ST. JMC JOURNAL OF MEDICINE ISSN 0970-4221VOL.II NO. 2 SEPTEMBER 1989.pdf
Media
- extracted text
-
ISSN 0970 - 4221
ST. JOHN'S MEDICAL COLLEGE
JOURNAL OF MEDICINE
VOL II No 2
EDITORIAL
COMMUNITY HEALTH CELL
326. V Main, I Block
Koramangale
Bangalore-560034
India
Sept 1989
29
ORIGINAL ARTICLES
Post Operative wound infection. Can it be prevented?
31
Regression equations for stature estimation of females from foot size.
33
SPECIAL ARTICLES
Basal metabolic rates in the assessment of human energy requirements
38
REVIEWS
Drugs in pregnancy
43
Treatment of hyperthyroidism
47
TRAINING TRENDS
Involvement of pre-clinical student in national health programmes
52
Makings things happen - An experiment in health management
53
CASE REPORT
Gastric perforation in a newborn
INFORMATION FOR CONTRIBUTORS
EDITORIAL BOARD
Ashley. J. D'Cruz
Rajini Macaden
Ravi C. Nayar
Mario Vaz
A.B. Kilpadi
A.S. Arvind
Submitting the Manuscript
The St. John's Medical College Journal of Medicine accepts scientific contributions from all fields of
modem medicine and from all institutions and health care professionals. The journal is a quarterly
publication which will be published in March, June, September and December. It is owned by the
C.B.C.I. Society for Medical Education and published by the Principal, St John's Medical College. The
journal is a part of it’s commitment to continuing medical education. Articles and all editorial
communications should be addressed to the Editor, Alumni Office, St. John’s Medical College,
Bangaloro-560 034.
Original articles, short case reports and review articles are accepted for publication. Review articles
and editorials are usually on invitation by the Editorial Board. Letters to the Editor will be considered
for publication only if received at least six weeks prior to the next publication.
PREPARING THE MANUSCRIPTS
All manuscripts should be submitted in 3 copies (including the glossy prints). They should be neatly
typewritten on bond paper, one side of the paper only, with double spacing and margins of at least
2.5 cms. Please be sure to include an accurate address for editorial communications and for reprint
requests.
A brief abstract of the material of the paper should precede the body of the paper, to run no more than
500 words. INDEX WORDS for the purpose of indexing and computer programming, should appear
on the same page.
OVERSEAS
The format for articles suggested is as follows: INTRODUCTION, MATERIALS AND METHODS,
RESULTS, DISCUSSION, REFERENCES.
R.R. Baliga
Measurements should be in metric system.
A.V. Kurpad
ILLUSTRATIONS AND TABLES
Figures and tables should be cited in order in the text; their position should be marked in the margin
of the manuscripts. Arabic numbering should be used for both figures and tables. All line drawings
should be submitted in duplicate as clear, glossy, black and white, 5“ x 7" photographs. Photomicro
graphs should also be submitted in duplicate, with allowance made for the effects of reduction if
necessary. Legends for illustrations should be typewritten, double-spaced, on a separate sheet, and
included at the end of the manuscripts. A legend must accompany each illustration. Each table should
be typed on a separate sheet and appropriately numbered. Legend should be typed on the same sheet
as the tables. The contributors must bear all the costs connected with printing colour illustrations.
REFERENCES
PUBLISHER
Prof. A.F.A. Mascarenhas
Principal
References should be compiled at the end of the articles according to the order of citation in the text,
not alphabetically. They should be typewritten, double-spaced under the'heading REFERENCES.
Abbreviation for titles of medical periodicals should conform to those used in the latest edition of Index
Medicus. Give inclusive page numbers.
EXAMPLES OF REFERENCES
Journal Articles upto six authors, list all names:
Kurpad AV, Shetty PS: Dietary Fibre and the colon. StJohn’s J Med, 1988;1:5-12.
Journal Articles more than six authors, list three authors followed by et al:
Complete book
Gallagher JR: Medical Care of the Adolescent (ed 2). New York, Appleton, 1966; pp 208-215
Subscription
Single Copy
Rs. 30/Annual
: India Rs. 100/Abroad U.S. $ 20/Payable in cash/bank drafts/ cheques to the St. John's Medical College Journal of Medicine, I Floor,
Robert Koch bhavan, St. John’s Medical College, Bangalore 560 034.
PUBLICATION COMMITTEE
C. Ramachandra
S.C. Rajendra
The advertisement charges:
Cover (back age): Rs. 3000/- Inside Cover (back page): Rs. 2000/All contributions towards the Journal come under 80 (G) exemption.
J. Alapatt
Founded by the Alumni Association of St. John's Medical College in 1988.
St. John’s Medical College Journal of Medicine
EDITORIAL
DERMATOLOGY - NOT JUST SKIN DEEP
The skin - the largest organ in the body - receives scant attention from the treating physician. Quite often this veritable
treasure-house of clinical signs is dismissed with a mere casual glance or a hasty referral. Professor Paul Gerson Unna,
one of the founding fathers of dermatology, said over one hundred years ago, that he who cannot learn anything from the
skin, which is open before him, cannot be expected to learn from any other subject.1
The psychiatrist may be helped by the characteristic photosensitive dermatitis of pellagra when faced with a recent
onset dementia. The ash-leaf macule may be of assistance to a neurologist in diagnosing tuberous sclerosis to be the cause
of seizures in a child. The paediatrician may recognize the periorificial erosions of acrodermatitis enteropathica in a child
presenting with diarrhoea. Or the dark velvety appearance of acanthosis nigricans may alert an endocrinologist to the
possibility of an endocrine disorder. The plebian itch, a symptom that is treated with little respect could be the presentation
in a patient with a host of internal disorders.
The list is apparently endless - but the message is the same-a careful look at the skin, hair and nails can be a gratifying
exercise. This is not an attempt to convince internists and other specialists to dabble in dermatology; it is only a reminder
that an awareness of the possible cutaneous manifestations in your speciality, and a rigorous clinical application can yield
dramatic results in an apparently vexing diagnostic dilemma.
Anil Abraham
Lecturer, Dept of Dermatology
St John's Medical College & Hosp.
1.
Scher RK (quote); Hair and Nails, Cutis 1987;40:197.
CHOICE OF THERAPY FOR HERNIATED LUMBAR DISC
Since the recognition of the herniated lumbar disc syndrome byMixter and Barr in 1939, surgery has been the mainstay
of treatment. The syndrome is easily identified when the presentation is classical. The typical “disc patient” presents
with sudden onset of shooting pain in the gluteal region and the leg which is worsened by coughing or sneezing. The cardinal
physical signs are restriction of straight leg raising, spasm of back muscles, sensory loss in a lower lumbar or sacral
dermatome and weakness of ankle or toe musculature. Such a complete syndrome is however not common. The majority
of patients present with a chronic low backache with intermittent episodes of leg pain which are relieved, albeit partially,
with rest. Some patients present with neurogenic intermittent claudication in which tingling, numbness and leg pain are
brought about by walking. These patients tend to have minor or no neurological deficits at rest. Examination after a brisk
walk is sufficient to produce pain, the ‘walk test’ may disclose a fresh sensory/motor deficit, thus separating these patients
from those with vascular claudication. Some patients usually have an associated spinal canal stenosis. The less common
presentations include urine retention, bilateral sudden foot-drop and the cauda equina tumour syndrome which are related
to large midline herniations.
Conservative measures of therapy are applicable only to those with minimal or no deficit, those with recent onset of pain
and those whose general health does not permit surgery. Although much has been said in favour of the various types of
conservative methods, none of them have been clearly proved superior to absolute rest in bed for a week along with orally
administered analgesics. A longer duration of bed rest may not result in any further improvement. Short wave diathermy,
ultrasound massage and local injections of steroids or anaesthetics are useful in relieving back pain which generally arises
from reflex muscle spasm or facet joint arthritis. They do nothing to the radicular pain. Conventional skin or pelvic traction
is probably useful only inasmuch as it confines the patient to bed. Gravity lumbar reduction therapy has been proved to
be of value in relieving radicular pain but the apparatus is costly and not widely available. Several-instances of deterioration
of neurological deficits have been noted during traction and hence neurosurgeons usually do not resort to its use.
From the foregoing it is clear that patients who have significant limitation of daily activities (occupational or recreational),
patients who obtain no relief from bedrest and those with significant neurological deficits must be evaluated for surgery.
X-rays of the lumbar spine are essential to rule out disorders such as spondylolisthesis, vertebral tuberclosis, metastases
& compression fractures which may cause a similar clinical picture. They reveal little about the level and degree of disc
prolapse and the size of the canal.
SEPTEMBER 1989
29 —
St. John’s Medical College Journal of Medicine
The traditional pre-operative investigation was myelography with a water soluble contrast injected into the sub arachnoid
space by a lumbar puncture. Currently the investigation of choice is high resolution computerised tomography (CT) of the
lumbar spine. Intra thecal contrast CT is only rarely needed. The diagnostic accuracy of CT is around 95% which is better
than the 85% accuracy of myelography. Besides, CT also reveals extreme lateral disc prolapses, identifies associated central
or lateral lumbar canal stenosis, depicts pathology of the facet joints, delineates ligamental hypertropy and is unmatched
in imaging the post-operative spine.
The time honoured procedure for lumbar disc is laminectomy anddiscoidectomy. The conventional operation involves much
muscle dissection bone removal, neural retraction and ligament damage. Hence though relief of radicular pain occurs in upto
80% of cases many patients have a chronic back pain which results. This has led to designing operations which preserve
the anatomy of the back, as far as possible. Removal of half a lamina (hemilaminectomy) and enlarging the inter
laminar space by ronguering the edges of the ligamentumflavum in the interlaminar space (flavectomy) are progressively
more physiological approaches.
Mico lumbar discetomy has been increasingly performed over the last 15 years. The advantages of using the operating
microscope include excellent visualisation at depth ( due to magnification and illumination), minimal soft tissue,nerve
root,vascular trauma and reduced post-operative stay and morbidity. The initial fears about a higher recurrent disc rate after
micro lumbar discectomy have been disproved by long term results.
Another alternative to surgery has been the enzymatic dissolution of the disc by percutaneous injection of chymopapain
or collagenase enzymes. This procedure known as chemonucleolysis began in the sixties, suffered a set back in the seventies
due to adverse reactions and has re-emerged in the eighties as a viable alternative. Its limitation is that it cannot be applied
to patients with major neurological deficits, those with extruded disc prolapse or allergy to the enzyme. In controlled studies
it has been proved less valuable than microlumbar discectomy. It requires physician training and radiological control.
A more recent choice is percutaneous discectomy. A cannula is introduced into the disc space under radiological control,
a rotating device is passed into the disc space to fragment the nucleus and the bits are aspirated by suction. The procedure
can be done on an outpatient basis in 30-45 mins. The immediate pain relief is significant but the risk of recurrent disc prolapse
is uncertain. Microdiscectomy, chemonucleolysis and percutaneous discectomy are contraindicated in patients who have
narrow lumbar canals and in those in whom the diagnosis is uncertain.
The patients with segmental instability require a fusion. Neurosurgeons favour posterior interbody fusion while orthopae
dic surgeons favour inter-transverse bone fusion or posteriorinstrumentation (plates and pedicular screws). Postoperative
care includes advice on back exercises and avoidance of harmful back postures.
Proper case selection, preoperative CT scan to identify the causes of the syndrome, tailor-making the operation to the
needs of the individual patient, use of fat grafts to prevent dural tube adhesions and exclusion of patients with a
‘compensation neurosis’ or endogenous depression have helped in reducing the incidence of ‘failed-back surgery syndrome’
in the last decade.
Disc disease is often a part of the progressive age-associated lumbar spondylotic degenerative disease. Surgery can only
be expected to relieve symptoms and prevent some of the future disability but it cannot reverse the basic degenerative
process. It is hoped that the future will find a solution to this problem.
Ramakrishna E.
Asst Prof. Dept of Neurosurgery
St John's Medical College & Hosp.
SELECTED READING:
1. Cauthen JO, Lumbar spine surgery, Williams and Wilkins Baltimore 1983.
2.
Clinical neurosurgery Vol. 33, Williams and Wilkins, Baltimore 1985.
3.
Mooney V (ed) Evaluation and care of lumbar spine problems Orthopaedic clinics of North America! 14(3) 1983.
4.
Genant AK(ed) Spine update, RREF. San Francisco 1984.
5.
Maroon JC Onik A, percutaneous automated discectomy J. Neurosurgery 66:143-146;1987.
—
30
VOL II No. 2
ORIGINAL ARTICLES
St. John’s Medical College Journal of Medicine
POST I OPERATIVE WOUND INFECTION - CAN IT BE
PREVENTED ?
PRABHA UNNY KRISHNAN, RAGINIMACADEN
INTRODUCTION
We have come along way from the days of ‘laudable pus’
and ‘spontaneous generation’1. The accent now is on
‘asepsis’ and the prevention of wound infections. Although
the advent of antibiotics offered a transient respite, the
emergence of multidrug resistant strains of bacteria has
anulled its benefits to a certain extent. Development of new
techniques in surgery combined with sophisticated methods
of maintaining asepsis in theatres have helped in reducing
infection, but newer hazards of infection arose with the use
of immuno-suppressive therapy and complicated surgical
techniques. The fact still remains that surgical wound
infections are the second most frequent nosocomical
infection in most hospitals and are an important cause of
morbidity, mortality and excessive hospital costs2.
