglegislation is considered vital, as it serves not only the interests of the divers but also of associated commercialf irms which would in turn help the nation's economy.
KEY WORDS : Diving legislation
i'CALRTEM SUPPLIMENT
EI]ATES
WN TYPE
LTD.Photo,;htro)
INTRODUCTION
fflhe Indian Navy has taken great strides in the
I f ield of diving and rescue operations sinceI 1950's. Untilrecently, the mainstay ofdiving
activit ies in India was the Navy, which not only metthe service requirements, but also the governmentand commercial requirements. Subsea technologyhas in the last two decades made dramatic advancesto meet the requirements of the offshore oil andnatural gas industries, who have responded withincreasing urgency to India's energy needs. In noother commercial industry are there pressures moredemanding and sustained than those imposed on theoff shore industry.
In the last twenty years the empha$s has movedto ensure that o i l , gas and eventual ly minerals wi l lcontinue to be extracted from ever increasing depthsofthe oceans. The diving industry has to keep aheadof the shore operational requirements in order toreduce the inherent risks in exposing man to increas-ing barometric pressures. The advances in sub seaengineer ing and d iv ing medic ine wi l l a l low an in-crease in present operational depths with greatersal'ety. Within the broad scope of ocean technology,d iv ing is a re lat ive ly smal l but h ighly specia l isedand demanding d isc ip l ine. The Indian Navy has
contributed significantly towards this industry byway of experienced divers, who after retirementfrom theNavy, get absorbed in the cornmercial f ield.At a rough reckoning, there are at least 500 retiredIndian Naval divers if not more, in the commercialf ield [4].
There have been numerous cases of exploitationof divers with total disregard for their safety under-water. There is a definite upward trend in the mor-bidity and mortality amongst these divers. There isno statistical evidence of the same, due to the ab-sence of reliable records. The divers have very l itt lesay in the matter because ofabsence ofany statutorycontrol or adequate legal backing. The number ofdivers being released from the Navy is considerableand they are in great demand in all Civil/Offshoreagencies. They are wil l ing to undertake unwarrantedrisks because of f inancial considerations and haveunknowingly themselves colluded with the manage-ment.
Established firms have either evolved a code ofconduct for diving oftheir own or they have retainedNaval regulations for diving []. The smaller f irmshowever, continue to work without any code ofconduct, creating an unsafe environment. In diving,regulations are no doubt very stringent and at t imes
*Addi t iorra l Adviscr . Mar inc ancl l lyperbar ic Mcdic ine (Navy). **Submarine Mcdical Of l icer ; **+Graded Special is t l Mar ine andl lyperbar ic Medic ine .
,lour. lllarinc lt'ledical Soceitv. June 1996. I'ol. 3. No. I
ne will be held onnt, Mumbai, under
rc to be forwardednecessary security{M. INHS Asvini
)
they do become counter productive for civil organ-isations.
DISCUSSION
The aim of this paper is to evolve a code ofconduct for diving operations in the Indian environ-ment. Enactment of diving legislation would servethe interests of not only the divers, but also theassociated commercial f irms which would in turn bebeneficial for the nation's economy.
Role of Indian Navy in framing the legislation
The Indian Navy should shoulder the responsi-bil i ty of sponsoring this legislation in the largerinterests of the country for the following reasons :
a. No other authorify has adequate knowledge,experience or interest in this field.
b. There is no significant lobby in the Govemmentfor sponsoring such a legislation.
c. Majority of the divers involved with this indus-try are from the Indian Navy. Therefore, theNavy has a moral and ethical obligation to-wards these divers as an ex-employer.
d. There is a need for establishing operating andsafety standards for divers to prevent unwar-ranted morbidity and mortality. The Navy al-ready has the necessary safety and operatinginstruction [2].
In the Navy, divers undergo courses of trainingspecific to the kind of operation that they wouldeventually be deployed in. lt is needless to say thatthe kind of training that a ship's diver (shallow waterdiving) receives is vastly different from the trainingthat a clearance or a saturation diver gets. Thus it isensured that a diver is adequately trained forthe kindof task he would undertake. Periodic refresnercourses are also carried out to keep the diver uptodate.
Besides training, medical f itness of the diver isalso ensured by subjecting them to a thorough medi-cal examination every year. Exacting standards forfitness are laid down and scrupulously adhered to
[2]. In addition the infrastructure to provide medicalcover for various types of diving operations areavailable.
'I 'his includes cover at the diving site as
well as specialist cover in the Naval hospitals.
Type of legislation
After establishing the need for a diving legisla-
I
t ion, it is important to decide on the fype and modelof legislation suitable to our diving industry. IndianNaval diving regulations were based on the Brit ishregulations and are considered safe for conductingdives.
The Brit ish Model
After the second world war, reconstruction workinvolved tremendous commercial underwater activ-ity. It was necessary to regulate this activity and in1960, the Diving Operations Special Regulations1960 were passed under the Factories Act [3]. Withthe advent of modern undersea techniques andequipments used in North sea oil explorations, itbecame necessary to expand the scope ofthe FactoryAct and after a prolonged debate, a new legislationcame in to being - The Offshore Installations Actl97l as a statutory Instrument 1974 No. 1229 [2].
The Indian Scenar io
In India we have the Factories Act and ONGCAct 1959 which were enacted by Parliament to coverspecifically the factories and the activities of theONGC [4]. There is no mention of under wateractivit ies or diving. As compared to the Brit ish Actwhich was enforced gradually while keeping pacewith the developments in the diving activit ies, ourunder sea activities have developed very rapidlymainly because of sheer economic necessity.
Factors for legislation
Although the professional divers and the divingsupport organisation are not competent to recom-mend as to how the legislation should be enacted,they could be associated from a practical and tech-nical point of view to assist in the formulation ofthese legislations. While enacting the legislation, itis essential to consider the following aspects:
a. Appropriate medical fitness standards for eachtype of diving (recreational diving, saturationdiving and so on.)
b. Medical and technical support of diving.
c. Standards ofhealth care and hvoerbaric facil i-t ies.
d. Establishment of a Diver Alert Network to ren-der prompt and correct first aid and treatment.
e. Medico legal compensations in case of a divingaccident
f. Adequate insurance cover in which the employ-
Jottr. A4arine lvledical SoceiN. Jnne 1996. tr'ol. 3. No. I
ers l iabil i ty should be
g. Training of alldivers a
Enforcement and Regula
One important asPect othe establishment of an enommended that an "Oceanbe created to carry out tlAdvisory Board of India" tlaw enforcement agency albody. The Ocean Advisor5quate representation from
a. Ministry of Defence(lDirectorate of Medica
b. Directorate of HYdrog
c. ONGC and Ministry csources.
d. Representative fromcivil diving firms.
Committees of the Advist
The Ocean Advisory Bassisted by various committioning [5]. ' The followingconstituted:
a. Executive Committee
b. Safety Committee
c. Education / Training (
d. Workshop Commiffee
e. Research and DeveloP
CONCLUSION
Diving is a field whichmany years. In the past, it Iwhich employed divers trWith the advent of increastthe exploration of the ofincreasing number of divethe civil side.
The Indian Navy hastowards this industry bY wwho after retirement from
Jour. ll{arine Medical Soceit
ecide on the type and modelr our diving industry. Indianls were based on the Britishrsidered safe for conductrns
rld war, reconstruction worktmmercial underwater act iv-regulate this activity and inrations Special Regulationsr the Factories Act [3]. Witht undersea techniques andorth sea oil explorations, itpandthe scope ofthe Factory;ed debate, a new legislation: Offshore Installations Actrument 1974No. 1229121.
e Factories Act and ONGCracted by Parliament to coveres and the activities of theto mention of under watercompared to the British Actadually while keeping pacein the diving activit ies, ourtve developed very rapidlyr economic necessity.
sional divers and the divinge not competent to recom-;islation should be enacted,d from a practical and tech-assist in the formulation ofe enacting the legislation, it;he following aspects:al fitness standards for eachreational diving, saturation
cal support ofdiving.
care and hyperbaric facili-
Diver Alert Network to ren-"ect first aid and treatment.
:nsations in case of a divine
cover in which the employ-
ceity, June 1996, I'ol. 3, No. I
?ers l iabil i ty should be spelt out.
g. Training ofall divers and support organisations.
Enforcement and Regulatory Instrument
One important aspect of the legislation would bethe establishment of an enforcing agency. It is rec-ommended that an "Ocean Advisory Board of India"be created to carry out these duties. "The OceanAdvisory Board of lndia" should be seen as a futurelaw enforcement agency and a major policy makingbody. The Ocean Advisory Board should have ade-quate representation from the following sections
a. Ministry of Defence (Directorate of Diving andDirectorate of Medical Services Navy).
b. Directorate of Hydrography / Oceanography.
c. ONGC and Ministrv of Mines and Natural Re-sources.
d. Representative from hyperbaric centers andcivil diving firms.
Committees of the Advisory Board
The Ocean Advisory Board of India should beassisted by various committees for its efficient func-tioning [5]. The following committees need to beconstituted:
a. Executive Committee
b. Safety Committee
c. Education / Training Committee
d. Workshop Committee
e. Research and Develooment Committee
CONCLUSION
Diving is a field which has been in existence formany years. In the past, it was only the lndian Navywhich employed divers trained for specific tasks.With the advent of increased construction work andthe exploration of the offshore oil resources, anincreasing number of divers are being employed inthe civil side.
. The Indian Navy has contributed significantlytowards this industry by way of experienced divers,who after retirement from the Navy get absorbed in
the commercial f ield. At a rough reckoning there areat least 500 retired Indian Naval divers if not more,in the commercial f ield and therefore the Indian
. tNavy has'a moral and ethical obligation towardsthese divers as an ex employer. As there is nogoverning body or legislation to keep these diversfrom being exploited by their employers, it wasobserved that diving was being carried out withminimal safeguards and practically no facil i t ies totreat any casuality arising from diving.
The establishment of an Ocean Advisory Boardof India would bring all the personnel employed inthe field of diving under a common umbrella rvhichin turn would provide adequate training, diver se-lection, comprehensive health care and other facil i-t ies. The Indian Navy, which has the infrastructureand the concerned specialists, would be in a positionto contribute significantly towards the formation ofthe Board.
RECOMMENDATIONS
In view of the above it is strongly recommendedthat enactment of a diving legislation by the parlia-ment would prevent undue exploitation of diversengaged in the off shore industries. This would alsoestablish a uniform code ofconduct for the civil iandivers. By appointing an Ocean Advisory Board ofIndia, a law enforcing agency and a governingauthority for the divers working in the offshoreindustries would be established.
REFERENCES
l. The necessity for legislation on diving operations in India -
paper read by Capt. I l Sahney NM, in Intcrnat ional Div ingMedic ine Symposium 1981.
2. Div ing BR 2806.
3. Thc Offshore installation Act l97l as a statutory instrument1974 no. 1229 - Br i t ish Act .
4. Factor ies Act and ONGC Act 1959.
5. Technical diving conference - Tek 94. Report published inpressure, Vol 23 no. 2 March/April 1994 (Under sea andFlyperbaric Medical Society INC).
Jour. lvlarine Medical Soceiv, June 1996, L'ol. 3, No. I
Contemporsrv IssueTRANSPLANTATION OF HLMAN ORGANS ACT(ACT No 42 of 1994)
As passed by the houses of parliament - Rajya Sabha on 5th May 1993, Lok Sabhaon 14th June 1994. Amendments by Lok Sabha approved by Rajya Sabha on l5thJune 1994. Assented to on 8 July 1994)
made under this Ac
(m) "recipient" mthuman organ is otplanted;
(n) "registered mta medical practitiorognised medical cclause (h) of sectirCouncil Act, 1956State MedicalRegiof that section;
(o) "therapeutic p'treatment of any cimprove health acmethod or modaliq
(p) "transplantatiany human organdeceased person to rtherapeutic purpose
CHAPTER I I
AT]THORITY FORTHUMAN ORGANS
3. ( l )Anydono rmayto such conditions aise the removal, beforgan ofhis body fi
(2) If any donor Ipresence oftwo or rof whom is a neaiunequivocally authrdeath, the removalbody, after his deatthe person lawfulllbody of the donorreason to believesequently revokedtlto a registered medable facil i t ies for t lpurposes, of that hbody ofthe donor.
(3) Where no such isub-section (2), washis death but no otby such person tobeing used after hi:poses, the person la
.Jour. ll4arine iVledical Soct
CHAPTER I
PREL IMINARY
Short T i t le , Appl icat ion and Commencement
I . ( I ) This Act may be called the Transplantationof Human Organs Act 1994.
(2) It applies, in the first instance, to the wholeof the States of Goa. Himachal Pradesh andMaharashtra and to all the Union territories andi t shal l a iso apply to such other State whichadopts this Act by resolution passed in thatbehal f under c lause ( l ) o f ar t ic le 252 of theConst i tu t ion.
(3) It shall come into force in the State of Goa,Himachal Pradesh and Maharashtra and in allthe Union territories on such date that the Stateand Central Government may, by notif icationappoint and in any other state which adopts thisAct r - rnder c lause ( l ) o f ar t ic le 252 of the Con-stitution on the date ofsuch adoption; and anyreference in this Act to the commencement ofth is Act shal l . in re lat ion to any State or Unionterritory means the date on which this Actcorrres into force in such a State or Union terri-tory.
Def in i t ions
2. In this Act unless the context otherwise re-q u ires:
(a) "advertisement" includes any fonn of ad-vertising whether to the public generally or toany sect ion of the publ ic or ind iv idual ly toselected persons:
(b) "Appropr iate Author i ty" means the Ap-propriate Authority appointed under section l3;(c) "Author isat ion Commit tee" means thecommittee constituted under clause (a) or
clause (b) ofsub-section (6) ofsection 3;
(d) "brain-stem death" means the stage atwhich all functions of the brain-stem have per-manently and irreversibly ceased and is so cer-tif ied under sub-section (6) ofsection 3;
(e) "deceased person" means a person inwhom permanent disappearance ofall evidenceoflife occurs, by reason ofbrain-stem death orin a cardio-pulntonary sense, at any time afterl ive birth has taken place;
(f) "donor" means any person, not less thaneighteen years of age, who voluntarily author-ises the removal of any of his human organs fortherapeutic purposes under sub-section (l) orsub-section (2) ofsection 3:
(g) "hospi ta l " inc ludes a nurs ing home, c l in ic ,medical centre, medical or teaching institutionfor therapeutic purposes and others l ike institu-t ion;
(h) "human organ" means any par t of a humanbody consisting ofa structured arrangentent oftissues which, if wholly rernoved cannot bereplicated by the body;
(i) "near relative" means spouse, son, daugh-ter, father, mother, brother or sister;
( ) "not i f icat ion" means a not i f icat ion publ ish-ed in the Official Gazette;
(k) "payment" means payment in money ormoney's worth but does not include any pay-ment for defraying or reimbursing - (i) the costof rernoving, transporting or preserving the hu-man organ to be suppl iedl or ( i i ) any expensesor loss.ofearn ings incurred by a person so faras reasonably and directly attributable to lrissupplying any human organ tiom his body:
( l ) "prescr ibed" means prescr ibed by ru les
Jour. Nlarine A'ledical Societv. .lune 1996. I'ol. 3. ,\'o. I
?
May 1993, Lok SabhaRajya Sabha on l5th
iection (6) of section 3;
death" means the stage ats ofthe brain-stem have per-venibly ceased and is so cer-rction (6) of section 3;
erson" means a person inCisappearance of al I evidenceeason ofbrain-stem death ornary sense, at any time aftern place;
ns any person, not less thanage, who voluntarily author-lany ofhis human organs forses under sub-section (l) orsection 3:
, ludes a nurs ing horne. c l in ic .edical or teaching institutionposes and others l ike institu-
t" means any part of a humanfa structured arrangement ofwholly removed cannot bendy;t 'means spouse, son, daugh-, brother or sister;
means a not i f icat ion publ ish-iazette;
leans payment in rnoney orLt does not include any pay-
; or reimbursing - (i) the costporting or preserving the hu-rpplied; or (i i) any expensesincurred by a person so fardirectly attributable to his
ran organ from his body:
means prescribed by ru les
ccielv, June 1996, I'ol. -1, ,\'o. /
made under this Act;
(m) " recipient" means a person into whom anyhuman organ is or is proposed to be, trans-planted;
(n) "registered medical practit ioner" meansa medical practitioner who possesses any rec-ognised medical qualif ication as defined inclause (h) of section 2 of the Indian MedicalCouncil Act, 1956 and who is enrolled on aState Medical Register as defined in clause (k)ofthat section;
(o) "therapeutic purposes" means systematictreatment of any disease or the measures toimprove health according to any particularmethod or modality; and
(p) "transplantation" means the grafting ofany human organ from any living person ordeceased person to some other l iving person fortherapeutic purposes.
CHAPTER I I
AUTHORITY FOR THE REMOVAL OFHUMAN ORGANS
3. ( I ) Any donor may in such manner and subjectto such conditions as may be prescribed, author-ise the removal, before his death, of any humanorgan ofhis body for therapeutic purposes.
(2) If any donor had, in writ ing and in thepresence of two or more witnesses (at least oneof whom is a near relative of such person),unequivocally authorised at any time before hisdeath, the removal of any human organ of hisbody, after his death, for therapeutic purposes,the person lawfully in possession of the deadbody of the donor shall. unless he hq5 anyreason to believe that the donor had sub-sequently revoked the authority aforesaid, grantto a registered medical practit ioner all reason-able facil i t ies for the removal, for therapeuticpurposes, of that human organ from the deadbody ofthe donor.
(3) Where no such authority as is referred to insub-section (2), was made by any person beforehis death but no objection was also expressedby such person to any of his human organsbeing used after his death for therapeutic pur-poses, the person lawfully in possession of the
Jour. Ilarine tr4edical Societv. June 1996. Llol. 3. No. I
dead body of such person may, unless, he hasreason to believe that any near relative of thedeceased person has objection to any of tlredeceased persons human organs being used fortherapeutic purposes, authorise the removal ofany human organ of the deceased for its use fortherapeutic purposes.
(4) The authority given under sub-section ( I ) orsub-section (2) or as the case may be, sub-sec-tion (3) shall be sufficient warrant for the re-moval for therapeutic purposes, of the humanorgan; but no such removal shall be made byany person other than the registered ntedicalpractit ioner.
(5) Where any human organ is to be removedfrom ihe body of a deceased person, the regis-tered medical practit ioner shall satisfy himself,before such removal, by a personal exam inationof the body from which any hunran organ is tobe removed, that l i fe is extinct in such a bodyor, where it appears to be a case of brain-stemdeath, that such death has been certif ied undersub-section (6).
(6) Where any human organ is to be removedfrom the body of a person in the event of hisbrain-stem death, no such removal shall be un-dertaken unless such death is certif ied. in suchform and in such manner.and on satisfaction ofsuch conditions and requirements as ma1, beprescribed, by a Board of medical experts con-s is t ing of the fo l lowing, namely: -(i) the registered medical practit ioner in chargeof the hospital in which brain-stem death hasoccurred;(i i) an independent registered medical practit io-ner, being a specialist, to be nominated by theregistered medical practit ioner specified inclause (i), from the panel ofnames approved bythe Appropriate Authority;(i i i) aneurologist ora neurosurgeon to be norni-nated by the registered medical practit ionerspecified in clause (i), from the panel of narnesapproved by the Appropriate Authority; and(iv) the registered medical practit ioner treatingthe person whose brain-stem death has oc-curred.
(7) Not withstanding anything contained in sub-section (3), where brain-stem death ofany per-
son, less than eighteen years ofage, occurs andis cerlif ied under subsection (6), any of theparents ofthe deceased person may give author-ity, in such form and in such manner as may beprescribed, for the removal of any human organfrom the body ofthe deceased person.
Removal of human organs not to be authorisedin certain cases
4. (l) No facil i t ies shall be granted under sub-sec-tion (2) of section 3 and no authority shall begiven under sub-section (3) ofthat section forthe rernoval of any human organ from the bodyof a deceased person if the person required togrant such facil i t ies, or empowered in grantingin such authority, has reason to believe that aninquest may be required to be held in relation tosuch body in pursuance ofthe provision ofanylaw for the time being in force.
(2) No authority for the removal of any humanorgans from the body ofa deceased person shal Ibe given by a person to whom such body hasbeen entrusted solely for the purpose of intern-ment, cremation or other disposal.
Authority for removal of human organs in caseof unclaimed trodies in hospital or in person
5. ( l) In the case of a dead body lying in a hospitalor prison and not claimed by any of the nearrelatives of the deceased person within forty-eight hours from the time of the death of theconcerned person, the authority for the rernovalof any human organ from the dead body whichso remains unclaimed may be given, in theprescribed form by the person in charge, fbr thetime being, of the management or control of thehospital or prison or by an employee of suchhospital or person authorised by the person incharge of the management or control thereof.
(2) No authority shall be given under sub-sec-tion (1) if the person empowered to give suchauthority has reason to believe that any nearrelative ofthe deceased person is l ikely to claimthe dead body even though such near relativehas not conre fbrward to claim the body of thedeceased person within the time specified insub-sect ion ( l ) .
8
Authority for removal of human organs frombodies sent for post-mortem examination formedicolegal or pathological purposes
6. Where the body of a person has been sent fbrpost-mortem exam ination :
(a) for medico-legal purposes by reason of thedeath of such person having been caused byaccident or any other unnatulal cause; or
(b) for pathological purposes,
The person competent under this Act to giveauthority for the removal of any human organfrom such dead body may, if he has reason tobelieve that such human organ wil l not be re-quired for the purpose for which such body hasbeen sent for post-mortem examination, author-ise the removal, for therapeutic purposes, ofthathuman organ ofthe deceased person providedthat he is satisfied that the deceased person hasnot expressed, before his death, any objectionto any of his human organs being used, fortherapeutic purposes after his death or, wherehe had granted an authority for the use of anyof his human organs for therapeutic purposesafter his death, such authority had not beenrevoked by him before his death.
Preservation of human organs
7. After the removal of any human organ from thebody ofany person, the registered medical prac-tit ioner shall take such steps forthe preservationof the human organ so removed as nray beprescribed.
Savings
8. ( l ) Noth ing in the foregoing provis ions of th isAct shall be construed as rendering unlawtirlany dealing with the body or with any part ofthe body of a deceased person if such dealingwould have been lawful if this Act had not beenpassed.
(2) Neither the grant of any facil i ty or authorityfor the removal of any human organ from thebody of a deceased person in accordance withprovisions of this Act nor the removal of anyhuman organ frorn the body of a deceased per-son in pursuance of such authority shall bedeemed to be an offence punishable under sec-t ion297 of the Indian Penal Code.
Jour. ll'larine it[edical SocieN. Jurrc ]996. I'ol. 3. No. I
Restrictions on remov:human organs
9. (l) Save as otherwi(3), no human orgaofa donor before hisinto a recipient unletive ofthe recipient,
(2) Where any donoany of his human orsub-section (2) ofsepetent or empowereremoval ofany humany deceased persorthe human organ mplanted into the bodlbe in need ofsuch h
(3) Ifany donor autlof his human orgalsub-section (l) ofseinto the body ofsuchrelative, as is specifiofaffection or attachor for any other sptorgan shall not bewithout the prior apyCommittee.
(a) (a)The Central Gby notification one ormittees consisting oinominated by the Ceterms and conditionsnotification for eachthe purposes ofthis r
(b) The State Governotification, one ormittees consisting olnominated by the Sterms and conditionnotification forthe p
(5) On an applicatiorand in such mannerthe donor and the reCommittee shall, affafter satisfoing itselcomplied with all thand the rules madeapplicants approvalplantations of the hu
Jour. l+4arine Medical Socit
of human organs fronlortem examination forrgical purposes'a person has been sent fbrination:
rl purposes by reason of the;on having been caused byer unnatural cause; or
r purposes,
tent under this Act to givemoval of any hunran organdy may, if he has reason touman organ wil l not be re-rse for which such body hastortem exam ination, author-therapeutic purposes, of thato deceased person providedhat the deceased person hasrre his death, any objectionran organs being used, for:s after his death or, ,uvhereauthority for the use of anyns for therapeutic purposesch authority had not beenlore his death.
l organs
f any human organ from thethe registered rnedical prac-rch steps for the preservationln so removed as nray be
foregoing provisions of this'ued as rendering unlarvfLrlre body or with any part oflsed person i fsuch deal ingwful if this Act had not been
t ofany facil i ty or authorityany human organ frorn theperson in accordance with
\ct nor the rernoval of anythe body ofa deceased per-rf such authority shall betnce punishable under sec-an Penal Code.
ciety, June 1996, I'ol. J, ,\o /
Restrictions on removal and transplantation ofhuman organs
9. (l) Save as otherwise provided in sub-section(3), no human organs removed from the bodyofa donor before his death shall be transplantedinto a recipient unless the donor is a near rela-tive of the recipient.
(2) Where any donor authorises the removal ofany ofhis human organs after his death undersub-section (2) ofsection 3 or any person com-petent or empowered to give authority for theremoval of any human organ from the body ofany deceased person authorises such removal,the human organ may be removed and trans-planted into the body of any recipient who maybe in need ofsuch human organ.
(3) Ifany donor authorises the removal ofanyof his human organs before his death undersub-section (l) ofsection 3 for transplantationinto the body ofsuch recipient, not being a nearrelative, as is specified by the donor by reasonof affection or attachment towards the recipientor for any other special reasons, such humanorgan shall not be received and transplantedwithout the prior approval of the AuthorisationCommittee.
(a) (a)The Central Government shall constituteby notif ication one or more Authorisation Com-mittees consisting of such members as they benominated by the Central Government on suchtenns and conditions as may be specified in thenotif ication for each of the Union territories forthe purposes of th is sect ion.
(b) The State Government shall constitute, bynotif ication, one or more Authorisation Com-mittees consisting of such members as may benominated by the State Government on suchterms and conditions may be specified in thenotif ication for the purposes ofthis section.
(5) On an application jointly made in such formand in such manner as may be prescribed, bythe donor and the recipient, the AuthorisationCommittee shall, after holding, an inquiry andafter satisfoing itself that the applicants havecomplied with all the requirements of this Actand the rules made thereunder, grant to theapplicants approval for the removal and trans-plantations of the human organ.
Jour. lt'larine ltledical Society, June 1996, I/ol. 3, No. I
(6) lf, after the inquiry and after giving anopportunity to the applicants ofbeing heard. theAuthorisation Comrnittee is satisfied that theapplicants have not complied with the require-ments of this Act and the rules made thereunder, it shall, fbr reasons to be recorded inwrit ing reject the application for approval.
CHAPTER I I I
REGULATION OF HOSPITALS
Regulat ion of hospi ta ls conduct ing theremoval , s torage or t ransplantat ion of humanorgans
10. ( l ) On and f rom the comrnencement of th is Act :
(a) no hospi ta l , unless regis tered underth is Act ,shall conduct or associate with, or help in, theremoval, storage or transplantation of any hu-man organ;
(b) no medical practit ioner or any other personshall conduct or cause to be conducted or aid inconducting by himself or through any otherperson, any activity relating to the removal,storage of transplantation of any human organat a place other than a place registered underth is Act ; and
(c) no p lace inc luding a hospi ta l regis tered un-der sub-sect ion ( l ) o fsect ion l5 shal l be usedor cause to be used by any person for the re-moval, storage or transplantation of any humanorgan except for therapeLrtic purposes. (2) Not-withstanding anything contained in sub-section( I), the eyes or the ears may be removed at anyplace from the dead body of any donor, fortherapeutic purposes, by a registered medicalpractit ioner.
Explaination - For the purposes ofthis sub-sec-tion, "ears" includes ear drums and ear bones.
Prohib i t ion of removal of human organ fort ransplantat ion for any purpose other thantherapeutic purposes
I l. No donor and no person ernpowered to giveauthority for the removal of any human organshall authorise the removal of any human organfor any purpose other than therapeutic pur-poses.
Explaining effects, etc. to donor and recipient
12. No registered medical practit ioner shall under-take the removal or transplantation of any hu-man organ unless he has explained, in suchmanner as may be prescribed, all possible ef-fects, complications and hazards connectedwith the removal and transplantation to thedonor and the recipient respectively.
CHAPTER IV
APPROPRIATE AUTHORITY
13. ( l ) The Centra l Government shal l appoint , bynotif ication, one or more officers as Appropri-ate Authorit ies for each of the Union territoriesfor the purposes of this Act.
(2) The State Government shall appoint, bynotif ication, one or more officers as Appropri-ate Authorit ies for the purposes of this Act.
(3) The Appropriate Authoriry shall performthe following functions, narnely : (i) to grantregistration under sub-section ( I ) of section I 5or renew registration under sub-section (3) ofthat section; (i i) to suspend or cancel registra-t ion under sub-sect ion (2) ofsect ion I 6 ; ( i i i ) toenforce such standards, as may be prescribed,for hospitals engaged in the removal, storage ortransplantation of any human organ; (iv) toinvestigate any complaint of breach of any ofthe provis ions of th is Act or any of the ru lesmade thereunder and take appropriate action;(v) to inspect hospitals periodically for exanri-nation of quality of transplantation and the fol-low-up nredical care to persons who haveundergone transplantation and persons fromwhom organs are renroved, and (vi) to under-take such other measures as mav be orescribed.
CHAPTER V
REGISTRATION OF HOSPITALS
Registration of hospitals engaged in theremoval, storage or transplantation of humanorgans
14. ( l ) No hospi ta l shal l commence any act iv i tyrelating to the removal, storage or transplanta-tion of any human organ for therapeutic pur-poses after the commencement of this Act
1 0
unless such hospital is duly registered underthisAct :
Provided that every hospital engaged, eitherpartly or exclusively in any activify relating tothe removal, storage or transplantation any hu-man organ for therapeutic purposes immedi-ately before commencement of this Act, shallapply for registration within six days from thedate of such commencement:
Provided further that every hospital engaged inany activity relation to the removal, storage ortransplantation of any human organ shall cometo engage in any such activity on the expiry ofthree months from the date of commencementof this Act unless such hospital has applied forregistration and is so registered or t i l l suchapplication is disposed of whichever is earlier.
(2) Every application for registration under sub-section (l) shall be made to the AppropriateAuthority in such form and in such manner andshall be accompanied by such fees as rnay beprescribed.
(3) No hospital shall be registered under thisAct unless the Appropriate Authority is satis-fied that such hospital is in a position to providesuch specialised services and facil i t ies, possesssuch sk i l led manpower and equipments andmaintain such standards as mav be orescribed.
Certif i cate of registration
15. ( l) The Appropriate Authority shall, after hold-ing an inquiry and after satisfying itselfthat theapplicant has complied with all the require-ments ofthis Act and the rules made thereunder,grant to the hospital a certificate of registrationin such form, for such period and subject to suchconditions as may be prescribed.
(2) If, after the inquiry and after giving anopportunify to the applicant of being heard, theAppropriate Authority is satisfied that the ap-plicant has not complied with the requirementsof this Act and the rules made thereunder, itshall, for reasons to be recorded in writ insreject the application for registration.
(3) Every certificate of registration shall berenewed in such manner and on payment of
. such f'ees as may be prescribed.
Jour. lt4arine Medical Socien. June 1996. l'ol. 3. No. I
Suspension or cancellat
16. (l) The Appropriateor on complaint, isstto show cause whYAct should not be stthe reasons mention€
(2) Il after giving abeing heard in theAuthority is satisfiebreach ofany ofthethe rules made thereldice to any criminalagainst such hospitalfor such period as it tregistration:
Provided that where tis ofthe opinion that itso to do in the public itto be recorded in wtiltion of any hospital w
Appeals
17. Any person aggrieverthorisation Committerfor approval under sulor any hospital aggriAppropriate Authori!for registration underI 5 or an order of suspregistration under sub,r1ay, within thirty dtreceipt of the order, 1manner as may be pnder to -
(i) the CentralGovemagainst the order ofthtee constituted under(a) of section 9 or rAppropriate Authorilsection (l) ofsection
(ii) the State Governragainst the order ofthtee constituted under( ) of section 9 orAppropriate Authorisection (2) ofsection
Jour. Marine Medical Societ
--l
I is duly registered under this
ry hospital engaged, eitherly in any activity relating to1e or transplantation any hu-:rapeutic purposes immedi-lencement of this Act, shallon within six days from therencement:
rat every hospital engaged inrn to the removal, storage orlny human organ shall comerch activity on the expiry ofthe date of commencement
;uch hospital has applied for; so registered or t i l l suchlsed of whichever is earlier.
rn for registration under sub-,e made to the Appropriatebrm and in such manner andied by such fees as may be
all be registered under thislropriate Aulhority is satis-tal is in a position to providervices and facil i t ies, possessrower and equipments andJards as may be prescribed.
lion
e Authority shall, after hold-tfter satisf, i ing itselfthat theplied with all the require-d the rules made thereunder,I a certificate of registration;h period and subject to suchrc prescribed.
rquiry and after giving an,pplicant of being heard, therity is satisfied that the ap-plied with the requirements: rules made thereunder, itto be recorded in writ ing,,n for registration.
te of registration shall betanner and on payment of, prescribed.
ciety,June 1996. I'ol 3. No. I
P' - Suspension or cancel la t ion of regis t rat ion
16. (l) The Appropriate Authority may, suo motoor on complaint, issue a notice to any hospitalto show cause why its registration under thisAct should not be suspended or cancelled forthe reasons mentioned in the notice.
(2) If, after giving a reasonable opportunity ofbeing heard in the hospital, the AppropriateAuthority is satisfied that there has been abreach of any of the provisions of this Act orthe rules made thereforQ it may, without preju-dice to any criminal action that it may takeagainst such hospital, suspend its registrationfor such period as it may think fit or cancel itsregistration:
Provided that where the Appropriate Authorityis ofthe opinion that it is necessary or expedientso to do in the public interest, it may, for reasonsto be recorded in writ ing, suspend the registra-tion of any hospital without issuing any notice.
Appeals
17. Any person aggrieved by an order ofthe Au-thorisation Committee rejecting an applicationfor approval under sub-section (6) ofsection 9,or any hospital aggrieved by an order of theAppropriate Authorify rejecting an applicationfor registration under sub-section (2) ofsection| 5 or an order ofsuspension or cancellation ofregistration under sub-section (2) ofsection 16,
ryay, within thirty days from the date of thereceipt of the order, prefer an appeal, in suchmanner as may be prescribed, against such or-der to -
(i) the Central Government where the appeal isagainst the order of the Authorisation Commit-tee constituted under clause (a) of sub-section(4) of section 9 or against the order of theAppropriate Authority appointed under sub-sect ion ( l ) o fsect ion l3 ; or
(ii) the State Govemment, where the appeal isagainst the order of the Authorisation Commit-tee constituted under clause (b) of sub-section(4) of section 9 or against the order of theAppropriate Authority appointed under sub-section (2) ofsection 13.
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CHAPTER VI
OFFENCES AND PENALTIES
Punishment for removal of human organswi thout author i ty
18. ( l ) Any person who renders h is serv ices to orat any hospital and who, for purposes oftrans-plantation, conducts, associates with, or helpsin any manner in the removal of any humanorgan without authority, shall be punishablewith imprisonment for a term which may ex-tend to five years and with a fine which mayextend to ten thousand rupees.
(2) Where any person convicted under sub-sec-tion ( I ) is a registered medical practit ioner, hisname shall be reported by the AppropriateAuthority to the respective State Medical Coun-cil for taking necessary action including theremoval of his name from the register of theCouncil for a period of two years for the l lrstoffence and permanently for the subsequentof-fence.
