Editorial

Dr. W. B. Tayade M.S. (Ortho.)

Director, Medical Education & Research, Mumbai

Government of Maharashtra

It is indeed a great pleasure to present to you yet another issue of `Milestone'. The landmarks achieved and the knowledge gained by specialists in the field of Medicine has to spread to the new generation of doctors. This can be best achieved through `Milestone'. Medical Research Council of Maharashtra has taken this great step forward in the direction of research in the field of Medicine. The office bearers, the members of scientific Advisory Board, the members of Editorial board are taking untiring efforts to achieve this noble goal. Dr. H. R. Nagrale Member Secretary, The medical research council of Maharashtra & Jt. DMER with his valuable suggestions and

studied criticism provides a valuable impetus to this work.

I am sure that the seeds, which are sown by our ancestors in the field of Medicine will bear rich fruits in future. High standard, high hopes and high-level technique is our motto.

Once again, I congratulate my colleagues and all those who are deeply involved in this great task. I sincerely welcome suggestions and constructive criticism from the readers, for improving quality of this Journal and also the research work, so that research in medicine in state of Maharashtra contributes to knowledge and wisdom on the global level.

Original Article

ESTIMATION OF TIME SINCE DEATH FROM CEREBROSPINAL FLUID CHEMISTRY

Dr. A. P. Dongre *

Dr. R. V. Bardale **

rely heavily on ordinary methods of observing the external and internal changes in the dead body that take place after death. On most of the occasion, it gives useful information in the range of duration regarding time since death. However, unfortunately, some times it is so wide that it is not useful to pinpoint the estimation of time since death.

Historically, analysis of postmortem blood specimen had been most extensively studied. However, numerous analytes in blood shows varying degree of postmortem changes making evaluation difficult or impossible. To overcome the inadequacies of blood, a wide variety of body fluids such as, vitreous humor, cerebrospinal fluid, pericardial fluid, synovial fluid has been studied to determine the time since death.

The present study is designed to study the changes of sodium, potassium, chloride, inorganic phosphorus, lactate, protein, and glucose in the postmortem CSF in humans. The merits of studying this fluid lies in the fact that, it is more secure, protected, subject to less

ABSTRACT

In the present study, Sodium, Potassium, Chloride, inorganic phosphorus, lactate, protein and glucose levels were studied in cerebrospinal fluid samples obtained from 100 medicolegal autopsy cases; the samples were drawn at six, twelve and sixteen hours after death, in the Dept. of Forensic Medicine, Indira Gandhi Medical College, Nagpur. The levels of potassium, inorganic phosphorus, lactate and protein increases after death whereas sodium, chloride and glucose decrease. The level of potassium and inorganic phosphorus rises, chloride level falls, and the values were linear with time and can be utilized to estimate the time since death.

Introduction

The estimation of time since death is paramount important in both civil and criminal cases, which has been appreciated from the beginning of centuries. Even today, one has to

* Professor & Head, Dept. of Forensic Medicine

** Junior Resident, Dept. of Forensic Medicine

Indira Gandhi Medical College, Nagpur.

contamination or environmental influences, and above all the CSF lies in close proximation to brain. Obviously, the changes, which are taking place in brain, are apt to be reflected in the CSF. Hence, the study has been made to evaluate the applicability of CSF chemistry for estimation of time since death in our country environment.

Material and methods

This prospective study was carried out in the Department of Forensic Medicine & Toxicology, Indira Gandhi Medical College, Nagpur, conducted from October 2002 to November 2003. The CSF samples were drained from 100 cases at a fixed interval of six hour i.e. at 6, 12, & 18 hours after death. The age group ranged from 11 year to 80 year. There were 73 men and 27 women. The time of death was known and was confirmed from doctors, relatives, police personal and death summary. The cases, in which head injury, spine injury or intracranial hemorrhage was suspected or apparent or was detected at autopsy, were not included in the study.

The control group comprised of 10 subjects with no neurological disorder; six men and four women scheduled for elective surgery. The CSF control samples in these subjects were obtained by lumbar puncture, prior to induction of spinal anesthesia. The age range of these patients was 19 to 60 years.