CLASSIFICATION OF WOUNDS
Wounds can be classified according to the degree of
wound contamination at the time of operation3. A widely
accepted scheme is as follows :
Clean wounds - These are wounds which are least likely
to decontaminated with endogenous organisms from the
respiratory, alimentary or genito-urinary tract.
Clean-contaminated wounds -These are wounds in
which the bronchus or gut was entered but without undue
contamination.
Contaminated wounds - include fresh traumatic wounds,
Dirty wounds include old traumatic wounds and wounds
over an abscess.
Clean wounds have 1-5% risk of infection, clean-contami
nated 3-11%; contaminated 10-17% and dirty, over 27%4.
This classification helps in predicting the probability of
infection and the clean-wound infection rate in particular, can
be used by surgeons to compare their own infection rates
with other surgeons.
POST-OPERATIVE WOUND INFECTIONS AS SEEN IN
ST. JOHN’S MEDICAL COLLEGE HOSPITAL
A retrospective analysis of the laboratory records of post
operative wound infections in St. John’s Medical College
Hospital has shown evidence of clustered outbreaks in some
of the units. A review of this outbreak implicates staphylococ
cus aureus as the most common bacterial agent, followed by
gram-negative bacilli such as Escherichia coli, Klebsiella,
Proteus species and Pseudomonas aeruginosa.
The alarming fact is that 95% of the Staph, aureus strains are
B-lactamase producers and 98% of the Klebsiella and
Escherichia coli isolates are resistant to ampicillin and the
first generation cephalosporins. Resistance to gentamicin
is also rapidly emerging and may be attributed to its
widespread usage, especially as a prophylactic antimicrobial.
The source of hospital associated post-operative wound
infection may be defined as a place where pathogenic (i.e.
potentially disease-producing) microorganisms are growing
or have grown, and from which they can be transmitted to
patients5. The common sources are droplet nuclei,fomites,
infected wounds and carriers. Perhaps the most commonly
implicated method of transmission are the contaminated
fingers of medical personnel who handle the patients.
Ironically, this is also the most easily preventable. Routine
surveillance of certain areas in the hospital has shown the
presence of various pathogenic bacteria colonising air
conditionervents, theatre equipment (eg. anaesthetic tubing)
and in use dilutions of antiseptic lotions.
CONTROL MEASURES
PRABHA UNNY KRISHNAN M.B.B.S.,M.D.
RAGINI MACADEN M.B.B.S., M.D.
DEPARTMENT OF MICROBIOLOGY
ST. JOHNS MEDICAL COLLEGE & HOSPITAL
BANGALORE 560 034.
REPRINT REQUESTS :
DR. RAGINI MACADEN
PROF. & HEAD OF DEPT. OF MICROBIOLOGY
ST. JOHNS MEDICAL COLLEGE
BANGALORE 560 034.
SEPTEMBER 1989
While every surgeon knows that the most important
measure to prevent wound infections is operative technique,
there are many factors beyond the immediate purview of the
surgeon that may contribute to increased infection rates.
Some of the precautions to be taken include the following:
PRE-OPERATIVE PREPARATION OF THE PATIENT
If the operation is elective, pre-operative stay should be as
short as possible. Unless hair near the operative site inter
feres with the surgical procedure it should not be removed;
if removal is necessary it should be clipped (rather than
31 —
St. John’s Medical College Journal of Medicine
shaved) and the procedure
deferred to the day of
operation, to prevent colonization of minor abrasions by
hospital pathogens 4. The operative site including the entire
incision and a large adjacent area should be washed and
cleaned with an effective antimicrobial agent.
IN THE OPERATION THEATRE
While it is unthinkable that the surgical team would work
without proper scrubbing and donning‘of sterile attire in
a well established teaching hospital like ours, emphasis must
be paid to certain details of this procedure.
All persons entering the operating room (OR) during an
operation should wear high efficiency masks. To fully cover
the mouth and nose and a cap/hood to fully cover the hair.
Scrubbing should be done for 5 minutes before the first
procedure for the day and for 2-5 minutes for consecutive
operations6. The fabric of the sterile gown should be effective
barriers to bacteria even when wet. If a glove is punctured
during the operation, it should be changed as promptly as
safety permits.
SURVEILLANCE
Routine microbiological sampling of the environment or
hospital personnel does not help much in preventing infection.
Instead a person in charge of surveillance should formulate
a composite record where the surgical procedure (clean,
clean-contaminated etc.), presence or absence of infection,
organism isolated, coard, theatre used, operating surgeon
and certain other parameters are incorporated5-9. If an
outbreak occurs, appropriate epidemiological studies should
be initiated. The concerned surgeon should be confidentially
alerted about his/her infection rate procedure-wise so that
appropriate preventive measures can be undertaken6-10.
ACKNOWLEDGEMENT
The authors wish to acknowledge the help and cooperation
extended by the staff of the department of Microbiology, St.
John’s Medical college. The secretarial assistance of Mrs.
L.A. Menon is gratefully acknowledged.
REFERENCES
Operation theatre ventilation should include a minimum of 20
air changes per hour and proper traffic control’ should be
ensured by limiting unnecessary activity and making the
OR self-sufficient6.
A healthy wound is remarkably resistant to infection but the
presence of necrotic or foreign (like suture) material makes
the wound highly susceptible to infection. If drainage is
necessary, closed suction drainage system from an adjacent
stab wound is recommended5-6.
THE POST-OPERATIVE WARD
Personnel should not touch an open or fresh wound directly
unless they are wearing sterile gloves. Hand washing is a
must before and after taking care of each surgical wound.
Routine antimicrobial prophylaxis for wound infection cover
ing much of the post-operative stay in hsopital has proved not
only ineffective but positively dangerous to the individual
patient and to the hospital ecology7-8. Perioperative antimi
crobialprophylaxis (starting shortly before the operation and
being promptly discontinued after the operation) is recom
mended for1 operations associated with high risk of infection
or2 those in which infection, if it occurs, would lead to
catastrophic consequences.
1. Dubos J, Louis Pasteur. Free Lance of Science. Little. Brown and company,
Boston 1950.
2. Guidelines for prevention of surgical wound ifections. Centres for Disease
Control. Atlanta, Georgia 1985.
3. National Research Council. Ad hoc Committee of the Committee on
Trauma. Post-operative wound infection : the influence of ultraviolet
irradiation on the operating room and various other factors. Ann. Surg. 160
(Suppl.2): 1-192.
4. Cruse PJE. Foord R. The epidemiology of wound infection. A 10-year
prospective study of 62, 939 wounds. Surg. Clin. NOrth. Am. 60:27-40.
5. Lowbury EJL, Ayliffe GAJ, Geddes AM and Williams JD. Control of Hospital
Infection. A practical handbook. 2nd edition. Chapman and Hall.
6. CDC guideline for prevention of surgical wound infections, Centres for
Disease Conntrol, Atlanta, Georgia *1985),.
7. Altemeier WA. Perspectives in Surgical infections. Surg. Clin. North. Am.
60:5
8. Pullock AV. Prophylactic antibiotics in surgery. Recent advances in
surgery (11) Edited by RCG Russell, Churchill Livingstone 1984.
9.
Shanson DC. Microbiology in Clinical practice. Wright PSG 1982.
10. Topley and Wilson's. Principles of Bacteriology, Virology and immunity.
Vol.3, 7th Edition. Edited by GR Smith, Edward Arnold.
Nasal carriers of Staph, aureus should be treated for four
weeks with a cream containing neomycin and chlorhexidine
or more effectively, pseudomonic acid, when available.
32
- VOL II No. 2
St. John’s Medical College Journal of Medicine
REGRESSION EQUATIONS FOR STATURE ESTIMATION OF
FEMALES FROM FOOT SIZE
T. ABRAHAM PHILIP
ABSTRACT
The importance of estimation of stature in Medicine,*
Forensic Sciences and in Anthropology can never be over
emphasised. Traditional methods of estimation of stature
takes advantage of the correlation, parts of the body have
to the whole. Most regression equations have been
generated for the estimation of stature from long bones.
However the forensic scientist cannot always choose the
parts of the body he or she receives to extract evidence. In
this study the foot outlines and footprints of 312 females
between the ages of 20 to 32 years were studied in order to
obtain regression equations for the estimation of stature. The
equations were later examined for internal contradictions, as
well as for confidence limits of prediction.
INTRODUCTION
No other identification procedure used by the forensic
specialists has undergone such a complicated course of
development as that concerned with the estimation of stature
from more or less detached parts of the skeleton1. Among the
earliest attempts to express, in definite metrical terms, the
proportions of various bones of the skeleton limited to a
standard human stature of 5 feet 6 inches (167.5 cm) was
that of Jean Sue in 17502. A treatise by Orfilla & Leseur in
1831, includes 2 tables giving measurements of the stature
and long bones of 51 cadavers and 20 mounted skeletons2.
The Bertillon system of identification and registration of
criminals based on anthropometric measurements was
introduced in France in 1882 3. In 1898, Karl Pearson4
presented regression equations and correlation coefficients
for estimating stature from long bones. In 1901., Macdonnel5
developed equations for estimation of stature from foot
size,for males.
T. ABRAHAM PHILIP. M.B.B.S
FORMERLY:
DEPARTMENT OF FORENSIC MEDICINE
KASTURBA MEDICAL COLLEGE
MANGALORE 575 001 INDIA.
PRESENTLY:
DEPARTMENT OF FORENSIC MEDICINE
ST.JOHN'S MEDICAL COLLEGE AND HOSPITAL
BANGALORE 560 034 INDIA.
Various other authors have also studied many aspects of the
foot, the ratio relationship to stature and some have derived
rule of thumb formulae for predicting stature from foot
size6-7’8. In 1968, Ruttihauser9 developed regression for the
estimation of stature from foot size in African children under
6 years of age. Physical anthropologist Pales,10 also has pub
lished regression equations for males. Qamara, Inder Jit and
Deodhar11 are the only authors to have published regression
formulae for females. Their formula:
Ht = 75.49 + 3.43 x Foot Length + 4.02
can only be used, however, for foot outlines.
Recognising that a difference exists between foot outlines
and footprints, in this study foot sizes of 312 females
between the ages 20 to 32 years were studied with a view
to develop regression equations forthe estimation of stature
if a known foot size was available. The equations generated
were first tested for internal contradictions. They have been
shown to have confidence limits similar to that of more
traditional formulae, for e.g. of Trotter & Glesser12 and
others, for estimation of stature from long bones.
MATERIAL AND METHODS
312 apparently healthy female volunteers formed the
subjects selected for this study. Approximately half the sub
jects selected were students of Kasturba Medical College,
Manipal, while the rest were from amongst the relatives of
patients attending the Primary Health Centres attached to
Kasturba Medical College, Manipal.
The heights of the subjects were recorded. Table 1 gives a
summary of the minimum, maximum and mean heights with
std. dev. The subjects were then made to stand on a well
inked stamp pad and allow the ink to spread evenly on the
plantar surface of the foot. Later they transferred one foot
at a time, onto the proforma sheets spread in front of the
stamp pad.
Table 1: Summary of Heights of subjects
No.
Min...'
Max.
Mean
S.D.
312
137.50
177.70
157.16
6.56
All measurements taken In cms. to nearest mm.
SEPTEMBER 1989
33 —
St. John’s Medical College Journal of Medicine
maximum length. These maximum toe lengths were used
for further calculations.. Table 2 gives a summary of the
maximum toe lengths on all eight parameters.
With the subjects standing as they normally do on two feet
the foot outline was drawn with a jotter refil in accordance with
the procedure laid down by the 1912 Geneva Agreement13.
Thus when asked to step off, the sheets retained the foot
print and foot outline on the same proforma sheet. The
footprint represents the weight bearing part of the foot in
actual contact with the ground. The foot outline indicates
the fleshed margins of the foot.
RESULTS
The correlation of maximum toe lengths to stature was first
calculated by the computer. The results obtained is shown
in Table 3.
The foot print and foot outlines were measured on the parallel
and diagonal axis following the methodology advocated by
Robbins14. A detailed discussion on the sampling design,
method of recording foot outlines and the Robbins method
ology is given in an earlier paper published by this author15.
The values of constants‘A’and‘B’ were calculated mathe
matically by standard formulae, bythecomputer. The results
obtained are given in Table 4. In this table ‘r’ is correlation
coefficient and S.E. is the standard error of estimate.
Substituing the appropriate values of the constants in the
formula for regression line, i.e. X = A + BxY the following
regression equations are obtained.
The toe measurements were taken on the parallel and
diagonal axis of footprint and foot outline from right and left
feet. Thus for each subject there were eight sets of
measurements. An analysis of the measurements was done
using a computer Zenith 8000. As no ready made package,
like the SPSS, was available, a programmer and me had to
develop a program in Basic after consultations with a
Statistician.