Punishment for commercia l deal ings in humanorgans
19. Whoever -
(a) makes or receives any paynrent tbr the sup-ply ol or for an offer to supply. any hunrarrorgan;
(b) seeks to find a person rvil l ing to supply forpayment any hurnan organ;
(c) offers to supply any human organ for pay-ment;
(d) init iates or negotiates any arrangement in-volving the making of any payment for thesupply of, or for an offer to supply, any humanorgan;
(e) takes part in the management or control of abody of persons, whether a society, firm orcompany, whose activit ies consists of or in-clude the init iation or negotiation of any ar-rangelnent referred to in clause (d); or
(f) publishes or distributes or causes to be pub-lished or distributed any advertisement-
(a) invit ing persons to supply for payment ofany human organ;
(b) offering to supply any human organ for
1 t
payment; of
(c) indicating that the advertiser is wil l ing toinitiate or negotiate any arrangement referred toin clause (d),
shall be punishable with imprisonment for aterm which shall not be less than two years butwhich may extend to seven years and shall beliable to fine which shall not be less than tenthousand rupees but may extend to twenfy thou-sand rupees:
Punishment for contravention of any otherprovision of this act
20. Whoever contravenes any provision of this Actor any rule made or any condition of the regis-tration granted, thereunder for which no punish-ment is separately provided in this Act, shall bepunishable with imprisonment for a term whichmay extend to three years or with a fine whichmay extend to five thousand rupees.
Offences by companies
21. (1) Where any offence, punishable under thisAct has been committed by a company, everyperson who, at the time of the offence wascommitted was in charge ol and was responsi-ble to, the company for the conduct of thebusiness of the company, as well as the com-pany shall be deemed to be guilty ofthe offenceand shall be l iable to be proceeded against andpunished accordingly:
Provided that nothing contained in this sub-sec-tion shall render any such person liable to anypunishment, if he proves that the offence wascommitted without his knowledge or that hehad exercised all due dil igence to prevent thecommission of such offence.
(2) Notwithstanding anything contained in sub-section ( I ), where any offence punishable underthis Act has been committed by a company andit is proved that the offence has been committedwith the consent or connivance of, or is attrib-utable to any neglect on the paft ofany director,m.h.Dpr ..a...at?n., or other officer of (he com_/ , 1 9 | q 5 ! , t
pany, such director, manager, secretary or otherofficer shall also be deemed to be guilty of thatoffence and shall be l iable to be proceededagainst and punished accordingly.
t 2
Explanation - For the purposes ofthis section,-
(a) "company" means any body corporate andincludes and or other association ofindividuals;and
(b) "director", in relation to a firm, means apartner in the firm.
Cognizance ofoffence
22. ( I ) No court shall take cognizance ofan offenceunder this Act except on a complaint made by- (a) the Appropriate Authority concerned ofany officer authorised in this behalf by theCentral Government or the State Governmentor, as the case may be, the Appropriate Author-ity; or (b) a person who has given notice of notless than sixty days, in such manner as may beprescribed, to the Appropriate Authority con-cerned, ofthe alleged offence and ofhis inten-tion to make a complaint to the court.
(2) No court other than that of a MetropolitanMagistrate or a Judicial Magistrate of the firstclass shall try any offence punishable under thisAct.
(3) Where a complaint has been made underclause (b) of sub-section ( I ), the court may, ondemand by such person, direct the AppropriateAuthority to make available copies of the rele-vant records in its possession to such person.
CHAPTER VI I
MISCELLANEOUS
Protection ofaction taken in good faith
23. (l) No suit, prosecution or other legal proceed-ing shall l ie against any person for anythingwhich is in good faith done or intended to bedone in pursuance ofthe provisions of this Act.
(2) No suit or other legal proceeding shall l ieagainst the Central Government or the StateGovernment for any damage caused or likely tobe caused for anything which is in good faithdone or intended to be done in pursuance oftheprovisions of this Act.
Power to make rules
24. (l) The Central Government may, by notif ica-tion, make rules for carrying out the purposesof this Act.
Jour. Marine Medical Sociely, June 1996, Vol. 3, No. l
(2) In particular, andgenerally of the forelmay provide for all rmatters, namely: (a) tithe conditions subjectauthorise removal, befman organ of his bodysection 3; (b) the forma brain-stem death isconditions and requinsatisfied for that purpoof section 3; (c) the fwhich any of the parenthe case ofbrainstem <removal of any humartion (7) of section 3;authority for the remo,from an unclaimed deathe person incharge oftrol of the hospital or p( | ) of section 5; (e) theprcservation ofthe hunthe body ofany personform and the manner imay be jointly, maderecipient under sub-secthe manner in which alplications and hazardsmoval and transplantatithe registered medical 1and the recipient under rards as are to be enfor,authority for hospital estorage or transplantatiunder clause (i i i) of sul3; (i) the other measrAuthority shall underlfunction under clause ('section I 3; (j) the form ran application forregistthe fee which shall be arsection. (2) of section.service and the facil i t iermanpower and the equiand rhe sranclards to be n
Jour. ll4arine Medical Socien..
the purposes ofthis section,-
oans any body corporate andrer association of individuals;
relation to a firm, nreans al .
e
take cognizance ofan offencecept on a complaint rnade byriate Authority concerned ofrrised in this behalf by theent or the State Governmenty be, the Appropriate Author-n who has given notice of notys, in such manner as may ber Appropriate Authority con-lged offence and ofhis inten-mplaint to the court.
rr than that of a Metropolitanudicial Magistrate of the firstoffence punishable under this
rplaint has been made undersection (l), the court may, onlerson, direct the Appropriatee available copies of the rele-; possession to such person.
taken in good faith
cution or other legal proceed-inst any person for anythingfaith done or intended to be
r of the provisions of this Act.
rer legal proceeding shall l ieral Government or the State.ny damage caused or likely toything rvhich is in good faithto be done in pursuance oftheAct.
iovernment may, by notifica-for carrying out the purposes
Society, June 1996, Itol. 3, No. I
(2) ln particular, and without prejudice to thegenerally of the foregoing power, such rulesmay provide for all or any of the followingrnatters, namely: (a) the manner in which andthe conditions subject to which any donor mayauthorise removal, before his death, of any hu-man organ ofhis body under sub-section (l ) ofsection 3; (b) the fbrrn and the number in whicha brain-stem death is to be certif ied and theconditions and requirements which are to besatisfied for that purpose under sub-section (6)of section 3; (c) the form and the manner inwhich any of the parents may give authority, inthe case of brainstent death of a mincr. for theremoval of any human organs under sub-sec-tion (7) of section 3; (d) the form in whichauthority for the removal of any human organ'from an unclaimed dead body may be given bythe person incharge of the management or con-trol ofthe hospital or prison. under sub-section( I ) of section 5; (e) the steps to be taken for thepreservation of the human organ removed fromthe body ofany person, under section 7; (f) theforrn and the manner in which an applicationmay be -jointly, made by the donor and therecipient under sub-section (5) ofsection 9; (g)the manner in which all possible eff-ects, com-plications and hazards connected with the re-moval and tlansplantation is to be explained bythe registered medical practit ioner to the donorandthe rec ip ient undersect ion l2 ; (h) the stand-ards as are to be enforced by the Appropriateauthority for hospital engaged in the removal,storage or transplantation of any human organunder clause (i i i) of sub-section (3) of sectionl3; (i) the other measures as the AppropriateAuthority shall undertake in performing itsfunction under clause (vi) ofsub-section (3) ofsection l3; [) the tbrm and the manner in whichan application for registration shall be made andthe fee which shall be accompanied, under sub-section. (2) of section. la; (k) the specialisedservice and the facil i t ies to be provided, skil ledmanpower and the equipments to be possessedand the standards to be maintained bv a hosoital
Jour. lr4arine Nledical Societv, June 1996, I/ol. 3. ,\'o I
for registration. under sub-section (3) ofsectionl4; (l) the form in which, the period for whichand th9 conditions subject to which cerlif icateof registration is to be granted to a hospital.under sub-sect ion ( l ) o f sect ion l5 ; ( r r r ) themanner in which and the fee on payrnent ofwhich certif icate of registration is to be re-newed under sub-sect ion (3) ofsect ion t5; (n)the manner in which an appeal may be preferredunder sect ion 17; (o) the manner in which aperson is required to give notice to the Author-ity Authority of the alleged offence and of hisintention to make a complaint to the court,underclause (b) ofsub-section ( I ) ofsection22:and (p) any other matter which is required to be,or may be, prescribed.
(3) Every ru le made underth is Act shal lbe la id,as soon as may be after it is made. befbre eachHouse of Par l iament , whi le i t is in session, fora total period of thif iy days which rnay becomprised in one session or in two or moresuccessive sessions, and if, before the expiry ofthe session immediately follorving the sessionor the successive sessions aforesaid, bothHouses agree in making any modification in therule or both Houses agree that the rule shouldnot be made, the rule shall thereafter have effectonly in such modifled forrn or be of no effect,as the case may be: so, however, that any suchmodi f icat ion or annulment shal l be wi thoutprejudice to the validity of anything previouslydone under that ru le
Repeal and Savings
25. (1) The Ear Drums and Ear Bones (Authorityfor Use for Therapeutic Purposes) Act. 1982and the Eyes (Authority for Use for TherapeuticPurposes) Act, 1982 are hereby repealed.
(2) the repeal shall, however, not affect theprevious operation of the Acts so repealed oranything duly done or suffered thereunder.
K.L. Mohanpur iaSecv to Govt. of India
13
Contemporevy IssueTRANSPLANTATION OF HUMAN ORGANS ACT -
A CzuTICAL APPRAISAL
Surg Lt Cdr MSN MURTHY*, Srrrg Cdr RK MALIK**'
Lt Col .A RAJVANSHI*
ver since the first successful renal transplantwas performed using a kidney from a healthyidentical twin in 1954, the question of "assault
and battery" in the performance of surgery on a
healthy individual were raised. Legal issues inter-
wined with ethical issues continue to capture the
concern of nephrologists, transplant surgeons aswell as polit icians, lawyers and health policy ex-perts.
The magnitude of renal failure incidence in India
is estimated to be about 80,000 new ESRD (end
stage renal disease) cases per year and about 2000
transpfants are done annually (i.e. 2.5% of new
E,SRD cases) mostly l ive related and live unrelated.Most of the countries have passed laws forbiddingthe use of l ive unrelated donors and one of the last
countries to pass such a law was India, which prom-
ulgated the "Transplantation of Human organs Act
i n 1994" ! 1 .
RELATED VS UNRELATED
In the Indian context, arguing in favour of live
unrelated donation, Reddy (1990) [2] opines that
one must strike a balance between ethical, social,commercial and scientif ic values and render justice
to all parties. One does not have control over money
changing hands even between related donors - thus,
normally it is not so different from unrelated donors.Thiagaraj an et al (1990) [3] in a strong case in favour
of unrelatcd transplantation, conclude their argu-
ment - "As a transplant team, we sincerely believethat the values gained, greatly overshadow the val-
ues lost" .
However LURD (live unrelated renal donation)
is a practise abhorrent to the conscience of a civi-lized society, rvhere patient care is relegated to the
laws of the market place and unscrupulous brokersmake hay with methods reminiscent of the slavetrade. Section 9[1] ofthis act, categorically statesthat unrelated donor should not be used and then
only may be considered if a near relative is not
available as a donor. LURD can only be acceptedwith prior approval of an authorisation committeeand these checks are by and large, acceptable to all
of us. But the fact remains that the law makers havenot really banned LURD. As long as there are pa-
tients requiring organs, who do not have a suitable
"near relative" donor - LURD can not be done awaywith. The only solution being, that cadaveric dona-tion should catch up in a big way.
The inclusion ofa spouse as a near relative doesdefeat the whole exercise. at least to some extent'Biologically a spouse is unrelated and the inclusionofthis clause leaves enough ground for the unscru-pulous to act, particularly in our lndian setting. In
India, what we often observe is that the wife is thedonor 900/o of t imes and the husband in about l0%o.This speaks volumes for the equaliry of sexes andthe value of th is leg is lat ion.
The act also makes the criteria for selection of arelated donor more stringent, which is unnecessaryto say the least. Section 4(c) of the Transplantationof human organ rules (Maharashtra) [5] emphasisesthat the medical prrctioner shall satisfy himself with
tests for MHC (major histocompatibil i ty complex)bv conventional serological technique - which even25o/o of the siblings are not expected to match.
Alternatively, they have recommended gene RFLP
and DNA polymorphism, which are not widely
available. Thus processing a sibling as an unrelateddonor in comparatively simPler.
ACCEPTANCE OF A CiSTEM DEATH
There is only one kinrineversible loss of caPaciqbined with irreversible lossand hence to sustain a IWhereas the function ofthbe taken overby machines,Thus death, by this persPdeath, as the key functionslas an independent biologitthe brainstem. Brainstem cthe bedside.
Para 2(d) [ ] legislates tdeath". Though imPortantit has also clearly wider imintensive care units whertmaintained on cardioresPidoes give us the sanctiorbrainstem death is diagnos
CADAVERDONATIOI
As per para 3(2) [] thremoval of his organs aftepeutic purposes, in writinlor more witnesses, with atnear relative. In view ofthof organs for transPlantatirnumber of cadaveric donotadequate education ofthe 1of presumed consent lavperson yho dies would brdonate his organs, unlessunwillingness to donate -
and increase the availabili'the legislation is almost tlof cadavers transplants arrtutions like AIIMS have b,cadaveric transplants anrnone at all.
ORGAN SHARING
Our principle concem tmust be to maximise thOverall eraft survival aftr
*Classified srrecialist in Medicine and Nephrologist; +*Classified Specialist in Mcdicine and Nephrology
Jour. Marine Medical Society, June 1996, L'ol. 3, No l Jour. Marine Medical Socie
t -
place and unscrupulous brokerslthods reminiscent of the slaveof this act, categorically states
rr should not be used and thenidered i f a near re lat ive is notrr. LURD can only be acceptedI of an author isat ion commit tee'e by and large, acceptable to allemains that the law makers have-URD. As long as there are pa-;ans, who do not have a suitable:r - LURD can not be done arvayrtion being, that cadaveric dona-p in a big way.
'a spouse as a near relative doesxercise, at least to some extent..se is unre lated and the inc lus ions enough ground fbr the unscru-cularly in our Indian settirrg. In:n observe is that the rvit-e is the; and the husband in about l09ir.res for the equality of sexes andlislation.
<es the criteria for selection of astringent, which is unnecessaryf ion 4(c) of the Transplantat ion:s (Maharashtra) [-5] emphasisesutioner shall satisfy himself withjor histocompatibi l i ty complex)ological technique - 'uvhich evengs are not expected to match.have recommended gene RFLPrphism, which are not rvidelycessing a sibling as an unrelatedvely simpler.
Iephrology.
al Society, June 1996, I'ol 3, No. I
ACCEPTANCE OF A CONCEPT - BRAIN-STEM DEATH
There is only one kind of human death : theineversible loss of capacity for consciousness, com-bined with irreversible loss ofthe capacity to breatheand hence to sustain a spontaneous heart beat.Whereas the function of the lungs and the heart canbe taken over by machines, those ofthe brain cannot.Thus death, by this perspective means brainstemdeath, as the key functions that define a human beingas an independent biological unit are subserved bythe brainstem. Brainstem death can be diaenosed atthe bedside.
Para2(d) [ I ] legislates the concept of "brain stemdeath". Though important in organ transplantation,it has also clearly wider implications, particularly inintensive care units where many such patients aremaintained on cardiorespiratory support. This law,does give us the sanction to pull the plug, oncebrainstem death is diagnosed.
CADAVER DONATION
As per para 3(2) [] the donor has to authoriseremoval of his organs after his death for the thera-peutic purposes, in writ ing and in presence of twoor more witnesses, with at least one of them being anear relative. In view ofthe short fall ofavailabil ityoforgans for transplantation, efforts to increase thenumber ofcadaveric donors should be made throughadequate education of the population. Incorporationof presumed consent /arrs - assuming that everyperson yho dies would be presumed to consent todonate his organs, unless the family indicates theirunwill ingness to donate - should simplifo the lawsand increase the availability oforgans. Even thoughthe legislation is almost two years old - the numberof cadavers transplants are very few. Premier insti-tutions l ike AIIMS have been able to do only elevencadaveric transplants and PGIMER Chandigarh,none at all.
ORGAN SHARING
Our principle concern after the patients' survival,must be to maximise the longevity of the graft.Overall graft survival after cadaver transplants has
been 90% at one year with the currently prevalentimmune suppression techniques. MHC matching isimportant for the long term graft survival. The halflife for grafts with zero mismatch is estimated to beeighteen years compared to eight years for a sixmismatch [4]. For matching to be possible incadaveric transplants - regional or national sharingneeds to be practised. This would require co-ordina-tion between centres and also formulation of groundrules. In this direction, a voluntary organisation,National Kidney Foundation (lndia), has beenformed with concerned individuals, corporate bod-ies and professionals to fi l l this void in our country'shealth services. The organisation is also launching acadaveric donation drive through patient and adulteducation.
Thus this legislation does take us many stepsforwards : not only it attempts to abolish the practiceof commercialism in organ transplants, it also legal-ises the concept of brainstem death with its implica-tions spreading beyond the cadaveric organ dona-tion and opens the gates for possible countrywidecadaveric transplant programme. It also takes us afew steps backwards, particularly with the mostsurprising clause ofincluding the spouse as the "nearrelative". As far as we are concerned, we wouldalways prefer a "Chacha, Bhua, Mama or Mausi" orany of the cousins - who all have atleast have somegenetic common ground, rather than a spouse whois unrelated genetically.
Over all, this legislation of transplantation ofhuman organs Act 1994, is a step in the right direc-tion. Now it is our duty, to achieve our goal ofproviding an organ transplant to the needy withoutwithout commercialisation and exploitation. Inshort we should confine the "Great Indian KidnevBazaar" to the realms of history.
REFERENCES
l. The Transplantation of Human Organ Act 1994.
2. Reddy KC et al. Transplant Proc 1990; 22 : 910.
3. Thingaraj an el al Transplant Proc I 990: 22 : 912.
4. Terasaki elal. Transplant Proc 1989; 21,615 - 7.
5. Transplantation of Human Organ Rules (Maharashtra) 1995
Jour. Marine Medical Society, June 1996, Vol. 3, No. 1 15
Acudemic RuminstionsTAKING A TEACHING WARD ROUND
Surg Cdr ARUN BEHL, VSM*
fT\h" traditional form of teaching in medicrne
I has been an apprenticeship and for many
I- specialit ies, the cornerstone of this teach-ing has been the ward round. This approach of
basing teaching on close contact with patients is
unfortunately, over the years, decreasing in medi-
cal institutions.
There is a distinctive drift away from the bed-side and into the lecture and seminar room.Medical educationalists have emphasised the im-rnense importance of problem based learning -
which is in essence, a patient based teachinground; where the problem presented by the patient
has not only to be dealt with, but identif ied in the
tirst place.
What is the essence of a good ward round? Weall have memories from our student days, manyrelating to the charismatic, sometimes fearsome,
consultant's ward rounds, but these memoriesoften include the patients and their conditions. Ourrecall of these patients presented on ward rounds,is far superior to our memory of pages of text-books thumbed endlessly through the nights. This
surely testifies to the effectiveness of these teach-ing rounds.
Medical curriculum is becoming more andnrore crowded, as everybody wants to teach theessential facts of his speciality/subspecialty. Sucha course which would cover all possible options,would havc to be several years longer than at pre-
sent, and teachers therefore, need to be selectiveand deal r ', i th the principles and approaches en-tailed in dil j 'erent subjects rather than with straightfacts.
Today, there is an increasing pressure on ateacher's t ime as well as on the students and one isoften tempted to combine business with teachingrounds. My advise to teachers would be to resistthis temptation. There is no harm in taking stu-dents on business rounds, particularly ifthey knowall about the patients, as they should, but don'tfool yourself that this can replace their teachinground. lt is impossible to devote enough time andthought to teaching in the context of the businessround.
Over the years, I have come to recognise fourmain elements to the teaching round; the rvard, thepatient, the students and the teachers and wouldl ike to e laborate on each indiv idual lv .
THE WARD
Many of us, due to logistic reasolts, rvork inshared 'rvards and are thus deprived of a personalward and a devoted sister, who would control theward and maintain silence during the teachinground. Sanity, is therefore best rnaintained by ar-ranging ward rounds clear of meal t irnes and otherconsultants' scheduled rounds. There are distinctadvantages in having case notes and relevant X-rays available and a ward sister should accompanythe rounds, as it introduces the post graduate stu-dents to a team approach.
As discussion about a patients' condition in hispresence can be upsetting to the patient, teachinghospitals should have a room available in eachward, where the patient and problems he presentscan be discussed.
PATIENTS
ln teaching institutes, t l
tients rvho take a great p
clinical signs to anyone !
interest, but such professi
minority. Others, subjectward rounds for a variety crealisation that students nran obligation to the staffeven a deep seated apprehprejudice their managemewamed that the discussion
to general principles and dinot neccssarily to their owrworry unnecessarily.
Feu patients in hospitalerating a worthwhile wa
always be some interestingclinical examination. inverground or treatment, whicdebate. Some discussionhave to take place at the beis best to move away fromthe importance of the fincment. A side room is best frother patients, who are l ikeldebate of a ward round an,garbled version ofthe storythe ward-bush-telegraph-wspeed.
STUDENTS
Most consultants in hotretinue for ward rounds.number, I feel, is three to fiunable to see or elicit abnctake an adequate part in a r
need for all students to hemass. during the round. Obeen demonstrated and ontbeen convinced, there iscannot return to see the sis
,lour. Alarirrc ,lledical Socierv.
tClassi f ied Spccral is t Surgery and Oncosurgcry. INI IS ASVINI. Mumbai .
t 6 .Jour. lt4arine lv'ledical Socieht, June 1996, I'ol. 3, No. I
:\. c
n increasing pressure on aas on the students and one isrb ine business wi th teaching' teachers would be to resiste is no harrn in taking stu-tds, particularly if they know;, as they should, but don'ts can replace their teachinge to devote enough time andr the context of the business
lave come to recognise foureaching round; the rvard. theand the teachers and wouldch indiv idual ly .
:o logistic reasons, work inthus deprived of a personalister, who would control therilence during the teaching:fore best maintained by ar-lear of meal t imes and otherI rounds. There are distinctcase notes and relevant X-ard sister should accompanyluces the post graduate stu-:h.
: a patients' condition in his;ing to the patient, teachinga room available in each
tt and problems he presents
rciety,June 1996, tr'o|.3, No. I
PATIENTS
ln teaching institutes, there are always some pa-tients rvho take a great pride in displaying theirclinical signs to anyone who shows the slightestinterest, but such professional patients are in theminority. Others, subject themselves to studentward rounds for a variety ofreasons, one being therealisation that students need to learn. another asan obligation to the staff looking after them andeven a deep seated apprehension that refusal mayprejudice their management. Patients should bewamed that the discussion they may hear, appliesto general principles and differential diagnosis andnot necessarily to their own case and they need notworry unnecessarily.
Few patients in hospitals are incapable of gen-erating a worthwhile ward round. There willalways be some interesting aspects in the history,clinical examination, investigations, social back-ground or treatment, which is likely to generatedebate. Some discussion and examination wil lhave to take place at the bedside, but in general, itis best to move away from the patient to explorethe imporlance of the findings and the manage-ment. A side roorn is best for this, out of earshot ofother patients, who are l ikely to misunderstand thedebate of a ward round and are l ikely to relate agarbled version ofthe story back to the patient viathe ward-bush-telegraph-rvorks at an impressivespeed.
STUDENTS
Most consultants in hospitals vie for a largeretinue for rvard rounds. However, the optimalnumber, I feel, is three to five. Larger numbers areunable to see or elicit abnormal physical signs ortake an adequate part in a discussion. There is noneed for all students to hear a murmur or feel amass. during the round. Once the technique hasbeen demonstrated and one or two students havebeen convinced, there is no reason why otherscannot return to see the signs for themselves later.
Jour. llarine lletlical Societv,.lune 1996. I,'ot. 3. No. t
Ward rounds should, however, be used to checkthe abil ity of students to elicit histories and to ex-amine sc ient i f ica l ly .
If learning is really based on patients, then stu-dents working in a ward should be able to presentcases without an advance notice. Some units donot run in this way and it is usually best to give aprior warning, at least for the main case on theround. This allows the student and the teacher toprepare for the session. Most teachers have sometopics that they would prefer not to teach unre-hearsed. It is possible to do so, but it may limit thedirections the round can take. One of the best stirn-uli to students learning is the fear of examinations.The ward round has advantages, since it can mimiceither a short or a long case format.
TEACHERS
The most important function of a teacher is notto give out information but to inspire the studentsto do dig out information and learn in the process.When students have seen and discussed a problemon a ward round, they should be left with a feelingto go away and read further on the subject. Thissort of patient based or problem based learningsticks much better in the mind, because it has rrn-mediacy and interest. which reading page by pagethrough a textbook or l istening to a forrnal lecturecan never have.
Few medical teachers are taught how to teachand much of their techniques come from their ear-l ier experience. There are different approaches. butthe essential feature is the enthusiasm exhibitecl bythe teacher. as students respond accordingly andlearn ing depends on the response of the students. I tis not a passive transfer of information.
Teaching rounds are not lectures. Ifyou rvant togive a lecture, it is much more comfortablc andefficient to move to a lecture soon and talk to alarger number of students.
Ward rounds need interaction - with the patientand most i rnpor lant ly , wi th the students. Rounds
l 7
can be used to elucidate points in the history, toshow physical signs and to explore the techniquesof diagnosis and management. Symptoms andsigns in a textbook are just components of a listcontributing to a diagnosis. In real patients, theyare specific experiences with their own unique fea-tures, that can be further explored and interpreted.Few lecturers are gifted enough to bring their de-scriptions to life in the same way, in a lectureroom.
Rounds should be used to explore the students'diagnostic methods and cognitive processes. Stu-dents should be taken through the processes theyhave used to come to their conclusions. It is impor-tant not to let a student jump into a diagnosis, butguide him through right format of thinking and tolet him see the processes he is using and the alter-natives available. This form of questioning andexploration is far more valuable than the provisionof a l ist of the causes of clubbing or the familiar"guess what I am thinking of' approach.
Facts and understanding wil l change during thestudents' careers, some even before they qualifu,
but the basic techniques of how to deal with thesefacts and fit them with the patient's need. neverchanges.
The number of patients to be seen on a wardround will vary. A reasonable length for a round isprobably an hour and a half, allowing time forhearing the history, demonstrating physical signsand discussion. This allows time for a reasonablediscussion of one patient or two, if specific aspectsare to be dealt with. Longer rounds are a physicalas well as a mental strain.
Probably, the greatest importance of a wardround is that it deals with patients not diseases, itdevelops thinking processes and it introduces theapproach to patients that most doctors will followfor the rest of their working lives. Of the advancesthat modern medicine makes, clinical medicine re-mains the centre of the diagnostic process,dictating the direction of investigations and differ-ential diagnosis. This tradition of medical practiceinvolving doctors' interaction with patients shouldnot be lost in the future, with computers invadinsthe domain of doctors.
i>
ENVIRONMENTAL P(MICROCLIMATE RE
Surg LCdr VRG PATNAIK*, SSurg Cdr G VERGHESE***, SSurg Cdr PS LAMBA##, Surg (
Surg Lt CS SAXENA+
ABSTRACT
Inspite of the technological advancconsiderable problems for environenvironmental factors in submarineof environmental stress on pulmonPulmonary Function Tests (PFT),continuous exposure to l.2Yo ofcarlwere carried out in harbour, durinlvarious classes of Indian Naval suprocessor based analyzers, Averageduring surface or submerged sail ingon continued exposures to increaser
KEY WORDS: Pulmonarv Functio
INTRODUCTION
Habitabil ity in submarine durirmergence and the selection ofa suihave posed considerable problemental and marine rnedicine specithis, the need for defining toleranfor long exposures, especially witlnary function parameters, is becorimportant with the developmentofextended submarine patrols [].
Although acute tolerance limienvironmental factors in submarirknown. there is a lack ofknowledsimportant areas:
l. The range of adaptation tonents: The changes in pulmotrameters. if any, on continincreased levels of CO2 espe
*Gradcd Specialist, Marine and HyperbaricNavy. ***Special is t , Mar ine and HyperbrCOMSUB (W). ##Classi f ied Special is t in ITrainee, Marine and Hyperbaric Medicine,
.Jour. llarine llledical Society, June It 8 Jour. Llarine lt,ledical Socien, June 1996. l'ol. 3. No. I
ques of how to deal with thesewith the patient's need, never
patients to be seen on a ward'easonable length for a round ismd a half, allowing time for
, demonstrating physical signss allows time for a reasonablertient or two, if specific aspects. Longer rounds are a physical;train.
reatest importance of a wardls with patients not diseases, it)rocesses and it introduces thes that most doctors wil l followworking l ives. Of the advancesne makes, clinical medicine re-
of the diagnostic process,on of investigations and differ-is tradition of medical practice
nteraction with patients shouldrture, with computers invadingrfs.
tl Society, June 1996, l'ol. 3, No. I
INTRODUCTION
Habitabil ity in submarine during prolonged sub-mergence and the selection of a suitable space cabin,have posed considerable problems for environ-mental and marine medicine specialists. Along withthis, the need for defining tolerance limits of C02for long exposures, especially with regard to pulmo-nary function parameters, is becoming increasinglyimportant with the development of submersibles andextended submarine patrols [ ].
Although acute tolerance limits to most of theenvironmental factors in submarines are quite wellknown. there is a lack ofknowledge in the following
microenvironment [2].2. The interaction of environmental stresses is as
yet an unexplored field.
3. The threshold l imi t va lue (TLV) for cont inuousexposure have to be newly determined, sinceTLV for toxic substance (including C02); asused in industry are not applicable.
Various classes of submarines of the Indian Navyconduct periodic war petrols of prolonged duration,during which the crew are exposed to higher levelsof CO2 than the general populace. This offered anideal microenvironment to study the PFT changesduring prolonged exposure to increased C02.
. 2
ENVIRONMENTAL PHYSIOLOGY OF SUBMARINES(MICROCLIMATE REQUIREMENTS OF CONFINED SPACES)
Surg LCdr VRG PATNAIK*, Surg Cdr PP BELLUBBI VSM*** ,Surg Cdr c VERGHESE***, Surg Cdr AM JOGLEKAR#,Surg Cdr PS LAMBA##, Surg Cdr KMR NAIR###,Surg Lt CS SAXENA+
ABSTRACT
Inspite ofthe technological advances, habitabil ity in conventional and nuclear powered submarines, has posedconsiderable problems for environmental and submarine medicine. Although tolerance limits to most of theenvironmental factors in submarines and space crafts are well known, the degree ofadaptation and the interactionof environmental stress on pulmonary functions of the crew are not defined. An attempt was made to correlatePulmonary Function Tests (PFT), the pulmonary tolerance limits and the level of adaptation to extendedcontinuous exposure to l.2o/o of carbon dioxide (CO2). Pulmonary function tests, with hand held micro spirometerwere carried out in harbour, during surface sail ing, prolonged submerged passage and on return to harbour, onvarious classes of Indian Naval submarines, CO2 levels were monitored constantly with portable and microprocessor based analyzers. Average CO2 levels were recorded to be 0.37o in harbou r in the subm arine,to 0.6-1.2o/oduring surface or su bm erged sail ing. The results showed no significa nt changes in pu lmonary function param eterson continued exposures to increased levels ofcarbon dioxide.
KEY WORDS: Pulmonary Funct ions - Submar iners,
rmponant areas: MATERIALS AND METHODS
l. The range of adaptation to gaseous compo-nents: The changes in pulmonary function pa- A total of 300 trained submarine personnel oframeters, if any, on continued exposure to various classes of submarines were involved in thisincreased levels of CO2 especially in a closed trial. All were physically f it males and the age range
*Cradcd Spccia l is t , Manne and lJyperbar ic Medic ine. COMSUII (W). **Addi t ional Advisor. Mar ine and l l , pcrbar ic Mcdic inc. IndianNavy. *+*Spccia l is t . Mar ine and Hypcrbar ic Medic ine. COMSUB (W). #Classi l icd Special is t , Mar inc and Hyperhar ic Mcdic ins.COMSTJB (W). ##Classi f ied Special is t in Mcdic inc and Endocr inologyl ###Classi l icd Spccia l is t , Mcdic ine and Chest Physic iant + l ) ( iTraince. Mar ine and Hvnerbar ic Medic inc. SNM: INI IS Asvin i . Mumbai-400 005.
.Jour. itlaritte llfetlical Socieh,. June 1996. L'ol. 3. No. I l 9
I 'ABLt] I
PF-l- Profi le before sai l ing, during sai l ing and after sai l ing (n=300)
FEVI (L )+ 2SD
FER(%)+ 2SD
PEF(r- lS)t 2SD
FVC( t . )+ 25t)
Belbre sai l ing
Dur ing sai l ing
Al ier sai l ing
3 . 1 I 0 . 9
2 . 7 ! 0 . 1
2 . 9 ! l
9 3 9 + 1 4
98.4 r 9.5
9 8 r 7 6
326.4 t271
503 !262.3
373.2 r 30s .2
3 . 4 + 6 . 1
2 .82+ 1 .2
3 t 1 . 3
L - [.itres. 7o - Pcrcentage, L/S - Litres per second
was 19.2 to32.4 years (mean 25.5!6.2 years). Thepersonnel were familiarised with the procedures forperforming PFT in advance. PFT was performedbefore, during sail ing (day l5) and on the day ofreturn to harbour. The duration ofthis study variedform 18-21 days. These subjects aoted as their owncontrols.
Hand held microspirometer was used to assessthe pulmonary functions. Microprocessor based andportable CO2 and oxygen (O2) analysers were em-ployed to monitor ambient CO2 and 02 levels in aneffort to correlate environmental CO2 levels andPFT readings.
RESULTS
PFT profi le before sail ing, during sail ing andafter sail ing is shown in Table 1. Comparison offorced expiratory volume I st second (FEV I ), forcedexpiratory rate (FER), peak expiratory flow (PEF)and forced vital capacity (FVC) values before, dur-ing after sail ing are shown in Table 2.
TABLE 2Comparison of FEVI, FER, PEF, and FVC values beforc.dur ing and af ter sai l ing (n=300)
[]eforesai l ing
DISCUSSION
Marked adaptation to exposures to inspired carb-on dioxide levels between 1.5 to 3o/ohas been dem-onstrated. This adaptation is characterised by in-creased tidal volume and a lowered respiratory rate.There is a reduction in the ventilation response tohypercapnia produced by exercise. Biochemically,there is a reversal ofthe init ial increase in the hydro-gen ion concentration, a rise in the plasma carbonateand a fall in plasma chloride. The latter changes arealmost complete within three to five days of expo-sure, although there is a significant reduction in theventil latory response in the first two hours. Whileat rest the average submariner tolerates up to 3 to 4o/oof inspi red CO2(PCO? of25-30 mm of Hg) wi thoutincapacitating physiological changes. However,slow adaptive processes are observed in respiration,electrolyte exchange and acid base balance. Thesemight induce significant pathophysiological stateson prolonged exposures to l.5oh of CO2.An attemptwas made to determine threshold l imit values ofCO2 and other noxious agents on subnrariners byperforming simple measurements of basic physi-ological functions and standard perfonnance tests.Evaluation ofchanges in the body chemistry, thoughconsidered to be more sensitive indicators of longrange effects of environmental stresses, was notundenaken because of lack offacil i t ies on board aswell as in the base MI Room.