The fluid was drawn by performing cisternal tap. Three successive taps were made and at each tap 1.5-4 ml sample was collected. The samples were collected into plain polycarbonate tubes. The samples were preserved at four-degree Celsius and until the analysis was made, cold chain was maintained.

The samples were analyzed at Dept. of Biochemistry. The sodium and potassium were analyzed on flame photometer (Mediflame Systronics, India), whereas chloride, inorganic phosphorus, lactate, protein and glucose over semiautomatic analyzer (Transasia ERBA Chem-5 Plus). The reagents used were pre-prepared, commercially available.

Results

The value obtained from the control subjects, as displayed in table No.1, were treated as baseline.

Potassium: There was an increase of potassium concentration in the postmortem interval (PMI) with the time. At sixth hour after death, it ranges from 2.9 to 28.3 meq/L with a mean of 9.92 meq/L, and SD 5.69, at twelfth hour postmortem interval (PMI); it ranges from 5.1 to 39.1 meq/L, with an average of 17.63 meq/L, and SD 8.47. At the end of eighteenth hour, it varies from 6.9 to 56 meq/L with a mean of 24.93 meq/L, and SD 10.41. The rise was statistically significant (p< 0.001) and is relatively linear. The 95 % limits of confidence of the CSF potassium, at six-hour postmortem interval are ±11.15 in meq/L, at twelve hours are ±16.60 in meq/L, and by eighteen hours are ±20.40 in meq/L.

Sodium: There is a decrease of sodium concentration with increasing postmortem interval. At sixth hour of PMI, the value ranges between 88.3 to 210 meq/L with an average of 124.8 meq/L and SD 20.01. There is decrease of sodium at 12 hour PMI with a range of 56.4 to 175.4 meq/L with a mean of 103.46 meq/L, and SD 18.12. By 18 hour after death, the value of sodium ranges from 42.1 to 152 meq/L with a mean of 85.60 meq/L, and SD 18.73. Though the fall is was significant, it was not linear.

hour PMI, the range is 19.1 to 287.4 mg/dL with a mean of 86.848 mg/dL, and SD 42.11. At 18-hour of postmortem interval, the range is 23.2 to 299.4 mg/dL with an average of 101.55 mg/dL, and SD 45.41. The rise in the level is not linear.

Protein: After death, the protein increases in the CSF. At 6^th hour postmortem interval, it ranges from 20 to 411.9 mg/dL with a mean of 76.52 mg/dL, and SD 45.28. In the midst of 12-hour PMI, the range is 24 to 435.2 mg/dL with a mean of 93.29 mg/dL, and SD 48.91. At 18-hour postmortem, the range is 28 to 450 mg/dL with an average of 110.30 mg/dL, and SD 51.19. The rise is not linear.

Glucose: The concentration of glucose decreases after death. At the end of 6^th hour of PMI, it ranges from 1.5 to 93 mg/dL with a mean of 31.44 mg/dL, and SD 24.02. At 12^th hour of PMI, it ranges from 0 to 57 mg/dL with a mean of 8.39 mg/dL, and SD 10.92. By the end of 18^th hour of PMI, the value ranges from 0 to 32 mg/dL with an average of 2.28 mg/dL, and SD 5.58. The decrease is not linear and many times it is precipitous and at time erratic.

Discussion

Cooper, Leshner and Bellet (1958) have studied changes in CSF components with disease extensively. There is remarkably constancy of CSF components in life. However, after death, these components start to change and these changes serves as guide to estimate the death interval.

Sodium in postmortem CSF has been reported to decrease by Naumann, Meyer et al, Paulson et al Schoning et al and Karkela.

Chloride: After death, there is decrease in the concentration of chloride. At the 6-hour postmortem interval, the concentration of chloride ranges from 90.1 to 159.3 meq/L with a mean of 120.97 meq/L, and SD 15.20. Next to 12 hour after death, the value ranges from 61.2 to 129.3 meq/L, with a mean of 100.96 meq/L, and SD 13.78. At 18-hour it ranges from 47.3-129.7 meq/L, with a mean of 83.71 meq/L, and SD 16.01. The fall of chloride concentration is statistically significant (p< 0.001) and is linear with time. The 95 % limits of confidence of the CSF chloride, at 6-hour postmortem interval are ± 29.79 meq/L, by 12^th hour are ± 27 meq/L, and then at 18^th hour after death are ± 31.37 meq/L.