FOR RIGHT FOOT:
Parallel Axis Foot Outline Ht = 60.63 + 4.05 ( Max. Toe
length)
Diagonal Axis Foot Outline Ht = 62.54 + 3.96 ( Max. Toe
length)
Parallel Axis Footprint Ht = 61.52 + 4.28 (Max. Toe length)
Diagonal Axis Footprint Ht =60.85 + 4.31 (Max. Toe length)
Of the five measurements in each set of toes measured,
the computer first sorted and selected the toe which had the
Table 2: Summary of Maximum Toe Lengths recorded of subjects.
N = 312
Diagonal
Parallel
Side
Type
Min.
Max.
Mean
S.D
Min.
Max.
Mean
S.D
Right
Outline
F. Print
21.40
20.20
27.00
25.90
23.82
22.32
+ 1.06
+ 1.05
21.50
20.20
27.30
25.90
23.88
22.34
+ 1.07
+ 1.05
Left
Outline
F. Print
21.20
19.90
27.30
25.50
23.78
22.26
+ 1.05
+ 1.06
21.20
19.90
27.40
25.50
23.86
22.30
±1.04
+ 1.05
All measurements taken In cms. to nearest m.m.
Table 3: Correlation of Maximum Toe Lengths to height.
N = 312
Parallel Axis
34
Diagonal Axis
Type
Right
Left
Right
Left
Outline
0.65
0.66
0.65
S>.64
F.Print
0.68
0.66
0.69
g|.64
VOL II No. 2
St. John’s Medical College Journal of Medicine
FOR LEFT FOOT:
Parallel Axis Foot Outline Ht = 59.04 + 4.13 (Max. Toe
Length)
Diagonal Axis Foot Outline Ht = 60.04 + 4.07 (Max. Toe
Length)
Parallel Axis Footprint Ht = 66.59 + 4.07 (Max. Toe Length)
Diagonal Axis Footprint Ht = 67.50+4.02 (Max. Toe Length)
DISCUSSION
Table 3 shows a positive correlation is present between
maximum toe length and stature. From the table it can be
seen that it ranges between 0.65 to 0.69.
Robbins 14 in her study was unable to develop regression
equations for pre d'cting stature if a footprint or foot outline of
known size was available. The author recommended the use
of the graph with regression line as a conveinient method
for estimating stature. This method and the use of the
appropriate ratio index values were the methods suggested
by Robbins14. However in this study the values of the
constants were calculated mathematically.
The heights of the subjects were next calculated using the
values of the minimum, maximum and mean values of the
MTL in the regression equations generated. The calculated
values were then compared with the actual minimum,
maximum and mean of heights recorded. Table 5 shows the
Table 4 : constants for Regression equation for estimation of stature
Diagonal
Parallel
Side/Type
r
A
B
S.E
r
A
B
S.E
Right Foot
Outline
F.Print
0.65
0.68
60.63
61.52
4.05
4.28
4.99
4.81
0.65
0.69
62.54
60.85
3.96
4.31
5.03
4.77
Left Foot
Outline
F.Print
0.66
0.66
59.04
66.59
4.13
4.07
4.95
4.96
0.64
0.64
60.04
67.50
4.07
4.02
5.04
5.04
For explanation of r, A-, B, & S.E. see text.
Table 5 : Comparison of Actual height with calculated heights
Side/
Type
Mln.value
of M.T.L
Calc.
Ht.
Max.Value
of M.T.L.
Calc
Ht.
Mean.value
of M.T.L
Calc.
Ht.
R-PFO
R-DFO
R-PFP
R-DFP
21.40
21.50
20.20
20.20
147.3
147.68
147.98
147.91
27.00
27.30
25.90
25.90
169.98
170.65
172.37
172.48
23.82
23.88
22.32
22.34
157.10
157.10
157.00
157.13
L-PFO
L-DFO
L-PFP
L-DFP
21.20
21.20
19.90
19.90
146.60
146.92
147.58
147.50
27.30
27.40
25.50
. 25.50
171.79
171.56
170.38
170.01
23.78
23.86
22.26
22.30
157.25
157.15
157.18
157.14
Mean Calc. Ht.
Actual Height
Difference
147.43
137.50
9.93
171.15*
177.70
- 6.55
157.14
157.16
0.02
Where M.T.L = Maximum Toe Length & R - Right; L - Left.
PFO - Parallel Axis Foot Outline; PFP - Parallel Axis Footprint.
DFO - Diagonal Axis Foot Outline; DFP - Diagonal Axis Footprint.
SEPTEMBER 1989
35 —
St. John’s Medical College Journal of Medicine
results. From this table it can be seen that the regression
equation overestimates the stature for minimum values,
while it underestimates it for maximum values. However it is
bang on target for mean values, there being only a very
negligible difference.
It is worthwhile here to repeat an often unstated fact that
applies to all regression equations. In a test sample, 68% of
predicted values should include the actual height within one
standard error of estimated range, while.95%of the calcu
lated statures should include the actual height within two
standard error range15.
From Table 6 it can be seen that it is true for this study. From
the table we see that 68 to 72% of calculated heights fall
within 1 x S.E. range, while 93 to 94% fall within the 2 x S.E.
range. The slightly lower rates of prediction is due to the fact
that this study was conducted partly under field study condi
tions vide Ruttihuser9.
This is however not the ideal methodology for testing the
goodness of fit and confidence limits for prediction by the use
of regression equations. The proper way is to take a fresh
sample of footprints and examine the regression equations
for goodness of fit and confidence limits of prediction.
However due to constraints of availability of computer time
this part of the study had to be deferred to a later date.
obtained that the formulae for estimating stature from foot
prints and foot outlines will prove as effective as the more
traditional methods like long bones. Hence an additional and
important method can be added to the armamentarium that
the forensic expert has to estimate stature from skeletal
remains.
CONCLUSIONS
A significantly high degree of positive correlation was ob
served between measurements of the toe length and
stature, in a study of foot outlines and footprints of 312
females between the ages of 20 to 32 years. Regression
equations were developed to predict stature if a footprint or
foot outline was obtained. The regression equations were
tested on the available data and shown to have no internal
contradictions. It was also seen that the regression equa
tions have confidence limits comparable to the traditional
formula for estimating stature from long bones.
ACKNOWLEDGEMENTS
The author hereby wishes to express his gratitude to Mr.
Ganapathy Nayak, Mr.T. Krishna Rao of Manipal and Mr. L.
George of Ahmedabad without whose help all this would not
have been possible. The author is also indebted to Dr. Indar
Jit Dewan of Chandigarh and Prof. Eugene Giles of Illinois,
for valuable reprints, help and guidance.
Nevertheless it is possible to presume from the results
Table 6: Summary analysis of confidence limits of prediction of stature from regression equations of Maximum
Toe Lengths N = 312
Within range
of 1 x S.E
Outside range
of 2 x S.E
Within range
of 2 x S.E
Side/Type
No.
%
No.
%
No.
%
R-PFO
213
68.27
295
94.55
17
5.45
R-PFP
222
•71.15
292
93.59
20
6.41
R-DFO
216
69.23
295
94.55
17
5.45
R-PFP
220
70.51
293
93.91
19
6.09 •
L-PFO
223
71.47
293
93.91
19
6.09
L-PFP
226
72.44
294
94.23
18
5.77
L-DFO
225
72.12
294
94.23
18
5.77
L-DFP
222
71.15
295
94.55
17
5.45
.
For explanation of code for Side/Type see table 5.
—
36
VOL II No. 2
St. John’s Medical College Journal of Medicine
REFERENCES
1. Stewart TD ed: "Estimation of Stature” in Essentials of Forensic
Anthropology. C.C. Thomas Spring field U.S.A, 1979; 190.
2. Boyd JC and Trevor JC: "Problems in Reconstruction of Race, Sex, Age
and Stature from skeletal Materials" in Modern Trends in Forensic Medicine;
Ed. K. Simpson; Butterworths U.K. 1953;143-152.
8. Sharma VK, Garg RK and Chattopadhyay PK: “Calculation of Stature
from measurements: A study of Gaur Brahmins" Coll. Antrep, Zagreb,
Yugoslavia, Vol.2,1978;194-195.
9. Ruttihauser IHE: * Prediction of Height from froot length; Use of measure
ments in Field Survey" Arch. Dis. Child. Vol.43,1968;310-312.
10. Pales L: "Les Emprientes de Peids Humains dans les cavernes" cited
Robbins op cit, 1976.
3. Davis AB ed: "Diagnosis and Instruments” In Medicine and its technology, H.QamraSR, Jit I and Deodhar: “A model of reconstruction of stature from
Greenwood Press U.K. 1981 ;161-168.
foot measurements in an Adult population of North West India" J Ind Med Res,
Vol.71,1980;77-83.
4. Pearson K: “Mathematical Contributions to the theory of evolution: On
the reconstruction of Stature of prehistoric races" Philosophical Transactions
12. Trotter M andd Glesser GC: "Estimation of Stature from Long Bones of
of the Royal Society London 192 A; 1898;169-244. cited Stewart TD op cit.
American Whites & Negroes" Am J Phys Anthropol, Vol.10,1952;483-514.
5. Macdonnel WR: "On Criminal Anthropometry and the Identification
of Criminals" Briometrica, Vol.1, 1901;177-227.
13. Comas J ed: Manual of Physical Anthropology. CC Thomas Springfield
U.S.A., 1960;713-717.
6. Sharma BR: "Footprints Tracks & Trails in Criminal Investigation &
Trials" Central Law Agency, Allahabad, 1980;171-175.
14. Robbins LM: "Estimating Height & Weight from size of Footprints J
ForensicSci, Vol.31,1986;1:143-152.
7. Mukherjee JB Ed: "Forensic Medicine & Taxicology" Vol.1, 1st edition,
Academic Publicatirons Calcutta, 1981 ;119-120.
15.SterwartTD: "Recent Improvements in estimating Stature Sex, Age and
Race from Skeletal Remains" in Modern Trends in Forensic Medicine-3, Ed.
A.D. Mant, Butterworths U.K., 1973,194-198.
SEPTEMBER 1989
37 —
SPECIAL ARTICLES
St. John’s Medical College Journal of Medicine
BASAL METABOLIC RATES IN THE ASSESSMENT OF HUMAN
ENERGY REQUIREMENTS
M. J. SOARES, P.S. SHETTY
INTRODUCTION
With International agencies suchasthe Food & Agricultural
Organisation (FAO), World Health Organisation (WHO) and
the United Nations University (UNU) having now adopted the
principle of relying on measures of energy expenditure rather
than intake for arriving at the energy requirements of man,
measurements of energy output have gained prominence. As
a consequence, accurate measures of Basal Metabolic Rate
(BMR) which constitutes between 60-70% of the total
energy expenditure has gained great importance. BMR now
forms the basis of the FAO/WHO/UNU factorial approach for
the assessment of energy requirements of individuals,
communities and population groups worldwide1. This has
naturally resulted in a renewal of interest in BMR and its
measurement in human subjects. In this article, we highlight
the FAO/WHO/UNU method of arriving at energy require
ments of individuals of population groups. We also review
certain issues that have serious food policy implications in
the use of this method, as well as critically examine the
suggestion that BM Rs of normal Indians are lower than their
Western counterparts even when matched for age, sex and
body weight,2 thus lowering their energy requirements.
ENERGY INTAKE VS ENERGY EXPENDITURE
The range of variability in the energyneeds of man are based
largely on meticulous studies of energy intakes and expen
diture, which have shown that in any group of 20 or more
similar individuals, undertaking much the same activity, the
daily energy intake varied as much as two-fold3"6. Recent
reports have confirmed the wide variation in the daily energy
intakes, with coefficients of variation (CV) of the order of
between 15 to 20%. These reports indicate that a substantial
M.J. SOARES M.B.B.S.
P.S. SHETTY M.D., PH.D.
DEPT.OF PHYSIOLOGY
ST. JOHN'S MEDICAL COLLEGE
BANGALORE560 034.
portion (estimated at 70% in some population groups) of the
total variation is largely the result of within individual or intra
individual variation in intakes7'6. It is this extraordinary range
of variation in energy intake, both between and within
individuals, that has led the FAO/WHO/UNU Expert Consul
tation to state that, estimates of energy requirements,
whether actual or desirable, are to be based on measures
of energy expenditure rather than on measures of energy
intake. Estimation of energy intakes are time consuming,
call for a high degree of compliance from the subject and in
general tend to be less precise. In addition, measures of
intake of an individual have a low reproducibility since the
variability in energy intakes within the individual over a period
of days or weeks appears to be large. In contrast, measures
of energy expenditure are repeatable, more stable and with
the availability of newer techniques such as human whole
body calorimetry9, accuracies of upto +1% can be achieved
in the estimates of 24 hour energy expenditure.
METHODOLOGY OF BMR MEASUREMENTS
A natural consequence of the FAO/WHO/UNU Expert Con
sultation is the considerable importance being attached to
obtaining reliable estimates of BMR in large population
groups. These estimates are then used to determine the
energy requirements of populationsgroups. While collecting
data from the field and the laboratory or from different
centres in the world it is essential to assess how different
instruments compare with each other and whether errors in
methodology may result in systematic errors in BMR
measurements.