Tolerance Iimits for extended continuous exoo-sures to CO2 were determined in the United StatesNavy Medical Research Laboratory, Groton, Con-necticut, in a large scale experiment called operationHideout. 2l subjects rvere confined in a subnrarineand exposed to l.5yo CO2 over a period of 42 dayswith nine days of control periods priol to and fol-lorving exposure. The results shor.ved no signil icant
Jour. llluritrc itledic'al Soc'ieh,..ltne 1996. l'ol. 3. ,\:o. I
changes in performance orparameters, such as bloodweight and body temperaturon respiration, acid base baliphorous metabolism [4-6]adaptive changes. The chanSurinary CO2 clearly indicaphase of uncompensated reing for 23 days, which was:compensated respiratory acithe 42nd day ofexposure. Puland respiratory exchange r:two phases of respiratory acminute volume was increasrespectively during the two drexposure and during the nine
The degree of CO2 retentis remarkable and raises thernuch CO2 can be stored. FCO2 storage capacity of tissrconcluded that I l0 ofthe totcapacity are distributed incalcium phosphorous metalsame experimental conditionCO2 showed that the plasmleled the lowering of blood pIt has been shorvn [8], that lolfor the bone mineral carbonbrate with respiratory CO2.demonstrated that 6-28 days vthe bone CO2 on exposures t
Breathing pattern and dearCO2 exposure
Respiratory adaptation toby the development of a tygconsisting of an increasedcreased respiratory rate. Ttstimulation of the central chlocated in the medulla by apCO2 rvhich in tum leads topCO2. Ventilation rises by 3 |mm of Hg rise in pCO2. Iresponse to hypercapnia is Ichronic exposure to increasecventilatory response. ThroulC02. anatomical dead spaceventilation decreases. There
J<nrr. ,llarinc !t,lcdical Society. ..t
Duringsai l ing
Aftersai I ing
F E V I 3 . l 0 + 0 . 9( t . )
FER 93.76 t 14 0(%)
PEF' 326.39 + 274.0(L/S;)
F V C 3 . 3 6 + l 0( L )
2 .74 ! 1 .0 2 .85 + 0 .9
9 8 4 1 9 . ( r 9 7 . 9 6 x 7 . 6
502.96 + 262.3 373 22 + 305.2
2 . 8 2 + t . 2 2.99 + 0.3
Comparison bet\\'een thc thrce subgroups. did not rcveal an1'stat is t ical l l s igni t icant change
20
, I
t P
FVC( I , )1 2 S I )
t 1 A
2.3
)s.2
1 . 4 1 0 . 1
2 .82 + 1 .2
3 r r . 3
on to exposures to inspired carb-etween 1.5 to 3% has been dem-rptation is characterised by in-re and a lowered respiratory rate.rn in the ventilation response toced by exercise. Biochemically,fthe init ial increase in the hydro-on, a rise in the plasma carbonater chloride. The latter changes areithin three to five days of expo-: is a significant reduction in thetse in the first trvo hours. Whileubmariner tolerates up to 3 to 4o/olO2 of 25-30 mm of Hg) without,siological changes. However,)sses are observed in respiration,
1e and acid base balance. Theseficant pathophysiological statesures to 1.5% of CO2. An attemptmine threshold l imi t va lues oftious agents on submariners bymeasurements of basic physi-
lnd standard nerforrnance tests.;es in the body chem islry, thoughore sensitive indicators of longrvironmental stresses. n,as not,of lack of facil i t ies orr board asvll Room.
for extended continuous expo-determined in the United States:arch Laboratory, Croton, Con-:ale experiment cal led operations were confined in a subnrarine/o CO2 over a period of 42 daysontrol periods priol to and fol-te resul ts showed no s igni f icant
tl Socieh,. .lune 1996, I'ol 3, ,\'o. I
changes in performance or in basic physiologicalparameters, such as blood pressure, pulse rate,weight and body temperature [3]. However, studieson respiration, acid base balance and calcium phos-phorous metabolism [4-6] exhibited remarkableadaptive changes. The changes in the blood pH andurinary CO2 clearly indicated the existence of aphase of uncompensated respiratory acidosis last-ing for 23 days, rvhich was followed by a phase ofcompensated respiratory acidosis from the 24th tothe 42nd day ofexposure. Pulmonary C02 excretionand respiratory exchange ratio also exhibited thetwo phases of respiratory acidosis. The respiratoryminute volume was increased by 38% and 34%orespectively during the two described phases of C02exposure and during the nine-day recording period.
The degree of CO2 retention lasting for 23 days,is remarkable and raises the question of where somuch CO2 can be stored. Rahn [7] estimated theCO2 storage capacify of tissues in a 70kg man andconcluded that I l0 of the total of 130 litres of CO2capacity are distributed in the bones. Studies ofcalcium phosphorous metabolism [6], under thesame experimental conditions of exposure to | .5Vo,CO2 showed that the plasma calcium level paral-leled the lowering of blood pH and CO2 excretion.It has been shorvn [8], that long periods are requiredfor the bone mineral carbonate contents to equil i-brate with respiratory CO2. Freeman and Fenn [9]demonstrated that 6-28 days were needed to increasethe bone CO2 on exposures to l0o/o CO2.
Breathing pattern and dead space in chronicCO2 exposure
Respiratory adaptation to CO2 is characterisedby the development of a typical breathing patternconsisting of an increased tidal volume and de-creased respiratory rate. This occurs due to thestimulation of the central chemoreceptor for CO2located in the medulla by an increase in alveolarpCO2 rvhich in tum leads to an increase in arterialpCO2. Ventilation rises by 3 l itres/minutes foreverymrn of Hg rise in pCO2. At a lower pCO2, theresponse to hypercapnia is highlighted. However,chronic exposufe to increased CO2 levels blunts thisventilatory response. Throughout the exposure toCO2. anatomical dead space increases and alveolarventilation decreases. There is an increase in non
Jour. .l ' larina tllcdicol.soc;c1r'. .Jttnc I 996. l'ol. 3. .\:o. I
ventilated and non perfused alveoli during CO2exposure.
In this study, using l imited parameters, an effortwas made to correlate changes in PFT readings oncontinuous exposure to increased levels of C02 overa prolonged period of t ime. The findings have re-vealed that the PFT are not altered sisnificantlv.
CONCLUSION
This study has shown that no significant changervas observcd in the respiratory physiology in as faras the pulmonary function tests paranreters wereconcerned, during prolonged sail ing in the closedambience of a submarine. However. it is felt that amore deta i led study involv ing b lood gas analys is ,serum electrolytes and blood pH studies wil l have tobe undertaken before any definit ive conclusions aremade.
The physiological alteration of lung volumes,peak flow rates and other indices needs to be evalu-ated and corroborated with alteration in the bloodchemistry in the form of changes in pO2, pCO2, pH,bicarbonate etc. which are known to occul' onchronic exposure to CO2 levels frorn 0.8Yoto 1.5%o.The alteration in pulmodynamics wil l perhaps bemore ev ident when CO2 levels above 1.5%o exis t inthe environment.
Such studies may help broaden knowledge andhighlight potential areas where research is neededfor example the effects of cornposite mixture ofgases as they are encountered in confined spaces. Itwil l help in acquiring comprehensive and systernicknowledge of the responses of human being to en-vironmental alterations.
REF EREN(]ES
l . Schaefer KE. Paper rcad belbrc thc l ( r th Annual Mect ing ol 'the Anrcr ican Acaderny olOccupatronal Mcdic ine . l lar t lbr .Connect icot . Fob l9(r4: 5-7.
2. Schacl 'cr MD. Archives of environmcrr ta l hcal th ScD 1964;vol 9. PP 320-3 l .
3. Schaefcr MD. Kt l . C'onccpt o l ' t r ip le t ( r lcrancc l i rn i ts [ ] onchronic carbon dioxidc toxicitv studics. .^lcrosrrace .\ledt96 t ' . 32 . t 97 -204 .
4. Schael'cr MD. Kl,. e t a l. Respiraton accl irnatisation to carh-on dioxidc. J,4ppl Phls io l 196.3: l8: I07l-7f t .
5. Schael t r MD. KE. Nichols G. l r , Carq Cl l . Acrdosis balancc
2 !
\-_
-_-----_r
22
and biood and unne cicdrro/]aes ol'man during acc[i.matl-saion to carbon dioxide. J Appl Ph:'siol 1964 19 .48.
Schaefer MD. KE. Nichola G JR, Carey CR. Calc ium phos-phorus metabolism in nran during acclimatisation to carbondioxidc. J Appl Phl,siol 1963. l8 : I079-84
Rahn H. Gas stores of body rvith particular referencc tocarbon dioxrde. In : Man's dependence on carthly atmos-phere. KE Schaefer ed. New York : The Macmi l lar Co. 1962:
p 297.
8. Nichols G Jr . Ser ia l changes in t issues carbon dioxrde con-tent during acute respiratory acidosis. J Clin Invest I 958t 37: l l l l - 1 2 .
9. Freeman Fl l. Fenn WO. Changes in carbon dioxide stores ofrate due to atmosphere low in oxygen and high in carbondioxide. Aner J Physiol 1953.174 422.
T]NCONSCIOUSNESSUBMARINE ESCAI
Surg Cdr B SUDARSHAN*
ABSTRACT
Submarine personnel undergoinpressure gradient and to dillerenlis one such not uncommonly elsubmarine escape training are an
KEYWORDS : Submarine escap,
INTRODUCTION
Jn the unfortunate event of a
I hap and if the submarine irIwith herown power, thenth(ers in the sunken submarine shouto the surface. Hence. all the sublin the escape procedures duringcourses under simulated condilfrom a sunken submarine, the srwear submarine escape set whirubber suit with woollen gambreathing apparatus. During thrtrainees are exposed to variouswhich may cause some diving runconsciousness.
MATERIALS AND METHOI
A four years study from l99lout on 1837 trainees who underracourse at the Submarine Escap,All the trainees were below 35 ytgeneral medical examination sh(ity. The escape drills were condrpool, torpedo tube, 30 meter escarecompression chamber. Duringing, various diving disorders vimonary barotrauma, decompreslgen toxicify, carbon dioxide toxcosis, hypoxia and unconscicencountered.
*Graded Specialist in Marine Medicine,
Jour. Marine Medical Society, JuneJour. Marine ll'ledical Societv, June 1996. t'ol. 3. No. I
Rx Shelcql3zso/soo
The High
Specio
Polency Colcium Supplemenlprepored from
lly Processed OYSTER SHEttS
i
*t
provides the highest elementol colcium per tobletcanloins Vitomin Ds for enhanced obsorptioncon be swallowed. need not be chewed
Shelcol 250C O M P O S I T O N
[och fr lm cooled toblet of SHETCAL 250cofr lo ns(, ;15 mg Co c um Corbonole l rom on Orgonrc3ource foster She ls l equ voleni lo
250 mg125 u
[roce mrnerols lrom oysler shells: Copper. iron,mo9nes um. mon90nese, stltco ond 2tnc.
Shelcol 500COMPOSITION:Eoch fi lm cooted toblei of SHELCAL 500conlorns1250 mg Colcium Corbonole from on OrgonicSource (qster Shells) equivolenl to[.ementol Corciu- . 500 mgVi tomin D3 . . . . . . . . . . . . . . 250 i .uTroce minerols from oysler shellsi Copper, iron,mognesium, mongonese, sil ico ond zinc.DOSAGE As directed by the Physicion.
€lementol ColcrumVLlomrn Dl
ffi For further Informoliono EtDEn PHAnIACEUIT LS LYO.a ir B Dhanrar Mahar &k Au^da.
ranges in t issues carbon dioxids con-'atory acidosis. JClin Inye.st 1958: 37
). Changcs in carbon dioxidc stores ofe lorv in oxvgcn and high in carbon' t l 1953 .1 ' 14 :422 .
lAr 500
)m on OrgonrcI l o. . . . . . . . . . .500 mg.......... 250 i.u
i: Copper. iron,ond zrncsrc|on.
INTRODUCTION
Jn the unfortunate event of any submarine mis-
I hap and if the submarine is unable to surfaceIwith her own power, then the trapped submarin-ers in the sunken submarine should be able to escapeto the surface. Hence, allthe submariners are trainedin the escape procedures during basic and refreshercourses under simulated conditions. For escapingfrom a sunken submarine, the submariners have towear submarine escape set which constitutes of arubber suit with woollen garrnents inside and abreathing apparatus. During the escape drills, thetrainees are exposed to various ambient pressureswhich may cause some diving disorders includingunconsciousness.
MATERIALS AND METHODS
A four years study fiom 1992 to 95 was caniedout on 1837 trainees who underwent escape trainingcourse at the Submarine Escape Training School.All the trainees were below 35 years of age and theirgeneral medical examination showed no abnormal-ity. The escape dril ls were conducted in swimmingpool, torpedo tube, 30 meter escape tower and in therecompression chamber. During the course of train-ing, various diving disorders viz., aural/sinus/pul-monary barotrauma, decompression sickness, oxy-gen toxicity, carbon dioxide toxicity, nitrogen nar-cosis, hypoxia and unconsciousness etc. wereencountered.
OBSERVATIONS
Unconsciousness was observed in ten persons(0.54%) during this four years period. The cases ofunconsciousness occurred in the trainins areas asshown in Table l.
TABLE IUnconscious cases in t ra in ing arcas (n: |0) :
Si te ofexerc ise No. of cascs
Swimming Pool 2
Torpedo tube 6
30 Mtrs escape tower I
30 Mtrs compression chambcr I
In all these cases, the trainees were lying in anunconscious state in the swimming pool/torpedotube/escape tower for a duration of one to threeminutes. The attendants/buddy trainees noticed anabscence ofresponse from the unconscious traineesand immediately pulled them out to a safer place.The unconscious person's air t ight rubber suit wasremoved and immediate resuscitative measuressuch as mouth to mouth breathing, clearing of theair way, oxygen inhalations, correction ofdehydra-tion and shift ing to airconditioned spaces etc., wereinstituted. The unconscious patients recoveredwithin one to three minutes without any sequelae.
They were subjected to detailed clinical exami-nation and other than heat exhaustion, no otherabnormal ity was detected.
1 ?
UNCONSCIOUSNES S DURINGSUBMAzuNE ESCAPE TRAINING
Surg Cdr B SUDARSHAN*
ABSTRACT
Submarine personnel undergoing submarine escape training under simulated conditions are cxposed to apressure gradient and to different breathing gases. This may cause various diving disorders and unconsciousnessis one such not uncommonly encountered disorder. Ten cases of unconsciousness which occurred duringsubmarine escape training are analysed. The possible causes and preventive measures are discussed.
KEYWORDS : Submarine escape training, unconsciousness.t0menf
LLS
)r tobletion
mont rD.
SocieN,.June 1996. l 'o1.3, No. I
*Graded Spe c ia l is t in Mar ine Medic ine.
Jour. lt4arine lr4edical Sociery, June
INS Satavahana, C/o FMO
1996, L'ol. 3, No. I
Visakhapatnam 530 014
23
- )
They were also sub.jected to the detailed investi-gatiorrs viz., Electro encephalogram, ECG, X-Rayskul l /chest , rout ine b lood and ur ine tests. Al l theseinvestigations were found to be within normal l irn-its.
The breathing sets ofthese cases rvere chcckedtbr oxygen pressure and rate of f low into the breath-ing bag. The 03 chernical ( re-generat ive chernical )was also checkcd by calcimetry analysis. TheseDarameters rvere found to be within normal l inrits.
PROBABLE CAUSES OF UNCONSCIOUS-NESS
In a l l these cases ofunconsciousness, the com-mon contr ibut ing factors are [ l -3 ] :(a) Fatigue : The trainees were exposed to unac-
customed, vigorous warming up exercises be-fore the comrllcncenrent of escape trainingdr i l ls which caused the fat igue.
(b) Lt1,ytgl.t,c'aenriu. Probably due to:
( i )V igorous *arming up exerc ises
(ii)Not takirrg enough refreshments during thetea break.
( i i i )Late conrmencement of t ra in ing dr i l ls i .e . ,a f t e r l l 00 - l 200h rs .
(c) Heat Exhaustion pJ. Commonly develops dueto the fo l lowing:
(i)lfarnr clothing; Wearing of air t ight rubberhydrosuit with woollen garments inside in-creases the body ternperature ranging from99o to lo2o F.
(ii)Sunner : High tenrperature ranging fi'orn35" - 40n C prevail in Visakhapatnam fromMarch to July, thus contributing to heat ex-haust ion.
(iii)Humidi4' : The humidity in eastern coast(Bay of Bengal) is general ly h igh rangingfrorn 60 to 80 %.
(d) Claustrophohia and Anxiety : The inexperi-enced diver is more prone to claustrophobia andanxiety in the hosti le environment l ike waterand the torpedo tube. This anxiety might causecardiac dysrhythmias related to sympatheticnervous systenl s t imulat ion.
(e) Syncope. A viqorous Valsalva manouvre mayincrease the l ikelihood of syncope due to re-duced venous return and hence decreased car-
?J
dlac output.
DIVE PROFILE AND SPECIFIC CAUSESOF UNCONSCIOUSNESS
(a) Swimming pool exerc iscs
On two different occasions, rvhile undergoirrgdeep swimrning pool dr i l ls (F ig. l ) . t rvotra ineesbecame unconscious and were fbund lying atthe bot tom of the swimming pool (F ig.2) . lm-mediately, they were recovered from the swim-ming pool, their rubber suits rvere removcd andresuscitative measures instituted. On examina-tion, they were found to be sweating and lookedexhausted. The dive profi le shorved that onetrainee had consumed alcohol the previousnight and the other trainee had consumed anti-biotics for the relief of mild acute naso-pharyngitis. In both the cases, the trainees werewearing rubber suits with woollen garmentsinside and had participated in the exercise dril lsafter | 200 hrs. during the summer tnonths. Theyalso underwent v igorous rnorn ing phvsical ex-
l r g . L I n r r ncc * r t l r r ubbc r s t r r l . a r t d b re i r t l r r r r q i t l ) l l i u i l l u \ .
,Jour. .llarine .l,ledit'al Srx'iaty. June 1996. I'ol. 3. .\o. l
[:ig. 2 : [Jrrconscious traince in the
ercise and did not have rtea break.
The probable causes ofuncases were heat exhaustion, 1mia.
lnside Torpedo Tube
Sixty per cent ofunconscthe torpedo tube (Fig 3). Thcases are as follows. The trarubber suit with woollen gbreathing apparatus. They enand were lying horizontally irtube was closed on both sirstarted. In five cases. the atterhad not replied to the diving strainee was having convulsirit was noticed by the buddy tnpersons were pulled out ofescape suit removed and radopted. They regained consrtwo minutes.
Jour. Marine Medical Societv,,t
t t
AND SPECIFIC CAUSES,USNESS
rol exercises
3nt occasions. rvh i le t rndcrgoingg pooldr i l ls (F ig. l .y . t rvo t ra ineesrscious and rvere found lyine atthe swimming pool (F ig. 2) . lm-y were recovered from the swirn-ir rubber suits rvere removed andleasures inst i tu ted. On examina-,found to be sweating and lookede dive profi le shorved that oneonsumed alcol ro l thc prev iouslther trainee had consumed anti-re relief of rnild acute naso-both the cases, the trainees wererr suits with woollen garmentsparticipated in the exercise dril lsduring the sumrner rnonths. Theyt v igorous rnorn ing phvsical er-
?'I
. (st!f.-J
l bc r sur l . a r td l t rc l r l l t r r rg i l l ) l ) iu i l l l l \ .
il SocieA.', June 1996, I-ol. 3. .\o. I
I : ig . 2 : Unconscious t ra ince in thc s* inrnrrng rrot , l
ercise and did not have refreshments during thetea break.
The probable causes ofunconsciousness in thesecases were heat exhaustion, fatigue and hypoglyce-mia.
Inside Torpedo Tube
Sixty per cent of unconscious cases occurred inthe torpedo tube (Fig 3). The dive profi le of thesecases are as follows. The trainees wore an air t ightrubber suit with woollen garrnents inside and abreathing apparatus. They entered the torpedo tubeand were lying horizontally in a prone position. Thetube was closed on both sides and pressurisationstarted. In five cases, the attendants noticed that theyhad not replied to the diving signals. In one case, thetrainee was having convulsions inside the tube andit was noticed by the buddy trainee. The unconsciouspersons were pulled out of the torpedo tube, theescape suit removed and resuscitation measuresadopted. They regained consciousness within one totwo minutes.
Jour. Marine Medical Societv, June 1996, L'ot. 3. No. I
l : ig . -1 : lorpcdo rube
In these flve cases, the probable causes ofuncon-sciousness were :
(r)Hltpercapnia : As the trainees rvere lying ina horizontal position and the nose strapswere a Iitt le loose, they might be breathingfrom the helmet space which contains accu-mulated carbon dioxide.
(ir)Dilutional Hj,poxict [5J : lt is due to rheoxygen in the counter lung being d i lu ted bynitrogen. The unwanted nitrogen may enterthe system by three methods.
(aa) From air bottle (mixer bottle) of breath-ing set.
(ab) Counterlung not washed off nitrogerleading to d i lu t ional hypoxia.
(ac) Diver had not exhaled completely priorto breathing from the set.
(iii)Clau.strophobia : Fear caused due to theenclosed space of an torpedo tube causessympathetic nervous systeln stimulation re-
25
sulting in tachycardia with reduced cardiacoutput and shallow, rapid respirations.
(iv)Syncope: As the trainees l ies in an horizon-tal position in the torpedo tube, vigorousValsalva manoeuvre is required to clear theears. This results in a reduced venous returnand decreased cardiac output. The pressureon the vestibular apparatus during the Val-salva may also cause syncope.
(v)Other contributing factors such as fatigue,heat exhaustion and hypoglycaemia mayalso have playeci a role.
ln one case there were clonic convulsions andunconsciousness. This mis,ht be related toei ther .
(i)Solitary attack of epilepsy .' Even thoughthere was no previous history of epilepsy.the stress of diving and breathing of pureoxygen might have provoked the epilepticattack,
(i i)Oxygen Toricity. Breathing 100% oxygenunder pressure can cause central nervoussystem oxygen toxicity and result in gener-a l ised convuls ions in a sensi t ive person.Horvever. the oxygen tolerance test carriedout later, showed no abnormalify. The casewas referred to neurophysician and treat-ment for generalised seizures started.
(c) In Esc'ape Trtrer : The trainee underwent 30meters free ascent in the escape tower (Fig 4)and orr reaching the surface, he became uncon-scious. Imrnediate therapeutic recompressionto l8 meters wi th oxygen inhalat ion was inst i -tuted. He recovered without any sequelae.
During the 30 meter free ascent in the escapetower, if the diver fails to breath out the ex-panded gas from the lungs, it wil l result inoverdistention of lungs and alveolar capil larytear. The breathing gas may enter into the sys-temic circulation through the ruptured pulmo-nary vessels. These gas emboli may lodge inany blood vessels of the body including cere-bral, coronary and pulmonary vessels. Due tothe blockage of the cerebral vessel with airemboli, unconsciousness and other neurologi-cal abnormalit ies can occur. The final diagnosisin this case is pulmonary barotrauma of ascent
26
I r ig. . l : 30 rnctcrs cscapc to\ \cr .
with cerebral arterial gas enrbolism.
(d) In RCC Chamber. The trainee had completeda 30 meter dive in a recompression chamber.After about ten minutes. the trainee had confu-sion, giddiness, pain in the right knee and weak-ness in both lower l imbs. After about two tothree minutes he became unconscious. Imrnedi-ate therapeutic recompression by using l8 me-ter oxygen table was instituted and the traineebecame alright without any sequelae.
The dive in the chamber was slightly prolongeddue to diff icuity in clearing the ears. However,the total duration of the dive was within the nodecompression dive period. Probably the mul-tiple ascents during the dive might have init i-ated gas emboli which were trapped in thepulmonary fi l ter but escaped into the arterialsystem during subsequent compression and fi-nallv resulted in joint and neurological decom-pression sickness.
.lour. lllcu'ine ll,ledical Sociev. June 1996. I'ol. 3. No. I
DISCUSSION
Normal brain function dtply ofoxygen and glucose t,ofcerebral circulation and aglucose wil l rapidly cause Ibral function may also be altgases, drugs and metaboliterdiver during or after a divecauses and should be treatedof the causes require prompfirst aid. Attempts should al'date the specific factors leadness. A number of interactirenvi ronment . s tate of d iv ingological changes in the bo,unconsciousness. The causvaries upon the type of didiving, compressed gas divmixed gas diving etc. Howering causes of unconsciousnediv ing:
L l{ypocapnia due to hypr
2. Near drowning due to ufaultl, equipment or tecl
3. Cold exposure leading trdiac arrhythmias
4. Thoracic squeeze
,5. Vorniting and aspiration
6. Syncope due to loss ofl
7. Decompression sicknesr
8. Trauma
9. Mar ine animal in jur ies
10. Sudden death syndromeIn addition to the aoovr
causes relating to compressm ixed gas breathing diving e
l. Pulmonary barotrauma <
,/our. lllarinc llledical Society, "
'tr{.
/>
' i t
rterial gas embolisnr.
ber : The trainee had completecl,e in a recompression chatnber.r minutes, the trainee had confu-
, pain in the right knee and weak-rwer l imbs. After about two tore became unconscious. Immedi-recompression by using I 8 nte-le was inst i tu ted and the t ra ineewithout any sequelae.
chamber was slightly prolongedy in clearing the ears. However,on of the dive was within the nodive period. Probably the mul-
uring the dive might have init i-l l i which were trapped in theer but escaped into the arterialsubsequent compression and fi-n joint and neurological decom-)ss.
'al Socien'.,lune 1996. I'ol. 3. .\'o. I
DISCUSSION
Normal brain function depends on a steady sup-ply of oxygen and glucose to the brain. Impairmentofcerebral circulation and a fall in blood oxygen org lucose wi l l rapid ly cause unconsciousness. Cere-bral f lnction may also be altered by toxic eff 'ects ofgases. drugs and metabol i tes. Unconsciousness in adiver during or after a dive can result from ntanycauses and should be trcated as an ernergency. Sorreof the causes require prornpt action bey,ond sirrrplefirst aid. Attempts should ahvays be made to eluci-date the specific factors leading to the unconscious-ness. A number of in teract ive s i tuat ions re lat ing toenvi ronment , s tate of d iv ing equipment and physi -ological changes in the body are responsible forunconsciousness. The cause of unconsciousnessvar ies upon the type of d iv ing v iz . . breath holddiving, compressed gas diving and rebreathing ormixed gas diving etc. Horvever, sorne of the lbllor"-ing causes ofunconsciousness re lates to a l l types ofd iv ing:
l . Hypocapnia due to h1 'pervent i l la t ion
2. Near drowning due to underwater entrapment,faul t l , equiprnent or technique.
3. Cold exposure leadine to hypothermia and car-diac arrhythmias
4. Thoracic squeeze
-s. Vomit ing and aspi rat ion
6. Syncope due to loss of'hydrostatic support
7. Decompression s ickness
8. Trauma
9. Mar ine animal in jur ies
10. Sudden death syndrontesIn addi t ion to the above causes, the speci f ic
causes relating to compressed gas rebreathing orntixed gas breathing diving are:
l. Pulmonary barotraunta ofasccnt (lung burst)
2. Syncope ofascent
3. Iner t gas narcosis
4. Oxvgen tox ic i t r
-5. Carbon d iox ide tox ic i ty
6. Hypoxia due to faul ty ,equipment or technique.Underwater, unconsciousness fiorn rvhatever the
cause, ma) ' resul t in loss of rcspi rable ntediumand/or aspi rat ion of water . Manv accidents in thewater are fatal. not because of the pathology, butbccause there is no one to rescue the r rnconsciousvic t i rn. I lence, imrnediate rescuc i t r . rd resusci tat rvcrncasures play a vital role irr s:ving the l it 'e of anunconscious d iver . The f -ata l i t ies in the above r ren-tioned cases \vere prevented mainly by the alerlnessof the at tendants. who rescued the casual i t ies andinst i tu ted inrnrediate resusci tat ive rneasures. B1,adopt ing the fb l lorv ing lneasures, cases o1-Llncon-sc iousness dur ing the escape t ra in ing can be reducedconsiderably.
l . Restr ic t the escape dr i l ls to the cooler hours of 'the day.
r . I rnprove adequate physical l i tness by conduct-ing pre-cscape t ra i r r ing phy s ica l endurarrce ex-erc ises at least tbr a nonth.
3. Ensure adequate hydrat ion and prevent hypo-glycaentia by providing enough refi 'eshntents.
4. By st r ic t ly fo l lorv ing the technic lues of prepara-t ion ofescape sets and thei r ut i l isat ion.
l l l l l.-I.]lt I.]N(rIlS
l . I :dnronds C' . l -osn C' . I ,cnnclat l rcr . l . I ) i r ing arr t l subaquat. rcNlcdic inc: fh i rd t :dn l t ) t ) ] . 4 l i - i0.
2. l 'e tcr I l l lonrrcr . Drvrd l l I : l l io t . ' l
hc l ,hysio logv and nrcdi-c ine ol 'd iv ing. I h i rd l :dn | 982: 550-( ;2.
3. Stanlc i Nl i les. I )E N, lackcr. . I cr t book ol 'under \ \atcr ntcol-crne. .+th l :dn. | 979. I ( r t l -8 l .
.1 . loelekar ANI. I )atnaik Vl t ( ; . A study ol 'heat st rcss dur ingsubnrar inc cscapc t ra in ing. . / r ,1 1n r t nc, l I ed Soc r e t t ' .1an | 99.1.l l - 3 5 .
. lour. l lar ine, l ladical .Sot ' ia ty. June 199(t . l 'o l . 3. . \o. I 2 7
RE,PRODUCTIVE HORMONE RESPONSES DURINGSIMULATED NORMAL AND SATURATION DIVES
Surg Cdr PS LAMBA* Surg Capt AM MADHWAL** ,
Surg Cdr MJ JOHN*** , POMA BS Rawat** * *
Surg LCdr VRG Patna ik#
ABSTRACT
Reprorluct ive hormone responses (LH, FSH, Testosterone and Prolactin PRL) to simulated hyperbaric stress wasstudied in three groups of divers. The f irst group (Group A) comprised of four civi l inn divers, who were subjectedto 4 atmospheres (ATA) pressure (30 meters of sea water - msw) dive for 45 minutes. Group B consti tuted of 20service divers, who underwent a 70 msw dive at 8 ATA for 20 minutes. Group C was made up of f ive service divers,who d id sa tura t ion d iv ing a t a depth o f 150 msw, a t a p ressure o f l6 ATA fo r 48 hours . Hormona l ana lys is wasdone predive, immediately post dive and 48 hours post dive. A signif icant elevation of PRL was seen in Group A,which persisted 48 hours later. In Group B and C, PRL elevations were seen immediately post dive, but werenormal .18 hours later. PRL levels were elevated post dive. I t is remarkable that no changes were seen in LH, FSHand testosterone levels in any of the groups studied. I t is recommended that a large number of divers be studiedto corroborRte these f indings.
KEY WORDS: S imula ted normal and sa tura t ion d iv ing , Reproduc t ive hormona l response,
INTRODUCTION milieu reflects a steady state level different fronrnormal population.
The divers of Indian Navy are a group of spe-c ia l ly t ra ined and mot ivated indiv iduals. Thei r jobrequirements exposes thern to an a l ien envi ronrnentunderwater, where they are exposed to hyperbariccondi t ions, absence ofrespi rable a i r , usage ofar t i f i -cial gas mixtures. exposures to higher concentra-t ions of tox ic gases such as carbon d iox ide, co ld.physical exeftion and other types ol'environrnentalfactors. These factors induce a degree of stress,usually not encountered on surface.
This study was undertaken with a view of quan-tify the types of reproductive hornronal (LH, FSH,testosterone, PRL) adaptative changes which occurunder these conditions. Studies of this sub.ject havebeen few and far betrveen. Further. the nurnber ofsub.iects studied have been few and thus the resultshave not been easy to interpolate. It is usually not
J ioss ib le to s tudy d ivers in thei r actual p lace of dufyand thus s imulated d ives (carr ied out in recompres-sion chambers) are used as an alternative.
That human beings can adapt to hyperbaric stress
xposure to an alien environrnent generallyresults in a stress response. Hyperbaric expo-sures (exposure to pressure more than one
atnrosphere absolute ATA) is one such environ-nrent . Stress acts v ia the neurohormonal ax is andinduces var ious rnetabol ic adaptat ive responses.Many of these changes are transient and tend torevert to pre exposure levels on cessation ofstress.Horvever. some changes tend to attain steady newlevels on repeated exposures to stress suggestingbio-chcm ical adaptat iorr .
Stress responses to known clinical conditionssuch as exercise, starvation, infection. injuries,burns. surgery etc are rvell established. However,grey areas sti l l exist in our knowledge of adaptivechanges to hy'perbaric strcss. Unlike other forrns ofstress, h),perbaric exposul'cs are usually' of shortduration and severc stress is irnposed for a periodvarying from hours to days. Further, most of thepersonnel involved in d iv ing act iv i t ies are physi -cal ly and psychological ly condi t ioned indiv idualsand as such their basal horrnonal and rnetabolic
has long been suspected. Most edate has been largely incidentaFew prospective studies exist.[1amined acclimatization in asystteral military and commercial dihave performed workup or simlperbaric chambers) during the pdiving tasks and for research [{available, document research inticular hormone or a group ofcatecholamines [8-14], thyroidcortisol [,6,8,9], insulin [6] ormones [5 , ] l , l 2 ] .
Endocrine system is an imp,various metabolic processes. T1ships are complicated and they rfunctions by various mechanismrloop feed back, short loop feed tfeed back. The interaction of tlsystem through the hypothalamrcates the issue.
Daily newer biogenic aminesproteins, receptors and other intetabolism are being discovered. Tin a state offlux and greater discoon the horizon. In this study, etconcentrated on determination rreproductive hormones, namely Iterone and Prolactin (PRL).' '
The subjects for this study wrphysically fit and motivated servicivilian divers. The subjects actedtrols. The aim of this study was tresponses in simulated saturationdure is rarely canied out in the lnario and is more often encountediving practice (offshore oil rig,ous adminishative formalities Ithrough before sanction is obtaidivers under going this activity.study five divers who were subjedives at the depth of 150 metenduration of two days. This formeThese studies were caried out olVessel (DSV) Nireekshak. Thewere compared with hormonal rerdives in civilian divers (depth 30 rand service divers (depth 70 mete
Jour. Marine Medical Sociev, June l
* l :ndocr inologist and Classi l led Special is t Mcdic ine: **Senior Adviser. N{ar inc and I l lpcrbar ic Medic ine (Rctd) . lnst i tute o l NavalN4cdic inc: ***Classi f icd Special is t . Mar inc and l l lpcrbar ic Mcdic inc. I r rst i tutc o l 'Nalal Medic inc: ****Senior l 'cchnic ian. I { lAl -aboratory: INI IS Asvin i . Colaba. Murnbai 400 005. #Gradcd Spccia l is t . l \4ar ine and l lyperbar ic Mcdrcrnc. COMStJU. Mumbai .
28 Jour. Morine Nledical Socien. June 1996. l:ol. 3. No. I
GS
imulated hyperbaric stress waslian divers, who were subjectedutes, Croup B constituted of20s made up offive service divers,hours. Hormonal analys is wasn of PRL was seen in Group A,nmediately post dive, but werer changes were seen in LH, FSHge number ofd ivers be studied
rl response.
rdy state level different from
ian Navy are a group of spe-t ivated indiv iduals. Thei r jobthem to an alien environrllentey are e\posed to hyperbaricf respirable air, usage of artif i-posures to higher concentra-;uch as carbon dioxide, cold,other types of environrnental
's induce a degree of stress,ed on surtace.
Jertaken with a view of quan-rductive hormonal (LH, FSI-1,aptative changes which occurs. Studies ofthis subject haveiveen. Further, the nurnber ofbeen few and thus the resultsl interpolate. It is usually notrs in their actual place of duryres (carried out in recompres-ed as an alternative.
can adapt to hyperbaric stress
Medic ine (Rctd) . lnst i tute o l ' Navall i c i ne : * * *+Sen io r ' l c chn i c i an . l { lAMedic ine. COi\{St J l l . Murr tbai .
Societ.v, June 1996. I'ol -1. .\'o. /
2
has long been suspected. Most evidence collected todate has been largely incidental and retrospective.Few prospective studies exist.[1-9] which have ex-amined acclimatization in a systematic fashion. Sev-eral military and commercial diving organizations,have performed workup or simulated dives (in hy-perbaric chambers) during the preparation for deepdiving tasks and for research [8-13]. Most studiesavailable, document research in reference to a par-ticular hormone or a group of hormones such ascatecholamines [8-la], thyroid hormones 14,7,91,cortisol [,6,8,9], insulin [6] or reproductive hor-mones [5, ] l , l2 ] .
Endocrine system is an important regulator ofvarious metabolic processes. Their inter relation-ships are complicated and they control each othersfunctions by various mechanisms such as ultra shortloop feed back, short loop feed back and long loopfeed back. The interaction of the central nervoussystem through the hypothalamus further compli-cates the issue.
Daily newer biogenic amines, peptides, carrierproteins, receptors and other intermediaries of me-tabolism are being discovered. Thus this science isin a state offlux and greater discoveries are floatingon the horizon. In this study, emphasis has beenconcentrated on determination of fluctuations ofreproductive hormones, namely LSH, FSH, Testos-terone and Prolactin (PRL).
The subjects for this study were divers, mainlyphysically fit and motivated service divers and fewcivilian divers. The subjects acted as their own con-trols. The aim of this study was to sfudy hormonalresponses in simulated saturation dives. This proce-dure is rarely canied out in the Indian Naval sce-nario and is more often encountered in the civiliandiving practice (off shore oil rig operations). Vari-ous administrative formalities have to be gonethrough before sanction is obtained for studyingdivers under going this activity. We were able tostudy five divers who were subjected to saturationdives at the depth of 150 meters (16 ATA) for aduration of two days. This formed the core group.These studies were carried out on Diving SupportVessel (DSV) Nireekshak. The results obtainedwere compared with hormonal responses to bouncedives in civilian divers (depth 30 meters, number 4)and service divers (depth 70 meters, number 20).
Jour. Marine Medical Society, June 1996, l'ol. 3, No. I ,
MATERIAL AND METHODS
This study was conducted at the department ofMarine Medicine at the Institute of Naval Medicine(lNM), Bombay. Hormonal assays were performedat the endocrine and metabolic laboratory, INM.Simulated dives were conducted in COMEX (seven
man) multiplace compression chamber of INHS As-v in i .
SUBJECTS
The subjects were chosen form two majorgroups, civilian commercial divers and serving Na-val divers. Informed consent was taken and approvalobtained from the ethical committee of INM. Agevaried from 23 to 38 years. The subjects were di-vided into three groups.
a) Group A Civil ian Divers (CD). A total of fourcommercial divers were selected for assess-ment during a thirty meter dive for a durationfo 45 minutes (4 ATA).
b) Group B Service Divers (SD). Twenty navaldivers were included in the group. They werestudied during a 70 meter dive for a duration of20 minutes (8 ATA).
c) Group C Saturation Divers (SAT). Five servicedivers formed this group. They were studiedduring a 150 meter saturation dive for a durationof 48 hours (15 ATA).
All subjects were thoroughly evaluated prior tosimulated dives. Clinical examination was followedby evaluation ofhaemogram, metabolic parameters,pulmonary function tests, ECG, EEG and X-Raychest PA. Those with any abnormality were ex-cluded fiom the study. Prior to subjecting them tosimulated dives, the whole procedure was explainedand they were familiarized with the compressionand decompression schedules. Details of the com-pression and recompression schedule is shown inTable l.
Group A, comprising of civilian divers were sub-jected a simulated dive of 30 meters depth lastingfor45 minutes. Decompression time was 25 minutesand air was the gas mixture used. Group B of servicedivers were subjected to a simulated dive of 70meters depth, of 20 minutes duration, using air asgas mixture. Decompression time was 80 minutes.
Saturation dive is defined as a dive profile inwhich all the tissues of the body are saturated with
29
E -
.TABLE IProtocol fol lowcd for simulatcd ordinarv and saturation dives
TABLE 3
Comparison of LH, FSH, Testosteror
Group Subject Pressuresdepth
Gas mixtures De-CompTrme
De-Comp'l'able L H '
(3-20 rr.Air
A i r
45min20mtn48hrs
20B.
Civi l ian divers
Service divers
Saturation divers
4 ATA30 MSW
8 ATA70 MSWI6 ATA
150 MSWHel iox
25 min
80 min
5 days
RN
COMEX
Arithmetic mean
PRD
POD
48 POD
Standard deviation
PRD
POD
48 POD
6.67
6.37
6.52
4 . 1 3
2.92
l . &
ATA: atmospheric absolute. MSW: meters of sea water. min: minutes, hrs: hoursRN: Royal Navy, COMEX: Trade name. Heliox: Helium oxygen mixture. De-comp - Deconrpression
TABLE 2Interassay, intrassay coeff icient ofvariat ion, sensit ivi ty and normal values ofhormones assessed in the study
l lormone NormalValues
InterassaycoF (%)
Intra-Assay(coF %)
Sensi t iv i ty
PRD Pre dive. POD Post dive.48 POD /
TABLE 4
Comparison of LH, FSH, TesstosteronI , t I
I ]STI-l'ostosteronc
I)ro lact in
3 - 20 tutLl . l - 8 . 0 t u / Ll0 - 35 nmol/L
150 - 360 mlU/L
O.I IU/L
0.3 run-0.2 nmol/L
2.6m mlU/t-Mean t 2SD
7 . 13 6
10.4
3 . 7
t 6
2 .74 .5
0 8
COF coefflcicnt of variation
the gases in the breathing medium. The advantageof such a procedure is that irrespective of the timespent at the bottom, the diver needs only one decom-pression schedule. Five divers (service clearancedivers) were subjected to a saturation dive lastingfor 48 hours at a depth of 150 meters using Heliox(Hef ium 93%o and Oxygen 7%o) gas mixture. Thedecompression time was five days. This was doneonboard diving support vessel Nireekshak of theIndian Navy.
Blood samples were withdrawn from cubital veinusing disposable syringes. Samples were taken priorto a dive, immediately after a dive and 48 hours aftera dive. Samples were collected in steri le bottles. Tenml of blood was collected and after clotting, theserum was separated and stored at -20 C. This sam-ple was uti l ized for estimation of PRL, LH, FSH,Testosterone. Hormones were estimated either byradioimmunoassay (RIA) technique or by immuno-radiometric assay (IRMA). Testosterone was esti-mated by RIA technique. LH, FSH, PRL were meas-ured by IRN4A technique. Interassay and intrassaycoefficient of variation along with norrnal values ofthe hormones estimated and the sensitivity of theassays are shown in Table 2.
30
RESULTS
The hormonal profi le of civil ian divers (GroupA) who underwent a dive of 30 msw for 45 minutes,is shown in Tables 3 and 4. This group comprised offourdivers (mean age 27.1 + 6.32). The mean valuesof all the hormone estimated were within the normalrange. Prolactin levels were significantly raised inboth post dive and 48 hours post dive sub groupswhen compared with pre dive samples. There wasno significant change between post dive and 48hours post dive groups, thus indicating that prolactinlevels remained significantly elevated 48 hours later(Table 4). There were no significant changes inlevels of LH, FSH or testosterone in pre dive versuspost dive samples, pre dive versus 48 hours post divesamples or post dive versus 48 hours post divesamples.
Group B comprised of 20 service divers(meanage 28.4 + 8.18 years), who dived to a depth of 70msw for 20 minutes. Various hormonal changesalong with arithmetic mean and standard deviationare shown in Table 5 and 6. Prolactin levels rosesignificantly post dive and retumed to base linevalues 48 hours post dive. There was a significant
Jour. l,larine Medical Societv. June 1996. L'ol. 3. No. l
PD Pre dive: POD Post dive:48 POD 48# not significant; ** Significant
TABLE 5
70 meter dive for 20 minutes (service d
PRL'( l 50-36mlU/ml
PRL(mlU/L)
LH
0u/L)FSH(ru/L)Testo sterone(nmol/L)
t57.5r.10.88
6.67!8 .26
3.85t3.44
2 l .58 +t7 .52
Arithmetic mern
PRD
POD
48 POD
Strndard deviation
PRD
POD
48 POD
232.54t5.7199.3
73.3987.8754.36
PRD Pre dive; POD Post dive;48 POD 4
Jour. Marine Medical Society, June
De-CompTime
De-CompTable
j-TABLE3
Comparison of LH, [SH, Testosterone, PRL predive, postdive and 48 hours postdive in civilian divers (depth 30 msw)
L H #(3-201u/L)
FSH #(l. l-8.0 ru/L)
Testosterone #(10-35nmol/L)
Prolactin #(150-360mlU/ml)
25 min
80 min
5 days COMEX
RN
RN
prcssron
rssessed in the study
iayot
Sensitivity
O.I IU/L
0.3 IU/L
0.2 nmol/L
2.6m mlU/L
Arithmetic mean
PRD
POD
48 POD
Stendrrd devirtion
PRD
POD
48 POD
6.67
o.J /
6.52
4 . 1 3
2.92
1.64
3.85
3.5
3 . 5
1 .721 A
a i
2 l .s8
19.95
20.7
3 .76
2.071 n <
157.5322.5230
20.4496.0139.37
PRD Pre dive. POD Post dive. 48 POD 48 hours post dive. # normal values.
TABLE4
Comprrison of LH, FSH, Tesstosterone, PRL predive, postdive and 48 hours postdive in civilian divers (depth 3Q msw)
Mean t 2SD 48 POD PD vs PODP value
PD vs 48 POD POD vs 48 POD
PRL(mrU/L)
LH(ru/L)FSH
0u/L)Testo sterone(nmol/L)
I 57 .5r 40.88
6.67+ 8.26
3.85t3.44
2 l .58 I+ 7.52
322.5+ 192.02
6.37+ 5.84
3 . 5r 4.8
19.95t 4 . 1 4
230.0t 78.746.52+ 3.283.5r 4.820.70+ 4.90
3.361 8* *
0 . 1 1 8 5 #
0.2371#
0.7462 #
3.2688*t
0.4504 #
0.2371#
0.3925 #
|.7829#
0.0898 #
0.000 #
0.4687 #2rofile of civilian divers (Groupa dive of 30 msw for 45 minutes,3 and4. This group comprised ofEe27 .7 + 6.32). The mean valuesestimated were within the normalvels were significantly raised inI 48 hours post dive sub groupsith pre dive samples. There wasmge between post dive and 48ups, thus indicating that prolactin;nificantly elevated 48 hours laterwere no significant changes inortestosterone in pre dive versuspre dive versus 48 hours post divelive versus 48 hours post dive
PD Pre dive; POD Post dive;48 POD 48 hour Post dive; LH Leutinizing hormone; FSH Follicle stimulating hormone;# not significant; *t Significant
TABLE 570 meter dive for 20 minutes (service divers) Group B, LH, FSH, Testosterone, PRL
PRL*(1 50-360mlU/ml)
LH*(3-20IUiL)
FSH* ( l . l - 8 . 0
IU/L)
Testosteroner( I 0-35nmol/L)
rised of 20 service divers(meanars), who dived to a depth of 70tes. Various hormonal changesrtic mean and standard deviatione 5 and 6. Prolactin levels rosedive and retumed to base linerst dive. There was a significant
:al Society, June 1996, l'ol. 3, No. l
Arithmetic mern
PRD
POD
48 POD
Strndrrd deviation
PRD
POD
48 POD
232.541s.7r99.3
73.3987.8754.36
2.522.392.6
1.07l . t 41.45
3.63.243.2r
1.481.34t . l 2
16.30
t6.27
17.98
3. l6
3.48
4 . 1 8
PRD Pre dive; POD Post dive;48 POD 48 hour Post dive; *Normal value
Jour. Marine Medical Society, June 1996, Vol. 3, No. I 3I
1'ABLE 6Comparison ofgonadotropin, testosterone and prolact in in service divers (70 msw)
- p
TABLE 8Comperison of LH, FSH, Testmterone
Mean1 2SD
Pre dive Post dive 48 hrsPost dive
SEDX
Mean + 2SD Pre dive
LH(ru/r-)FSH(ru/L)l 'est(nmol i t - )
I)RL(mlU/ l - )
2.52t 2 . 1 4
3 6+ 2.96
16.3+ 6.32232.5
I t46 .78
2.39t228
3.24+ 2 6 8
t6.27t 6.96415.7
t 175.74
2.60! 2 . 9 03 . 2 1
+ 2.2417.98+ 8 .36199.3
r | 08.72
0.37 t4 #
0 . 8 1 8 1 #
0.0285 #
7.1562++
0 . 1 9 9 0 #
0.9512 #
1 .4358 #
| .6258 #
0 .5 109 #
0.0769 #
t.4062 #
9 .3801 *+
PRLmlU/LLH(ru/L)FSH(ru/L)Test(nmol/L)
202.6+ 151.96
4.44x4.483.42
r 3.88| 8.6
+ 7.78
PRD Pred ive .POD-Postd ive ,43POD-48hourspos td ive ,SEDX- s tandarder roro fd i f fe rence(mean) .#nots ign i f i can t .+t signi l icant
.fABLE 7Saturation Dive to 150 msw (Group C) LH, FSH, Testosterone, PRL
rt* P < 0.01; # not significant; Test Testc
TABLE 9Comparison of Gonadotropins, Prolactr
Hormone Subgroup
CDPRL(150-360 mlU/ml)
LH*(3-20 IU/L)
FSHr ( t . l - 8 . 0 IU /L )
Testosterone*( l0-35 nmol/L)
Ari thmct ic mcan
PRI)
POD
48 POt)
Standard deviation
PRD
POD
48 POD
202.63962t3
75.9875.7 4
77.98
4.44
2.73.04
1 1 /
t . 44
1 . 6 9
3.422.583.08
t .94I . J )
t . 3 2
1 8 . 61 8 . 71 8 . 4
3 .U93.423 . 7 |
LH PD(ru/L) PoD
48 POD
FSH PD(ru/L) PoD
48 POD
TESTO PD(nmol/l) POD
48 POD
PRL PD(mlU/L) POD
48 POD
6.67 t8.266.37 r 5.846.52+3.28
3.85r 4.83.5 + 4.83.5 r 4.8
21.58t7.5219.95t 4. l420.7t4.9
I 57.5+ 40.9322.5+ 192230t78.7
PRD pre divel PRL Prolactin; POD Post divel 48 POD 48 hour post dive: *Normal values
change betwecn post dive and pre dive samples, aswell as between post dive and 48 hours post divesamples. There was no significant change betweenpre dive and 48 hours post dive levels. There wereno significant changes in LH, FSH or testosteronein either ofthe subgroups.
Group C constituted five service divers who un-der went saturation dive at the depth of 150 msw fortwo days. Their mean age was 26.8 + 8.62 years.Hormonal data collected along with mean and stand-ard deviation is shown in Table 7 and 8.
Prolactin levels exhibited a rise post dive butreturned to baseline 48 hours later. There were nosignificant changes in either LH, FSH or testoster-one in any oFthe sub groups studies. Gonadotropinsand testosti'rone level changes befween various subgroups is shown in Table 9. No significant changeswere observed in LH level between the three groups
J Z
in pre dive and post dive groups. In the 48 hours postdive group, LH levels were higher in group A (civil-ian divers) when compared to group B and C. FSHlevel showed no significant statistically significantchanges. Pre dive and post dive levels oftestoster-one were significantly lower in service divers(Group B) when compared to Group A and C. Therewere no significant changes in 48 hours post divesub groups. Prolactin levels were significantly lowerin Group A (civil ian divers) in the predive subgroup. No significant changes were observed inother sub groups.
DISCUSSION
The physical conditioning of civil ian divers(Group A) was significantly different from that ofservice divers studied in Group B and C. An analysisof hormonal responses in Group A revealed that allhormone levels remained within the physiological
Jour. Marine Medical Society, June 1996, Vol. 3, No. I
CD civilian divers; SD service divers;SAT# not significant; $ P < 0.001; P < 0.01; @
limits pre dive (PD), immediatelyand 48 hours following the dive (4PRL levels rose significantly immand remained significantly high 4reflecting a persistance ofstress rlater. There were no significant chLH, FSH and testosterone betweetPOD samples (Table 4). LH, FSFresponses were similar to those(Group A) in service divers (Grouwere significantly higher post di\Group C, which had divers unde
Jour. Marine Medical Societv. June l
,TABLE 8
Comprrison of LH, FSH, Testosterone, PRL levels in saturation diving (Depth 150 meters)
SEDXm Post dive 48 hrs Post dive PD vs POD
P valuePD vs 48 POD POD vs 4tl PODMean + 2SD Pre dive
0.1990 #
0 .9512 #
1 .4358 #
1 .6258 #
0 .5 109 #
0.0769 #
| .4062 #
9 . 3 8 0 1 * *
PRLmlU/L
LH0u/L)FSH(ru/L)Test(nmol/L)
202.6r 1 5 1 . 9 6
4.4414.48
3.421 3 . 8 81 8 . 6
+ 7 .78
396+ 1 5 1 . 4 8
2.7+ 2 .882.58+ 2 .71 8 7
+ 6.84
2t3 4+ 145.96
3.04i 3 . 3 8
3 0 8+.2.64
18.47 : L 4 Z
4.0358+ i * i
| . t749#
0.7948H
0.043 I #
0.2294#
l . l t 5 5 #
0.3241#
0.083 r #
3 . 8 8 I 8 * * +
0.2562#
0.5924#
0.1329#
Ierence (mean). # not significant, * * *P<0.01 ;#nots ign i f i can t ; Tes t ' Ies tos terone*** *P<0.0001;PDProd ive ;PODpostd ive ;48POD48hourpos td ive
TABLE 9Comparison ofGonrdotropins, Prolactin Nnd Testosterone in different sub groups
Hormone Subgroup
CD SD SAT P valueCDVS
SAT
S DV S
SAT
Iru/L)
Testosteronei( I 0-35 nmol/t.)
CDVS
SD
1 8 61 8 . 718.4
3 .893.423 . 7 |
LH PD(ru/L) PoD
48 POD
FSH(ru/L)
TESTO PD(nmol/l) POD
48 POD
PRL PD(mtU/L) POD
48 POD
6.6 ' t !8 .266.37 + 5.846.52+ 3 .28
3.85+ 4.83 . 5 1 4 . 83 .5 + 4 .8
2t.58+ 7 .5219.95+ 4 .1420 7t 4.9
PDPOD48 POD
2.52+2.t4 4.44+ 4.48239!228 2.7 + 2.882.6 !2 .9 3 .04 + 3 .88
3.6+ 3.0 3.42+ 3.883.24+ 2.7 2.58+ 2.73.2t!2.2 3.08+ 2.6
16.3+ 6.32 l8 6+ 7.78t6.27+ 6.96 18.71 6.8417.98+ 8.36 18.4+ 7.42
2.0048#1 . 4 8 r 8 #3.9796$
0.2446#0.2l03#0.2369#
[email protected] .7673#
3.8799i| .797 t#t.3284#
0.973#| . 5 9 5 5 #3 . t 2 3 t @
0.352t#0.685#0 . 3 1 4 1 #
1.5204#0.6793 #l . l l i l #
1.2704#| .25 t2 i l0.4356#
1.8622#0.3734 #0.4'7 t5 #
0 .1749 #0.9806
0.2031 #
2 s@,1 . 4 1 7 7 #0.221#
0.8016#0.80 | 6#0.405 I #
157.5+ 40.9 232.5+ 146.8 202.6+ 15t.9322 5+ t92 415.7+ t75 .7 396r I 5 r .5230!78.7 199.3+ 108.7 213.4+ 145.9
;t dive groups. In the 48 hours post/els were higher in group A (civil-lompared to group B and C. FSHiignifi cant statistically signifi cantand post dive levels of testoster-cantly lower in service diversompared to Group A and C. Therent changes in 48 hours post divetin levels were significantly lowerilian divers) in the predive subicant chanses were observed in
conditioning of civil ian divers
3nificantly different fiom that ofied in Group B and C. An analysisnses in Group A revealed that allmained within the physiological
rcal Society, June 1996, Vol. 3, No. I
l imits pre dive (PD), immediately post dive (POD)and 48 hours following the dive (48 POD). HoweverPRL levels rose significantly immediately post diveand remained significantly high 48 hours post dive,reflecting a persistance of stress response 48 hourslater. There were no significant changes in values ofLH, FSH and testosterone between PD, POD and 48POD samples (Table 4). LH, FSH and testosteroneresponses were similar to those of civilian divers(Group A) in service divers (Group B). PRL valueswere significantly higher post dive only (Table 6).Group C, which had divers undergoing saturation
Jour. Marine Medical Socie\,,lune 1996, Vol. 3, No. I
dives did not show any significant changes in LH,FSH and testosterone (Table 8). PRL levels wereelevated post dive alone (P < 0.001). These changessuggest that the gonadotropins and testosterone lev-els due not alter significantly during normal andsaturation dives. Changes, ifany, are l ikely to occuronly on prolonged exposures. On the other hand,PRL is a stress hormone and the response was con-sistently seen in all three groups. Lower physicalconditioning may be responsible for persistance ofthis response 48 hours later, in civil ian divers. Workby other authors (l-8), have found very variable
CD civilian divers; SD service divers;SAT saturation divers; PD Pre dive, POD Post divel 48 POD 48 hours post dive
# no t s i gn i f i can t ; $ P< 0 .001 ; P< 0 .01 : @ P<002 , i P< 0 .005
J-l
changes in ACTH, Cortisol, GH and PRL values.Our study shows a consistent response. Severalworkers have demonstrated changes in LH, FSH andtestosterone (6-10), mainly mimicking hypogo-nadotropic hypogonadism or low testosterone val-ues in presence ofnormal gonadotropins. Our studyhas not shown any significant change in any ofthethree groups.
REFERENCESl. Leach CS, Alexander WC, Fisher CL, Lambertson CJ,
Johnson PC. Endocrine studies during a 14 day continuouscxposurc to 5.2%o oxygen in nitrogen at pressure equivalentto 100 FSW (4 ATA). Aerosp Med 1973;44(7): 855-859.
2. Bert and Chuitor. Study ofbiochemical parameters duringsimuf ated saturation dives. Cent Etud Biophysiol Appl MedAug 79 ; 79 -101 .
3. Carlyle LF, Nichols G, Rowis PM. Abnormal red cells inblood ofmen subjected to simulated dives. Lancet 1979l' I,I l l 4 - l l l 6 .
4. Habermann JT. Eversmann P. Erhardt F. Goftsmann. Kal-brecht D, Soriba PC. Increased urinary excretion of tno-dothyronine and thr_r'roxine and decreased serum TSHinduced by motion sickness. Aviation Space Eviron Med1 9 7 8 ; l 2 : 5 8 - 6 1 .
5. Rockert HOE, Haglid K. Reversible changes in the rare ofDNA synthesis in the testis ofrats after daily exposure to ahyperbar icenvironmentofai r . lRCS Med Sci 1983; I I : 531.
6. Mateev C, Djarova T, Ilkov A, Sachanska T, Klissurov L.Hormonal and cardiorespiratory changes following simu-Iated saturation dives to 4 and I I ATA. Undersea Biomed
Res 19901 I : (7 ) : l - l l .
7. Andersen J, Bennet PB, Carlyle RF, Carrad MP. Thyroidhormone metabolism in men during simulated saturationdives to a maximum depth of 686 msw, 69.6 bar. J Physiol(London) : 1982: 238 : 47-48.
8. Clayburg JR, Matsui N, Hong SK, Park YS, Nakayama H,Shiraki K Seadragon VI; A 7 day dry saturation dive at 3lATA. Alterations in basal and circadian endocrinology. Un-dersea Biomed Res 1987; l4(4);331-41
9. Catron PW, Thomas LB, McDermott JJ; Smallridge RC,Lake CR, Kinzer C, et al. Hormonal changes during decom-pressron sickness. Undersea Biomed Res 1987; l4(4),331-4 t .
10. Boran Gr, Chaundry L, Brubakk AO, Garrad MP. Hyper-baric fiver dysfunction in saturation divers. IJnderseaBiomed Res 1985; l2 :151,64.
ll. Cumming DC, Brumsting LA, Strich G, Ries AL, RebarRW. Reproductive hormone changes in response to acuteexercise in men. Med Sci Sport Exercise 1986; l8(4) .369-373.
12. Fryer P, Gross J, Halsey MJ, Monk S, Warley-Smith B.Sperm maturation associated with subfertility tbllowing hy-perbaric exposure ofmice. Undersea Biomed Res 1986; 13:413-23.
13. Manalasay AR, Langworthy HC, Layton RP. Catecholaminelevels in divers subjected to stress ofimmersion and hyper-baric exposure. Undersea Biomed Res 1983, l0 : 95-106.
14. Epstein M, Johnson G, Denunzio AC, Effects of waterimmersion of plasma catecholamines in normal humans. JAppl Physiol 1983; 54 : 59-63.
Jour. Marine Medical Society, June 1996, Vol. 3, No. I
RELIGION DIFFERECHARACTERISTIC!AT KOCHI (KERAL,
Surg Cdr KK DUTTA GUPIDr (Mrs) NATARAJAN***, ISurg Cdr MJ JOHN+, Surg ISurg LCdr A CHATTERJEI
ABSTRACT
A study wrs carried out at Kochi rsterilisation. Age at marriage andin Christians. Overall acceptancethe low income group. Average n!a terminal method of sterilisation
KEY WORDS : Religion differen
INTRODUCTION
y 2025 AD, India is likeas the country with highran estimated population
demographic profile of a vast cnot uniform. Kerala has the louinfant mortality and highest fenis quite different from states wlike UP, Rajasthan, MP, Bihar adocumented that ceftain characlgirl at maniage, religion, femalenomic status contribute to accrfamily norm []. In addition,Indof immensely varied political,guistic and religious groups. (
which affects the acceptance <method is misconceived religioences in views and norrns with r€tion and family size has been rrparts of the world [2,3]. Femaremained the over whelming mtmore tubal Iigations are being pe
[ ]. The present study was plarsocio-demographic characteristlonging to various religion grobectomy at Kochi (Kerala)
*Classi f ied Special is t (PSM); ** Fami l '
Jour. Marine Medical Society, June31
: l - l l .
net PB, Carlyle RF, Carrad MP. Thyroidlism in men during simulated saturationum depth of686 msw, 69.6 bar. J Physiol238:47-48.
Ltsui N, Hong SK, Park YS, Nakayama H,gon Vl; A 7 day dry saturation dive at 3 I; in basal and circadian endocrinology. Un-es 1987; l4(4) ;33 l -41
mas LB, McDermott JJ; Smallridge RC,C,el al.Hormonal changes during decom-. Undersea Biomed Res 1987', l4(4),331-
tdry L, Brubakk AO, Ganad MP. Hyper-lnction in saturation divers. Undersea; ; 12 : 151 ,64 .
lrumsting LA, Strich G, Ries AL, Rebarre hormone changes in response to acute. Med Sci Sport Exercise 1986; l8(4) :
, Halsey MJ, Monk S, Warley-Smith B.r associated with subfertility following hy-- ofmice. Undersea Biomed Res 1986; l3
angworthy HC, Layton RP. Catecholamine
"rbjected to stress of immersion and hyper-Indersea Biomed Res 1983; l0 : 95-106.
son G, Denunzio AG, Effects of watersma catecholamines in normal humans. J1 54 . 5A -61
,
RELIGION DIFFERENTIALS IN ACCEPTORCHARACTERISTICS OF FEMALE STEzuLISATIONAT KOCHI (KERALA)
Surg Cdr KK DUTTA GUPTA*, SM NAIR**,Dr (Mrs) NATARAJAN***, Surg Cdr S NANGPAL+,Surg Cdr MJ JOHN+, Surg LCdr K PAARI,++Surg LCdr A CHATTERJEE++
ABSTRACT
A study was carried out at Kochi (Kerala) to find out the religion differentials in acceptor characteristics of femalesteril isation. Age at marriage and age at which a terminal method has been accepted, have been found to be higherin Christians. Overall acceptance rate was higher than the all India average amongst all religions a nd even amongstthe low income group. Average number ofchildren in the study population was found to be 2.3. Over 70%o accepteda terminal method of steri l isation with two children.
KEY WORDS : Religion differential, Acceptor characteristics, Female steri l isation.
INTRODUCTION
y 2025 AD, India is likely to replace Chinaas the country with highest population, withan estimated population of 1.4 bil l ion. The
demographic profile of a vast country like ours, isnot uniform. Kerala has the lowest fertiliry, lowestinfant mortality and highest female l iteracy, whichis quite different liom states with highest fertilityl ike UP, Rajasthan, MP, Bihar and Orissa. It is welldocumented that ceftain characteristics like age ofgirl at marriage, religion, female education and eco-nomic status contribute to acceptance of a smallfamily norm [1]. In addition, Indian sociefy consistsof immensely varied polit ical, social, ethnic, l in-guistic and religious groups. One of the factorswhich affects the acceptance of family planningmethod is misconceived religious notions. Differ-ences in views and norms with regards to contracep-tion and family size has been reported from manypafts of the world [2,3]. Female steri l isation hasremained the over whelming method of choice andmore tubal l igations are being performed worldwide
[a]. The present study was planned to study somesocio-demographic characteristics of \.vomen be-longing to various religion groups uqdergoing tu-bectomy at Kochi (Kerala)
MATERIALS AND METHODS
The present study was canied out in the familywelfare centre, Naval base, Kochi. This centre pro-vides family welfare services free to the local civil-ian population in addition to the service personnel.A proforma to collect the desired information wasdesigned and was pretested. Proformas were fi l ledup by interviewing 800 consecutive women belong-ing to three religious groups on whom tubectomywas performed from lst April 1993 onwards.
FINDINGS
Age group at which the terminal method of ster-i l isation was accepted is shown in Table l.
TABLE IAge at which a terminal method of sterilisation was acceptsd
Number ofCasesAge group I - l i ndu Ch r i s t i an Mus l im
N o % N o % N o %
2t -25yrs l2s (30 7) 5 l (1s .6 ) 22(32 .8) 198(24 8)
26-30 yrs I 75(43.0) I 78(54.r;) 30(44.8) 383(47.9)
3 l -35 y rs 78( t92) 58(17 .8) I l (16 4) 147(18.3)
36yrs& above 29(7 .1) 39(12 .0) 4 (6 .0 ) 72(9 .0)
407 326
TotalNo 7o
o /
tClassi f ied Special is t (PSM); ** Fami ly Planning Extension Educat ion SI IO (K); *+*Medical Off icer Fami ly Welfare Centre. SHO
ical Society, June 1996, tr'ol. 3, No. I Jour. Marine Medical Society, June 1996, L'ol. 3, No. l JJ
: b
No.ofChi ldren
ItwiII be seen that over 70o of acceptors belong-ing to different religious groups accepted the termi-nal methods of sterilisation before reaching the ageof 30 years. 125(30.7%) Hindu acceptors and22(32.8%) Muslim acceptors accepted the terminalmethod before the age of 25 years. The maximumacceptance amongst Christians was observed in theage group of 26-30 years. The mean age of marriageof Hindu, Christian and Muslim acceptors were21 .01, 21.66 and 20.46 y ears respectively.
Number of children at the time of accepting theterminal method and the educational level of theacceptors in different groups are shown in Table 2and 3.
Table 2
Number of chi ldren r t the t ime of accept ing a terminalmethod.
Table 3 shows that, about 50% of the targetpopulation studied only upto the primary level.There is a statistical difference in the education levelamongst the various religious groups. But the accep-tance rate and the education level in Hindus andChristian when evaluated separately, showed nosignifi cant difference.
Monthly income of families of acceptors of aterminal method and the acceptor characteristics areshown in Table 4. It is seen from the table, that theacceptance of a terminal method among Hindus andMuslims in the income groups of upto Rs. 1000/- ismore than in Christians and that this difference isfound to be highly significant. The mean age ofmarriage of Christian acceptors was not only morethan the other groups but the age at which a terminalmethod was accepted was also higher in Christians.
TABLE 4Monthly income of families of acceptors of terminalmethod:
Hindu Christ ianN o % N o %
Muslim TotalN o %
Upto Rs 1000 290(7t.3) 168(5r.5) s9(88.1) st1(64.6\
Rs l00l-2000 88(21.6) 100(30.7) 7(10.4) t93(24.4)
More thanRs 2000
Total 407 5 Z O
The type of the terminal method for sterilisationaccepted is shown in Table 5.
TABLE 5Type of the terminr l method ofster i l isat ion a accepted:
Type Christian Muslim TotalN o % N o % N o %
tubectomies have been carriscopic sterilisation camp at I
DISCUSSION
For couples desiring no msterilisation of one of the pative method. This study indirage of acceptance of family p72.75% study population imethod by 30 years (Tablemarriage of the study populOver 70.4 percent of the studa terminal method after havirage number of children in the2.3. There is a high level of alow income group in all relig92 percent ofthe study populcation. (Table 3), over 90 ppopulation accepted post pal5.6 percent of the sample pterminal method with MTp.
In a study carried out in Shthe acceptor of female sterilisr
Jour. Marine Medical Society, Jun,
Hindu Christian MuslimN o % N o % N o %
TotalN o %
2 or less
34
300(73.7) 2tt(64.7) s2(77.6)97(23.8\ 107(32.8) t2(t7.9)r0(2.s) 8(2.s) 3(4.s)
563(70.4)2t6(27.0)2t(2.6)
Total 407
X 2 = 7 . 8 8 D F - 2 P < 0 . 0 5
It will be seen that more than 70o/o accepted aterminal method of sterilisation with two living chil-dren. The acceptance rate with two children wasless in Christians. It is seen that 2.5% of studypopulation had more than three children. None hadmore than four children. Four ladies (0.5%) ac-cepted a terminal method with one child only. Thedifference in acceptance pattem in the variousgroups has been found to be significant.
TABLE 3Education level of female acceptors of a terminal method
2e(7. t ) s8(17.8) l ( r .s) 88( l 1 .0)
800b /326
67
HinduN o %
Ni lHinduN o %
TotalN o %
PostPartum
IntervalTubectomy
MTP withTubectomy
724(90.s)
3 r (3.9)2t(s.2)
33(8. l )
r0(3. r )
7(2 . t )
353(86.7) 309(94.8) 62(92.5\
Educationlevel
Christian MuslimN o % N o %
No formal 28(6.9) 23(7.1) 13(19.4) 64(8.0)education
Primary 207(50.9) t7l(52.4) 40(s9.7) 418(52.3)
High School 136(33.4) 106(32.s) t2(t7.9) 2s4(3t.7)
Colle$e 36(8.8) 26(8.0) 2(3.0) 64(8.0)
Total
X2=22.4'7
36
D F : 4 P < 0.05
5(7.s) 4s(s.6)
Total 6 I 800
It is seen that post partum sterilisation is the mostpopular method. 45 tubectomies with MTP havebeen done. It is seen that even five Muslim acceptorshave accepted terminal method with MTP. Interval
Jour. Marine Medical Society, June 1996, Vol. 3, No. I
326407
800o /
T
* f -
luYo
that, about 500/o of the targetI only upto the primary level.rl difference in the education levels religious groups. But the accep-: education level in Hindus andvaluated separately, showed nonce.
re of families of acceptors of and the acceptor characteristics areIt is seen from the table, that theminal method among Hindus and)ome groups of upto Rs. 1000/- isistians and that this difference isly significant. The mean age oftian acceptors was not only morerps but the age at which a terminalrted was also higher in Christians.
rmilies of acceptors of term inal
Christian MuslimN o % N o %
Total
r .3) 168(s1.5) 59(88.1) s t7(64.6).6) r00(30.7) 7(10.4) te3(24.4)
r ) 58(17.8) l ( r .5) 88( l 1 .0)
: terminal method for sterilisationr in Table 5.
method of sterilisation a accepted:
Christian Muslim TotalN o % N o % N o %
t.7\ 309(e4.8) 62(e2.5\ 724(90.5)
l 0 (3 .1 )
1 \2 . t )
3 | (3.e)
l ) s(7.s) 4s(s.6)
)st partum sterilisation is the most45 tubectomies with MTP havernthateven five Muslim acceptorsninalmethod with MTP. Interval
ical Society, June 1996, Vol. 3, No. 1
tubectomies have been carried out during the lapro-scopic sterilisation camp at the Naval Base.