The BMR of any individual can simply be defined as “the
minimal rate of energy expenditure compatible with life". It is
measured under standard contitions of immobility in the
fasting state (12-14 hr after a meal), with an environmental
temperature of 26°-30°C, which ensures no activation of heat
generating processes such as shivering. It can quantified
by direct or indirect calorimetric techniques; the former
measuring the heat output directly, while the latter measures
the O2 consumption and CO2 production which are then ap
propriately converted to their energy equivalents.
_______________ •- vfjfrV''
Recent comparisons of BM R measu rements made using five
different systems, all based on indirect open-circuit calori
metry showed that measurements of BMR on the Oxylog,
Hartmann & Braun metabolator, ventilated hood, ventilated
tent and using whole body
indirect calorimeter were
comparable with the small differences seen being non
significant10. Similar results have also been obtained by
others11 comparing two or more instruments. Hence it can
■—
------------ —-------------------------------------------------------- VOL II No. 2
REPRINT REQUESTS
DR. P.S. SHETTY
NUTRITION RESEARCH CENTRE,
ST. JOHN'S MEDICAL COLLEGE,
BANGALORE560 034.
38
........
'
—
St. John’s Medical College Journal of Medicine
be stated that differences in BMR between individuals,
groups or populations are unlikely to be influenced by
methodological errors, if measurements are made under the
imposed strict conditions, with proper attention to technique
and potential sources of error11.
VARIABILITY OF BMR IN MAN
Inter-Individual Variability In BMR: It is generally recog
nised that in a group of apparently comparable individuals,
there is a considerable inter-individual i.e. between subject
variation in habitual total energy expenditure. Edholm12
reviewed a number of studies in which repeated measure
ments of total energy expenditure were made. These
indicated a coefficient of inter-individual variablity of about
+12.5% on a body weight basis. Recent studies looking at
the inter-individual variability in BMRs have yielded similar
results13*20. In effect, whether energy intake and physical
activity were kept constant or individually manipulated, the
variability between subjects was high and values ranged
between a CV of 7.9% to 17.9%. Hence inter-individual
variability contributes substantially to the total variability in
BMRs.
Intra-lndividual Variability in BMR: The basal metabolism
of any individual is generally assumed to be relatively con
stant when factors such as body size, age, sex and nutritional
status have been accounted for21. Sukhatme SiMargen22
have argued that within individual variations and that the
observed inter-individual variations can largely be explained
in terms of large irtra-individual variations. These investiga
tors consider the well-documented variation in intakes
observed among apparently healthy individuals indulging
in similar 'levels of activity, as evidence that different
individuals operate at different levels of metabolic efficiency
within what they consider to be the intra-individual range of
“costless” adaptation. This has resulted in an unsubstanti
ated claim that intra-individual variations in energy expendi
ture are also large, with a wide coefficient of variation even
in subjects accustomed to similar levels of physical activity
every day, and that these wide variations need to be
considered when assessing the energy requirements of an
individual23. These statements, if true, have serious implica
tions for food policies related to assessment of energy
requirements of populations. Hence many studies have
attempted to specifically answer these questions.
If large variations exist in total energy expenditure of the
same individual, then the BMR should show similar variations
since the BMR comprises the major portion of total energy
output. Table 1 summarises some of the recent data on
the within-individual variations in BMR obtained in different
study protocols. It is quite evident that regardless of the ex
perimental protocol, theCV of the measured BMR has never
exceeded 5% and was frequently below 3%. An analysis of
the variations in BMR within the same subject over long
periods of time is presented in Table 2. This shows that the
Table 1 : Intra-individual variability of BMR
Range of Variation
(CV%)
References
1. Energy intake and physical
activity controlled
1.5-4.7
(15,24)
2. Energy intake controlled
physical activity varied
2.2
(18)
3. Energy intake varied
physical activity controlled
2.8
(20)
4. Energy intake and physical
activity uncontrolled
1.5-4.7
(25,30)
Protocol
Table 2 : Intra-individual variability of BMR with time
-----
Time
Duration of
Measurement
Range of Variability
(CV%)
References
Days
Weeks
Months
2-15
2-5
2.36
1.5-4.7
1.5-4.8
2.5-4.0
(15,30-32)
(28,30-32)
(25,29)
SEPTEMBER 1989
--------
UUMMUMITY HEALTH CcU
___________:___________ V
J Block
39_
Koramth^ele
Ba ng a l«r*-160034
St. John’s Medical College Journal of Medicine
BMR is a relatively stable parameter when measured over
days, weeks and even over longer periods of months to years.
The overwhelming evidence thus indicates that despite
uncontrolled physical activity and wide fluctuations in adlibitum energy intake, the BMR of an individual is relatively
constant with a variability no greater than that for other
physiological data. Intra-individual variations in BMR are
unlikely to be significant in the assessment of energy
requirements since they are extremely small, inseparable
biologically from technical causes and are likely to be even
smaller when intakes are also controlled. Although within
individual variations in energy intakes are evident all the time,
there is insufficient reason to believe that such variations in
intakes reflect in variations either in 24 hour energy
expenditure or BMR within the same individual. This stability
of BMR measurements hence validates its usefulness in
deriving energy requirements of individuals or population
groups.
DO INDIANS HAVE LOWER BMRS ?
measured BMR to the predicted BMR values over 5 Kg body
weight ranges showed that as the body weight increased,
the deviation from Schofield’s equation decreased to a
minimum and then increased again. This was true even with
the older data from India 35,36. Around 55 Kg body weight
range, which is the currently accepted ideal weight for a
Reference Indian for estimating energy requirements38, the
deviations were the least, at 4.6%. the relationship between
BMR and body weight may therefore not necessarily be
linear over the entire weight range since the proportion of lean
tissue to fat is likely to change as body weight increases.
Perhaps the existence of a series of straight lines for different
body weight ranges or even a curve over the entire range of
body weights, as suggested by Francois39, would be more
appropriate for deriving predictive equations for BMR from
body weight.
Climate and environmental factors could account for these
small differences (approximately 6%) seen between the
better nourished Indians in this study and North American
or European subjects ratherthan ethnic variations. Reports
are available to support the observations that Europeans
living in tropical climates have BMRs which are about 5
percent lower than their counterparts in Europe 40-42 while
Asians living in UK, have BMRs that are comparable to their
Western counterparts 43,44. In a recent review on the effect
of race on BMR, Henry & Rees45 have shown that the lower
BMR of Indians was not unique but reflected a phenomenon
found in other Asiatic groups as well. They proposed, that part
of the differences are due to an interaction of climate and race
while part may possibly be attributed to a greater degree of
muscle relaxation during BMR measurements in the Asians.
It is our opinion that the precise values reported by Schofield,
suggesting a 11.2% lower BMR for Indian males reflects an
inherent defect in the data-base used to derive these
equations. There is therefore an urgent need to review this
problem by the concerned International agencies that delib
erate on energy requirements of population groups world
wide. Till such time, a 5% lower BMR for Indians than that
predicated by Schofield’s International equations seems a
reasonable estimate for computing energy requirements38-.
Schofield, Schofield and James 2at the behest of the FAO
collated BMR data collected worldwide over the last 60
years. Working from this data-base, they derived predictive
equations for BMR based on independent physiological
variables such as weight, after laying down five criteria for
the choice of this variable. Among the criteria was included
the need for as small an error of prediction as possible, as
well as equations that would be simple to use. These
equations (commonly called Schofield’s equations) were
derived for both sexes and different age spans, using body
weight as the best single predictor of BMR. During these
computations Schofield made the observation that when the
measured BMRs of Indians in the data-base were compared
with the predicted value derived from equations excluding
Indians, there was a significant lack of fit. The actual BMRs
of Indians were 11.2% lower than that predicted formales and
9.9% lower for females as compared to the data on
Europeans and N. Americans. A plot of BMR vs body weight
and BMR/weightvs body weight, revealed that even for the
same weight, Indians on an average had lower BMRs. Lack
of sufficient data precluded an extension to other Asiatic
subjects although an earlier analysis by Quenouille et al33 had
suggested the same. Since the bulk of the Indian data which
lead Schofield to arrive at this conclusion was reported 30
to 40 years ago 34-36 and since the genuineness of the
observation was not in doubt, we examined its validity in view
of the fact that a 10% lower BMR, has serious implications
towards arriving at the energy requirements of this nation.
From our data on 123 young adult males 37 it was evident
that the entire group has mean BMRs 9.3% lower than those
predicted using Schofield’s equations. The percent devia
tion from Schofields predictive equation, however, varied
among sub-groups of the same ethnic origin in our sample.
The better nourished were only 5.5 to 6.6 percent away from
the predicted values, a comparison of the observed or
Measures of total energy expenditure are essential to arrive
at estimates of energy requirements. Although whole body
human calorimeters measure accurately the total energy
expended by an individual, only recently has it become
possible to measure total energy expenditure of free living
individuals over an appreciable period of time using doubly
labelled water. Since the whole process of obtaining reliable
measures of energy expenditure is technically tedious, time
consuming and complex a new approach has
been
suggested by the Expert Consultation 1,46 by specifying the
total energy used by individuals of any age and size by
40 ---------- ---------------------------------------------------------- ------------------------- -
------------------------------------------------------------------------------- VOL II No. 2f —
—
BMR FACTORIAL METHOD FOR ESTIMATING
ENERGY REQUIREMENTS
St. John’s Medical College Journal of Medicine
relating all the energy costs of activities to their BMR.
BMR IN A CLINICAL SETTING
The traditional physiological approach has always been
to consider the 24 hour energy expenditure of an individual as
being made up of three main components:
It has long bee i recognised that, together with the medical
or surgical management of hospitalised patients, proper
nutritional assessment and management is essential for
reducing morbidity. Nutritional management assumes even
greater relevance when dealing with the critically ill, the
hyper-metabolic, the post-surgical, trauma, burns or cancer
patients. Medical literature is replete with studies aimed at
defining average nutrient requiremerits in different disease
states, the influence of nutritional support on the outcome
of treatment as well as the modification of drug metabolism
in nutritionally depleted patients. The principle of assessing
nutritional requirements of hospitalised patients47 is no differ
ent form that outlined for normal, healthy individuals in our
review. A common denominator in all such studies is the
BMR or Resting metabolic rate; the latter in patients who
cannot withstand an over-night fast. In a recent article, Lee
& Hershey48 have even argued that BMR measurements
should be a routine diagnostic procedure, since a raised
BMR could denote the outset of a variety of medical
problems ranging from endocrine disorders, to cardiovascularabnormalities.tocancer. Recent improvements in BMR
measurementtechniques, togetherwith reliable, inexpensive
and easy to use apparatus have gone a long way in making
such suggestions a reality. Needless to say, the renewed
interest of the busy clinician,
in a parameter that
‘traditionally’ gained its importance in the endocrinology
ward, augurs well for the science of nutrition and for research
in patient care in general. .
(1) BMR which constitutes the largest component ( 70%),
(2) regulatory thermogenesis which is categorised into
obligatory and facultative components and includes the
metabolic response to the food ingested i.e the use of energy
in digesting, absorbing storing and disposing of ingested
nutrients as well as the response of the body to stimuli such
as cold, stimulants and drugs. (3) physical activity which
includes both the cost and quantum of the activity as well as
the type of activity viz. (a) essential
economic
or
occupational activities and (b) discretionary activities which
include household tasks, socially desirable activities and
activities aimed at maintenance of physical fitness.
For all practical purposes the component of energy expen
diture related to regulatory energy output or thermogenesis
are knwon to merge into the measurements related to cost of
physical activity. Consequently the new simplified approach
has only two prinicipal components of energy expenditure:
BMR and physical activity. Assessment of energy require
ments is then based on specifying the needs for the BM R and
then considering all physical activity costs as effectively
occurring in the fed state (i.e. inclusive of the energy costs of
thermogenesis). The cost of this physical activity is then
expressed as a multiple of the BMR. The BMR value then
becomes the key to the assessment of
energy
requirements because all other energy costs are now consid
ered as multiples of BMR. This is the BMR Factorial ap
proach. Using the Factorial method, the FAO/WHO/UNU
Expert consultation has recommended BMR Factors for
men and women involved in light, moderate and heavy
activity.
Thus the lowly BMR, a simple measurement, considered to
have little clinical value with the advent of radio-immuno
assays for thyroid hormones and banished to the student
laboratories of physiology departments has risen as it were,
like the pheonix from the ashes. The BMR of an individual
is a reliable observation, which can be measured quite
easily or predicted readily from body weight. It constitutes
the largest component of total energy expenditure and is a
stable parameter showing insignificantly small * within
individual variations.
These qualities of BMR have
prompted the Expert Consultation of the FAO/WHO/UNU on
protein and energy requirements, to the formulation of the
BMR factorial method for arriving at the actual or desirable
energy requirements of communities or population groups
all over the world. The day is not far off when the BMR will
reappear as an important clinical measurement which will be
increasingly used to assess the daily nutritional needs of
medical and surgical patients.
SEPTEMBER 1989
ACKNOWLEDGEMENTS :
The studies on BMR reported in this review from our
laboratory were supported by the Food & Agricultural
Organisation (FAO), Rome.
REFERENCES:
1. FAO/WHO/UNO (1985): Energy and protein requirements. Report of a Joint
FAO/WHO/UNU Expert consultation. WHO Technical series No 724. Geneva
:WHO.
2. Schofield WN, Schofield C. and James WPT : Basal metabolic rate.
Review and prediction, together with an annotated bibliography of source
material. Hum Nutr Clin Nutr 1985;390:1-5.
3. Edholm OG, Fletcher JG, Widdowson EMet al: The energy expenditure
and food intake of individual men. Brit J Nutr 1985,9:286.
4. Rose GA, William RT: Metabolic studies on large and small eaters. Brit
J Nutr 1961;15:1.
5.
Widdowson EM : Nutritional individuality. Proc Nutr Soc 1962;21:121.
6. Wynn-Jones C, Atkinson SJ & Nicholas P: Nutrient intake by students over
a 3 month period. Proc Nutr Soc 1972;31:83A.
7. De Boer JO, KnuimanJT, WestCE, et al : Within-person variation In
daily dietary intake of boys from Finland, the Netherlands, Italy, the
Philippines and Ghana. Hum Nutr Appl Nutr 1987;41A:225.
41 —
St. John’s Medical College Journal of Medicine
8. Rao S : Variations in dietary intake in adolescents. Hum Nutr Clin Nutr
1987;41C:71.
27. Dubois EF : Basal metabolism in health and disease, Philadelphia,
Lea and Febiger 1936; (3)
9. Shetty PS, Sheela ML, Murgatroyd PR & Kurpad AV : An open circuit
indirect whole body calorimeter for the continuous measurement of energy
expenditure of man in the tropics. Ind J Med Res 1987;453.
28. Soares MJ & Shetty PS : Intra-individual variations in resting metabolic
rates of human subjects. Hum Nutr Clin Nutr 1986:400:365.
10. Soares MJ, Sheela ML, Kurpad AV, Kulkarni RK & Shetty PS : The
influence of different methods on basal metabolic rate measurements in
human subjects. Am J Clin Nutr 1989:50:731.
11. Segal KR : Comparison of indirect calorimetric measurements of resting
energy expenditure with a ventilated hood, face mask and mouth piece. Am
J Clin Nutr 1987;45:1420.
12. Edholm OG: Energy expenditure and calorie intake in young men. Proc
Nutr Soc 1961;20:71.
13. Garby L, Lammert O & Nielsen E : Between subjects variability in
24 h energy expenditure for a fixed activity programme. In Human energy
metabolism, ed AJH Van Es. EURO-NUT report. Wageningen, Netherlands,
1984;5:209.
14. De Boer JO: Energy requirements of lean and obese women, assessed
by indirect calorimetry. PhD Thesis. Agricultural University, Wageningen,
Netherlands 1985.
15. Jequier E & Schutz Y: The contribution of BMR and physical activity to
energy expenditure, in The body weight regulatory system : normal and
disturbed mechanisms, ed. Cioffi LA, James WPT and Van Itallie TB New
York, Raven Press 1981 ;89.
29. Soares MJ & Shetty PS: Long term stability of metabolic rates in young
adult males. Hum Nutr Clin Nutr 1987:41 C: 287.
30. Soares MJ. Piers LS, Kraal L & Shetty PS : Day-to-day variations In
basal metabolic rates and energy intakes of human subjects. Eur J Clin Nutr
1989:43:465.
31. Garby L & Lammert O : Within-subjects between days and weeks
variation in energy expenditure at rest. Hum Nutr Clin Nutr 1984:380:391.
32. Lammert O, Garby L, Maron K et al: Effect of the proceeding days energy
intake on the energy cost of rest, arm and leg exercise. Hum Nutr Clin Nutr
1987:141.
33. Quenouille MH, Boyne AW, Fisher WB & Leitch I: Statistical studies of
recorded energy expenditure of man. Commonwealth Bureau of Animal
Nutrition Tech Comm. Bucksburn, Aberdeen 1951:17
34. Mason ED & Benedict FG : The basal metabolism of South Indian
women. Ind J Med Res 1931 ;19:75.
35. Niyogi SP, Patwardhan UN & Modecai J : Studies on basal metabolism
in Bombay. Ind J Med Res 1939:27:99.
36. SokheySS& MalandkarMA: Basal metabolism of Indians. A study based
on the examination of 60 normal Indian men. Ind J Med Res 1939:27:501.
16. Schutz Y, Bessard T & Jequier E: Diet induced thermogenesis measured
over the whole day in obese and non-obese women.
Am J Clin Nutr
1984:40:542.
37. Soares MJ & Shetty PS : Validity of Schofield's predictive equations for
basal metabolic rates of Indians. Ind J Med Res 1988:88:253.
17. Daly JM, Heymsfield SB, HeadCAet al : Human energy requirements,
over estimation by widely used prediction equation. Am J Clin Nutr 1985:1170.
38. Expert Group ICMR : Nutrient requirements and recommended dietary
intakes for Indians. In Press 1989.
18. Dallosso HM & James WPT: The effect of fat over-feeding on 24 h energy
expenditure. Brit J Nutr 1984:52:49.
39. Francois PJ: The relationship between basal metabolism, height, body
weight and sex of individuals. FAO Report 1981 ;EPR/87/5a.
19. Shetty PS, Soares MJ & Sheela ML : Basal metabolic rate of South Indian
males. FAO Report, Rome: FAO 1986.
40. Mason ED: The metabolism of European women in South India and the
effect of change of climate on European and South Indian women. J Nutr
1934;8:695.
20. Dallosso HM, Murgatroyd PR & James WPT : Feeding frequency and
energy balance in adult males. Hum Nutr Clin Nutr 1982;36C:25.
21. Mitchell HH : Comparative nutrition of man and domestic animals, New
York, Academic Press 1961 ;1.
22. Sukhatme PV & Margen S : In Newer concepts in nutrition and their
implications for policy, ed. Sukhatme PV, Pune, Macs 1982.
23. Sukhatme P V & Narain P: Intra-individual variation in energy requirements
and its implication. Ind J Med Res 1983:78:857.
24. Murgatroyd PR, Davies HL & Prentice AM : Intra-individual variability and
measurement noise in estimates of energy expenditure by whole body
indirect calorimetry, Brit J Nutr 1987:57:347.
25. Harris JA & Benedict FG: A biometric study of basal metabolism in
man. Carnegie Institution of Washington Publication 1919;279.
26. Berkson J & Boothby WM : Studies of the energy metabolism of normal
• individuals. The interindividual
and intraindividual variability of basal
metabolism. Am J Physiol 1938:121:669.
—
42
41. Mac Gregor RGS &LohGL: The influence of a tropical environment
upon the basal metabolism, pulse rate and blood pressure in Europeans. J
Physiol 1941;99:496.
42. MuroAF : Basal metabolic rates and physical fitness scores of British and
Indian males in the tropics. J Physiol 1950:110:356.
43. Mahadeva K : The energy expenditure at rest of southern Asiatics in
Britain. Ind J Med Res 1954:42:181.
44. Henry C JK, Piggott S & Emery B: Basal metabolic rate and diet-induced
thermogenesis in Asians living in Britain. Hum Nutr Clin Nutr 1987;41C:397.
45. Henry CKJ & Rees DG: A preliminary analysis of basal metabolic rate
and race. In Comparative Nutrition (Ed. Blaxter, K & Macdonals, I). John
Ubbey 1988:149
46. James WPT & Schofield EC : Human energy requirements. A manual
for planners and nutritionists. Oxford: Oxford University Press 1989.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------VOL H No. i
-------
St. John’s
Medical
College Journal
REVIEWS
of Medicine
DRUGS IN PREGNANCY
ARUN MHASKAR, RITA MHASKAR
INTRODUCTION
of increased renal perfusion and glomerular filtration2.
Drugs may be prescribed to pregnant women in ambulatory
and hospital situations. Drugs may also be used in the
treatment of other disorders which affect the course of
woman’s pregnancy and the health of the fetus.
2.
This review article aims to enhance awareness of the
principles of perinatal pharmacology and rationale behind
the use of various drugs in pregnancy.
PRINCIPLES OF PERINATAL PHARMACOLOGY
Perinatal pharmacology is the complex interrelationship of
maternal, placental factors, fetal development and neonatal
adaptation.
ROLE OF PLACENTA
The placental transfer of drugs and other substrates is
complex and no method of study is ideal. It has been
determined that the transfer of drugs across the placenta is
primarily by simple diffusion and is dependent on the
chemical properties and concentration gradient of the free
drug3. Most drugs have a molecular weight of 250-500. An
unbound and unionised .drug of molecular weight of less than
1000 is usually lipid soluble and will rapidly penetrate the
trophoblast, connective and endothelial tissues which
seperate the fetal and maternal circulation1. Drug transfer
is greater during late gestation.
The reasons for increased placental drug transfer in late
1.
MATERNAL CHANGES
The distribution of a drug taken during pregnancy is influ
enced by many factors. Before or during conception the
luminal secretions and drug concentration in the semen,
fallopian tubesand uterus are influenced by certain drugs1.
The extracellular volume, intracellular volume and uterine
blood flow increase gradually during pregnancy. Despite an
increased production during pregnancy, serum albumin
has a relatively lower concentration because of plasma
volume expansion. The albumin binding capacity to drugs
is also decreased and more free drug is therefore available
for placental transfer.
The metabolism of drugs in the liver during pregnancy is
influenced by increasing amounts of circulating steroid
hormones. Enzyme induction or inhibition by the hepatic
microsomes canariseby stimulation from certain drugs2. The
excretion of drugs by the kidneys can be more rapid because
DR. ARUN MHASKAR M.D.
DR. RITA MHASKAR M.D., D.N.B.E. (OG)
DEPARTMENT OF OBSTETRICS & GYNAECOLOGY
ST.JOHNS MEDICAL COLLEGE HOSPITAL
BANGALORE560 034. INDIA.
CORRESPONDENCE TO:
DR. ARUN MHASKAR
DEPARTMENT OF OBSTETRICS & GYNAECOLOGY
ST.JOHNS MEDICAL COLLEGE HOSPITAL
BANGALORE560 034. INDIA.
------ SEPTEMBER 1989
pregnancy are:
a) Increased free drug available for transport.
b) Increased uteroplacental blood flow.
c) Increased placental surface area.
d) Decreased thickness of the semipermeable lipid mem
brane between the placental capillaries.
e) Greater physical disruption of placental membranes.
f) More acidic fetal circulation “traps” basic drugs4.
Examples of drugs which readily cross the placenta within
minutes after maternal administration include: Ampicillin,
Penicillin-G, Cephalothin, Kanamycin, Tetracyclin, Sulponamides, Streptomycin, Diazepams, Phenytoin, Barbitu
rates, Ethanol, Meperidine, Salicylates, Lidocaine, Mepivacaine, Bupicavaine, and Propranolol1.
3.
DRUG EFFECTS ON THE FETUS
Drugs that cross the placental barrier usually reach fetal
levels which often correspond to 50 to 100 percent of
maternal serum concentration1. Exceptions are diazepam
and local anesthetics that reach drug levels in fetus at
equilibria which are greater than those in mother. The total
exposure of a drug in a fetus is more important than the
transplacental transport. Chronic drug exposure rather than
single dose therapy may influence fetal cell growth during
the early (hyperplasia) or later (hypertrophy) stages of
development5. Drugs may act as teratogenic agents in
many ways: abortions, malformations, altered fetal growth,
functional deficits, carcinogenesis or mutagenesis. How
ever, it should be kept in mind that drugs contribute to only
2-5 percent of cases of congenital malformationsand hence
other causes should also be investigated in such cases6.
4 3—
St.
John’s Medical
College Journal
of Medicine
The total concentration of plasma proteins and protein
binding properties are lower in the fetus than in the mother.
More free drug is therefore available fortissue penetration or
competetive protein binding with other drugs or endogenous
compounds.
The rate of tissue permeability of a drug is unknown but
probably increases with gestation7. Some drugs may also
have a higher affinity for specific target tissues. Examples
of organs which are affected by specific drugs include the
heart (digoxin, phenytoin); skeleton (tetracyclines, warfarin);
red blood cells (sulfonamides); central nervous system
(diazepam, ethanol, narcotics); platelets (aspirin); adrenal
glands (sex steroids, phenytoin); mullerian duct and vagina
(diethyl stilboesterol) and auditory nerve (aminoglycosides)1.
Many fetal organs are capable of substantial metabolic
activity but drug metabolism occurs principally in fetal liver.
Oxidation- reduction reactions have been described as early
as 16th week8. The activity and concentration of certain
hepatic microsomal enzymes and the rate of oxidative and
conjugative reactions are probably less than in the adult
8. Therefore, direct pharmacodynamic effects from drugs
may be more pronounced and more prolonged in the fetus
than in the mother.
The excretion of most drugs is slower in the fetus than in the
adult, as many systems are not fully developed. The
primary routes of elimination involve the placenta and fetal
urine. The placental transfer of drugs from the fetus to the
mother is the primary route of drug elimination in early
pregnancy and is dependent on simple diffusion, free drug
chemical properties and concentration gradient. Drug elimi
nation in the later half of pregnancy is determined by the
immature fetal kidneys contributing to the amniotic fluid.