DISCUSSION
For couples desiring no more children, voluntarysterilisation of one of the parents is the most effec-tive method. This study indicates that though meanage of acceptance of family planning is 28.65 years,72.75% study population accepted the terminalmethod by 30 years (Table l). The mean age atmaniage of the study population was 21.2 years.Over 70.4 percent ofthe study population accepteda terminal method after having two children. Aver-age number of children in the study population was2.3. There is a high level ofacceptance even in thelow income group in all religious groups (Table 4).92 percent ofthe study population had formal edu-cation. (Table 3), over 90 percent of the samplepopulation accepted post partum sterilisation and5.6 percent of the sample population accepted aterminal method with MTP.
In a study canied out in Shimla [5], mean age ofthe acceptor of female sterilisation was found to be
Jour. Marine Medical Society, June 1996, Vol. 3, No. I
27.5 ! l. l yrs. The mean number of l iving childrenwas 2.9 and majority of the acceptors (98%o) wereHindu.
The findings of this study signifies that there is ageneralised acceptance of a terminal method of ster-ilisation with or without MTP and a small familynorm is common in all religious groups at Kochi,Kerala. Higher age at marriage and a small familysize in all religious groups is due to a higher level offemale literacy.
REFERENCESl. Sidram Shelter SC. The small family norm : A sociological
study ofdual eamer couple. The Jour Family Wefare 1993.39 :1544.
2. Berhanu B. Religion fertility differentials in Shewa" CentralEthopia. The Jour Family Welfare 1994;40 :22-29.
Khurana AB. Acceptor characteristics ofwomen undergoingtubectomy. The Jour Family l4/elfare 1976;22 :33-39.
Nigam SK, Malik SK, Das HC. A profile of acceptors ofnonscalped vasectomy. The Jour Family Welfare 1994; 40 .t9-26.
Kumar A, Bandhawa T. Female sterilisation - Acceptorcharacteristics Indian J Public Health 1990 34 : | 69-170.
67
lu%
800t ) /326
37
NON HODGKIN'S LYMPHOMATFIE INHS ASVINI E)GEzuENCE
Surg Lt Cdr S RANJAN*, Surg Cdr A BEHL VSM**,Surg Cdr B FANTHOME'r**
ABSTRACT
We evaluated ten patients of Non Hodgkin's Lymphoma (NHL) at MDTC, INHS ASVINI. These patients wereeither subjected to various combination chemotherapy protocols (with or without radiotherapy), treated withbiological response modifiers (lnterferon alpha), splenectomized or simply observed. We observed that CHOPregime was best tolerated and gave better results.
KEY WORD: Non Hodgkin 's Lymphoma (NHL).
INTRODUCTION
I Ton Hodgkin's lymphomas CNHL) are an
l\l extremely diverse collection oftumours re-I ! sultine from clonal expansion of B or Tlymphocytes a1 various stages oidifferentiation [ ].The over all incidence and incidence of varioussubtypes, varies in different parls ofthe world. Therehas been a global increase in number of NHL casesand a large proportion of this increase has beenattributed to acquired immuno deficiency syndrome
12).The Working Formulation devides the lympho-
cytic lymphomas into three groups (Table l) - low,intermediate and high grade. The purpose of thisclassification is to bring together similar cases, todefine common mechanisms and disease specifictherapies and for comparison of results betweenvarious centres [3]. Combination chemotherapy(CT) has made rapid strides, especially so far asintermediate and high grade NHLs are concerned,in that there has been an increases in disease freesurvival (DFS), overall survival (OS) and low re-lapse rates. Contrary to this, there is no area oflymphoma therapy which is more controversial thanthe treatment of patients with low grade lymphomas(LGL) [4] .
MATERIALS AND METHODS
Ten previously untreated patients with low, inter-mediate and high grade NHL were evaluated in this
TABLE I
Working Form ulat ion NHL Classif icat ion
l-ow GradeSmal l lymphocyt ic consistent wi th CLL.Fol l icular smal l c leaved.Fol l icular mixed, smal l c leaved and large cel l .
Intermediate GradeFollicular predominantly large cell. diffuse area.Dilfuse small cleavcd cell. sclerosis.Dilluse ntixed, small and large cell, sclerosis.Diffuse large cell. cleaved ccll, non cleaved cell.
High GradeLarge cel l , immunoblast ic , p lasmacytord, c lear cel l .Lymphoblast ic , convoluted cel l , non-convoluted cel lSmal l non c leaved cel l . Burk i t t 's .
study between Jan 1990 to Dec. 1995 or t i l l the timeof death. Other inclusion criteria were age between| 3-75 years, no history of malignancy, cardiac, renalor hepatic disease and a performance status of morethan 60% on the Kamofsky's scale (KPS).
Patients evaluation included history, clinical ex-amination, complete haemogram (CBC), renal andhepatic parameters, serum uric acid, serum LDH,bone marrow biopsy, CXR, USG-abdomen and 2-DEcho cardiography for cardiac toxicify indicated inanthracycline based protocols.
Clinical staging was done according to Ann Ar-bor Conference criteria [5] (Table 2) and the resultsare shown in Table 3.
TABLE 2Ann Arbor staging (NCl, modificr
Stage CharacteristicsI Invol'ement of a single lyml
extra lymphatic organ or siteextra nodal disease.
I I lnvolvement of two or moresame side of the diaphragn (of an extra lymphatic organ rnodal sites ofdisease or a locdraining nodes with none oftstatus < 70, "B" Symptoms, rmeter (particularly gasfointethree or more extra nodal siteInvolvement of lymph node rdiaphragm (lll) or localized ilymphatic organ or site (lII E(lll SE) /Stage II plus poor pr
Diffuse or disseminated involextra lymphatic organs with rnode involvement. The organsymbol = A. asymptomatic, Eweight loss > l0% of body w,
TABLE 3Clinico-Pethological ch3recteristicr
Clinical
Sex (N{/F) ratioAge (Yrs)
(Range)Mean
'B'Symptoms
HepatomegalySplenomegaly
Stage Il lI I IIV
Bulky DiseaseExtra nodal sitesPathologicalBone Marrow-lnvolvementLow grade
Intermediate GradeHigh grade
Bulky disease was classiflmeasured more than l0 cmspalpable abdominal mass or alroutine CXR. Histological clras per criteria of Working Fon
Jour. Marine Medical Societv. Jr,
I I I
IV
*Graded Special is t Medic ine and Medical Oncologist ; ** Classi t led Special is t Surgery and Surgical Oncology; *** Classi f ied Special is t
Jour. Jvlarine Medical Sociely. June 1996. l'ol. 3. lrto. I38
TABLE 2Ann Arbor staging (NCl, modified)
TABLE 4Histopathology of NHL: l0 patients
i ASVlNl. These patients wereut radiotherapy), treated with'ved. We observed that CHOP
lL Classi l icat ion
consistent wi th CLt- .lved.nall cleaved and large cell.
rantly large cell, diftirsc arca.ed cell. sclerosis.ll and large cell, sclcrosis.leaved cell, non cleaved cell.
blastic, plasmacytoid, clear cellrvoluted cell, non-convolutcd cel I:e l l , Burk i t t 's .
90 to Dec. 1995 or t i l l the t ime;ion criteria were age betweeny of malignancy, cardiac, renalla performance status of morerofsky's scale (KPS).
r included history, clinical ex-laemogram (CBC), renal anderum uric acid, serum LDH,lXR, USG-abdomen and 2-Dr cardiac toxicity indicated in'otocols.
is done according to Ann Ar-a [5] (Table 2) and the results
Oncologl ; *+* Classi l lcd Special is t
iociet.v, June 1996, I'ol. 3, No. I
Stage Characteristics
I Involvement ofa single lymph node region (l) or a singleextra lymphatic organ or site (lE)/ Localized nodal orextra nodal disease.
ll lnvolvement of two or more lymph node regions on thesame side ofthe diaphragm (ll) or localized involvementof an extra lymphatic organ or site (ll E)/ Two or morenodal sites ofdisease or a localized extra nodal site plusdraining nodes with none ofthe following. Performancestatus < 70, "B" Symptoms, any mass > l0 cm in dia-meter (particularly gastrointestinal), serum LDH > 500,three or more extra nodal sites ofdisease.
Involvement of lymph node regions on both sides of thediaphragm (lll) or localized involvement an extralymphatic organ or site (lll E) or spleen (lll S) or both(lll SE) /Stage Il plus poor prognostic features as above.
Diffuse or disseminated involvement of one or moreextra lymphatic organs with or without associated lymphnode involvement. The organ(s) involved identified by asymbol = A. asymptomatic, B, fever, sweats,weight loss > I 0% of body weight.
TABLf, 3Clinico-Pathologicrl ch3racteristics of ten patients
Clinical
Low Grade
Diffuse small lymphocytic
Follicular small cleaved
Cutaneous T-Cell lymphoma(Mycoses Fungoides)
Intermediate Grade
Diffuse small cell cleaved
Diffuse mixed small and large
Cell sclerosis
Diffuse largc cell
High Crade
Large cell lmmunoblastic
Lymphoblastic(Diffuse undifferentiated)
2I
ogy ofour ten patients is as per Table 4.
With bulky disease, patients were primed withgood hydration and allopurinol therapy to avoid riskof tumour lysis syndrome. Therapy was postponedwith Hb < l0 gryrs, TLC < 4000/mm' and platelets< I.00.00/- mm.r Patients with MACOP-B receivedtrimethoprim sulphamethoxazole and clotrimazoleduring the therapy. Antifungal therapy (Flucona-zole) was added when indicated.
Patients with high grade disease were given ad-ditional CNS prophylaxis with intrathecal triple(Methotrexate, ARA-C and Hydrocortisone), for atotal ofsix doses.
Ttixicity of chemotherapy and its severity wasrecorded as per WHO - criteria. Evaluation of re-sponse to chemotherapy was done one month afterthe completion of treatment. Complete response(CR) was defined as complete disappearance of alldisease related symptoms/measurable disease. Par-tial Response (PR) was defined as the decrease by50% of all measurable disease. Patients with bulkydisease received external radiotherapy to the localsite, while those having PR or progression of disease(PD), received salvage CT (MINE/ESHAP). Twomonthly follow up was done fortwo years, followedby six monthly check for two years and thereafter ayearly review was done
Patients with low grade disease were either keptunder observation ortreated with CT (COPP). Thosewho changed the grade of disease to intermediate orhigh grades were treated with CHOP and thereafter
I I I
I V
No
Sex (N4/F) ratio
Age (Yrs)(Range)Mean
'B'Symptoms
Hepatomegaly
Splenomegaly
Stage II II I IIV
Bulky Disease
Extra nodal sites
Pathological
Bone Manow-lnvolvement
Low grade
Intermediate Grade
High grade
6:4
t3-5232.4 ! t3.5534
II44
3
3
4
352
50
3040
l 0t 04040
30
30
40
305020
Bulky disease was classified when nodal massmeasured more than l0 cms in greatest diameter,palpable abdominal mass or any mass visualized byroutine CXR. Histological classification was doneas per criteria of Working Formulation. H istopathol-
Jour. Marine Medical Society, June 1996, Vol. 3, No. I 39
IlL
kept under follow up. Splenectomy was performedwhere primary lymphoma of spleen was suspectedor features of hypersplenism (decrease in cellularl ineages eg. pancytopenia) were present. A patientof cutaneous T-Cell lymphoma (Mycoses Fun-
TABLE 5Responses vs clinical characteristics
Resoonse Characteristic No PR(%)
goides) was treated with pulses of CT (Methotrexate+ Bleomycin) sensitization followed by total bodyirradiation (TBI). Observations on response to CT isshown in Table 5 and duration of follow up in Table6 .
RESULTS
Six out of ten patients were treated with CHOPregimen, one with MACOP-8, one with COPP, onewith chemo-sensitization by Methotrexate-Bleomy-cim followed by TBI in Mycoses Fungoides and thelast with splenectomy in LGL when he presentedwith hypersplenism leading to pancytopenia.
Six out of the ten patients achieved CR and thebalance of four patients could achieve PR (out ofwhich one died of CNS relapse).
There was no difference in the response rate (RR)when pre-treatment features like sex, age, bone mar-row involvement and extra nodal disease were con-sidered. However, there was a tendency of patientswith absent 'B' symptoms to have higher RR/CRwhen compared with no 'B' symptoms. Similarlypatients with non bulky disease had a higher CR ratethan those with bulky disease. Patients with stage Iand ll as a group, had higher response than stage IIIand IV (Table 4).
Out of the ten patients six achieved CR (60%)and four patients had shown PR. Relapses occurredeven after twelve months of chemotherapy comple-tion. There were no significant differences in age,
TABLE 7Toxicity record often patients dapy/radiotherapy
Toxic iw
SEX
Male
Female.B 'SYMPTOMS
Present
Absent
STAGE
I and I I
I I I and IV
TUMOUR BULK
Non bulky
Bulky
BONE MARROW
Involved
Uninvolved
HISTOLOCY
Diftuse large cell
Diffuse small cell cleaved
Large cell immunoblastic
2(20.0) 4(40.0)2(20.0) 2(20.0)
3(60 0) 2(40.0)2(40.0) 3(60 0)
2 (100.0)4(s0.0) 4(50.0)
2(28.6) s(7 r .4)2(66.7) l(33.3)
3(75.0) r(25 0)l ( r 6.7) s(83 3)
r (100 0 )r (s0 0) r (s0.0)
2( r 00.00)
LEUCOPENIN
Cr. IGr . l l
C r . I I I
Gr . IVMUCOSITISGr. I
Gr . I lGr . I I I
Cr . IV
HEPATICMi ld
Severe
CARDIACNEUROPATLIYGr. I
Gr . I I
Gr . l l l
CR(%)
64
)5
28
7l
4
t)
I22
I'R - Partial response, CR - Complete response
TABLE 6Follow up since disease onset
S.No Age(years)
Sex Regimen Relapse(Months
later)
RR F/U(Months)
L2.
3 .
o .
7.8 .
9 .t 0
30
384044
46
505 l54
56
M
F
M
F
M
M
M
F
M
F
a p
CRCRPRPR
PR
CRCR
CRPR
l l
36229*27
l 5
5333
397
I C L
IGL
HGL
HGL
LCL
HGL
LGL
LGL
IGL
IGL
CHOPCHOP
CHOPCHOP
SplenectomyMACOP.B
COPP+IFNMTX-BLM+TBI
CHOPCHOP
26
7
l 0
stage, presence of 'B' symlformance status in patients'
Toxicity was recorded arble 6). The most frequent 1followed by mucositis, hepadiac toxicities. Peripheral ralmost 30% of cases (Gr. I)chemotherapy induced skinNone of them developed strfemoral head necrosis or hy
DISCUSSION
Lymphomas are chemoschemotherapy. The rationachemotherapy is that diffenstages of the cell cycle and
t6l.Intermediate and high gr
first generation agents CH(doxorubicin, vincristine an<sively studied. This produceof patients and might as welto 35 percent [7]. Third gtregimens using as many asdrugs are known to give 55
Jour. Marine Medical Societv.
RR= Responserate,CR=CompleteResponse,PR=Part ia l Response,LCL=LowGradeLymphoma, IGL=lntermcdiateGradeLymphoma, HGL: High Grade Lymphomq * = Died, F/U - Follorv up
Jottr. Marine Medical Societv, June 1996. L'ol. 3. No. I40
h pulses of CT (Methotrexarettion followed by total bodyrvations on response to CT isuration of follow up in Table
rts were treated with CHOPCOP-B, one with COpp, oneln by Methotrexate-Bleomv-Mycoses Fungoides and thein LGL when he presentedding to pancytopenia.
lt ients achieved CR and the.s could achieve pR (out ofi relapse).
nce in the response rate (RR).ures l ike sex. age. bone mar-xtra nodal disease were con-) was a tendency of patients)ms to have higher RR/CRro'B ' symptoms. Simi lar lydisease had a higher CR rateisease. Patients with stage Iigher response than stage Il l
nts six achieved CR (609"7rown PR. Relapses occurreors of chemotherapy comple-nificant differences in age,
R F/U(lr lonths)
ttR
L
il36
22
27
I 5
5l
33397
na, IGL: Intermediate Cirade
iety, June 1996, I'ol. 3. Io.
I
I - l :UCOPIINIA
Gr. I
G r . I I
G r . I I I
G r I V
MUCOSITIS
G r I
C r . I l
G r . l l l
G r . IV
HEPAT IC
Mi td
Severe
CARDIAC
NEUROPATIIY
Gr. I
G r . l l
G r I I I
TABLE 7Toxicit l record of ten patients during course of chemother-apy/rad ioth cra py
Toxic i tv
remission, but are diff icult to administer, more toxicand expensive regimes. However a recent trial withm-BACOD, PToMACE, CytoBOM and MACOP-Bhas failed to prove any superiorify over'gold stand-ard' CHOP regimen (except in few highly aggres-s ive NHLs) [8] .
The lymphoblastic lymphoma and diffuse non-small cleaved cell lymphoma must be treated ag-gressively by alternate methods. Several studieshave suggested treatment of lymphoblastic lym-phoma to be the same as acute lyrnphoblastic leuke-m ia [ 9 ,10 ] .
About half of all patients treated for aggressiveNHL will not be cured by init ial therapy. The im-portant prognostic factor in these patients seem tobe whether a CR was achieved init ially and whatwas the duration of the remission. The term DFS insuch patients is approximately l0 percent. Amyeloablative chemotherapy followed by autolo-gous bone marrow transplant (BMT), peripheralstem cell transplant or allogenic BMT is now con-sidered as salvage therapy for young patients withresistant disease or those who relapse within oneyear after chemotherapy completion I I l ].
For low grade lymphoma (LGL) with their indo-lent behaviour, most of the cells are in G-O- (restingphase) and the disease is diff icult to cure. Majoriryof patients become refractory to treatment anddeath occurs because of infections, marrow failureand progressive disease. Median survival is f ive toten years. In early stages (True I and Limited II).involved field radiation (400 rads/4 weeks) wil l cure50 percent of patients. With more advanced disease,patient can be offered "wait and watch" policy orchemotherapy. As said before, most of the cellsbeing in G-O- phase, chemotherapy is not veryeffective and rather has significant side effects. With"Wait and Watch" policy at t imes they achievespontaneous remission or the grade of lymphoma isseen to shift to intermediate or high grade, whenchemotherapy is found to be effective [ 12]. Recentl'.there is an interest in prolonging remission durationand treatment of minimal residual disease with In-terferon-alpha (with or after combination chemo-therapy) [13,14]. That this translates into a longerover all survival is debatable. TBI can induce remis-sion in upto 90 percent of cases, but is toxic andeventually patients relapse.
9 / 1 05/ r 02 / t0
l / t 0
5 / 1 03 / 1 02il0l / l 0
2^0
l / 1 0l / 1 0
3il0l / r 0
90%50%20%t0%
50%30%20%ljYo
20%t0%100/o
30%t 0 %
stage, presence of 'B' symptoms, histology or per-formance status in patients who had a relapse.
Toxicity was recorded as per WHO criteria (Ta-ble 6). The most frequent toxicify was leucopeniafollowed by mucositis, hepatic, neuropathic and car-diac toxicit ies. Peripheral neuropathy was seen inalmost 300/o of cases (Gr. I). All patients developedchemotherapy induced skin and nail pigmentation.None ofthem developed steroid induced avascularfemoral head necrosis or hyperglycemia.
DISCUSSION
Lymphomas are chemosensitive to combinationchemotherapy. The rationale behind combinationchemotherapy is that different drugs act at differentstages of the cell cycle and are non cross-resistant
t6lIntermediate and high grade NHL : Amongst the
first generation agents CHOP (Cyclophosphamide,doxorubicin, vincristine and predinsolone) is exten-sively studied. This produces CR in 45 to 55 percentof patients and might as well cure approximately 30to 35 percent [7]. Third generation chemotherapyregimens using as many as eight non cross resistantdrugs are known to give 55 to 85 percent complete
Jour. Marine Medical Society. June 1996. Vol. 3. No. I J 1
Our interaction with NHLs has been varied. Wehave encountered almost all kinds of lymphomas,nodal and extra nodal disease, including primary gutlymphoma, MALT-omas (Mucosa AssociatedLymphoid Tissue-MALT) tl5l and primary lym-phomas of spleen as well as of thyroid (two extranodal lymphomas are still under evaluation and notincluded in this study).
We found that the best tolerated chemotherapywas CHOP regime with a reasonably good response,including almost 40% CR and 20Yo partial re-sponder. MACOP-B third generation regime wasmore toxic and a high grade disebse showed relapseshortly after chemotherapy was concluded. We treatLGLs, where patient has discomfort with nodal bur-den and elevated serum LDH, with aggressive com-bination chemotherapy and thereafter followup withinterferon alpha 2b (lFN), 3 mill ion units (s/c) thricein week for total duration of six months. One patientwas seen as a partial responder to the COPP regi-men, whereas another patient of LGL has beensplenectomized and has recovered from the effectsof hypersplenism and has achieved PR. Our casesare sti l l under follow up and prediction of overallsurvival requires further observation and inclusionof a larger number of patients.
REFERENCESL Berard CW, Dorfman RF. Histopathology ofmalignant lym-
. phomas. ln Roschberg SA, ed. Clinics in hematology, Phila-delohia- WB Saunders. 1974'. 3'. 39.
2. Opportunistic NHL among FllV infected patients - Uniredstarcs. lvllrltyR l99l;40 : 591-600.
3. National Cancer Institute studv of classifications of NHLS.
Summary and description of working formulation for clinr-cal usage. Cancer 1982;49 :2112-2135.
4. Rosenberg SA. The Low grade N HLs chal lenges and oppor-tunities. J Cliz Oncol 1985: 3 : 299-310.
5. Moormeier JA, Williams SF, Colomb HM. The staging ofNHLs. Sezrn Oncol 19901' 17 :43-50.
6. Anderson T, Bender RA, Fisher Rl et al. Combinationchemotherapy in NHLs; Results of long term follow up.Cancer treat rep 1977, 6l : I 057-66.
7. Jones SE, Grozea PN, Metz EN at al Superiority of adriamy-cin containing combination chemotherapy in treatment oldiffuse lymphoma. A Southwest Oncology Croup study.Cancer 1979: 43 : 417-25.
8. Fisher Rl, Gayron ER, Dahlberg S er al Comparison of astandard regimen (CHOP) with three intensive chemother-apy regimens for Non Hodgkin's lymphoma. N Engl J Med1993:328: 1002-6 .
9. Voakes JB, Jones SE, Mc Kelvey EM. The chemotherapy oflymphoblastic lymphoma. Blood l98l',57 : 186-91.
10. Coleman CN. Picozzi VJ Jr, COX RS er o/. Treatment oflympho-blastic lymphoma in adults. J Clin oncol 1986; 4:1620-36.
I I . Armitage JO. Bone Marrow Transplantation in treatment ofpatients with lymphoma. Blood 1989.73 : 1749-58.
12. Horning SJ, Resenberg SA. The natural history of initiallyuntreated low grade Non Hodgkin's Lymphomas. N Engl JMed 1984;3l l : l47l-75.
13. Cilewski TA, Richards JM. Biological response modifiersin NHLs. Semin Oncol 1990. 17 :74-87.
14. Gaynor ER, Fisher RI. Clinical trials with alpha interferonin treatment of Non Hodgkin's Lymphoma. Semin Oncoll99 l ; 18 (supp l 7 ) : 12-17 .
15. lssacson PG. Spencer J. Malignant lymphoma of MALT. In: Jones DB. Wright DH, eds Lympho-proliferative diseases.Immunology in medicine series. Norwell : Kluwer - Aca-demic. 1990; 15 : 123-43.
Jour. Marine Medical Society, June 1996, Vol. 3, No. 142
SUBACUTE Hl
Surg Cdr AC PRAVICoI DINESH PRASA
ABSTRACT
Ten cases ofsubacute helof varying severity, withnecrosis were studied. TlOf the four (40%) patiecontinue to be HBsAg pc
KEY WORDS : Subaeul
INTRODUCTION
1l-l ubacute hepatic
\entity distinct frrlJ chronic l iver failupatic failure is now recowith characteristics ofdefined by clinical and tgastro-entero logists havtowing to its rare occurrebeen termed as subfulmonset hepatic failure [3] rt is with impaired regenerof patients with hepatit isery, l iver failure is one oAcute l iver failure [5] isof encephalopathy withinance ofjaundice and thtl iver failure is six monthfalls in an intermediate prsix months of onset of acriteria [] for this condgressive jaundice for forpearance in a patiendevelopment of unequivcthe appearance of jaundiof hepatocellular necrosiing necrosis on l iver biol
MATERIAL AND ME
Ten cases of subacul
*Classifi ed Specialist MedicinrColaba, Mumbai 400 005.
Jour. Marine Medical Socit
of working lbrmulation for clinl-9 :2112-2135.
rade NHLs challenges and oppor-i ; 3 : 299 -310 .
SF, Golomb HM. The staging of, 17 : 43 -50 .
, Fisher RI et al CombinationResults of long term follow up.: 1057-66.
zEN et al. Superiority ofadriamy-rn chemotherapy in treatment ofuthwest Oncology Group study.
filberg S et ai. Comparison of awith three intensive chemother-
lgkin's lymphoma. N Engl J Med
(elvey EM. The chemotherapy ofB l o o d l 9 S l : 5 7 : 1 8 6 - 9 1 .
Jr, COX RS et al Treatment ofin adults. J Clin oncol 1986 4
w Transplantation in treatment ofllood 1989;73 : 1749-58.
\. The natural history of initiallylodgkin's Lymphomas. N Engl J
,1. Biological response modifierst01' 17 : 74-8'1 .
nical trials with alpha interferonlkin's Lymphoma. Semin Onco!
alignant lymphoma of MALT. Ins Lympho-prol i ferative diseases.series. Norwell : Kluwer - Aca-
ty,June 1996, Vol.3, No. I
SUBACUTE HEPATIC FAILURE
Surg Cdr AC PRAVEEN KUMAR*, Surg Lt Cdr H MANI* ' | ,CoIDINESH PRASAD***
ABSTRACT
Ten cases ofsubacute hepatic failure (SAH F) with progressive jau nd ice of more than four weeks, associated ascitesof varying severity, with or without encephalopathy and liver function tests showing evidence of hepatocellularnecrosis were studied. The clinica! course was of progressive ddterioration leading to death in six (60%) patients,Of the four (40%) patients who survived, two patients had complete recovery and the remaining two patientscontinue to be HBsAg positive at the end of f ive months of followup.
KEY WORDS : Subacute hepatic failure
INTRODUCTION corded over a period of four years at this hospital(Jun 92 to Jun 96). These included eight males andtwo females with an age group of 35-45 years (mean41.8 t 6.4 years). Each case was thoroughly evalu-ated. History of diabetes mellitus, alcohol consump-tion and possibil i ty of hepatotoxic drug intake wassought for. Patients with features of chronic l iverdisease and evidence of obstructive jaundice wereexcluded from the study. Workup of each patientincluded routine haemogram, urinalysis, biochemi-cal parameters l ike sugar, urea and creatinine. Liverfunction tests included bil irubin, serum glutamicoxaloacetic transaminase (SGOT), serum glutamicpyruvic transaminase (SGPT), alkaline phos-phatase, serum proteins, albumin and prothrombintime. Viral markers included IgM HAV, HBsAg,IgM anti HBc and anti Delta. Abdominal ultrasoundwas routinely done in all these cases, which wasfollowed by ascitic f luid analysis and upper gastro.intestinal endoscopy to rule out varices. Liver bi-Opsy, antemortem or post mortem was performed,depending upon the clinical situation. Patients werefollowed up periodically.
OBSERVATIONS
Ten patients of subacute hepatic failure werefollowed up. Eight were males and two were fe-males, with majority of patients in the fifth decadeof I ife. Persistent progressive j aund ice of four weeksduration after its first appearance was present in allthese cases. Abdominal distension suggestive of
ubacute hepatic failure (SAHF) is a clinicalentity distinct ffom acute l iver failure andchronic fiver failure.[] Though subacute he-
patic failure is now recognized as a distinct diseasewith characteristics of progressive hepatic failure,defined by clinical and biochemical criteria, not allgastro-enterologists have supported th is observationowing to its rare occurrence and the same entity hasbeen termed as subfulminant l iver failure [2], lateonset hepatic failure [3] and protracted viral hepati-t is with impaired regeneration [4]. Though majorityof patients with hepatit is have an uneventful recov-ery, l iver failure is one of its dreaded complication.Acute Iiver failure [5] is characterized by the onsetof encephalopathy within eight weeks ofthe appear-ance ofjaundice and the cut off point for chronicliver failure is six months. Subacute hepatic failurefalls in an intermediate position fronr eight weeks tosix months of onset of acute illness. The acceptedcriteria [] for this condition being, persistent pro-gressive jaundice for four weeks after its first ap-pearance in a patient with acute hepatitis,development ofunequivocal ascites four weeks afterthe appearance ofjaundice, bio-chemical evidenceofhepatocellular necrosis and submassive or bridg-ing necrosis on l iver biopsy.
MATERIAL AND METHODS
Ten cases of subacute hepatic failure were re-
tClassitied Specialist Medicine and Castroenterology; **Graded Specialist Pathology; *+*Senior Advisor Medicine; INHS ASVINI,Colaba. Mumbai 400 005.
Jour. Marine Medical Society, June 1996, Vol. 3, No. I 43
. laund ice
Asci te s
Pcdal oedcma
l)rodromal
symptoms
I lcpatonregal !
Spl enonrcgal l '
Terminal cvents
Sepsis. Coagulopathy
I lepatorenal syndronre
Enccphalopath; '
l lacter ia l per i toni t is
ascites and pedal oedema was recorded in eightpatients on admission and two patients developedascites later. All these ten patients developed pedaloedema and ascites between four to six weeks afterthe onset of jaundice. Hepatomegaly was recordedin six patients and splenomegaly in three patients.Table I summarises the clinical profi le of this study.
T'ABLE I( l l i n i ca l Fca tu r cs o fSA I lF ( n : l 0 )
Cl in ical Prof i le No.ofpaticnts Percentage
t ients on sonography showing shrunken liver orirregular l iver were not included in this series.Splenomegaly was found by sonography in fourcases. Endoscopy did not show any evidence ofvarices in any of these cases. Virological study onthese cases showed, six cases positive for HBsAgand IgM anti HBc. ln four cases, none ofthe sero-logical markers were positive. Anti HCV testingcould not be done. None of these patients had dia-betes mellitus or history of blood transfusion in thepast. Five pdtients gave history of consuming smallquantity of alcohol occasionally and their clinicalprofi le did not differ from non alcoholics. Twopatients were on anti tubercular drugs namely, Ri-fampicin 450 mg per day, INH 300 mg per day,Ethambutol 800 mg per day and Pyrazinamide 750mg twice daily for pulmonary tuberculosis and theyhad continued the same, inspite of developing jaun-dice, for more than four weeks after the onset, indis-criminately and without medical follow up.
Liver biopsy was possible in only four patientsante moftem and this showed features of acute viralhepatit is with bands of bridging necrosis and noevidence of regenerative activity. Six patients un-derwent postmortem Iiver biopsy which showedevidence of submassive necrosis. Of the four na-tients who survived from SAHF, two patients be-longed to the group ofantitubercular drugs inducedSAHF and their repeat l iver biopsy after a followupof six months was norrnal and the remaining twopatients are under followup, waiting for a l iver bi-opsy at the end of six months.
The clinical course of SAHF is characterized bya progressive and gradual deterioration. The presentseries recorded a mortality rate of 600/o.In our series,all the deaths occurred within six months after theonset of i l lness. None of our patients were admittedwith features of gastrointestinal bleeding or featuresofhepatic encephalopathy. Three patients died dueto features ofsepsis, gastrointestinal bleeding due tocoagulopathy and progressive encephalopathy. Inthe remaining three patients, end came with compli-cations l ike hepatorenal syndrome. Two patientsrecovered completely within three months afterstopping hepatotoxic anti tubercular drugs and in theremaining two survivors, HBsAg continues to bepositive without any evidence of chronic l iver dis-ease.
Jour. Marine Medical Soc'ietu. June 1996. I'ol. 3. No l
DISCUSSION
Subacute hepatic t 'ailure idifferent disease with characthepatic failure defined bY sP,chemical criteria []. Thouglonset of jaundice and develbeen debated amongst varioprogressive iaundice for fotappearance in a Patient wittaccepted criteria. lt is also iapart fronr the duration ofth,hepatic failure is probably mduration of the disease. Wori1983 a t t he A l l I nd ia I ns t i t u lident i f ied four d iagnost ic crfollowed in most centres. IUSA [7] and France [8] havas an essential feature ofhepcases of SAHF (studied overrecorded at the Rajgarhia LInst i tu te of Medical Scierencephalopathy was a pre-terthe varied course observedprobably related to the differraetiology of hepatic i l lness a
Viral hepatit is is the mSAHF. Other hepatotox ic agtoxins, drugs and Wilson's d j
aet io logical factors. ExPer i t
[9] group has shorvn that virecommon cause followed byone of thei r ser ies of 148 casassociated in 4%, Virus B(Hnon-A non-B in 58% and D,in 4oh of cases. With the arHCV and HEV, the numbernon-A non-B associated Slreduced. Sirni lar experiencethe Kashmir group [0] arthough there are variationstion, highlighting the fact thrthe Indian subcontinent itse
The exact pathogenesis (
is not known why in somthepatocyte necrosis cont inr
Jour. Alttrine lvledical Socieh,
l 0l 08
563
336
2
1 0 01 0 080
506030
3 03 06020
TABLE 2LF-I 'Profi le of S.\HF
Mean + 2SD
S Bi l i rubin (nrgidL)
sGol ' ( ru/L)scPT ( lu / r - )S. l ) rotc in (gm/dl)
S. Albumin (gnr/d l )
Prothronrbin ' [ ' ime (seconds)
9.5 r 3 .59 8 t 3 01 2 0 t l 04 + l . l2 + 0 . 52 0 t 4
Liver funct ion tests (Table 2) in SAHF pat ientsindicate cont inued hepatocel lu lar necrosis . Hyper-b i l i rubinaernia and hypoalbuminaemia was re-corded in all cases. Serum glutamic oxaloacetictransaminase (SGOT) and serum glutamic pyruvictransaminase (SGPT) analysis showed evidence ofongoing necrosis, but unlike acute l iver failure, en-zymes were not markedly elevated. Prothrombintime was abnormal in all cases. Ascitic f luid was atransudate in all the patients studied and in twopatients became an exudate when they developedfeatures of bacterial peritonitis. Sonographically,hepatomegaly was present in all the cases and pa-
rowing shrunken liver or: included in this series.d by sonography in fourot show any evidence ofases. Virological study oncases positive for HBsAgur cases, none ofthe sero-rsit ive. Anti HCV testingofthese patients had dia-
of blood transfusion in theristory of consuming smallsionally and their clinical0m non alcoholics. Tworercular drugs namely, Ri-ty, INH 300 mg per day,lay and Pyrazinamide 750Inary tuberculosis and theyinspite df developing jaun-reeks after the onset, indis-nedical follow up.
sible in only four patientsrwed features of acute viralbridging necrosis and nor activity. Six patients un-'er biopsy which showednecrosis. Of the four pa-n SAHF, two patients be-titubercular drugs inducedrer biopsy after a followupLal and the remaining two,up, waiting for a l iver bi-nths.