RECOMMENDATION FOR DRUG USE DURING
PREGNANCY
The average patient has been reported to consume four of
five prescribed drugs during pregnancy9. A history of any
drug taken at conception or du ring the first trimester should be
sought. A specific drug is to be continued during the first
trimester only if the anticipated benefit is reasonable and
considered to outweigh any known potential, suspected or
theoretical risk. Any indicated drug must be documented on
the antepartum chart and the pediatrician should be notified
prior to the time of delivery.
Relief of a patient’s symptoms and the medical welfare of the
pregnant mother (patient) must not be ignored. Drugs
which improve maternal health often benefit the fetus. To
minimise any fetal risks or adverse side effects to the mother,
a prescribed medication should be closely monitored, using
a therapeutic dose for the shortest duration. It is clinically
useful to place drugs in one of the three categories:
(a) drugs with known adverse effects,
(b) drugs with suspected adverse effects,
(c) drugs without known adverse effects at customary
dosage levels.
DRUGS WITH KNOWN ADVERSE EFFECTS (Table-1)
This category is small and fortunately contains only one group
of drugs -the anticonvulsants, where fetal risk does not
conclusively exceed maternal benefit.
Among anticonvulsants, trimethadione can be conclusively
Table 1 : Drugs with known teratogenic effect
Effect
Drug
1.
2.
Anticonvulsants
Trimethadione, Phenytoin
Facial dysmorphogenesis
Coumarin and Congeners
Epiphyseal stippling, Optic atrophy
3.- Alcohol
4 4
Fetal alcohol syndrome, growth retardation , mild
■ mental retardation, increase in anomalies
4.
Folic acid antagonists
Methotraxate, aminopterin
5.
Hormones
Diethyl stilbesterol and
congeners
Vaginal adenosis, carcinogenesis, Uterine
anomalies, epididymal anomalies.
6.
Androgens
Masculinization of female fetus
7.
Methyl mercury
CNS damage, growth retardation
8.
Thalidomide
Abortion, multiple malformations
♦
Phocomelia
VOL II No. 2
St. John’s Medical College Journal of Medicine
listed as a teratogen producing growth retardation, micro
cephaly, facial dysmorphism and other anomalies 10.Princi
pally used for petit mal seisures it can frequently be avoided
in pregnancy without hazard to the mother. The status of
phenytoin is less clear. The data regarding its teratogenicity
is inconclusive but it is sufficient to suggest that it be avoided
if possible.
Coumarin may be avoided in situations where anticoagu
lation is necessary by substitution of self-administered hepa
rin.
Excessive use of alcohol has been associated with a spec
trum of teratogenic effects, including growth retardation,
microcephaly, shortened palpebral fissures and mild mental
retardation n. The frequency of other anomalies is also
increased. This appears to be a dose dependent phenome
non. Though there is no safe threshold established, cases of
fetal alcohol syndrome have" not been reported when the
daily consumption is less than two ounces.
Other drugs in the table have no indication for use in preg
nancy.
DRUGS WITH
(Table 2)
SUSPECTED
ADVERSE
EFFECTS
This category could include any drug which has been the
subject of a case report suggesting possible teratogenicity.
Table -2 gives some important drugs in this category. These
medications may cause concern when inadvertant use
during pregnancy is discovered. None is sufficiently studied
to indicate pregnancy termination when exposure occurs.
DRUGS WITHOUT
(Table 3)
KNOWN
ADVERSE
EFFECTS
Some commonly used medications have not been associ
ated with anomalies in hymans despite their widespread
use. Analgesic compounds including narcotics, salicylates
Table 2: Drugs with suspected teratogenic effects
Drug
Suspected Effect
Hormones:
Oral contraceptives
Progestins
Limb and Cardiac defects
Lithium Carbonate
Ebstein's anomaly
Nicotine
Growth retardation
Sulfonylureas
Anomalies (?)
Tranquilizers
Benzodiazepines
Facial clefts
Table 3: Drugs without known teratogenic effect in humans at customary dosages
* Antiemetics
Analgesics
Aceteminophen
Narcotics
Salicylates
z
Benedectin
Promethazine
Antibiotics
Penicillins
Cephalosporins
Sulfonamides
Heparin
All confirmed by animal studies: no human studies available.
----- SEPTEMBER 1989
4 5—
St. John’s Medical
College Journal
of Medicine
and acetaminophen may be used in customary doses when
indicated.
DRUGS IN LATE PREGNANCY
Because of possible adverse effects on fetal organ devel
opment during the first trimester drugs are frequently avoided
or not used until later in pregnancy. The fetus is not entirely
spared from possible toxic effects during the latter half of
pregnancy as histogenesis and functional maturation con
tinue. Retarded growth of specific fetal organs may also
occur although malformation is unlikely after completion of
organogenesis. A toxic reaction within a fetus from a drug
is often unpredictable and difficult to prove, since a drug
may directly or indirectly act in any of the following ways:
induction or inhibition of certain enzymes, mutation
of
genes, changes in cell membrane integrity, competition
for circulating protein binding sites or interactions with other
drugs.
Antibiotics, antihistaminics, antihypertensives, sedatives
and mild analgesics are the most commonly prescribed
drugs in the later half of pregnancy. Side effects seen in the
mother may occur in the fetus with greater intensity and can
interfere with normal physiologic or homeostatic processes.
REFERENCES
1. Mirkin BL and Singh S: Placental transfer of Pharmacologically active molecules
In: Perinatal pharmacology and therapeutics, Ed. Mirkin BL, New York,
Academic, 1976;l-70.
2. Bynum TE: Hepatic and gastrointestinal disorders in pregnancy Med. Clin. North
A., 1977;61:129.
3. Ferris T: Renal disease, In: Medical complications of pregnancy, Eds: Burrow
G, Ferris T, New York, Saunders, 1975; 1-70.
4. Jachau MR and Dyer DC: Pharmacology of placenta, Pcdiatr., Clin. North A.,
1972;19:65.
5. Jachau MR: Drug biotransformation reactions in placenta. In: Perinatal Phar
macology and therapeutics, Ed: Mirkin BL, New York, Academic, 1976;71.
6. lams JD and Raybum WF: Drug effects on the fetus, In: Drug therapy
inobslctrics and
gynaecology, Eds: Raybum WF, Zuspan FP, Connecticut,
Appleton, 1982;9-17.
7. Waddci WJ and Marlowe GG: In: Perinatal pharmacology and therapeutics,
Ed: Mirkin BL, New York, Academic, 1976; 119-269.
8. McMurphy DM and Boreus LO: Pharmacology of the human fetus: Adrenergic
receptor function in the small intestine. Biol. Neonate, 1968; 13:39.
9. Blcyer WA and Au WY: Studies on the detection of adverse drug reactions
in the newborn: Fetal exposure to maternal medication JAMA, 1970;213:2046.
10. Feldman GL, Weaver DD and Louricn EW : The fetal trimethadione
syndrome, Am. J. Dis. Child. 1977; 131:1389.
11. Clarrcn SK and Smith DW: The fetal alcohol syndrome, New Eng. J. Med.,
1978;298:1063.
46
VOL II No. 2
St. John’s Medical College Journal of Medicine
TREATMENT OF HYPERTHYROIDISM
SR. AQUINAS M.D
The three major approaches to treatment of hyperthyroidism
are
1.
Use of antithyroid agents
2.
Ablation of thyroid tissue by Radioactive Iodine
3.
Surgery
ANTITHYROID DRUGS
The modern era of antithyroid drug (AT drug) therapy
started in 1941, with the introduction of thioureas by
Astwood. They have been replaced by carbamizole(CMZ)
methimazole (MML) and propylthiouracil (PTU).
Mechanism of action:1 (General for all the groups)
INTRATHYROIDAL
1. Inhibit thyroglobulin iodination by diverting oxidised
iodine away from tyrosine residues (AT drugs themselves
are iodinated and degraded)
2. Inhibit the coupling reaction of iodotyrosines (MIT & DIT)
to form iodothyronines (T3 & T4)
3. Bind to thyroglobulin and possibly alter its structure
(? role in vivo)
EXTRATHYROIDAL
1.
Inhibit convertion of thyroxine to T3 (PTU only)
2.
Affect immune system (? role in vivo)
(a)
(b)
(c)
(d)
Decreases lymophocyte responsiveness in vitro
Decreases circulating thyroid antibody titres
Restores normal suppressor - cell activity
May directly affect intrathyroidal autoimmunity.
THERAPEUTIC CONSIDERATIONS:
Antithyroid drugs are neither curative nor entirely risk free.
Generally the starting dose is 300 mg. PTU or 30 mg. MML
or 30-60 mg. CMZ. The usual concept regarding potency of
MMLvsPTU is 10:1. But recent studies show that MML may
be 100 times more potent.
Patients usually become euthyroid in 2-4 months after
starting treatment but it depends on a number of variables.
When euthyroid state is achieved, either the dose may
be gradually reducedby 50-75% (usually 5-15 mg. CMZ or
50-150 mg. PTU daily) or the initial blocking dose is
continued and a replacement dose of 150-200 mg. thyroxine
daily added to maintain euthyroidism.
One of the more controversial questions regarding AT drug
therapy is whether patients require single daily dose or
multiple doses. As the intrathyroidal drug concentration is
that which matters most, the present opinion is that single
dose of MML or CMZ will do. However PTU given as a single
dose is not effective.
What should be'the duration of therapy to maximise the
chances of remission? An optimal treatment duration is
still not established, most clinicians still treat the patients for
12-24 months before attempting to withdraw AT medication.
Why do patients treated with AT Drugs enter remission at all?
Graves' disease has been shown to be a disease of
disordered immunity in which circulating antibodies to the
thyrotropin receptor stimulate thyroid function2. In vitro stud
ies have shown that AT Drugs inhibit the mitogenic response
or the production of antibodies to the thyroid or both. Titres
of TSI fall in many patients while pn therapy with AT Drugs,
and they affect only the thyroid specific antibodies3. Ir
addition to effects on antibody production, AT drugs also
normalise the suppressor cell activity in Graves’ disease.
PREDICTORS OF REMISSION
Antithyroid drugs if taken regularly in adequate doses
almost always control the symptoms of hyperthyroidism.
Permanent remission occurs in 10 - 40% pts with Graves’
disease.
Clinical
: Mild disease, small goitre, T3 Toxicosis,
decrease in goitre size during therapy.
DR. SR. AQUINAS M.D.
FORMERLY
DEPARTMENT OF MEDICINE
ST. JOHN'S MEDICAL COLLEGE & HOSPITAL
BANGALORE 560 034.
----- SEPTEMBER 1989
Biochemical: Normal response to TRH test while on
treatment. TRH responsive group have higher rates
of remission4.
A
fall
in serum T3/T4 ratio (normal
20)
during
4 7—
St. John’s Medical College Journal of Medicine
Selected pharmacologic features of AT Drugs
Serum protein binding
Serum 1/2 life in hyperthyroidism
Volume of distribution
Metabolism of drug during illness:
Severe liver disease
Severe kidney disease
Transplacental passage
Levels in breast milk
PTU
75%
75 min.
20 litrs
MML
0%
240-360 min.
40 litrs
Decreased
w
Decreased
Low
Low
High
High
treatment is a favourable prognostic indicator for
Graves disease5.
Immunologic: Those patients in whom TSI titres
remain elevated at the end of AT drug therapy are sure
to develop relapse. However a negative or low titre is
not so helpful to predict remission6.
Genetic : HLA - DR3 positive patients are more likely
to relapse than others.
GUIDELINES FOR CAUTION :
Vast experience with the use of AT drugs indicate that the
side effects are uncommon. Problems are encountered in
only 1-5% patients. Fever, rash, urticaria, arthralgias, or frank
arthritis occur only in higher drug doses.
patients with thyrotoxic periodic paralysis. There is often
subjective improvement in sweating, but usually no major
effect on eye signs. Recent studies show a 10% reduction
in oxygen consumption/BMR with long term use of these
drugs7.
Many agents (Propranolol, Metoprolol, Nadolol and Sotolol,
but not Atenolol and Oxprenolol) reduce circulating T3 con
centration by 10-40%, however, the clinical significance of
this effect if any, is not established. Beta blockers may
also
have endocrinological effects on gastrin, cAMP,
catecholamines and other hormone levels. Given in ade
quate dosage, propranolol has been shown to control thyro
toxic hypercalcemia.
Minor side effects are common, but overall beta blockers
are well tolerated by thyrotoxic patients.
INDICATIONS
Transient leukopenia occurs in 12% .of adults and 25% of
children. This is not a harbinger of agranulocytosis and does
not require the discontinuation of drugs.
Agranulocytosis occurs in 0.05% of patients. It develops
within the first three months of therapy. This is an autoim
mune rather than a toxic phenomenon. Higher incidence
is seen in older patients. It requires permanent withdrawal
of drug therapy.
Toxic hepatitis, vasculitis and lupus like syndrome can occur
with PTU.
Spontaneous appearance of circulating antibodies to insulin
or glucagon has been reported with use of MML.
Cross reaction between drugs does not occur and one may
change therapy safely.
BETA BLOCKERS
All beta blockers relieve thyroxic symptoms, but particularly
suitable are those without intrinsic sympathomimetic activity
and are not cardioselective.
Beta blockers improve nervousness, tremor and severe
myopathy. They also reduce the frequency of paralysis in
4 8
1. The major use of these drugs is in symptomatic control
while awaiting definitive diagnosis or treatment.
As an adjunct to AT drugs or RAI, beta blockers will produce
a satisfactory clinical response, two weeks onwards, before
these forms of therapy produce an euthyroid state. Beta
Blockers are more convenient than AT drugs in the control
of patients receiving therapeutic RAI, in that, continous
therapy and assessment of biochemical response is pos
sible. The long term use of beta Blockers alone in the
management of hyperthyroidism cannot be recommended
except in mild and transient forms of the disorder such as
postpartum thyrotoxicosis.
2. I n the preoperative preparation for subtotal thyroidectomy,
the advantage is a major reduction in the time of prepara
tion. However, this regimen is not suitable for the more
severely toxic patient. Although beta blockers achieve
eumetabolism, hyperthyroxinemia may persist, therefore one
needs to be cautious in their use in preoperative preparation.
3.
In thyroid crisis. Dose : 80 -160 mg daily.
RADIOACTIVE IODINE
1311 is a simple effective outpatient treatment. It has been in
use for hyperthyroidism for the past 40 years and the earlier
concerns for the late effects of radiation, that limited it’s use
VOL H No.2
St. John’s Medical College Journal of Medicine
to older patients have largely disappeared. Many studies
have shown no evidence of post RAI leukemia or thyroid
cancer. Infact it has been suggested that RAI therapy may
actually decrease the risk of thyroid cancer, as it impairs
the ability of thyroid follicular cells to respond to TSH and to
reproduce, decreasing the number of cells at risk0.
The gonadal radiation dose from1311 treatment of Graves’
disease averages 0.8 -1.4 rem (the same range as in barium
enema or IVU). The potential genetic effects from RAI therapy
are found to be almost nonexistent at this dose. The average
human gonadal radiation dose at which spontaneous muta
tion rates are doubled is 156 rem for acute radiation and
approximately 468 rem for chronic exposure.
RAI THERAPY
*acts by beta irradiation.
* standard dose 80-120 mcg/gm thyroid tissue. .
With this dose, 50% of patients develop hypothyroid
ism in the first year. Thereafter the rate of developing
hypothyroidism is constant at about 3 - 5% per year.
* Thyroid
cells are less sentitive to RAI if prior
treatment with AT drugs is given.
* AT drugs should be stopped for 2 days before and
after RAI to allow optimum thyroidal uptake of1311.
Beta blockers may be continued.
* AT drugs with or without beta blockers may be used
to aid in control during the 2 - 3 months RAI takes
to achieve euthyrodism.
‘RAI s absolutely contraindicated only in pregnancy
and children.
‘Women of child-bearing age should delay concep
tion for at least six months after RAI therapy.
‘ Patients should be followed up for a lifetime.
SURGERY
Subtotal thyroidectomy remains the quickest and safest
treatment in the right hands. In the immediate post operative
period 5 -10% of patients become hyperthyroid again and
a similar number become hypothyroid. The incidence of
hypothyroidism, however, increases to 20 - 30% at 10 yrs.
PREOPERATIVE PREPARATION:
Patients should be made euthyroid with AT drugs preoperatively. Therapy with Iodine should not be started until meta
bolic control has been achieved on AT drugs.
Iodine ( 0.1 ml-0.3mlTDS)for7-10 days preoperatively
reduces the vascularity of the gland.
----- SEPTEMBER 1989
AT drugs should not be withdrawn when therapy with Iodine
is started. Some specialized centres have advocated
preoperative control with beta blockers alone, or with iodine,
before subtotal thyroidectomy. Using this approach it is
important to attain full beta blockade (erect HR of less than
70 beats/min) at the end of the dosage interval. It should be
maintained perioperatively and for upto 10 days postoperatively if iodine has not been used. Otherwise, rapid reemergence of florid hyperthyroidism can occur and the po
tential for thyroid crisis exists.
CHOICE OF THERAPY 9’10
In children, young adults, and pregnant females with
hyperthyroidism due to Graves’ disease - AT Drugs is the
treatment of choice.
Patients with a small thyroid, and mild disease of recent onset
should also be treated with AT drugs.
AT drugs are a reasonable first choice for many adults with
hyperthyroidism.
Patients in whom relapse occurs, and TSI titres remain high
may be given the benefit of one or more courses of AT Drugs.
If the relapse persists or recurs the treatment of choice is
RAI.
Since RAI has its effects on dividing thyroid cells, patients
with high TSI titres respond to a single dose and most often
become hypothyroid. It appears that many patients with high
titres of TSI are oversensitive to 1311 therapy.
Subtotal thyroidectomy is an acceptable form of treatment
for hyperthyroidism if a skilled and experienced surgeon
is available.
In recent years surgery has become less popular for adult
patients in whom RAI is the preferred form of treatment.
SURGERY IS PREFERRED IN FOLLOWING
SITUATIONS
1. Diffuse toxic goitre in children and young adults,
with failed AT drug therapy.
2. Pregnant female allergic to AT drugs, and those who
want to breastfeed.
3. Patients with a very large goitre.
4. Toxic nodular goitre or single autonomously func
tioning nodule. Ablative therapy is preferred as they
do not undergo ‘spontaneous' remission.
5. Patients with poor compliance and who cannot be
relied upon for follow up.
In patients with chronic thyroiditis with transient thyro
toxicosis (CT/TT) AT drugs or ablative therapy is not in
dicated. Symptomatic treatment with propranolol and mild
sedatives will do, as the thyroid is not hyperfunctioning in
this condition.
4 9—
St. John’s Medical
College Journal
of Medicine
AT DRUGS : PTU VS MML
NEONATAL HYPERTHYROIDISM
The choice of AT drug is usually based on personal experi
ence and preference, rather than on data showing that one
drug is superior to the other in therapeutic efficacy.
However, there are situations in which one drug may be
preferred to the other:
In Grave disease mother's TSI may cross the placenta and
cause neonatal thyrotoxicosis. Pretibial myxedema and tc
a lesser extent, significant exopthalmos in the mother are
clinical markers of TSI and should alert the clinician to the
possibility of neonatal thyrotoxicosis12.
* For patients in whom compliance is a problem, MML
preferable to PTU.
Treatment: Beta blockers and AT drugs. Digoxin and diuret
ics for heart failure if indicated.
The condition subsides within 1-2 months reflecting the rate
of degradation of maternally acquired Immunoglobulins.
* Severe hyperthyroidism is the only situation in which
PTU is preferred to MML since it acutely lowers serum
levels of T3 by blocking peripheral monodeiodination
ofT4.
* In pregnancy PTU preferred to MML, but this view is
still in controversial.
SURGERY VS RAI
In a study11 of treatment of hyperthyroidism due to Graves’
disease by surgery, RAI & CMZ in 837 cases it was shown that
5 yrs and 10 yrs cummulative relapse rates following a 2 yrs
course of CMZ were 56% and 62% respectively, following
surgery it was 6 and 10% and following RAI 3 and 14%.
The 5 yrs and 10 yrs cummulative hypothyroid rates were:
After surgery
10%
18%
After RAI
10%
30%
In patients who become euthyroid following surgery, annual
rate of developing hypothyroidism is 3-5% yr (same as RAI)
IN PREGNANCY AND LACTATION
Hyperthyroidism develops in approximately 2 of every
1000 pregnancies. In recent years, AT drugs have largely
supplanted surgery as the treatment of choice for hyperthy
roid patients who are pregnant.
AT drugs cross the placenta. PTU crosses only one fourth
as much as MML, and no teratogenicity is reported with
PTU. The frequency of neonatal goitre with AT drug therapy
is about 10% and this cannot be prevented by giving
thyroxine to the mother. This type of goitre is different from
the occasionally life - threatening goitres that develop in
infants born to mothers who have been exposed to iodides
during pregnancy. As a rule, doses of PTU should be as small
as possible-300 mg/day in divided doses, it can be lowered
to 50 -150mgperdayafter4-6weeks. It is important to
adjust the doses of AT drugs to attain thyroid function tests
which are within the normal range for euthyroid pregnant
females of the same stage of gestation. The normal ranges
for non-pregnant should not be used. The aim should be to
keep the serum FT4 concentration or the FT4I within normal
limits, and not the total serum T4. The severity of hyperthy
roidism usually decreases during the third trimester, and
recL-rs in pueperium..........
50
THYROTOXIC EYE DISEASE
While anyone with incresed serum levels of thyroxine or T3
may develop lid retraction and lid lag, it is only patients with
the immunological features of Graves' disease who will de
velop severe opthalmopathy, probably due to specific eye
muscle antibodies2. It does not respond to AT drugs.
Treatment of simple opthalmopathy :Hypromellose eye drops
Guanethidine eye drops (5%)
for lid retraction.
Partial lateral tarsorrhaphy
Treatment of severe congestive opthalmopathy :
High doses of steroids 60 - 80 mg prednisolone daily
for 1 - 2 weeks.
Immediate orbital decompression, if the visual acuity
falls acutely despite intense medical treatment.
Newer methods include plasmapheresis, supervoltage irra
diation to orbit and immunosuppressive therapies.
THYROTOXIC HEART DISEASE
A hyperdynamic circulatory state and the cardiac arrhyth
mias are an integral part of thyrotoxicosis and are entirely due
to excess thyroid hormone. Recent studies show hyperthy
roidism alone is capable of causing myocardial damage and
cardiac failure, that is, a thyrotoxic cardiomyopathy13. This
is mainly a congestive cardiomyopathy rather than a
hypertrophic one. Atrial fibrillation is not essential for
cardiac failure to occur, though it may aggravate the
condition.
Beta blockers are contraindicated in thyrotoxic cardiac
failure as even the advanced changes are reversible with AT
drug therapy13.
THYROID CRISIS
This is charactrized by
hyperpyrexia,
with severe
exacerbation of hyperthyroidism leading to shock and
coma. Abdominal symptoms may mimic an acute abdomen.
VOL II No. 2
St. John’s Medical College Journal of Medicine
Treatment
5. Ratio of serum T3 to T4 and the prognosis of T3 predominant
disease. Ann int Med 1984;100:372-75.
Intravenous propranolol 5 mg slowly in intervals titrated to
relieve symptoms.
Large doses of CMZ or PTU are given via nasogastric tube.
Iodine, a powerful inhibitor or thyroid hormones release is
also given orally or intravenously as potassium iodide.
Treat any precipitating cause. .
Corticosteroids, supportive care, treatment of cardiac
failure and hyperpyrexia, are necessary.
REFERENCES
1.
David Cooper: Antithyroid Drugs. N Engl J Med 1984:311:1353*60.
2. Davis T7: Diseases of the TSH receptor. Clin Endocrinol Metab
12:79-100.
3. Weiss & Davis: T7 Inhibition of Immunoglobulin-secreting cells
Antithyroid drugs. J Clin Endocrinol Metab 1981;53:1123-8.
1983;
by
4. Dahlberg Andres Karlssow et al: TRH testing during antithy- roid drug
treatment of Graves* disease as an indicator of
remission. J Clin
Endocrinol Metab 1985;61:1100-04.
----- SEPTEMBER 1989
Graves
6. Terry & Young: Changes in Thyroid stimulating antibody activity in
Graves* disease treated with Antithyroid drugs and its relationship to
relapse-a prospective study. J Clin Endocrinol Metab 1980;50:144-7.
7.
Beta blockers in Hyperthyroidism. Drugs May 1984.
8.
Witt JR: The approach to the irradiated Thyroid. Surg Clin N
Am 1979;59.
9. Becker DV: Choice of therapy for Graves hyperthyroidism. N Engl J Med
1984;311:464-6.
10. Dunn JT: Choice of therapy in young adults with hyperthyroi- dism of
Graves* disease. Ann Int med 1984;100:891.
11. D Sugrue and Freely: Hyperthyroidism in the land of Graves: Results
of treatment by surgery, radioactive iodine and carbamizole in 837 cases.
Quart J Med 1980;49:51-61.
12. Fisher DA and Klein AH: Thyroid development and disorders of
function in the newborn. N Engl J Med 1981:304:702.
thyroid
13. Hamid Ikram: Nature and prognosis of thyrotoxic heart disease. Quart
J Med 1985,213:19-28.
COMMUNITY HEALTH CELL
326. V Main, I Block
5,
Koranungala
Bsnga/ore-560034
India
St. John’s
Medical
College Journal
TRAINING TRENDS
of Medicine
INVOLVEMENT OF PRECLINICAL STUDENTS IN NATIONAL
HEALTH PROGRAMMES
AS MOHAMMAD,
INTRODUCTION
Currently major efforts are being made to address the most
important health problems of children,- namely diseases
included under the Expanded Programme on Immunization
(EPI). The greatest hope of reducing these problems lies in
immunization against the EPI diseases. The Bangalore City
Corporation has planned to implement the Universal
Immunization Programme (UIP) from April 1989 in the city
with the involvement of medical colleges.