SAHF is characterized byI deterioration. The presenty rateof 60oh.ln our series,rithin six months after therur patients were admitted:stinal bleeding or featuresy. Three patients died dueointestinal bleeding due torssive encephalopathy. Inrts, end came with compli-syndrome. Two patientsithin three months after:ubercular drugs and in theHBsAg continues to be
ence of chronic l iver dis-
zty, June 1996, L'ol. 3, No. I
DISCUSSION
Subacute hepatic failure is now recognized as adifferent disease with characteristics of progressivehepatic failure defined by specific clinical and bio-chemical criteria []. Though the interval betweenonset ofjaundice and development of ascites hasbeen debated amongst various workers, persistentprogressive jaundice for four weeks after its firstappearance in a patient with acute hepatit is is theaccepted criteria. It is also interesting to note thatapart from the duration ofthe illness, the pattern ofhepatic failure is probably more imporlant than theduration of the disease. Workshop on SAHF held in1983 at the All lndia Institute of Medical Sciencesidentif ied four diagnostic criteria which are beingfollowed in most centres. Authors from U.K [6],USA [7] and France [8] have used encephalopathyas an essential feature ofhepatic failure. Out of 148'cases of SAHF (studied over a period of four years)recorded at the Rajgarhia Liver Unit at All IndiaInstitute of Medical Sciences, New Delhi, [9]encephalopathy was a pre-terminal event, reflectingthe varied course observed in different countries,probably related to the differences in host responses,aetiology ofhepatic i l lness and nutrit ional factors.
Viral hepatit is is the most common cause ofSAHF. Other hepatotoxic agents, e.g. alcohol, planttoxins, drugs and Wilson's disease, are less commonaetiological factors. Experience of the New Delhi
[9] group has shown that viral hepatitis was the mostcommon cause followed by antitubercular drugs. Inone of their series of 148 cases, Virus A(HAV) wasassociated in 4%, Virus B(HBV) was found in34Yo,non-A non-B in 58oh and Delta agent was involvedin 4oh of cases. With the availabilify of assays forHCV and HEV, the number of patients classified asnon-A non-B associated SAHF will be very muchreduced. Similar experience has been published bythe Kashmir group [0] and Cuttack group [ 1],though there are variations in the clinical presenta-tion, highlighting the fact that there are variations inthe Indian subcontinent itself.
The exact pathogenesis of SAHF is not clear. ltis not known why in some cases of hepatit is theheDatocvte necrosis continues and there is inade-
Jour. Marine Medical Society, June 1996, Vol. 3, No. I
quate regeneration of liver cells [3,4] and conse-quent SAHF. The probably accepted theory is thatviral replication provides a stimulus for cell-medi-ated immune injury and prevents the proper regen-eration of hepatocytes that is necessary for the re-covery.The treatment of this disease has been essen-tially supportive, which included oral or parenteral1200 to 1800 calor ie d iet , wi th a low sodium con-tent, diuretics with proper monitoring of serum elec-trolyte levels and antibiotics if there is evidence ofinfection. Liver transplantation [3,7] has been sug-gested as a treatment option by many workers.
In conclusion, SAHF, a complication of acuteviral hepatit is, is a distinct clinical entity with unsat-isfactory treatment response. Antiviral agents andhepatic transplantation deserve a clinical trial.
REFERENCES
l. Tandon BN. Terminology, prevalence and clinical features.In : Subacute hepatic failure(eds) Tandon BN. Charak Pub-l ishing House, New Delhi . 1983; l -6.
2. Bernauau J. RueffB. Benhamou JP. Fulminant and subful-minant f iver f'aif ure. Dcfinitions andcauses. Senin Liver Dis1 9 8 6 ; 6 : 9 7 - 1 0 6 .
3. Gimson AE, O'Grady J, Ede RJ, Portrnann B, Williants R.Late onset hepatic l'ailure: Clinical, serological and histo-logical features. Heparologt 19861 6 : 288-94.
4. Peters RL, Omata M. Ascharai M. Lierv CT. Protracted viralhepatitis. In : Vyas CN, Cohen SN. SchmidR (eds). ViralHepatitis. Franklin Institute Press. Philadelphia 1978: 79-84.
5. Tandon BN, Joshi YK, Tandon M. Acute livcr f'ailure.Experience with 145 patients. J Clin Gostroenterol 1986,8: 664-8.
6. O'Crady JG. Schalm SW, Wi l l iams R. Acute l iver la i lure:redefining the syndrome. Lancet 1993'.342 : 273-5.
7. Pelemen RR, Gavaler JS, Van Thiel DH, et al. Orthotopicliver transplant for acute and subacute hepatic failure inadtrlls. He patolopSt 1987 . 7 : 484-9.
8. Bergau J, Rueff B, Benhamou JP. Fulminant and subtirlnri-nant fiver failure. Definitions and causes. Semin Liver Dis1 9 8 6 ; 6 : 9 7 - 1 0 6 .
9. Tandon BN, Joshi YK, Acharya SK. Subacute hepatic t'ail-ure. The Nat ltled J India 1988: | : 124-7 .
10. Khuroo MS, Dar MY. Subacute hepatic failure experienceat the Institute ofMedical Sciences,Srinagar. lnd J Gasroen-terol 1993' I 2(Suppl 3) : 7- I 0.
ll. Mohapatra, et al. Clinicopathological profile ofsubacutehepatic failure. J,4 Pl 1996',Yol 44 :375-77.
ANTIBIOTIC RESISTANCE PATTERNIN COMMON ISOLATESA SIX YEAR STTIDY - ASVINI E)GERIENCE
Lt Col S BHATTACHARYA*, Surg Lt Cdr D BAJPAYEE**,Col AK HUKKOO***
ABSTRACT
A six year study of antibiot ic resistance pattern of common bacterial isolates was carr ied out at INHS Asvini toformulate a pol icy regarding antibiot ic select ion in infect ions. The study brought out the emergence of resistancein common isolates over a period of six years. This enables correct select ion of antibiot ics in infect ions caused byfive common isolates, namely Staphylococcus aureus, Escherichi col i , Pseudomonas, Proteus and Salmonella.
KEY WORDS : Antibiot ic resistance. Bacteria
INTRODUCTION specimens were studied over this six years pe-riod.
4. The breakdown of the number and nature ofspecimens from which these isolates were ob-tained are given in Table l.
5. The antibiotics used to test for sensitivity foreach bacteria are as under :
(a) Staplrylococcus aureus - Penicillin, Eryth-romycin, Cloxacil l in, Chloromycetin, Gen-tamicin, Tetracycline, Augmentin,Cephaloridine and Cotrimoxazole.
(b) E. Coli - Nitrofurantoin, Nalidixic acid.Ampicil l in, Gentaminin, Chloromycetin,Netil im icin, Cotrimoxazole, Ciprofl oxacin.
(c) Pseudomonas pyocynae - Gentamicin, Car-benicil l in, Polymyxin B, Amikacin. Tobramy-c in, Net i l imic in, Kanamycin.
(d) Proteus group - Nitrofurantoin,Nalidixicacid, A.mpicil l in, Gentamicin, Chloromycetin,Norfl oxacin, Ciprofl oxacin, Netil im icin.
(e) Salmonella group - Ampicillin, Chloromy-cetin, Cotrimoxazole, Gentamicin, Ciproflox-acin, Cefotoxime, Netil imicin andCephaloridine.
6. The percentages of each organism resistant to aspecific antibiotic was worked out.
ntibiotic resistance is a day to day problemin treatment of infections in any hospital.Thus the knowledee of the trends of antibi-
otic resistance in isolates is helpful in choosing thecorrect antibiotics. This lowers the morbidity andmortality and also has financial implications. Use ofincorrect antibiotics generates resistance in bacterialstrains. Indiscriminate and incorrect use of antibiot-ics is the major contributing factor to the emergenceof multi drug resistance in common isolates. Drugresistance pattern thus forms an useful tool to for-mulate a policy for selection of antibiotics in infec-tions. A comparison of the resistance pattern overyears forms the basis of change in antibiotic policyin hospitals, from time to time. We have used thisinformationm to evolve our own antibiotic policy atINHS Asvini
MATERIAL AND METHODS
1. Antibiotic sensitiviry and resistance pattern ob-tained ffom various specimens was compiledfor a period ofsix years, from 1990 to 1995.
2. The rnethod used for carrying out antibioticsensitivity tests was the Stokes methods.
3. Five common isolates were identif ied. They areStaphvlococcus aureus, E. Coli, Pseudomonas,Proterrs and Salmonella. A total of 34,436
OBSERVATIONS
The antibiotic resistantfive common isolates stucpattem over the six years.found in each ofthese orga
TABLE IDistr ibut ion of number ofspeci
Organism
Staphylococcus aureus
E. Col i
Pseudomonas pyocynae
Proteus group
Salmonel la
Total
*ln infants
TABLE 2Resistance pattern observed inurine and throat swabs.
Ant ib iot ics
Penci l l in
Erythromycin
Cloxaci l l in
Chloromycetin
Gentamicin
Tetracycline
Augmentin
Cephaloridine
Co{rimoxazole
*Classified Spccialist Pathology, **Post Graduate trainee Pathology, ***Senior Advisor Pathologyl INHS ASVINI, Colaba, Munrbai400 00s.
Jour. Marine Medical Society, June 1996, Vol. 3, No. I46
8
l
I
5
t - Not tested
TABLE 3Resistance pattern observed in
Antibi iot ic
Nitrofurantoin
Nal id ix ic acid
Ampic i l l in
Centamicin
Chloromycetin
Net i l imic in
Cotrinroxazole
Ciprofloxacin
I7IJ
Jour. Marine Medical Socieh
f,rried out at INHS Asvini tott the emergence of resistanceriotics in infections caused bvs, Proteus and Salmonella.
rdied over this six years pe-
I the number and nature ofhich these isolates were ob-Table l.
ld to test for sensitivity fors under :
i aureus - Penicillin, Eryth-llin, Chloromycetin, Gen-acycline, Augmentin,Cofrimoxazole.
ofurantoin, Nalidixic acid,faminin, Chloromycetin,roxazole, Ciprofl oxacin.
yoq,tae - Gentamicin, Car-rtin B, Amikacin, Tobramy-anamycin.- Nitrofurantoin.Nalidixic
ientamicin, Chloromycetin,floxacin, Netilimicin.
rp - Ampicillin, Chloromy-,le, Gentamicin, Ciprofl ox-ne, Netilimicin and
each organism resistant to alas worked out.
INHS ASVINI, Colaba, Mumbai
ciety, June 1996, VoL 3, No. I
OBSERVATIONS
The antibiotic resistance pattem in each of thefive common isolates studied, showed a changingpattern over the six years. The antibiotic resistancefound in each ofthese organism is given in a tabular
TABLE IDistribution of number of specimens received (n=33136)
form in Table 2 to 6.
DISCUSSION
From the data available. a few clear resistanceand sensitivity pattems are evident. It is observed
Organism Nature of soecimenUr ine Pus Throat Vaginal
swabs swabsStool Others Total
Staphylococcus aureusE. ColiPseudomonas pyocynae
Proteus group
Salmonella
t l-:
1 6
268
85s4612237
888543383 1 5 8862
6 l l
4,0t2198l 9
Nil972+
2
3422 1 8l 68
10,2061 8,1 023,984l,t26
l 8
89
Total t ) 9671 t7243 584 33.436
*ln infants
TABLE 2Resistance pattern observed in Staphylococcus rureus (in percentages) - specimens from which isolates obtained - pus, blood,urine and throat swabs.
Antibiotics 1990 t992 l 993 t995
934
l99 l
PencillinErythromycinCloxacillinChloromycetinGentamicinTetracyclineAugmentinCephaloridineCo-trimoxazole
57.320
6.0818.248.69
87.47r6.3214.3258.42
59.2259.0
20. t57.59
85.4415.56t3.2561.52
78.M29.26
t - 5
13.418.5386.4
t6 .5015.4068.55
7526.18.28 .6
10.4
17.82| 6 . t66.2
7 3 . 1 334
19.74
t4.76
18. I16.4265.43
7336.2
222924
2 l1 7 . l68.4
* - Not tested
TABLE 3Resistance pattern observed in E. Coli (in percentrges) - specimens from which isotates obtrined - urine, pus and others
Antibiiotic 1990 l 993 19941992 1995
NitrofurantoinNalidixic acidAmpici l l inGentamicinChloromycetinNetilimicinCotrimoxazoleCiprofloxacin
6.2312.t479.r2t6.8258.560.72
46.263.8
7.45z1-z I
7 5.9625.2443.028.65
43.265
2.4025.3065.7724.0647.056 . 1 9
u.44t2 .8
9 .832.47 t . l27.664.9l2.l62.3| 5 .8
8.6445.26
. 5 8
2049.12I t . 37 l . 816.4
9.726
1 8 . 8+J
12.478
22.3
Jour. Marine Medical Society, June 1996, Vol. 3, No. I 47
I 'ABI,E 4Resistance pattern obscrved in Pseudomonas pyocynae ( in percentages). Specimens from which isolates obtaincd - pus. urincand others
TAtlLU TAntibiotic rcsistance patt
lso latesAnt ib iot ics I 990 1992 I 993 | 995
( ientamicin
Carbcnic i l l in
Polymyxin B
Amikacin
Tobramycin
Net i l i rn ic in
Kanamycin
61.290
21.22t . 2
47,36
68.497.l
23.687.89
48.1 544.93
s9.3100
9.378 . 150
34.7877
70. l95 .5
308.3
58.237.779.7
54.779.248.49
10.3756. lJ t ) . I
62.3
58.856328 8
54.332.3-rJ. )
Staphylococcus
t r . L O l l
I)roteus
Pseudomonas
Salnroncl la
t - Not tested
TABLE 5Ilesistance pattern observcd in Proteus group (in perccntages). Spccimens from which isolntes obtained - urinc, pus, othcrs.
Ant ib iot ics r 990 t992 | 995r 99l
N itroturantein
Nal id ix ic acid
, \mp i c i l l i n
Gcntanr ic in
Chloronryecetin
Norfloxacin
Ciprofloxcin
Net i l imic in
41.316.26 1 . 54 t . 268.2
46.1t 7 . 9
55.435.858.9
25.1t J . z
45.418.438.2
13.25Ni lN i l
28.2t5.4/ b . )
3 5.380
r8 .2Ni l
N i l
2 t 4 260
90.1742.8
64.2857.14
Ni lN i l
t8.248
86.4
30.878.848.4N i lN i l
i - Not tested
TABLE 6llcsistance pattern observed in Salmonella group (in percentagrs). Spccimcns from blood and stools
Ant ib iot ics 1990 l99 t 1992 I 993 t991 | 995
*Bascd on sensitivity/drug
Notc:
In vivo response may diffe
l. Erythronrycin estolate ist rvc.
2. Cephalosporirre - Cetazrcepharadine are the best or
3. Penicillin to be used onl'
4. New cephalosporins - Cr
of Proteus group ofctance is observed agaiacin, a increase in rerciprofloxacin and n,showed a reversal increase in resistance a€moxazole, which cartlre preferred antibioinfections nowadays
The present studyaim of making the pr€resi stance/sens it ivitythem to choose the Itreating infections.
Ampici l l in
Chloronrycetin
Cotrimoxazole
Gentanricin
Ciprofloxacin
Cefotoxime
Net i l imic in
Cephaloridine
67.8o / . 6
750
N i lN i l
28.5
62f t )
624
Ni lN i l30
26.0
52.259.749.25 .9N i lN i l8 .5
20.8
49.429.853.62 .0J . Z
4.98.2
12.3
642040N i l/ 1
9.2t0.2t3 .8
6026.4
42N i l
1 2 . 81 8 . 612.2t5.2
i - Not tested
that there is an increase in resistance to penicil l in,erythromycin and cloxacil l in by Staphylococcusaureus, ove| a period of six years. There is also avery high percentage of resistance seen to cotri-moxazole arrd penicil l in. In the case of E. coli iso-Iates, an increase in resistance is observed againstcotrimoxazole and ciprofloxacin, decrease in resis-
18
tance against ampicil l in, similar pattern against gen-tamicin and a very low resistance percentage isobserved against nitrofurantoin. Antibiotic sensitiv-ity pattem against gentamicin and amikacin hasbeen steady over the years in Pseudomonas pyocy-nae, increasing resistance against polymyxin B anda decreasing resistance against carbenicil l in. In case
Jour. Marine Medical Society, June 1996, Vol. 3, No. I Jom'. llarine lr1edical !
l lates obtaincd - pus, urincTABLE 7Antibiot ic rcsistance pattern in common isolates from 1990 to 1995 INHS ASVTNI f lnd drug sclect ion (Antibiot ic Pol icy)*
I 995lso lates Drug(s)
First choice+Alternativedrug(s)
Drug(s) shorving high resistancc(to be avoided)
54.7'19.24
8.4910.37
56. I36. l62.3
58.8) b
328.8
54.3) t . J
3 5 . 5
rined - urinc, pust othcrs.
t994 | 995
21.4260
90.4742.8
u.2857.14
NilNi l
18.248
86.43 0 878.848.4Ni lN i l
1994 I 995
642040Ni l4.79.2
10.213.8
6026.4
i a
N i l
t 2 . 8
r8 .6t2.2t5.2
larpattern against gen-iistance percentage isin. Antibiotic sensitiv-:in and amikacin hasPseudomonas pyocy-
rinst polymyxin B andt carbenicil l in. In case
lune 1996. VoL 3. No. I
Staphylococctts
E. Col i
I)roteus
Pseudomonas
Salnroncl la
Erythromycin fllCloxaci l l inCcphalosproin [2]
N itrbturantionCephalosporinGentamycinNorfloxacin
NitrofurantionGentamycrn
Polymixin-BNeqer Cephalosporins
ChloromycetinGentamycinCiprofloxacin
GentamycinAugnrcnllnVanconrycin
Net i l imycin
Newer CephalosporinsNorfloxacin
AmikacinNet i l imycin
Newer Cephalosporins [4]
Penic i l l ins [3]Cotrimoxazole
Ampic i l l inCotrinloxazole
Ampic i l l inCo-trinroxazoleChloromycctin
GentamycinCarbenic i l l inKanamycin
Anrpic i l l in
*Based on sensitivity/drug resistance patterns obtained in-vitro.
Notc:
ln vivo response may differ from case to casc. Ultimate usage of drug to be decidcd by treating clinician.
l. Erythronrycin estolate is the bcst absorbed in oral lbrnr and carries risk ofhepatitis. Erythronrycin ethylsuccinate is a sat'er alterna-
t ivc.
2. Cephalosporirre - Cefazolin, cephapirin, cephalothin, cetamandole and cefbxitin are parenteral cephalosporins. Cephalexin and
cepharadine are the best oral forms.
3. Penicillin to be used only ifshowing sensitivity.
4. New cephalosporins - Cefotoxinte, Cefoperazone, Cefuronc.
of Proteus group of organisms, a decrease in resis-tance is observed against nitrofurantoin and norflox-acin, a increase in resistance was observed againstciprofloxacin and neti l imicin. Salmonella group
showed a reversal in antibiotic sensitivity with de-crease in resistance against chloromycetin and cotri-moxazole, which can be attributed to the fact thatthe preferred antibiotics used to treat Salmonellainfections nowadays are the ciprofloxacin group.
The present study has been carried out with theaim of making the practicing clinicians aware of theresistance/sensitivity pattern which should enablethem to choose the most suitable antibiotic whentreating infections.
Based on these observations, the first l ine ofdrugs and the alternative drugs to be used in thesecommon isolates was worked out. These recommen-dations are presented in Table 7.
The antibiotic sensitivity pattem may vary fronplace to place and hospital to hospital. Interpolatingresults obtained from one center is fraught withhazards. However; studies from different centres allover the country have shown a broad similarity infindings. This siudy has shown clearly the need foiestablishing an antibiotic policy for all large ormedium sized hospitals. Smaller hospitals and thosepractising in units, ships or at the periphery, candefinitely benefit from these findings.
Jour. l4arine lr{edical Society, June 1996, Vol. 3, No. 49
Drug TherspvC ONC URRENT CI{EMOENDOTFIE RAPYIN TFM MANAGEMENT OFLOCALLY ADVANCED BREAST CANCER
Surg Cdr B FANTHOME*, Surg Cdr A BEHL, VSM#,Surg LCdr S RANJAN+
ABSTRACT
Locally Advanced Breast Cancer (LABC) has emerged as a dist inct cl inical enti ty, incompletely compartmental-ized by the TNM system. In India nearly 387o of breast cancers fal l into this group at presentation. The poornutr i t ional status of patients with advanced malignancy, the toxicity of aggressive combination chemotherapy andthe socio-economic status of some patients severely restr icts treatment options. This art icle discusses the rat ionalefor combining combination chemotherapy with hormonotherapy, thereby exploit ing kinetic interactions betweenchemotherapy and hormone therapy.
KEYWORDS : Local ly advanced breast cancer, Chemotherapy, Hormone therapy, Chemoendotherapy.
INTRODUCTION
ocally Advanced Breast Cancer (LABC) hasgradually emerged as a separate clinical en-tity, incompletely compartmentalized by the
TNM system. It is a disease entity characterized bythe presence of one or more of the following fea-tures:
- Peau d'orange- Infiltration of overlying skin- Satell i te skin nodules- Skin ulceration- Fixation of tumor to chest wall- Ipsilateral axillary nodes which are matted to-
gether or fixed to other structures- Ipsilateral supraclavicular node involvement- The absence of demonstrable distant metastasis
by routine screening techniquesIl ]LABC is a common clinical entity in India and
poses a major therapeutic challenge. Nearly 38Vo ofthe cases of breast cancer presenting at Tata Memo-rial Hospital have locally advanced disease [2].
THE PROBLEM
Although the disease is localized at presentation,
there is a high incidence of distant metastasis duringthe early follow up period [3]. Analysis of publishedreports employing aggressive multimodality treat-ment protocols for similarly defined stage groups,reveal a five year disease free survival (DFS) figuresof 28-33% and five year overall survival (OS) of40-44o/o [4,5]. This underscores the need for theimplementation of systemic therapy at the time ofdiagnosis to tackle the certain but undemonsffatedmicrometastasis and to make effective local controlpossible by surgery and radiotherapy.
As can be seen from the above, LABC meritsintensive multimodality therapy and current thera-peutic schedules are certainly aggressive. Often thepoor nutrit ional status of the patient, which is acombined effect of the advanced malignant lesionand the underprivileged socio-economic status, thetoxicify of chemotherapeutic drugs severely re-stricts treatment options. Number of randomizedcontrolled trials, comparing chemotherapy andchemoendocrine therapy in advanced breast cancer,have shown that combination chemohormono-therapy produces a higher response rate and prolon-gation of disease free survival (DFS). Overall sur-vival benefit has not been shown conclusivelv as vet.
Fie. I : Current Mult i Modal
No Response
II
Mitomycin
It
Mitoxantrone
CM
CMF - Cyclophosphami
however the early data is et
THE RATIONALE
The rationale for combinlies in the hope of exploi 'between chemotheraPY iBreast cancers exist as mixgen receptor positive)and Itor negative) tumor cells [8been known for many yeanby estrogen's. Estrogen's Iincrease production of TGD. It decreases production <mitogenic, metastatic andsimilarly controlled. A redeprivation of estrogen otestrogen's [9].
Even ER - VE tumors tcgrorvth modulation bY esttrine growth stimulation effpresent in the tumor. A cotbition is seen on estrogen vadministration. l3% of EIobjective response to tamc
Jour. ltlarine ll[edical Socieq
No
Ra<
*Classified Specialist in Surgery and Oncosurgeon; #Classified Specialist in Surgery and Oncosurgery; +Craded Specialist in Medicineand Medical Oncologist; INHS Asvini, Mumbai 400 005.
Jour. Marine Medical Society, June 1996, tr'ol. 3, No. I50
i ,r. , ' aurrunt Multi Modality Treatment Protocols for LABCLocally Advanced Breast Cancer
II
Diagnosis and staging
II
Induction Chemotherapy { CAF/CMF }
lompletely com partmentalI at presentation. The poor-bination chemotherapy andticle discusses the rat ionalerinetic interactions between
)hemoendotherapy.
f distant metastasis during
[3]. Analysis of pubtishedisive multimodalify treat-rly defined stage groups,iee survival (DFS) figuresoverall survival (OS) ofrscores the need for thetic therapy at the time ofrtain but undemonstratedfte effective local controldiotherapy.
:he above, LABC meritsterapy and cunent thera-nly aggressive. Often thethe patient, which is a
vanced malignant lesioncio-economic status, theutic drugs severely re-Number of randomizeding chemotherapy andadvanced breast cancer,tation chemohormono-esponse rate and prolon-ival (DFS). Overall sur-own conclusively as yet,
3raded Specialist in Medicine
t, June 1996, Itol. 3, No. l
No Response
II
RadiotherapyResponse
II
Surgery
III
CMF/CAF 3 Cycles
Response
II
SurgeryCMF/CAF 3 Cycles
II
Radiotherapy
No Response
It
Mitomycin
IMitoxantrone
however the early data is encouraging [7].
THE RATIONALE
The rationale for combining these two modalit ieslies in the hope of exploit ing kinetic interactionsbetween chemotherapy and hormone therapy.Breast cancers exist as mixtures of ER + VE (estro-gen receptor positive) and ER - VE (estrogen recep-tor negative) tumor cells [8]. ER + VE tumors havebeen known for many years to be growth stimulatedby estrogen's. Estrogen's have also been shown toincrease production of TGF a and 52 K CathepsinD. lt decreases production of TGF p and in addition,mitogenic, metastatic and differentiated status issimilarly controlled. A reverse effect is seen ondeprivation of estrogen or with exhibit ion of antiestrogen's [9].
Even ER - VE tumors to a certain extent undergogrowth modulation by estrogen's due to the parac-rine growth stimulation effect of ER + VE cells l inespresent in the tumor. A conesponding growth inhi-bition is seen on estrogen withdrawal and tamoxifenadministration. l3oh of ER - VE tumors exhibit anobjective response to tamoxifen [ 0].
Jour. Marine tr4edical Society, June 1996, Vol. 3, No. I
CMF - Cyclophospharnide; Methotrexate : 5 Flurouracil;CAF - Cyclophosphamide; Adriamycin; 5 Flurouracil
Hormones act directly on ER + VE cells whichare on the whole better differentiated and indirectlvon ER - VE cells.
Chemotherapy acts on ER - VE cells which aremore rapidly cycling as seen by the higher tumorload index (TLI), S phase fraction and aneuploidy.
Chemohormonotherapy aims at two different tar-get population of cells making up the tumor. Thenegative interactions reported between chemother-apy and hormone therapy stem from studies usingtamoxifen. Alteration of hepatic enzymes, myelo-suppression (with its resultant reduction inchemotherapeutic dose and frequency) and altera-tion in cell permeabil ity could explain the less thanadditive outcome.
The positive effect of concurrent chemoendo-crine therapy in postmenopausal women is undis-puted I I ]. In younger women in whom chemother-apy has been shown to more effective, paft of theeffect is attributed to chemical castration as indeedstudies have shown that women achieving persistentamenorrhoea during chemotherapy have an im-proved outcome as compared to those who continueto menstruate [2]. In this group, exhibit ion of the
51
OESTR@EN
INHIBTTION OF TGF P
Fig. 2 : Figure showing the autocrine and paracrine growth modulation ol'breast cancer cells
weakly estrogenic drug tamoxifen could well ex-plain the poorer outcome. On the other hand oo-phorectomy achieved surgically at the commence-ment oftreatrnent effectively cuts offestrogen levelmuch earlier. ER + VE cells in the tumor are specifi-cally targeted with the resultant drop in autocrineand paracrine growth and metastasis promoting se-cretions. The uninhibited,cycling ER - VE cells areavailable for the cytocidal chemotherapeutic drugs.
The current multi treatment protocol for LABCin shown in Fig. I and hormonal interactions areshown i n F ig .2 .
An overview of controlled randomized trials ofadjuvant therapy, covering 133 randomized trialsinvolving 31,000 recurrences and 24,000 deathsamong 75,000 women has confirmed that ovarianablation and cyclophosphamide, methotrexate, 5-fluroacil (CMF) confer a significant advantage tothe survival of women less than 50 years of age withearlv breast cancer. ahd that there is an additional
52K160 KPs2mRNA
gain from ovarian ablation in those women givenCMF. The issue of their relative value is sti l l unre-solved [3]. The adjuvant ovarian ablation versusCMF chemotherapy trial in premenopausal women,"The Scotiish Trial", suggests that ovarian ablationand chemotherapy affect different tumor types andto an extent, explains the accrued advantage ofbothforms of therapy noted in the overview [4].
Most patients in India are unable to afford thehigh cost of adriamycin and are usually treated withCMF. The mixed population of ER + VE and ER -
VE clones in any given breast cancer tumor popula-tion leave a window to exploit the kinetic interac-tions between the autocrine and paracrine growthmodulations made possible by concurrent chemo-hormonotherapy.
CONCLUSION
LABC is a common c l in ica l condi t ion in India, atherapeutic challenge, requiring an innovative and acost effective solution. Concurrent chemoen-
Jour. Marine Medical Societv. June 1996. Ilol. 3. No. l
dotherapy of locally ad'such solution. Since arcontrolled trial on the sument of large number <studied over at least fivrpublished with a view t,cians for a collaborativesis in our own setting.
R[[ERENCESl. Booser DJ, Hortobagyl C
breast cancer. Seminars it
2. Hospital Cancer RegistryReport 1990.
3. Rubcns RD, Amitage P.Prognosis in inoperable IEuropean Journal oJCan
4. Van Dongen JA. Supracltlre trcatment of breast c1977: | : 306-8.
5. Hortobagyi CN. Ames F(of stage lll prinrary breasapy, surgery, and radiatiort 6 .
6. Be-Baruch N. Lippman Imodality therapy in locall'(Mccling Abstract). Proc1 9 9 2 ; l l : 4 6 0 .
7. Pronzato P. Scrtoli MR,Arsequential adjLrvant chcr
PARACRINE CRO\YIH FACTORS
Jour. Marine Medical Socr
52Kt60KF92MRNA
)WII{FACIDRS
t in those women givenlative value is still unre-ovarian ablation versuspremenopausal women,sts that ovarian ablationifferent tumor types andcrued advantage ofbothte overview [4].re unable to afford theare usually treated withn ofER + VE and ER -
st cancer tumor popula-rloit the kinetic interac-: and paracrine growthby concurrent chemo-
:al condition in India. aing an innovative and aloncurrent chemoen-
June 1996. Vol.3. No. I
dotherapy of locally advanced breast cancer is one
such solution. Since any prospective randomized
controlled trial on the subject would require recruit-
ment of large number of volunteer patients, to be
studied over at least five years, this article is beingpublished with a view to recruit l ike minded clini-
cians for a collaborative effort to study the hypothe-
sis in our own setting.
REFERENCESl. Booser DJ, Hortobagyl GN. Treatment oflocally advanced
breast cancer. Seminars in Oncolog 19921' 19: 278-88.
2. Hospital Cancer Registry, Tata Memorial Hospital. AnnualReport 1990.
3. Rubcns RD, Armitage P. Winter PJ, Tong D, Hayward JL.Prognosis in inoperable stage lll carcinoma ofthe breast.European Journal ofCancer 1977: 13 : 805-l I
4. Van Dongen JA. Supraclavicular biopsy as a guideline forthe treatment of breast cancet. ll/orld Journal of Surgery1977: l :306-8 .
5. Hortobagyi CN, Ames FC. Buzdar AU, et al. Managementofstage lll prinrary breast cancer with primary chentother-apy, surgery, and radiation therapy. Cancer 1988:62 : 2507-t 6 .
6. Be-Baruch N, Lippman ME, Pierce LJ, et al. Combinedmodality therapy in locally advanced breast cancer (LABC)(Meeting Abstract). Proc Annu Meet Am Soc CIin Oncol1 9 9 2 : l l : , { 6 0 .
7. Pronzato P, Sertol i MR, Amoroso D, et a/. Concurrent versussequential adjuvant chemohormonotherapy for stage ll
Jour. Marine Medical Societv, June 1996, Vol. 3, No. I
breast cancer. [n : Salmon P ed. Adjuvant therapy ofcancerVI JB Lipincott. Philadelphia 1990'.297-304.
8. King WJ. Comparison of immunocytochemical and steriodbinding assays for estrogen receptors itr humatr breast tu-mors. Cancer Research 1985:45 :294-304.
9. Dickson RB, Knabbe C. Bates SE, et al. Crowth fhctors,receptors and oncogenes in breast cancer. Itt Mittra l. DesaiPB eds. Current perspectives in breast cancer, Tata McCrarvHil l . New Delhi. 1988: 73-80.
10. Lippman ME, Dickson RB, Bates S, el a/. Autocrinc andparacrine growth regulation ofhunran breast cancer. Breastcancer research and treatnrent. 1986; 7 : 59-70.
I l. Kaufman M, Jonat W, Abel U et al. Adjwant randomizedtrials of doxorubicin/cyclophosphamide versus doxoru-bicin/cyclophosphamide/tanoxifen and CMF chenrothcr-apy versus tamoxitbn in women with node-positive breastcancer.Journal oJClinical Oncologt 1993: I I :454-60.
12. Bees LVA. Adjuvant chemotherapy-in premenopausal pa-tients with prinrary breast cancer. relation to drug inducedanrenonhoea, age and the progestrone receptor status oflumour. European Journal ofClinical Oncologt 1988:4 :'t19-2t.
13. Early Breast Cancer Trail Collaborative Group. Systenictrsatment ofearly breast cancer by hormonal, cytotoxic, orimnrtrne therapy. Lancet 1992',339: l-15 and 7l-85.
14. Scottish Cancer Trail. Breast Group and ICRF Breast Unit,Guy's hospital, London. Adjuvant ovarian ablation versusCMF chemotherapy in premenopausal women with patho-logical stage ll breast carcinonra: The Scottish trial. Lancet1993;341 : 1293-98.
J3
Cqse ReportTRAN SIENT HEMIPLEGIA FOLLOWINGA SINGLE CLINICAL HYPERBARIC OXYGEN(HBO)EXPOSURE AT 2.5 ATA
Surg Cdr MJ JC)HN*, Surg Cdr S NANGPAL+,
Dr VJ RUPAREL#, Surg Cdr A BANNERJEE++,
Surg Cdr KK DUTTA GUPTA**
ABSTRACT
Patients of diabetic foot are routinely treated with hyperbaric oxygcn (HBO) at our Inst i tute. Most of the cascstolerate therapy without any adverse effect and almost al l patients benefi t from this modali ty. l lowever,ocassional ly a few cases, especial ly with uncontrol led diabetes on insul in therapy or with covert cardiovascularpa tho logy or hyper tens ion , can sudden ly deve lop compl ica t ions necess i ta t ing d iscont inunt ion o f HBO. Our pa t ien tsudden ly deve loped ton ic -c lon ic se izures in the chamber fo l lowed by t rans ien t hemip leg ia and s igns o f le f tventr iculnr fai lure. Although the recovery was complete and uneventful l , a careful evaluation ofal l patients priorto admin is t ra t ion o f HBO is recommended.