One of the
objectives of involving medical colleges in UIP is to utilise the
student man-power. This article highlights the methodology
adopted to utilise the services of pre-clinical students for
enumeration of eligible population under UIP along with their
immunization status. At the same time this exercise is of
value to demonstrate to the under graduate students the
rationale of a situational analysis relevant to implementation
of UIP in urban slums.
METHODOLOGY
The entire city population was divided into 12 adminis
trative zones (ranges) with 40 corporation health institutions.
It has been estimated that approximately 25% of the city
population live in slums. St. John’s Medical College was
given a total population of approximately 2,00,000 in 3
primary Health Centres under ROME and an urban
population of approximately 5 lakhs around the college
under UIP. The college has been involved in the UIP right
from planning to evaluation stages.
Sixty pre-clinical
medical students and six interns were involved in the
enumeration of eligibles (infants and pregnant mothers)
under UIP in 2 ranges of the city. Before sending the students
into the field, a thorough orientation was given to the group.
The ability to communicate in the local and regional
language with the immigrant population ofthe slums was the
basis for the division of the entire group of students into two
batches. Each batch was accompanied by the respective
range health workers (Lady Health Visitor & Auxiliary Nurse
Midwife) from Urban Family Welfare Centres, and was
further divided into groups of two having one male and one
female student. All dwelling units in the localities were
DR. (MRS) M.M. KEKRE M.B.B.S., D.P.H.
MR. AS MOHAMMAD M.SC., (STATISTICS).
DEPARTMENT OF COMMUNITY MEDICINE
ST.JOHN'S MEDICAL COLLEGE
BANGALORE 560 034.
52
MM
KEKRE
numbered by the students. A well structured proforma was
used for enumeration. Attending to minor ailments of the
children in the community itself prior to this exercise,
resulted in attracting a large number of mothers who were
briefed by the interns about the exercise. The leaders and
Voluntary Organisations working in the slums for Mothers
and Children were thoroughly briefed about this important
activity under UIP to ensure their cooperation. The students
were transported to work spots by the mobile clinic where they
worked from 9.30 am to 3.00 pm without a break. Each
participant was given a small daily allowance. The staff
members from the department of Community Medicine
supervised the whole operation in the field which lasted six
days.
Every morning following the day of enumeration, a meeting
of the groups was arranged to review the progress and to
get feedback and suggestions if any. The concurrent
evaluation revealed an increase in the interest in the work
allotted to the students which was sustained throughout the
week. The participants expressed extreme satisfaction, for
such result oriented activities in the field and desired to be
informed about the outcome of their work.
RESULTS
The total population of 92,585 in the 38 slums around the
college was covered. 3000 infants and 1064 pregnant
mothers were enumerated. The immunization status of
infants and pregnant mothers in these slums is as follows
Eligibles
Immunization
1. Infants
BCG
OPT/OPV
Number
%
-1
-11
-III
1798
1100
799
533
38
59.93
36.67
26.63
17.71
1.21
-1
-11
-B
368
213
27
34.59
20.02
2.54
Measles
2. Pregnant
Mothers
T.T
The analysis was displayed on the notice board within 2 days
of the completion of enumeration.
This activity organised by the Department of Community
Medicine has been useful in inculcating a favourable attitude
towards community-based work amongst pre-clinical stu
dents. This will ensure for students in the future, a better
understanding of and keener involvement in National
Health Programmes. Similar exercises in other areas will be
valuable in so far as the role of a basic doctor is concerned.
VOL II No. 2
St. John’s Medical
College Journal
of Medicine
MAKING THINGS HAPPEN - AN EXPERIMENT IN HEALTH
MANAGEMENT
SUNEETHA SINGH, M.M. KEKRE
“Administration is so boring! I am a doctor, how would I know
why field staff do not submit surveillance reports for measles
cases every month?” grumbles one ICDS Pediatrician consultant.
Today, no doctorcan affordtheluxuryofbeingunfamiliarwith
administration. In any field of action, he is the ‘Man-incharge’, a sort of medical manager-entrepreneur. As he
goes progressively higher on the hierarchical ladder, his
responsibilities grow. The reason that your boss is 'the boss"
is not necessarily because he is a better person than you. He
wields greater managerial powers than you. Today a doctor
has no choice. Management has become an imperative
requirement.
In the field of health, there is a growing realisation that we
need managers not only for Public Health programmes but
also to ensure leadership of medical teams in every sphere
of medical interest. The growing awareness of, and
increasing response to this need is manifest at both national
and international levels with many workshops, seminars etc.,
being organised to this end.
In the Department of Community Medicine of St. John’s
Medical College, we felt that while the present internship
programme is directed at preventive and curative program
mes, training for the managerial role that the young doctor
must play is theoretical rather than practical. The question
that confronted us was thus - how could we arrive at an
energetic innovative medical manager in the available, pres
ent training situation?
We
decided to adopt an unusual model.
Interns were
incorporated into the administrative pool of the department
as 'fire fighters’. They were asked to analyse trouble spots
within ongoing interns’ activities. This was done at a basic
micro level. Solutions were then developed under guidance
of a staff member within the policy framework of the
department. Projects given to them had direct and
immediate relation to ongoing departmental activities. All
projects involved learning through doing which really is the
best way of teaching.We found that this worked very well
indeed. Each intern had the individual responsibility as well
as the personal satisfaction of having completed a meaning
ful job. ‘Success’ in management is really the development of
realistic solutions that work. The success of trrfs experiment
can be judged by the fact that almost all projects generated
information for action. So far 15 projects of this kind have been
completed. Case studies of the projects have been put up for
publication.
This is our model: interns given “on the job” training, in
management of everyday problems to be solved under
everyday constraints. We think this model would be useful
to persons in all departments everywhere and should not be
limited only to the Community Medicine Department. No
matter whether you are a surgeon, physician, biochemist
or a general practitioner - you require managerial skills
appropriate to your situation.
This article is unusual. It does not describe a study in the
classical sense - there are no statistics, no neatly presented
tables, no hard nosed facts. It is an experiment that has been
attempted with some success in the field of health managment. It is offered as a model foruse in all spheres of health
care training.
DR. SUNEETHA SINGH M.D. (PSM) D.C.H
DR. M.M. KEKRE D.P.H
DEPARTMENT OF COMMUNITY MEDICINE
ST.JOHNS MEDICAL COLLEGE
BANGALORE.
REPRINTS TO:
DR. SINGH.
DEPARTMENT OF COMMUNITY MEDICINE
ST.JOHN'S MEDICAL COLLEGE
BANGALORE560 034.
------ SEPTEMBER 1989
5 3—
St. John’s
Medical College Journal
CASE REPORT
of Medicine
GASTRIC PERFORATION IN A NEWBORN
GERARD T. ROY, ASHLEY J.D'CRUZ, RAMACHANDRA C.
INTRODUCTION
Perforation of the stomach in a newborn infant is a surgical
emergency that is infrequently encountered and requires
prompt management. Iatrogenic gastric and duodenal
perforation in neonates, resulting from the use of
nasogastric tubes for aspiration or gavage feeding, have
been reported in the past. With the increasing use of such
tubes in neonatal nurseries and neonatal intensive care units
this complication likely to occur more often and therefore
one needs to be more cautious. This report presents a case
of gastric perforation in a newborn and also discusses the
causes of this entity.
On examination the child had lethargy, depressed neonatal
reflexes, feeble peripheral pulses, tachypnea and a core
temperature of 36.5° C. the abdomen was distended and
the abdominal wall was red and edematous. Bowel sounds
were absent. An erect abdominal X Ray confirmed the
pneumoperitoneum and showed a large fluid level (fig-1 )■
CASE REPORT
A 2.34 kg. male, firstborn to an elderly mother by an LSCS,
was referred on the 7th day after birth with abdominal
distention and refusal of feeds. He had developed vomiting
the day after birth for which a gastric lavage was done using
a polythene nasogastric tube. Four hours later, the child
developed abdominal distention and respiratory distress. A
plain X-Ray erect abdomen showed massive pneumoperi
toneum and an abdominal paracentesis was done to relieve
the distention. The child was managed conservatively and
as he improved, tube feeding was started. Three days later,
the child deteriorated and was referred to SJMCH.
GERARD T. ROY M.S., D.N.B.'
LECTURER
ASHLEY J.D’CRUZ M.S., M.CH.
ASST. PROFESSOR
RAMACHANDRA C. M.S., M.CH.
ASST. PROFESSOR.
DEPARTMENT OF PEDIATRIC SURGERY
ST.JOHN'S MEDICAL COLLEGE HOSPITAL
BANGALORE 560 034.
REPRINT REQUESTS:
ASHLEY J.D'CRUZ
ASST. PROFESSOR. 1/C DEPT. OF PEDIATRIC SUR
GERY
ST.JOHN'S MEDICAL COLLEGE HOSPITAL
BANGALORE 560 034.
PRESENT ADDRESS:
DEPT. OF PEDIATRIC SURGERY,
ROYAL INFIRMARY,
GLASGOW, SCOTLAND (U.K)
5 4
Fig. 1: Showing free intraperitoneal air and single large intraperitoneal fluid
level.
A paracentesis was done to drain the pus and relieve the
respiratory distress. The child was stabilized over the next
few hours. At laparotomy,, a severe degree of peritoneal
contamination and a 2 mm perforation was seen on the
anterior wall, of the body of the stomach close to the greater
curvature. There was pouting mucosa at the performation
and the surrounding gastric wall was healthy. The perfora
tion was converted into a gastrostomy using a No 10 Foley’s
catheter and the site was anchored to the anterior abdominal
wall.
On admmission, the blood culture grew E.Coli, and the
peritoneal pus grew pseudomonas aerugenosa. The child
was treated with amikacin and cefotaxime in high doses.
The blood and wound cultures taken before discharge were
sterile. The child made a remarkable recovery except for a
superficial wound infection.
The gastrostomy tube was removed two weeks after surgery
and the gastric fistula closed rapidly.
DISCUSSION
The first report of a neonatal gastric perforation was pub
lished in 1825 by Siebold1 and the first attempt to repair a
gastric perforation in a newborn was reported by Stern and
associates2 in 1929.
Neonatal necrotizing enterocolitis accounts for about 50%
of gastrointestinal perforations and they usually occur in the
small bowel and colon. The gastroduodenal area is the next
---------------------------------------------------------------- --------------- VOL II No. 2
—
St. John’s Medical
College Journal of Medicine
common site where tube perforations of the duodenum and
spontaneous perforations of the stomach are etiologically
implicated3. Factors responsible for neonatal gastric perfora
tions cited by other authors include congenital muscle
defects, peptic ulceration,
distal
obstruction,
birth
trauma, endoscopy, resuscitation, catheter trauma and
idiopathic causes.415-6
In one review4 catheter trauma accounted for 11 out of 143
cases of neonatal gastric perforation. Nasogastric tube
causing gastric perforation
have
been recorded by
Kellogg7, Potter8, Wagner9 and Wilson10. The evidence of
minimal inflammation at the site of puncture and history of
gastric lavage seemed adequate to implicate the tube as the
causative factor11. These perforations are generally smaller
than those seen with muscle defects.
The gastric perforation is usually closed in two layers but
may be incorporated in a gastrostomy as was done in our
case. Repeated blood and pus cultures enable infection to
be treated effectively.
The prognosis, hitherto, depended on the time elapsing
between the occurrence of the perforation and surgical
intervention. However, with increased awareness, prompt
recognition and treatment, and adequate antibiotic therapy,
it is possible to save these neonates, as is evident in this
REFERENCES :
1. Siebold : Heber Geschwursbildurgen des Gastro-Duodenal tractus im kin
desalter, Ergebn Inn Med Kindemeilk 1919;16:302-383.
2. Stern MA, Perkins EL & Nesse NS: Perforated gastric ulcer m a 2 day old
infant, Lancet, 1929;49:492-494.
3. Bell MJ: Perforation of the Gastrointestinal and peritonitis in the neonate.
Surg Gynec Obstet 1985;160:20-26.
4.
InouyeWY, Evans G: Neonatal gastric perforation. Arch Surg 1964;88:471.
5. Emanuel B, Zlotnikp, Raffensperger J: Perforation of the gastrointesti
nal tract in infancy and children. Surg Gynec Obstet 1978;46:926-928.
6. Eichelberger MR, Randolph JG: Abdominal Trauma In: Pediatric Surgery
Ed: Welch RJ, Randolph, Ravitch MM, Oneill JA, Rowe Ml. Yearbook Med.
Publisher Inc. 1986 pg 162.
7. Kellog HG, Abelson SM, Cornwall FA: Perforation of the stomach in
newborn infants. Pediat J. Louis S 1951;39:357-362.
8. Potter EL : Pathology of the fetus and newborn Chicago Yearbook
Publishers Inc. 1952 pp 295-296.
9. Wagner EA, Jones DV, Koch CA, Smith DC: Polythene tube feeding in
premature infants. Pediat J. Louis S. 1952;41:79.
10. Wilson MG : Abdominal surgery in the newborn. Surg. Gynec. Obstet
1955;100:141-148.
11. Vargus LL, Levin SM, Santulli TV: Rupture of the stomach in the Newborn
infant, surg. Gynec. Obstet 1955;101:417-424.
report.
------ SEPTEMBER 1989
5 5—
Position: 5346 (1 views)