KEY WORDS: Diabetic foot, t lyperbaric oxygen.
teristic ofcerebral orhypersensitiG indiviably precipitated bywhich was further agoxygen induced seizubeenreportedat l :10,inc idence is much h ines hastens and incrtoxicity and hypogl'counter-regulatory h(nes [2,3] .
All these f'actors rcantly to lowered threpatient had been on Mand dinner. This schtowards the afternoorpresent case, HBO haafter the last meal.hypoglycemia requiridergoing HBO therappatient treatments an(patient treatnrent.Thetremors, anxiety, confnormal behaviour andoxygen toxicity does rthe parlial pressure of
In the present case, tfundus examinat ion. Asciousness occurred insion and the hemiparellater. The two do not atrbly a vasospasm induccaused the neurologicmaintained for a few mdamage of the vascularfocal cerebral ischaem
There is an increasethrornbosis and infarcthyperviscosity and hyscan and other invest
( ]ASE REPORI'
A (r0 lcars o ld nralc * ' i th Non Insul in Dcpcndent DiabetcsMellitus of live lears duration rvas rel'crcd lbr llBO, fbr a largenon heal ing ulcer (20cm x 6 crn) over the antero medial aspect ofh is le l i lcg. of s ix ntonths durat ion. Cl in ical examinat ion did notrevcal any cardiovascular . gastro intcst inal . ncurological (CNS)
or respiratory systcm anornall', cxcept for an cnlarged liver.
F-undus cxanr inat ion rcvealcd grade l l d iabct ic ret inopathy wi th
nraculopathl , . Befbre being taken up for l lBO therapy, b loodsugar was 190 nrg% arrd he rvas running tenrperature of l0 l " [ r . ,had tachycardia o l '120/min and his UP rvas l4(r /100 rnnr l lg .X-ray ' ( l . t ) leg sho* 'ed osteom.vel i t ic changcs in the nredia lnral leolus. I tscudomonas acruginosa was grown on cul turc l iomthc local s i to. ECC and X-ra1'chcst rverc normal . l le rvas oninsu l i n .
ilBO PROTOCOT-
Pat icnt rvas compressed to l -5 nrcters s ' i th a i r . in a largcnrLr l t ip lace therapeut ic chambcr. uncvent l i r l ly ' , a long \ \ ' r th threcothcr pr t ients and a nrcdical at tcndanl . n t I 5 mctcrs. a l l pat ients
u'cre put on oxygcn brcath ing throLrgh t)l BS. Th irty nr in utes allcrbcing on BI BS, thc pat ient bccamc rcst lcss. palc and rvas srvcat ingand brcathlcss. Pat ient suddcnl l had a tonic-c lorr ic seizLrrc o l '45scconds to onc minutc dLrration. Scizurqs wcre controllcd bydiscont inuat ion ol - oxygen inhalat ion. Neurologic exanr inat iond id not rcveal any I ur thcr abnorrnal i t l . Pat icnt rvas conscious. butdisuriented. He was transt'crcd to the cmcrgency lock and gradu-
al ly deconrprcsscd. On sur l 'aoe. c l in ical ly he shorvcd the sanre
pictLrrc as bcfbre. but thc IJI ' recorded rvas l6r l /100 rnrn of I lgand he contpla incd ofdi rn in ishe<l v is ion. Pat icnt rvas given In j .Pentoxyphyl l ine and In j [ ; rusemide. t : ig l r t hours latcr , pat icntshorved mental obtundat ion. s l ight facia l assvmctn and hsrni-parcsis o l ' thc r ight s idc rv i th an cxtsnsor p lantar . No cxtrapyramidal signs rvere dctected. FLrndus rvas nornral except lirr pre
exist ing rct inopathy.
[ .aboratory invest igat ions including I lb. I 'LC. D[ .C and sc-runl cnzvnles werc nornral. l}lood sugar rvas 4.1 nrg%. liorrr horrrslatcr . the pat icnt had an cpisodc ol haenratenrcsis. C' l scan ol ' thchcad and chest X-ray u,crc norrnal.
Pat icnt was managcd conscrvat ivc l ) ' \ \ , i th I V l lu ios and drLrgsas bcfbre. Sixteen hours later , thc pat ient shoivcd s l rg l r t inrprovc-mcnt in h is mcntal status. I Ie could speak and obcl 'cd vcrbalcornrrands.
' l hc v isual dcf ic i t remaincd onlv on thc r ig l r t s idc.
Wcakness of the r ight s ide dccrcascd u ' r th porvcr of( j r . l l /V inboth uppcr and lorver l inrbs.24 hours al ter l l l lo . the pat icnt 'slcvel o l 'consciousncss cont inucd to in lprovc but hc \ \ 'cnt into lc l ivcntr icLr lar fa i lurc rvhich rvas managcd on convcnt ional l i r res.[ "o l lotv up al tcr t \ \ 'o u 'ceks rcvealcd a po\ \cr o l 'Cir lV/V and af'erv ba-sal crcpitations rvrth no lircial asvnlmctn and norrlulnrcntal s tatus. I ichocardiography shorred poor lc l i vcntr icularf i rnct ion. a lorv e. ;ect ion l iact ion and a nr ld d i latat ion ol thcvcntr ic lc .
DISCUSSION
Tonic-c lonic tvoe of convuls ions are charac-
*Classi l ied Specral is t Mar i r rc Mcdrcinc. +Classi l icd Special is t Mar ins Mcdic i r re . #P( i ' f ra incc Mar inc Mcdic inc. ++Classi l icd Spccia l is tMcdic inc & Neurology' . * tClassi l icd Special is t l 'SNl . lnst i tute o1'Naval Mcdic inc. MLrnrbai .100 005.
.Jour. ll.larinc lt'ledicul Socicttt. June 1996, I'ol. 3. ,\o. l Jour. ,I'lurine llledical Sor
titute. Most of the caseshis modali ty, However,h cover"t card iovnscularion of HBO. Our patientplegia and signs of leftrt ion of af l patients prior
led was 160/100 nrm of I lgision. Paticnt rvas givcn Ir1.;. Eight hours later. patientfacial assymctry and henti-extensor plantar. No exlraus was nomtal except for pre
ling Hb, lLC, DLC and se-gar was 44 nrg%. FoLrr hoLrrslematentesis. C'l' scan of thc
,ely rvith IV flui<rs and drugslient showed sl ight inrprovc-d speak and obcl,ed vcrbalined only on rhc right side.C with power of Clr. IIlV inrs after HBO. thc paticnt'snprove but hc rvcnt into leltged on convcnt ional l ines.a porver ofCr IViV and aal asymmetry and nornral)wed poor lcft ventriculard a mi ld d i latat ion ot ' thc
vulsions are charac-
ne. ++Classi lied Specialist
une 1996, t 'o \ .3, ho. I
teristic of cerebral oxygen toxicity in an otherwisehypersensitiG individual. The seizures were prob-ably precipitated by high fever and hypoglycemia,which was further aggravated by HBO. The risk ofoxygen induced seizures during HBO treatment hasbeen reported at I : I 0,000, although in diabetics, theincidence is much higher. Release of catecholami-nes hastens and increases the severity of oxygentoxicity and hypoglycaemia enhances release ofcounter-regulatory hormones such as catecholami-nes [2,3] .
All these factors may have contributed signifi-cantly to lowered threshold for oxygen toxicity. Thepatient had been on Mixtard insulin before breakfastand dinner. This schedule leads to hypoglycemiatowards the afternoon or late morning hours. In thepresent case, HBO had been given four to five hoursafter the last meal. The incidence of significanthypoglycemia requiring intervention in patients un-dergoing HBO therapy is 0.73 events per 100 totalpatient treatments and 1.3 events per 100 diabeticpatient treatment.The symptoms include sweating,tremors, anxiety, confusion, blunted cognition, ab-norrnal behaviour and loss of consciousness. CNSoxygen toxicity does not lead to any sequelae oncethe partial pressure ofoxygen drops.
In the present case, there was no papil loedema onfundus examination. Also, the disturbance of con-sciousness occurred immediately after the convul-sion and the hemiparesis appeared about six hourslater. The two do not appear to be connected. Possi-bly a vasospasm induced by hyperoxia could havecaused the neurological deficit. This vasospasmmaintained for a few minutes could lead to hypoxicdamage ofthe vascular endothel ium and consequentfocal cerebral ischaem ia.
There is an increased tendency towards cerebralthrombosis and infarction in diabetics because ofhyperviscosiry and hyperlipidemia. Although CTscan and other investigations did not reveal any
infarct, it is possible that the hemiparesis whichdeveloped six to eight hours after the incident andshowed progressive recovery over three to four daysperiod, could be due to acute cerebral vasospasm,which in the setting of diabetic angiopathy, has beenvariously reported in the literature.
Echocardiography showed poor left ventricularfunction, a low ejection fraction and mild dilatationof the ventricle. It is probable that the stress of theconvulsion and the stroke in addition to the toxemiaprecipitated the left ventricular failure. At our Insti-tute, this phenomena has been noted in the pastwhere a patient with hypertension or CAD with noovert evidence of cardiac decompensation have af-ter a single exposure shown signs of left venticularfailure.
ft is evident from the Veceeding nanativc that acarefu I clinical evaluation of all patients undergoingHBO is vital. The cardio pulmonary status of thepatient needs careful evaluation to avoid unneces-sary morbidity, although most of the complicationsare self l imiting and revert back to normal withconservative management
REFERENCES
L Hampson NB, Simonsm SC. Kranes CC. Piantadosi CA,Central nervous systenl oxygen toxicity during hyperbarictrcatments ofacute CO poisoning. Under sea and l-lyperbaricMedic ine Society Annual General Scient i l lc meet in g. 22-26Jun 94. Vol 2 l Page 13.
2. Clark JM, Fisher AB, Oxygen toxic i ty and extcnsion oftolerance in therapy. Chapter 6 Hyperbaric oxygen therapyedi ted by JC Davis and TK Hunt. Undcr Sea Medical Soci-ety, Bethesda USA 1977 Page 70.
3. Endocrine and Metabolic disease. Chaplcr 13 page 678,Davidson principle and practice of medicine. Ediled byChristopher RW, Edwards A.D. Boucher Sixteenth editiont992.
4. Edwin Berman. Atherosclerosis and other tbrnrs of artcrio-sclerosis. l jarr ison's Pr incip les of lnternal Medic ine, 1994;i l 14.
Jour. Marine Medical Society, June 1996, L'ol. 3, No 55
Case ReportAIR-EMBOLISM COMPLICATING HAEMODIALYSISFOR CHRONIC RENAL FAILURE TREATMENTWITH HYPERBARIC OXYGENATION
Surg Cdr S NANGPAL*, Surg Cdr MJ JOHN+,Surg Cdr KK DUTTA GUPTA#, Surg Lt CS SAXENA**,Surg Cdr R MALIK++
ABSTRACT
A pat ien t undergo ing haemodia lys is fo r chron ic renn l fa i lu re deve loped pu lmonary a i r -embo l ism due to fau l tywarning device of the pump, fol lowed by neurological effects and sequelae of pulmonary oedema. Patient wastreated with therapeutic recompression which lead to complete recovery.
KEY WORDS: Venous gas embol ism, Therapeut ic recompress ion , HBO, A i r -embo l ism.
nary vasculature causesl in ing resul t ing in pulm<ol 'A-V shunts, which crembol isat ion [5,6,7] .
Asyrnptomatic patentto be present in20-30% tThis can directly shunt gto arterial side and lead t
[3 ] . S ince subsequent indid not show a patent forthe venous circulation rdevice, when the pumpthe accidental emptying <sis circuit. Later, the air ccirculation because of faveoli to fi l ter out the air lrespiratory and neurologtory distress, pain chest, cin sensorium, disorientatdefects.
The patient had full rea nrodified I-lBO protocot ion of g iv ing HBO at 2.1minutes rvith cascade dec
Jour. ltlarine ltledical Socie
CASE REPOR'I '
A 32 1 'ear o ld sold ier . a case ol 'chronic rcnal fa i lurc, rvhi lcundcrgoing hacnrodial-vsis surldcnly dcveloped rcspiratory dis-tress and pain chcst along rvith cough. irritability, restlessness andnunrbness of bodl' rvith decreased sensations in lorver linrbs.i lacnrodialys is rvas discont inued bccause ai r embol ism. fo l lorv-ing l i r i lurc o l ' the warning dcvice of thc ptrmp, was suspectct l andpatient was put in hcad dorvn, left lateral position. Irrj. fruseomidc200 nrg and Inj. hydrocortisone 200 nrg l.V. along rvith oxl,gcn5 l i t rcs/nr in rvcre imnrediatc ly g iven. Pat ient had rro re l ic l 'andwas rcl-crred lbr emergency hyperbaric oxygen therapy (FIBO).
Cl in ical cxanr inat ion rcvcaled a conscious. though conl i rsedpat icnt . \v i th tachlcardia l32imin, B.P 180/104 mm of l lg . .tachy'pnoea ol '34/min. and he had bi - lateral basal crepi tat ions.Plantar rcf lcx on r ight s idc was extensor. rvhi ls on the lef t s idc*'as cquivocal, rvith brisk knec jerks. Abdonrinal rcllexes 'rverc
abscnt. Scusations rverc dccrcased in both the lowci limbs. nroreso on the r ight s ide. X-ray chest . PA vi*v. rvas nornral . Acl in icaldiagnosis of'nrassivc air cmbolism u'as nrade. Patient rvas inrmc-diate l ) , t ransfcrred to thc FIBO faci l i tv o i Inst i tute of NavalMcdic inc, u 'hcrc hc u,as placed in a nrul t ip lacc therapeut ic rc-conrprcssion chamber and conrpressed to 2.5 atn losphcrcs (A' l A)( I 5 nrctcrs sea water) $ hilc breathing pure ox) gcn. Paticnt tolcr-atcd thcrapy vcry rvel l and rv i th in 20-25 rn in sta(cd f ic l ing bel tcrwith rcduction in chcst pain and rcspiratory distrcss. HIIO rvashon'cvcr continucd fbr 60 minutes and patient n'ar dccomprcssedovcr a pcr iod ol ' l 0 minutcs rvhi le brcathing oxygcn.
On surfacing, patient rvas totally as1'nrptonratic. 'fherc
rvasno complaint ofpain chest or rcspiratory distress. Pulse rate canrcdou'n to 96/nr in and the B.P. 1 50/100 mnr of l lg . Chest s,as c lcarand the rellexes and lhe sensations rvere lbund to bc nonnal.
[]ollow up aficr 72 hours rcvealcd lirll rccovcry. rvith no ncuro-krgical dcf ic i t .
DISCUSSION
Air-embolism is a are rare, though serious. com-plication of diving and submarine practice. ln ananalysis of 10,000 simulated submarine escapes,only two cases of air-embolic complications werereported I I ]. Leitch and Green ( I 986) have reported140 cases ofdecompression related barotrauma overa twenty year period [2]. Air-ernbolism as a compli-cation of surgery, particularly cardiac surgery, is aknown entity. However this complication arisingduring haemodialysis for any indication is ex-tremely rare [3]. In a twenty year span, Cranrer(1986), has repor ted 43 cases of a i r -embol isrnmostly occurring frorn invasive medical procedures
t4l.In iatrogenic cases, air is either sucked into the
vein with a negative pressure or introduced into theblood vessels under pressure. The lung usual ly actsas an effective fi l ter tbr air bLrbbles greater than 22micro meter in d iarneter . A bolus in ject ion of 1.5 to3.0 ml of a i r per k i logram body weight , exceeds thefi ltering capacity of the lung and produces emboli-zation through the left heart in tlre arterial circula-t ion, t i l l i t b locks ar ter io les measur ing 30-60 rn icrometer in d iameter [3] . Ingress of a i r in to the pulno-
*C' lassi l ied Spccia l is t Mar inc Mcdic inc. +Classi l lcd Spccia l is t Mar inc Mcdic inc #C' lassi l lcd Spccia l is t I ) .S.N4. **P( l l ' ra incc Mur incMcdic ine . ++Cl iussi l led Snccia l is t Mcdic ine & NcDhrolocv.
Jour. l\lurine ll,ledic'al Socie tv. ,Jttne l()96. I:ol. 3. .\'o. l56
i r+mbolism due to faultytary oedema. Pntient was
n.
I full recovery, with no neuro-
re, though serious, com-tbmarine practice. In anfed submarine escapes,olic complications wereeen ( 1986) have repor-tedt related barotrauma overir-embolism as a compli-rly cardiac surgery, is aris complication arising
any indication is ex-enty year span, Cramercases of air-embolismsive medical procedures
is either sucked into there or introduced into the'e. The lung usually actsbubbles greater than 22bolus injection of 1.5 toody weight, exceeds theg and produces emboli-t in the arterial circula-measuring 30-60 micross of air into the pulmo-
P.S.M. t*PG Trainec Mar inc
', Jttne 1996, l"ol. 3. No. I
nary vasculature causes damage to the endotheliall ining resulting in pulmonary oedema and openingof A-V shunts, which can also lead to arterial gasembolisation 15,6,' l l .
Asymptomatic patent foramen ovale is reportedto be present in20-30Yo of normal adult population.This can directly shunt gas-emboli from the venousto arterial side and lead to arterial gas-embolisation
[3]. Since subsequent investigations in this patientdid not show a patent foramen ovale, the air enteredthe venous circulation due to failure of warningdevice, when the pump continued to operate afterthe accidental emptying of saline bottle in the dialy-sis circuit. Later, the air directly reached the arterialcirculation because of failure of the pulmonary al-veoli to fi l ter out the air bubbles resulting in cardiorespiratory and neurological signs such as respira-tory distress, pain chest, cough, restlessness, changein sensorium, disorientation and focal neurologicaldefects.
The patient had full recovery on being exhibiteda modified HBO protocol. The usual recommenda-tion of giving HBO at 2.8 ATA for 2 hours and l5minutds with cascade decompression in the cases of
Jour. Marine Medical Society, June 1996, Vol. 3, No.
gas embolism, though str ict ly adhered to in divingaccidents, was not used in the cl inical sett ing, as themodified regime has been used in the past at ourlnstitute with complete reversion of the pathology,
as was seen this case.
REFERENCES
l. Joglekar AM, et a l. Proceedings of the national conferencein marine and hyperbaric medicine, Bombay. I994.
2. Leitch DR, Grcen RD. Pulmonary barotrauma in divers andtreatnrent ofcerebral arterial gas-embolism. Av Space Envi-ron Med l 986; 57 : 93 I -38.
3. Jain KK. Text book of hyperbaric medicine, tlnd edition1996:137-45.
4. Cranrer FS. Air-embolism: Proceedings of first Europeanconference in hyperbaric ntedicine, Amsterdanr. Sept 1986;7-9
5. Bennet PB, El l iot DH. The physiology and nredicine ofdiving. Fourth edition. l.'enous gas bubbles 490.
6. EdmondsC. LowryC, Pennef'atherJ. Divingandsub-aquaticmcdicine. Third edition. L'enous gas emboli 150-52.
7. Wirewich CVZ, Mullar NL. Abboud RT. Leparvicky M.Non cardiogenic pulmonary oedenra caused by decompres-sion sickness. Rapid resolution tbllowing hypcrbaric therapyRadiology. 1987; 163 : 8l-82.
57
o .
Cose ReportURTICAzuA PIGMENTOSA
Surg Lt Cdr S NARAYAN*, Lt Col P RAMADASAN**,Surg Cdr MK GUPTA*"*
ABSTRACT
Urticaria pigmentosa is a form of mastocytosis with excessive mast cel l accumulation in the skin. This rarecondit ion, usually has i ts onset in infancy or early chi ldhood and produces characterist ic lesions that tend to clearup by adolescence. The case of a boy aged three years with typical history and cl inical features of urt icariapigmentosa is reported.
KEY WORDS : Mastocytosis, Urticaria pigmentosa
INTRODUCTION demonstrate a l ight perivascular infi l trate [3].The usual treatment of urticaria pigmentosa in-
volves a combination of H-l and H-2 receptorblockers fl,2]. There is one Indian report of treat-ment with the serotonin reuptake inhibitor drug,Doxipen [4].
The rarity of this entity and the rypical presenta-tion in our patient prompted us to repoft this case.
CASE REPORT
A boy aged threc years. presented rvith a history ofredncss,itching and pigmented spots scattered all over ihe body. He wasthe third child ofnon-consanguinous parents. A full terrn nornraldelivery. he was treated lbr neonatal septicemia (blood culturegrew strcptococci) and he recovered uneventfillly. At threemonths of age, he started having periodic episodes of f'cver,intense rcdness ofthe whole body and crops oflive to six bullaeappear ing predominant ly on the t runk and l inrbs, exccpt palms
and soles. These bullae used to errupt every ten days or so in lieshcrops, t i l l the age ofone and hal f l 'cars.
By about one and a hal f years of 'age, thc bul lae stoppedforming and mul t ip le d iscretc macules and ur t icar ia l rveals s la(edappearing all over thc body, except the palnrs and solcs. turninginto p igmented mactr lcs ovcr a per iod of t ime. Along wi th theselesions. the pat ients ' mother not iccd f lushing of the ent i re bodyof the chi ld on cry ing and intense i tching and erythema. Hisdevelopmcnt was nornral throughout.
-_--
nor \\'as tncrc any evl
l l lood counts. ur i rqral blood srrcar andrvas VDl l l . non-rcacl
bony involvenrcnt . Slcc l l in l l l t ratcs in the r
dcnronstratcd bt tolu
DISCUSSION
The typical h i :the absence ofan'our patient, promnrentosa. This uto logical ly by a rwith their onset it ient, have a goocclear up by adolehis study on the n
astocytosis comprises disorders where theprincipal abnormalify is the excessive ac-cumulation of mast cells in various body
tissues. Urticaria pigmentosa is one of the cutaneousforms of mastocytoses and in about 90% of patients,there is no systemic involvement. In about 55Yo ofpatients, the onset is between birlh and two years ofa g e I l ] .
A wide variety of cutaneous lesions l ike macules,papules, nodules, verrucae, vesicles or bullae, pete-chiae or ecchymoses, plaques and telangiectasiahave been described in urticaria pigmentosa [2]. Thecornmonest skin lesions are monomorphic pig-lnented maculopapular or nodular lesions spreadoverthe trunk in a symmetrical distribution [ ]. Firmstroking or gentle rubbing of affected skin causesurticaria with surrounding redness and wealing - thisis the diagnostic Darier's sign. Stroking may alsoproduce rveal ing in c l in ica l ly uninvolved sk in. Inabout 60%o of infants or children, blister formationmay be seen [ | ].
Despite the varied cutaneous manifestations, thehisto logical p ic ture is s t r ik ingly s imi iar , the onlydifference being in the degree of mast cell infi l tra-tion. With macules and papules, round or spindleshaped mast cells with abundant eosinophil ic cyto-plasm are mainly found in the papil lary dermis.Special stains l ike toluidine blue may be required to
On examrnat ion. he was noted to have mul t ip le p ink and darknlacules scattered all over the body except the palms and soles.A ferv urticarial rveals n'ere also seen and l)arier's sign rvasstrongly posrt ive. Thcre was no vesicular or u lccrated lesion. l la i rand nails were not involved. Mucosal nrcnrbranes rverc urtin-volved. ' I l rcrc was no c l in ical evidence ol systemic involvement,
*Graded Special is t (Pediatr ics) ' **Classi f led Special is t (Dermatologr and Venerology)Hematology); INHS Kalyani . Gandhigram Post . Visakhapatnam - 530 005.
Special is t (Pathology and
Jour. Marine Medical Societv. June 1996. l'ol. 3. No. lJ8 Jour. lvlarine lt[edic
the skin. This rarerns thf,t tend to clearieatures of urticaria
'infiltrate [3].ria pigmentosa in-and H-2 receptor
lian report of heat-rke inhibitor drug,
he typical presenta-lo report this case.
vith a history of redness,ll over the body. He wasrents. A full term nomral:pticemia (blood cultureuneventfully. At three
iodic episodes of fever,rop offive to six bullaemd linbs, except palmsrry ten days or so in fiesh
Uo, the bullae stoppedd urticarial weals startedralms and soles, turningtime. Along with thesehing of the entire bodying and erythema. His
multiple pink and dark,t the palms and soles.md Darier's sign wasr ulcerated lesion. Hairembranes were unin-'ystemic involvement,
ialist (Pathology and
t996, I/ot. 3, No. I
nor was there any evidence ofbleeding diathesis.
Blood counts, urinalysis,bleeding and clotting times, periph-
eral blood snrear and liver function tests were all nomtal. Blood
rvas VDRL non-reactor. There was no radiological evidence of
bony involvement. Skin biopsy sections revealed the typical mast
ccll infiltrates in the dernris with metachromatic granules being
demonstrated by toluidine staining.
DISCUSSION
The typical history and course ofthe disease andthe absence of any signs of systemic involvement inour patient, prompted a diagnosis of urticaria pig-mentosa. This was subsequently confirmed his-tologically by a skin biopsy. The multiple lesionswith their onset in infancy, as occurred in our pa-tient, have a good prognosis. These lesions tend toclear up by adolescence as described by Caplan inhis study on the natural course of urticaria pigmen-
Jour. Marine Medical Societv, June 1996, VoL 3, No. I
tosa [5]. Our patient is on a combination of antihis-taminics and is on follow-up.
REFERf,NCES
l. Creaves MW. Mastocytoses. ln : Champion RH, Burton JL,Ebling FJG, eds. Textbook of Dermatology, Oxford : Black-wef f Scientific Publications. 1992: 2065-68.
2. Sarasrvat PK, Laha NN. Urticaria pigme rtosa. Ind J Dertna-tol Venereol Leprol 1985:5 I : | 68-69.
3. McKee PH. Pathology of the skin with clinical correlations.JB Lippincot Co . 1992 :31 .
4. Chosh S, Flalder B, Sengupta S. Therapeutic response ofurticaria pigmentosa to doxipen. Ind J Dermatol l/enereolLeprol 1988:'54 : 2l l-13.
5. Caplan RM. The natural courseofurticariapignrentosa. ArchDermatol 1963: 87 : 146-57.
59
Case ReportACUTE RENAL FAILURE IN A CASE OFNECROTISING GRANULOMATOUS VASCULITIS
Lt Col S BHATTACHARYA, Surg Lt Cdr H MANI,Col AK HUKKOO
ABSTRACT
Vnsculit is has always been easier to define than to accurately diagnose. Clinically it may manifest itself locally(e.g. skin) or as a systemic involvement (multiorgan). Acute Renal Failure (ARF) secondary to vascutit is is not socommon. A 55 year old male, who init ially presented with non specific symptoms went into ARF. Autopsy findingsconfirmed the diagnosis of necrotising granulomatous vasculit is (NGV) i.e. Wegeners Granulomatosis.
KEY woRDS : Acute renal failure (ARF), Necrotising granulomatous vasculit is (NGV)
'r,.\BLU tOrgrtn invo
Vascul i t id is
( i iarr t ( 'c l l
1'l enrporalArtcr i t is)'l
akavasus/ \ r tcr i t is
I ) ( ) lv n r lcr i t iNodosa
K a* asakisSr ndronrc
M icroscopicI)o1."'angitis
\\'cgcncrs( i ranulonrato
'r',\Bt.|.] 2Schcnrat ic r r
n orta
l.rtrge to N4cd
Sized Artcry
Snrall Artery
Artcrro lc
( api I larv
VcnLr lc
Vc in
CASE REPORI'
A 5-5 ) iears o ld nrale rvas in i t ia l ly adrni t ted in a per ipheralmi l i tnry hospi ta l on 4th Aug 95 rv i th complaints and c l in icalf indir rgs suggest ivc of 'acute bronchi t is . Radiological ly non ho-mogeneous opaci t ies werc seen in the lef t lower zone and r ightnriddle zonc ofthe lungs. He was treated with antibiotics and hada transient response. l-le had recurrence of fever and persistenceol ' radio logical lung l indings and was subsequent ly t reated cm-pcrically rvith antimalarials. follorvcd by treatment for entcricf'cver and was also given ATT. Sincc he did not show an adequatercsponse, he was transt'errcd to lNtlS Asvini on 5th Oct 1995.Initial investigations revealed normal biochemical and haemato-logical paranreters. I llV and HBsAg were negative and RA factorand C-rcact ive protc in were posi t ive. Whi le st i l l bc ing managedconscrvat ivc ly, he rapid ly developed anur ia on lOth Oct 95.Blood urea rose to 200 mg7o. creatinine 14.2 ntg%o, Na I l2 mmol/L and K 6.4 m mol/L. He dcveloped pulmonary edenra andsuccunrbed to l r is i l lness on I I Oct 95. The oossib i l r t ies ofbronchi t is , malar ia. d isseminatcd tuberculosis and mal ignancywere entertained antc mortent
An autopsy was performed on I I Oct 1995. Salicnt grossfindings rverc suggestive ofbilatcral papillary necrosis, with tnthlungs shorvirrg areas of pulrnonary edema and patchy areas ofconsol idat ion. [ - iver and spleen werc congested wi th the lat terwcighing only 80 gms (atrophic) . Histopathological ly , lungsshowcd large areas of pulrnonary edema, with non caseatinggranulomas and necrot is ing vascul i t is involv ing the nr iddle andsmall size arterics. Therc werc areas of fibrinoid necrosis andtransnrural infiltration by neutrophils and lymphocytes. Sinrilarvascular lesions with perivascular granulomas were seen in thespleen, liver, oesophagus, tcstis and kidneys. ln addition 80% ofthe glomerul i ofboth kidneys showed fibrous crescents with areasofpapi l lary necrosis. Based on the c l in ical f indings, organ dist r i -but ion and the morphology of the lesions involv ing middle s ized
muscular a(eries and arterioles, a final diagnosis of Wegetrersgranulomatosis lvas arrivcd at.
DISCUSSION
The d ifferentiation between actual infl am mationof blood vessel and a mere perivascular collectionof inflammatory cells is subtle and needs histotogi-cal confirmation. In the past, vasculit is has beenclassified differently by different workers. Somebased their classification on clinical presentation,while others based it on histological f indings or onits etiopathogenesis. Copeman and Ryon Il] basedtheir classification upon the size of the vessel in-volved and whether the infi l trates were neutroph il ic,lymphocytic or granulomatous. Whereas Winkle-man et a/ classified vasculit is, based on necrosis orleukocytoclastic reaction secondary to immunecomplex, lymphocytic, mixed vasculit is or granu-lomatous deposits. Cupps and Fauci gave an exhaus-tive l ist of various fypes of vasculit is basing theirclassifi cation on clin ical presentation, infl ammatoryexudate, size ofblood vessels involved, histologicalfindings ofthe lesion and on etiopathogenesis. Thepresent classification of vasculit is was developed atthe Chapel Hi l lconsensus conference on the nomen-clature ofsystemic vasculit idis which is based on thepathogenesis and size of vessel involved [4]. Thusamongst the immunologically mediated vasculit is,it could either be immune mediated or due to directantibody attack either on the basement membrane
tClassi f ied Special is t (Pathology), Graded Special is t (Pathology), Senior Advisor (Pathology), tNl lS Asvin i . Colaba. Munrbai 400 005
Jour. Marine Medical Societv, June 1996. 3 , No. I60
* l lS I lcnoch S
(CoodpastrVascular i ranti neutr(which rvouWegners) ,nodosa). TId iated as stt r ibut ion o lvascLr l i t id isvotventent
The othr
. lo t r r . . l lar inr
TABI,E IOrgrn involvement in systcmic vasculitidis
Vasculitidis Skin Lung ctr Kidney Joints Eyes
rlf locnllyr is not sor findings
Giant Ccl l(TcmporalArtcritis)
TakayasusArteritis
Poly ArtcritisNodosa
KarvasakisSyndronre
MicroscopicPolyangitis
WegenersCranulonratosis
90% 20% 500
60%90%
75%
20Yo
60% 7 5o/o
65% 85%
50% 20o/o
WegenersTABLE 2.Schcmatic rcpresentation of vessefs involved in systemic vasculitidis
nmationlllectionistologi-tas beens. Some3ntation,gs or onll basedessel in-rophil ic,Winkle-crosis orimmunerr granu-rexhaus-ing theirnmatorytological3sis. The:loped at,nomen-ed on the41. Thusasculitis,to directembrane
Aorta
Large to MediumSized Artery
Small Artery
Arteriole
Capil lary
Venule
Vein
\ Giant
I Celli Arteritis
PAN*IMicroscopicPolyangitis
I Wegeners
IIIIII Churg
I Strauss
I Syndrome
I
III
HS*
PurpuraIIIII
\ Cutaneous
I Leucocytoclastic
I Angit is
I
,ai400 005.
l. 3, No. I
*llS Henoch Schonlein Purpura: ** PAN Polyarteritis nodosa
(Goodpastures) or on the endothelium (Kawasakis).Vascular injury could be mediated/associated byanti neutrophil cytoplasmic antibody (ANCA),which would again be due to cytoplasmic ANCA (egWegners) or perinuclear ANCA (eg peri arteritisnodosa). The immune attack could also be cell me-diated as seen in allograft organ rejection. The dis-tribution of organ involvement in various systemicvasculitidis is also important . The percentage in-volvement of various organs is depicted in Table I .
The other important determinant for classifying
,lour. A4arine Medical Societv, June 1996, Vol. 3, No. I
systemic vasculit idis is the size of the vessel in-volved, as represented in Table 2.
Hoffman et al[5] have reviewed 158 patients ofWegeners granulomatosis. From their study, it isevident that almost any organ in the body may beinvolved; the lesion may also be l imited to the lungin the form of l imited Wegeners. Histologically, themedium sized muscular arteries and afterioles areinvolved. There is f ibrinoid necrosis with destruc-tion of elastic fibres and an inflammatory exudate inthe form of neutrophils and lymphocytes. Perivas-
61
cular granulomas are often seen replete with Lang-hans type or giant cells. In addition, damage toendothelial cells may lead to vascular occlusion asa result of fibrin deposits.
REFERENCf,Sl. Copeman PWM, Ryon JJ. The problems of classification of
cutaneous angiitis with relerence to histopathology andpathogenesis. BrJ Dernt 1970;S2(Suppl 2).
2. Winkleman RK. Classification of vasculitis, Vasculitis Vol10, Major Problems in Dermatology. K Wolff, RK Winkel_
man, WB Saunders Company : philadelphia. l9g0; p l_24.
3. Cupps TR, Fauci AR. The vasculitidis, Vol 2 Maior prob_lems in Intcrnal Medicine. WB Saunders Co. : philadelnhia.1 9 8 1 .
4. Jannette JC, et al. Nomenclature of systernic vasculitides :The proposal ofan international consensus conferetrce. ArthrTheun 1994l'37 : t87 .
5. I-{offman GS. et al Wegeners granulonratosis : An analysisof 158 patients. Ann Intern Med 1992.. I l6 : 4gg.
Jour. I4arine Medical Society, June 1996, Vot. 3. No. I
Case RepoA CASE CVOLVULI
Maj SUBHAS
ABSTRACT
An unusual casemeal was foundrecu rrent type o
KEY WORDS:
INTRODUCT
A lthoughlI volvulu
I lcally armeal. It may o(symptoms of d'for this conditicRusselet diagnc1920. Delgaardthat a normal rl80o unless i ts iplenic and gastnpylorus becomestomach is full,(]ASE SUN,IITIARI
5 | year old servrvith symptorns of pyears duration. Painlhe cpigastric regioaggravated after hefullncss rvith bloatiIying dorvn and afterand systcmic examantiamocbics and anrncal stud1, revealerrv idcning of thc 'C' Ircveal any gall stonewas sought and gastsynlptonrs.
On exploration,was reduced and gsutures. Omentopcxlelt subdiaphragmatsurgcry and is asyn
Craded Special is t Su
Jour. l4arine Mea
: lphia. 1980: P l -24.
. Vol 2 Major l)rob-r sCo . : Ph i l ade lph ia .
stemic vascul i t idcs :;us conlbrcnce. z/r/,r.
natosis : An anall,sisI 16 : .188
Case ReportA CASE OF CHRONIC RECURRENTVOLVULUS OF THE STOMACH
MaJ SUBHASH CHAWLA
ABSTRACT
An un usual case ofchron ic recu rrent gastr ic volvu lus wh ich presented with sym ptoms ofdyspepsia and on bariuntmeal was found to be nn organoaxial volvulus. On explorat ion i t proved to be an idiopathic part ial , chronic,recurrent type ofvolvulus ofthe stomach. l t was treated successfut ly by gastropexy.
KEY WORDS : Volvulus stomach, Gastropexy, Organoaxial, Mesentr icoaxial.
INTRODUCTION
A l t l rough st i l l r rnconrnlon, chronic gastr icl{ volvulus has becotne recognized radiologi-
I lca l ly as an inc identa l f ind ing on bar iummeal. It nray occur without any symptoll ls or withsymptoms of dyspepsia. First successful operationfor this condition was carried out by Berg in 1896.Russelct d iagnosed th is condi t ion radio logical ly in1920. Delgaard in 1952. sho'uved in an autopsy studythat a normal stomach cannot be rotated throughI 80o unless its attachments (gastrohepatic, gastros-plenic and gastrocolic l igaments) are divided and thepylorus becomes approximated to cardia when thestomacll is full, thLrs makine the rotation easier.
CASE SUllt\t,\ttY5 | ycar o ld scrv ing sol t l ier was adnt i t ted kr a scrv icc hospi ta l
l ' i th synrptonrs ofpain abdonrcn and l i r l lness af tcr nrcals of l rvo
1'cars duration. Pain s'as localizcd to thc left hypochondriunr andthc cpigastrrc regions. u,as nr i ld and cont inuous in nalure. wasaggravatcd alicr hcavl mcals ancl hc uscd to havc a li:clins ollL l lncss rv i th b loat i r rg sensat ion. Synrptonrs rvcro re l icvcd only ing dorvn and af tcr thc pat icnt had passcd a lot ofrv ind. Gcncraland systcnric exanrination s'as norrlal. Paticnt rvas trcatcd byant iamocbics and ant ihclnr inth ic drugs. but rv i th no re l ic f . Bar iuntmcal stud1, rcvealcd a chronic organoaxial gastric volvulus an<lrv idcning of thc 'C' loop ol ' the duodcnurn. USG abdornen did notrevcal any gal l sbncs or a pancrcat ic nrass. Surgical consul tat ionrvas sought and gastropexy rvas planned in vicw ofthe pcrsistcnts),nrptonrs.
On cxplorat ion. mesentr icoaxia l volvulus tvas found rvhichwas rcduccd and gastropexy u,as donc by prolene intcrruptcdsutLrrcs. Onrcntopcxy wils donc by bringing thc onlentum to tlrelclt subdiaphragrnatic spacc. Paticnt has recovercd firlly alicrsLrrgcry arrd is as1'nrptontic. Rcpcat bariunr nreal stLrdy has re-
vcaled a nornral stonraclr.
DISCUSSION
Chronic, recurrent gastric volvulus is more cout-mon than the acute variety. It may be idiopathic orsecondary to an associated condition l ike hiatushernia, diaphragmatic hernia, eventeration of lefldiagphragm, pyloric outlet obstruction or postopera-t ive adhesions fo l lowing cholecystectomy or h ighlyselective vagotomy fl j . It may be total, partial oranterior/posterior. In anterior volvulus, pyloruspasses in front of stomach. Bariurn meal is diagnos-tic. Surgery is indicated if symptorns of chronicgastr ic vo lvulus are d isabl ing. Pat ient should beinvestigated to rule out associated conditions nren-tioned above. On exploration, careful search is rnadefbr adhesive bands, abnormal l igamental laxity. pcp-tic ulcer, tumour and other associated gonditions.
In case of id iopat l r ic vo lvulus, anter ior gas-tropexy is enough, but in secondary variety correc-tion of primary defect l ike repair of diaphragrnatichernia and d iv is ion of bands, must be done. Colonicdisplacement operation as described by Tanner [2]has shown good results in cases with eventeration ofthe diaphragm. Castrojejunostotny fixes the stotn-ach and hence prevents recurreltce ofvolvulus.
RIFEIIT]NCES
L KaLrshik SI) . Castr ic Volvulus lb l lorv ing highly sclcct ivcvagotonry . A casc rcport. Br J Surg 1979. (>6 : 574.
2. 'l
annr^r NC. Chronic and rcclrrrcnt volvulus of th(j stontachwith late rcsul ts o l 'colonic d isplacentcnt opcrat ion. ,4r , JSrrrg l9(r8; I l -5 : 505-15.
96, l'ol. 3, ,\o. I
Oraded Spccia l is t Surgcr) . MII Kamptec
.Jour. ltlarine ltledical Societv, June 1996. I'ol. 3. No. I 63
Cose ReportMALIGNANT HI STIOCYTOSIS
Surg L t Cdr S RANJAN*, Surg Cdr A BEFIL , VSM** ,Surg Cdr B FANTHOME#
ABSTRACT
l\{nl ignant hist iocytosis is a very rare disorder. I t occurs in adults and older chi ldren, but rarely has been describedin young chi ldrcn. The disease presents with general ised symptoms including fever, paltor, wasting, lymphaclc-nopathy, hepatosplenomegaly, bone and skin lesions. This rare case presented with al l the above symptoms anddiagnosis was confirmed on lymph node biopsy. He has been treated with anthracycl ine based chemotherapy an4is do ing we l l w i th no compl ica t ions so fa r .
KEY WORD: l l lal iqnant Hist iocytosis
INTRODUCTION
\
i
-
ised lymphadcutaneous infand Coomb's
Lymph no<acterised by ncells containinnent nucleolipositivity foresterase [6]. Inot as prominrchemistry of tl(a CNS specifia systemic maldothelial systermon.
Immunoharseen. Recommcytosis requirAdriamycin ccof Adriamycinmonths has ber40 months [7].
Our patienlmonths) to Vtherapies. Werescheduled hiTumour Boardtion/consolidatVAC.
Jour. ltlarine Me
hildhood histiocytosis are a rare group ofdisorders. that share a histology charac-terised b1, granulorna fonnation with infi l-
tration and proliferation of histiocytes inreticuioendothelial system (RES), resulting in gen-eralised lymphadenopathy and visceromegaly Il].To clarify the diverse group of histiocytoses; thell istiocytosis Sociery has classified this disease intoc lass I , I I and I I l , [2 ] . Class l l l be ing the rnal ignantsubtype. We describe a rare case of rnalignant histi-ocytosis.
CASI' II,DPOR'I'
Malc child. agcd live years, son o1'a scrving soldicr, presentcdu'ith gcnertlised l1'rrrphadcnopathl and hcpatosplcnomegalythree vcars ago. llc was dctccted to have Coonrb's positiveanaenr ia ( l lb ( r .5 gntTo) and a ly t ic lcs ion in the skul l . Lymph nodehiopsy rvas suggest ive ofmal ignant h is l iocytosis wi th bone ntar-rorv involvcrnent. I lc *,as lrcated with Vinblastinc-Prcdnisoloncat Pune. ilc had shorvn a partial responsc to abovc therapy andrvas rele rrcd to lNI|S-ASVINI lbr further nranagenrcnt.
I lc rvas re-evaluatcd at nralignant discases treatment ccntrc.INI IS ASV|Nl . and rvas put on l : - toposidc (Day l -3 inf i rs ion)therapl, lor six cyclcs. I)ost chernolhcrapy cvalLration rsvcaled nopcriphcral nodcs s,ith markcd rcgrcssion in hepatosplcnonrcgall,.inrprovenrcnt in hacntatologicill parantctcrs (llb | |.6 grn,Zo) anda per lbrrr rancc s latus KPS o1' 100%. I lorvever the rcnr issronduration rvas short livcd (live ntonths) and resurgcncc ol'discascoccurrcd rvith liank s)mptoms and signs. as on initial prcscnta-t ron.
1'hc paticnt rvas put on Cl,clophosphantide. Adriarnycin, Vin-
cr is t inc, I ) rcdnisolonc (C l lOP) and rcachcd rro cvidcnce of d is-case (NED) status al icr s ix such cyclcs. g iven at ntonthly intervalssuggesting conrplete rcsponsc (CI{). llc rvas planncd lor Vin-cr is t ine. Adr ianycin. Cyclophosphamidc (VAC) bascd mainte-nance, depcnding upon cardiac cuntulativc toxicitl clcarance lbradriamycin by MUCA srudics. l)rcsentll'hc is discase fice.
DISCUSSION
Histiocytoses are divided into three classes (1, l land III) depending upon their histopathological dif:ferentiation. Class I and ll are non malignant, whilcClass l l l is a t rue neo-plasm.
CLASS-l Langerhans cells histiocytosis (LCH) :previously known as histiocytosis X arrd relatedsyndrontes of eosinophil ic granuloma, l-land-Schuller Christian disease and Letterer-Sirver dis-ease. They are recommended observation or nti ldradiation or chemotherapy (Vinblastine oretoposide) and steroids [3].
CLASS-ll Two subtypes (i) Infecrion Associated
. Haemophagocyt ic Syndrome ( lA l lS) . ( i i ) Farn i t ia lErythrophagocytic Lymphohistiocytosis (FEL).Recommended therapy; experimental: Etoposide orBone Marrow transplant in FEL [4].
CLASS-l l l Is a t rue neoplasm (Acute n lonocyt icLeukemia, Mal ignant h is t iocyrosis , t rue h is t iocyt icLymphoma/Sarcoma). Out of the spectrum of ClassI l l - h is t iocytos is , mal ignant h is t iocytos is is bestknown disease. It is a non farnil ial, rapidly fataldisorder, where patient presents with fever, general-
\
I
( i radedSpccia l is tMcdic incandMcdical Oncologist ;Classi l icdSpeQial is tSLrrgcryandSurgical Oncology:Classi l icr . l Specia l is tSurgcryand Oncosu rqcon . lN l lS ASV lN l .
Jour. lr,larine ll,ledical Societv, Jwte 1996. I'ol. 3. No. t6J
been describeding, lymphade-symptoms andmothernpy antl
r evidence of d is-
monthly intcrvalsplanncd for Vin-iC) bascd mainte-
icitl 'clearance lbr
disease iice.
3e classes (1, I lrthological dif-alignant, while
;ytosis (LCH) :X and relatedrloma, I land-lrer-Siwer dis-vation or nildinblastine or
ion Associated
) . ( i i ) Farn i l ia lytosis (FEL).l: Etoposide or
;ute monocyticrue histiocyticctrum of Class:ytosis is best, rapidly fatalfever, general-
Specialist Surgery
96, I'ol.3. \'o. I
t
\
t
t,p
l : ,t ,
,
ised lymphadenopathy, hepatosplenomegaly, sub-cutaneous inflammatory infiltration, pancytopeniaand Coomb's positive haemolytic anaemia [5].
Lymph nodes in class-ll l histiocytoses are char-acterised by nodal effacement and infiltration withcells containing reticular chromatin patterns, promi-nent nucleoli and basophil ic cytoplasm with stainpositivity for acid phosphatase and non specificesterase [6]. Erythrophagocytosis may be seen (butnot as prominent as Class II - FEL). Immunohisto-chemistry of these cell is positive for S-100 protein(a CNS specific protein). Malignant Histiocytosis isa systemic malignancy involving entire reticulo-en-dothelial system. Bone marrow involvement is com-mon.
Immunohaemolysis (Coomb's positive) may beseen. Recommended therapy for Malignant Histio-cytosis requires use of intensive, aggressiveAdriamycin containing regimens. With the additionof Adriamycin, a median survival of less than sixmonths has been increased to one of approximately40 months [7].
Our patient has shown a short remission (sixmonths) to Vinblastine/Etoposide based chemo-therapies. We have re-evaluated the patient andrescheduled his chemotherapy as planned in theTumour Board at INHS-ASVINI. i.e, CHOP induc-tion/consolidation followed bv maintenance bvVAC.
Jour. I,larine A4edical Society, June 1996, I'ol. 3. No. I
He has shown a very good response (CR) to thegiven therapy and has achieved no evidence ofdis-ease (NED) status - (KPS-100%). We presume theanthracycline based chemotherapy wil l prolong thedisease free survival and remission duration. Atpresent he is under three monthly follow up and isfree of disease 42 months after diasnosis.
REFERENCESL Lichtenstein L. Histiocytosis X : Integration of Eosinophilic
granuloma ofbone. "Letterer-Siwer" and "Schul ler ChristianDisease" as related manifestation of a single nosologic en-tity. Arch Pathol 1953,56 : 84-102.
2. Lasser A. The mononuclear phagocytic syslenl. A reviev)Hun pathol 1983; l4 : 108-126.
3. Gadner H, Grois N, Heitger A. Favourable influence ofchemotherapy in disseminated Langerhans cell histiocy-tosis. Results ofthe DAL-HX 83 study after 8 years offollowup (abstract). Histiocyte Society Seventh Annual MeetingProceedings. (Med pediatric oncology in press)
4. Perry MC, Harrison EG, Burgert EO et al. Familial erythro-phagocytic lympho histiocytosis. Cancer 1976;38 : 209- I 8.
5. Zucker JM, Cailaux JM, Vanel D et al. Malignant histocy-tosis in childhood. Clinical study and therapeutic results in22 cues. Cancer 1980:45 : 2821-2829.
6. Histiocytosis. In : DeVita e/ a/. Principles and practice ofoncology. 4th ed philadelphia. JB Lippincott | 993; I 786-89.
7. The Histiocytosis. In Pizzo PA, Poplack DC eds : Principlesand practice ofpediatric oncology. 2nd ed Philadelphia. -rBLippincou 1993', 26 : 6l'l -3 l.
65
Submariners ViewpointSUBMARINER' S BODY CLOCK
Cdr ASPI CAWASJI NM*, Surg Cdr PP BELLUBBI** VSM
Human beings have been known to display rhyth-mic cycles relating to the basic physiological func-tions, mental abil ity, moods and emotion. This natu-ral control system ofthe body is known to follow thecircadian cycle which means "about a day" in Latin.This rhythm in turn is correlated with the period ofdarkness and daylight hours each day. lt thereforeimplies, that all our body functions l ike intake ofmeals, sleep, mental sharpness and physical effi-ciency are directly related to sunlight which in turncontrols the body clock. The body clock acts as theguardian of all rhythms, which when disrupted cre-ates the need to retune the clock.
According to an emerging science known aschronobiology when the circadian rhythms are dis-rupted, many body functions are throrvn out ofgear.An individual interestingly is aware of his local t imeby regularly eating meals at prescribed times. Veryoften, even without looking at the clock, the bodytransmits the message of hunger if any meal isoverdue. This steady rhythm of eat - work - sleep inrelation to daylighVdarkness ifdisrupted, can reducethe overall working capacity of the human body.
Normal human beings following a steady l if-estyle and exposed to the path of the sun, seldomdeviate from their schedules. The mode oftravel l ikeroad vehicle, rail or ship being inherently slow, asalso subject to the diurnal rhythms ofthe sun, doesnot induce a change in the human body functions, asthe body clock is subject to a very gradual change.Whereas when travell ing by air, across various timezones, the human body fails to adapt it self to thelocal t ime, thereby causing the body to feel undulytired, displaying lack of appetite and a lowering ofmental abil ity. This symptom is popularly known as"Jetlag". The body takes a couple to days to re-orientits clock to the new daylight/darkness pattern in thatlocal t ime zone. Mariners from time immemorialhave been adjusting their clocks both mechanical
and biological on crossing the time zones or theinternational date Iine by either advancing or retard-ing their watches. Therefore the human body is ableto readjust itselfeasily through sheer repetit ive prac-tice. With the advent of various fighting machines(the most deadliest of which, being the submarine)for fulf i l l ing mankind's quest for power, a specialbreed of men is required to run these formidablemachines. This set of people are wil l ingly lockthemselves up in sharks of steel and travel inside thedeep seas l ike predators, stealthily waiting to pounceupon their prey. The combat efficiency and of themodem submarines mainly depends upon the physi-cal and mental endurance of the crew. This daringlot is subject to the most vicious disruption of thechronobiological rhythms and their body clockshave to be given frequent false images so as to beable to run them in tune. Lif-e on a submarine is bereftof the luxury of being able to see the sun. Withartif icial I ighting switchqfon all the time inside thesubmarine, thc body clock very quickly loses itsbearings and results in making this daring lot abunch ofdull, constipated men, suffering frorn a lossof appetite. In order to be able to make this lot afighting force possessing razor sharp senses, ar1ifi-cial situations have to be introduced fiom time totime. The first and foremost factor governing thebody c lock is the l ight ing, therefore, whi te l ight ingbetween 0600h and 1800h sirnulates daylight andthereafter red l ighting substitutes for darkness. Thischange alone does not fool the body mechanisnrs,hence in addition special announcements are madefor various rneals. The red l ighting besides helpingthe body clock, also aids night vision when clandes-tinely looking at a target through the periscope atnight. The second most important factor is the sleepat night, but with frequent closing up at battle sta-tions and maintaining a rotating shift round theclock, an individual does not get to sleep for more
than three to fcrhythm is upset45 to 60 days,the body. The tlcrew to go thewould have norof space. Henc,body have to bto i le ts . Al l the:period of t ime r
Submarines,nrachines, needwhilst stealthil leither tracking Ithe adversary's 1rnentally alert,unlike the star sday and day intcby white and raffect the meclvanced or retardtage accrued frcobserves day duh igher standard ractualdayl ight hevasion from p4tage of this charthe crew are disr
,lour. llarine lr4edi
rCommanding OIflcer, INSM Shishumar. t+Additional Adviser, Marine and llypcrbaric Medicine (Navy) and l'}Mo. INS Va.jrabahu.Mumbai 40() 005.
Jour. Marine tr4edical Societv. June 1996. l'ol 3. No. I66
ne zones or theancing or retard-man body is abler repetitive prac-ghting machines
; the submarine)power, a specialhese formidable: wi l l ing ly lockI travel inside theraiting to pounceiency and of thes upon the physi-rew. This daringlisruption of theeir body clocks:ages So as to bebmarine is berefte the sun. Withe time inside the
luickly loses itshis daring lot a'ering from a lossmake this lot a
rrp senses, artifi-,ed from time torr governing thee, white Iightingtes daylight andrr darkness. Thisdy mechanisms,,ments are madebesides helpingn when clandes-:he periscope at.ctor is the sleepup at battle sta-;hift round thesleep for more
P, tNS Vajrabahu
96, l'ol. 3, No. I
than three to four hours at a stretch. Thus the sleeprhythm is upset over a prolonged period oftime upto45 to 60 days, which indeed, tells on the health ofthe body. The third factor is the inability ofthe entirecrew to go the toilet at the same time, which theywould have normally gone on land, due to paucityof space. Hence the physiological functions ofthebody have to be readjusted to the vacancy of thetoilets. All these factors acting over a prolongedperiod of time causes an upset in the body rhythms.
Submarines, by virtue of being noctumal fightingmachines, need to be more alert during dark hourswhilst stealthily working below the water surfaceeither tracking targets or collecting intelligence onthe adversary's parameters. In orderto keep the crewmentally alert, the Captain onboard a submarine,unlike the star sun, plays God and orders night intoday and day into night. This can easily be simulatedby white and red l ighting. This change does notaffect the mechanical clocks as watches are ad-vanced or retarded by I 2 hours at a time. The advan-tage accrued from this action is that the submarineobserves day during dark hours thereby ensuring ahigher standard of mental alertness, and night duringactual daylight hours when submarine tactics dictateevasion from prying eyes in the sky. The disadvan-tage of this change over is that the body clocks ofthe crew are disrupted during the change over and
on reverting back, for least a couple of days eachtime. This is due to change in meal t imes, l ikebreakfast at 1830h, lunch at 0100h and dinner at0600 hrs. This phenomenon at sea and on entry intoharbour can be termed as "sub lag".
The repurcussions of going against the bodyclock have been observed by many medical authori-ties, but in these modern days of technological revo-lution, when efficiency is paramount, tamperingwith the body clocks has become a way of life forthe submariners. This to a large extent has beenovercome by professional selection and by improv-ing the man-machine relationships by adequatetraining and by building new levels of conditionedreflexes. In the final analysis, it is the l ife style whichprevades over the body clock, which in turn wil laffect the changing health patterns. Abuse of thebody by tampering with the chronobiologicalrhythms could cause serious damage to the bodymetabolism in the long run.
Over the years the submariners body clock haslearned to adapt with the changes in working hoursin ardous conditions and breathing from an anificialmicroclimate. The silent message passed down bythem is that, they are a special breed wil l ing to betrapped in sharks of steel for protection of theirhomeland.
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,Jotrr. Alarine l,ledical Socien, June 1996. Vol. 3. No. I 67
ULTRASONOGRAPHIC DIAGNO SI S
Surg Lt Cdr M GOEL*, Surg Lt Cdr IK INDRAJIT**'Lt Col SP MITTAL***, Surg Cmde NR RAHA*rr*t'
A 60 years old, ex-serviceman, smoker, daily
A drinter for 30 years, was admitted to INHS.I- Isanjivani with complaints of generalisedweakness and dyspnea on accustomed exertion. Hedenied history of vomiting, hematemesis, malena,dyspeptic symptoms or any bowel complaints.There was no history of weight loss. He did not giveany history of any past major ailment.
Clinical examination. revealed a well built malewith normal vitals. Except for pallor, general exami-nation did not show any positive findings. Abdomi-nal examination revealed hepatomegaly of 2 cm,non tender, firm, with smooth edges. There was notendemess, free fluid, or any other mass. There wereno stigmata of chronic liver disease. Cardiovascularexamination revealed a ejection systolic murrnur(ESM) at the left sternal edge.
Blood counts were within normal limits. Periph-eral smear showed normocytic, hypochromic anae-mia with normal platelets and leukocytes. Metabolicparameters, ECG, CXR were all normal. Stool foroccult blood was negative and did not show any ovaor cysts. Bone marrow examination showed erythro-cytic hyperplasia. USG of the patient is shown inFigs l(a), (b) and 2(a), (b).
INTERPRETATION
Ulffasound of the abdomen shows a circumfer-entially thickened stomach wall, associated with anirregular hypoechoic mass, with air and mucosatrapped within the stomach cavity seen as a hypere-choic center (Fig. I a and b). No obvious lymphnodal masses in the draining territory are detected.Liver shows a diffuse fatty infiltration with featuresof moderate hepatomegaly. Multiple metastatic le-sions measuring less than I cm are visualised in bothlobes of the liver. Importantly, pseudo enhancementof metastatic masses was noted, distally, falselysuggesting the solid metastatic lesions to be cystic
(Fig2 a and b).
Barium meal study revealed irregularity of stom-ach mucosal outlines with normal distensibility.UGI Endoscopy showed a large friable, concentrictumor mass, located at the body of the stomach withextension into the pylorus. The mucosal surfaceshowed discolouration with ulceration and necrosis.CT abdomen, both plain and contrast scans, showeda circumferential 2.5 cm thickening of the gastricwall involving the entire hody with extension upto
Fig. I a & b : Scan showing a hypoechoro nrnss lesion in thc re gionofthe epigastrium arising fronr the stomach. Note thehypoechoic thickened muscular wall and the hypere-choic mucosa and air in the center.
Fig. 2a & b: Scanfatty livrwhich isinfiltrati<
the pylorus. Nring region. Thwith mild hep:evidence ofmthe tumor masnocarcinoma.matically andltre.
DISCUSSIOI
Carcinomason(s) has sho'From being th
Jour. Marine M
*Graded Specialist (Medicine), INHS Sanjivani; **Graded Specialist (Radiodiagnosis), INHS Sanjivani; ***Classified Specialist(Medicine)INHS Sanjivani; **i*Command Medical Officer, Southem Naval Command, Kochi 682 004.
Jour. Marine Medical Society, June 1996, Vol. 3, No. l68
arity of stom-listensibil i ty.e, concentricstomach with:osal surfaceand necrosis.cans, showed:f the gastric(tension upto
:sion ln thc rcgrontomach. Notc thcand the hypere-
ssified Specialist
t6, Vol. 3, No. I
[ : ig . 2a & b : Scan shorvrng nrul t ip le mctastat ic mass lcs ions in thefany liver. Note the presence of pseudocnhancenrent,which is characteristic of metastasis in a setting of firttyinfi ltration of the liver.
the pylorus. No nodal masses were seen in the drain-ing region. The liver showed diffuse fatty changeswith mild hepatomegaly. Interestingly, there was noevidence of metastasis on CT. Biopsy specimen ofthe tumor mass showed features suggestive of ade-nocarcinoma. The patient was managed sympto-matically and transferred to the regional cancer cen-tre.
DISCUSSION
Carcinoma of stomach for some unknown rea-son(s) has shown a decline overthe last 60 years[2].From being the commonest cause of cancer related
Jour. llfurine Medical Society. June 1996, L'ol. 3. No. I
death in the thirt ies, it is now the nineth commonestcause of death, with reported deaths per year esti-mated at 20,000 and 14,000 in the USA and UKrespectively []. A patient with advanced stomachcarcinoma has less than l0% chance of survivingfive years [ ]. It has been estimated that early super-ficial gastric cancer, which has not penetrated themuscularis propria, has a very good prognosis, witha five year survival rate of 80%. In cases with abreach ofserosa, or in the presence ofnodal involve-ment the five year survival rate falls dismally lorv toeven less than l 0% [ I ]. Low rates ofearly diagnosisand inoperability combine to produce this depress-ing prognosis. Most of the cases occur in the fifthdecade onwards. The early symptoms are slightlyvariable and uncharacteristic, but dyspepsia is pre-sent in most patients regardless of the extent of thedisease. In our patient there was no history of Glsymptomatology. Non operative staging providesinformation on the luminal and extra-luminal extentof lesion which influence the management protocol
[4,51.
In this case, there were fwo interesting imagingfindings which merit further discussion. lmpor-tantly, both these imaging findings concern theunique appearance of metastasis within a fatty l iver.Firstly, ultrasonography showed a pseudoenhance-ment of the metastatic masses. The metastatic le-sions, despite the deposit being solid, displayedmarked distal pseudo-enhancement, sirnulatingmultiple cystic lesions of the l iver. The metastaticlesions are solid, but exhibit a lower attenuation thanthe fatty l iver that surrounds it. The total gain con-centration (TGC), while scanning is adjusted usu-ally to compensate for the abnormally high attenu-ation ofthe fatty l iver, also pulls up the distal echoes,falsely suggesting that the metastatic lesion to becystic [6]. Another interesting finding was the ab-sence of any discernible metastasis within the fattyliver on the CT Scan. It is known, that in a l iver withdiffuse fatty changes, hypodense metastasis maybecome isodense due to a drop in the radiodensityofthe surrounding l iver [7]. In such an eventuality,administration of contrast media is the definitemethod to demonstrate the l iver metastasis [8].Other factors which influence the CT appearance ofmetastasis includes slice thickness and the size ofthe metastasis.
69
REFERENCES 365.70.
| . Carcinoma of thc stomach. In : Mislewicz JJ, Pounder RE, 6. Malignant liverdisease. ln : Cosgrove D, Meire H, DewburyVenables CM. eds. Diseases of gut and pancreas. 2nd ed. K. eds. Abdominal and gcncral ultrasound. Vol |. EdinburghEdinburgh : Blackwell Scicntific Publications. t994;335. Churchill Limingstone.1993:284 -85.
2. Cancerofthedigestivetract. In:del RegatoJ,SpjutHS,Cox 7. Theliver. ln:WegenerOH,FasselR,WclgerD.eds.WholcJV. eds . Cancer diagnosis - Treatment and prognosis. 6th body computed tomography. Boston. Blachtell Scientijccdn. New York : CV Mosby & Co. 1985:482. Publications. 19f.3:,264.
3. Neoplasms of the stomach and esophagus. ln : Wilson JD, g. Lewis E, Bemadino ME, Barnes pA. parvey HR. The fattyBraunwald E, lsselbacher KJ eds. Harisons principle^of liver : pitfalls of the CT and angiographit evaluation ofintemal medicine. 12 edn. Philadelphia. McGrav, Hill l99l:' metmtatic disete. J Conpt Assist ionog l9g3; 7 :235 -269. 41. ?
4. Bolondi L. Casanova P, Caletti GC, Crigroni CR. Primarygastric lymphomas versus gastric carcinoma : Endoscopy Editor's Noteind US evaluation. Radiologt 1987 l6i : 821 - 26. This article was submitted as.a case report. lt has bc exten-
r'
5. Derchi LE, Biggi E, Neumaier LE, Cucio GR. Ulhasonog- sively modified by Surg Lt Cdr VRG Patnaik and the editor to :
raphic appearance ofgastric canwr. Br J Radiol 1983; 56 : present it as an ultrasonographic diagnosis.
Jour. Mariw Medical Societv, June 1996, l/ol. 3, No. I70
ELECTROCARDIOGRAPHIC DIAGNOSIS
Surg Lt Cdr JP LAZARUS*, Col DINESH PRASAD**
es or theor retard-dy is abletive prac-machinesbmar ine)a specia lr rmidablergly lockinside the:o pouncend of thehe physi -r is dar ingon of thely c locksl a s t o b ee is bercft;un. Wi thins idc theloses its
' ing lo t arom a lossth is lo t aies, arti l l-n t ine to'rning thee l ight ing, l ight andress. This:hanisnr s,are made:s help ingr c landes-'iscope atthe s leep)attls sta-ound thefor more
erving soldier aged 46 years, a case of acute myocardial infarction was treated in the ICU withthrombolytic therapy. While on Streptokinase drip, the electrocardiographic monitor suddenly shorvedthe tracing in Fig. l. This arrhythmia terminated spontaneously without treatntent.
l ' l g . | :
ECG INTERPRETATION
l'lre E,CG monitor tracing reveals occurrence ofa broad, bizarre, QRS rhythm, at a rate of 84beats/minute identical to the previous sinus rhythm.The onset and termination of this rhvthrn is accom-panied by fusion beats.
DIACNOSIS
A case of acute rnyocardial infarction on throm-bolytic therapy, showing a burst of reperfusion ar-rhythmia in the form of accelerated idioventricularrhythrn (AIVR).
D ISCUSSION
. Reperfusion arrhythrnias are one of the mostreliable indicators of successful reperfusion follow-ing throrrrbolytic therapy in acute myocardial in-farction. Among the common arrhythrnias seen areAIVR, VPC's, AV blocks. Accelerated id ioven-tricr"rlar rhythrn is the commonest reperfusion ar-rhythmia described. It is postulated that reducedblood flow into the ischaemic area, along with re-lease of free radicals. leads to stimulation of foci inthe irritable myocardium generating these arrhyth-mias.
AIVR achieved popularity with the advent ofcoronary care units, rvhen constant ECG rnonitoring
led to its frequent detection. lt is best defined as aautomatic ectopic ventricular rhythrl at a rate be-trveen 50 -1O0/rrrinute and it takes over when thesinus rhythm is slow and pennits the ectopic rhythrnto escape. Also, when the ectopic pace ntaker accel-erates, it takes control t iom the sinus node and A IVRis generated. The run of AIVR is ushered by one ormore fusion beats. It usually stops spontaneouslyand does not need to be treated unless accornpaniedby haemodynam ic instabil ity.
REFERENCT]S
L Wcstveen [ )G. Stovard. l , Gangadharan V. crc l ' l
hc s igni l i -cancc oI rcper lusion ol 'arrhythnt ias rv i th thronrbolr t ic coro-nary rccanal izat ion.CircLr lat ion 1983; 68 : l l l - ;110.
2. Corr I ) l l . Wi lkorvski I ;X. Potcnt ia l e lcctrophrsio logicalnrcchanisnrs responsible fbr dy 'sarrhvthnr ias associatcd n ' i thrcperf i rs ion of rsc l raenr ic rnxtcardiurn. Circrr lat ion l98l : ( ru' . 1G24.
3. Fuj imoto ' l ' . Petcr ' l ' . eta l . Elcctrophl ,s io logical observat iorrson vcntr icular tachycardias lb l lorv ing rcpcr lusion. J . .1, '1/I lcurt 1981 . | 05 : 20 1 -7
4. Castc l lanios A, at . r l Mcchanisrn ol 's low vcntr icular tachr. -cardias in acute m1'ocardial inlarction. Chcst. | 9(r8. 5(r . 7().
5. L ichcsts in I l . e l a/ . Inc idcncc and dcscr ipt iorr of accelcratcdid io venlr icular rhythnr. , . l , { r ' , /Curdio l . 197() . 26 . 170.
6. FIenry J[ . Marr iot . I ) ract ical c lcctrocardiographr. Sth cdi-t i on . W i l l i ams & W i l k i ns Pub l i ca t i ons .
VajrabuhLr.
l. 3, i\to. l
*Cradcd Spccid ist (Mcdic ine). **Scnior Advisor (Mcdic inc) : INI IS Asvin i Colaba Munrbai - 400 005
.Jrttr. ll'larine ll.ledical Society, Junc 1996, l:ol. 3. No. I 7t
r I
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^
NEWS FROM THE DEEP
APPOINTMENTS
Surg VADM CD SASIKUMAR, PHS [CMO, Western Naval Command] on promotion,appointed as the Director General Medical Services (Navy) w.e.f l5 May 1996.
Surg Capt BPS Rawat, VSM (FMO, Western Fleet) appointed as Assistant Executive officer,INHS ASVINI w.e.f 3l Dec 95.
Surg Capt Paul Thomas (Assistant Executive officer INHS ASVINI) appointed as Fleet MedicalOfficer Western Fleet.Mumbai w.e.f 3l Dec 95.
SELECT LIST
Surg Capt BPS RAWAT VSM for Surgeon Commodore
Surg Cdr MP DIWEDI for Surgeon Captain
RETIREMENT
Surg VADM D GHOSH VSM, PHS, DGMS (Navy) w.e.f 29 Feb 96.
Surg Capt AR MAHADIK, PMO, Dockyard, Visakhapatnam w.e.f 31 March 1996.
DEATH
We regret to inform the untimely demise of Surg Cdr S Goil, who expired on l8 Jul 1996,following a massive myocardial infarction. Members of Marine Medicat Society send our heartfelt condolences to the bereaved members of his family.
AWARDS
VISHISHT SEVA MEDALSurg Cdr DC BHOIL (79013 Z)
Surg Cdr NA VERMA (79025 A)NAO SENA MEDAL
Surg Cdr A AHUJA (75169 N)COMMENDATION FROM CHIEF OF NAVAL STAFF
Surg Cdr G VERGHESE (75329 A)COMMENDATION FROM FLAG OFFICER COMMANDING IN CHIEF
Maj (Mrs) L VALSALA, (NR 17121 X)v stNGH, MCPOMA II (059850 Z)
R PRASAD, MCPOMA'Ir (058734 N)Smt P MARY. WARD SAHAYIKA
Jour. Marine Medical Society, June 1996, Vol. 3, No. I