Inorganic phosphorus: The concentration increases after death. At the end of 6^th hour after death, it ranges from 1.1 to 15.8 mg/dL with a mean of 4.88 mg/dL, and SD 3.05. At 12^th hour postmortem interval, value varies from 2.1 to 20.4 mg/dL with a mean of 7.50 mg/dL, and SD 3.94. By 18-hour postmortem interval, value ranges from 3.4 to 25.3 mg/dL with an average of 10.36 mg/dL, and SD 5.11.It indicates that the mean increase of inorganic phosphorus concentration in the postmortem interval is relatively linear with the time and the rise is statistically significant (p < 0.001). The 95 % limits of confidence of the CSF inorganic phosphorus at 6-hour postmortem interval are ± 5.97 mg/dL, by 12^th hour it laid ± 7.72 mg/dL, and at 18^th hour postmortem interval are ± 10.01 mg/dL.

Lactate: The concentration of lactate increases in the PMI. At 6^th hour of postmortem interval, it ranges from 18.3 to 240.7 mg/dL with a mean of 71.93 mg/dL, and SD 38.27. Whilst at 12^th

In the present study we also noted the fall, however, the fall in the level is not linear with time and we found it is not a good parameter to estimate time since death.

Potassium increases after death and the rise is with the time and is linear. It is useful indicator to determine the postmortem interval. The findings of the present study are consistent with that of Naumann, Fraschini et al, Meyer et al, Paulson et al Schoning et al, Karkela and Madea et al.

As the time interval increased, chloride dropped consistently and apparently as uniformly as potassium increase. Therefore, chloride can be a reliable indicator of postmortem interval as potassium. Naumann, Schoning, and Karkela also noted the same; however, Paulson and Stickney noted a rise in the concentration.

Naumann and Schleyer noted that inorganic phosphorus increased in CSF. Our works confirms their findings. Inorganic phosphorus increases with PMI and the increase is linear. It can also be utilized as a measure to estimate PMI.

After death, there is an increase in the concentration of lactate in the CSF. However, in the present study no correlation between the PMI and postmortem lactate concentration was observed. In this regard, our findings are consistent with that of Karkela et al.

There is an increase of protein in CSF after death. The rise is attributed to lysis of cell. Naumann and Coe also noted an increase of protein. Moreover, the increase is not regularly sufficient to estimate the time since death.

Naumann, Paulson and Schoning demonstrated that levels of glucose declines after death. In the present study, we also recorded the drop in the glucose level, but the fall is not related to time and sometime the fall is erratic. The authors do not found it a useful guide to determine PMI.

CONCLUSION

From the present study, the following conclusions is drawn. The potassium in the CSF increases with the increasing postmortem interval and the rise is linear. It can be fairly utilized as an indicator to estimate time since death. The 95% limits of confidence of potassium at 6-hour postmortem interval are ±11.15 meq/L, at 12 hour are ± 16.60 meq/L, and by 18-hour postmortem period are ± 20.40 meq/L. The sodium in the CSF decreases with the increasing postmortem interval and the decrease is not linear, it cannot be utilized precisely to estimate postmortem interval. The chloride falls in the postmortem interval in CSF and the drop is consistent with time. It can be used as a measure to estimate postmortem interval. The 95 % limits of confidence of chloride at 6-hour postmortem intervals are ± 29.79 in meq/L, at 12 hours are ±27 in meq/L, and at 18 hours are ± 31.37 in meq/L. The inorganic phosphorus increases in the postmortem interval in CSF and the increase is linear and with time. It is a sensible marker to estimate time since death. The 95% limits of confidence of inorganic phosphorus at 6-hour postmortem interval are ± 5.97 in mg/dL, at 12 hour are ± 7.72 in mg/dL, & at 18 hour are ± 10.01 in mg/dL. The concentration of lactate increases in the postmortem interval in CSF and

though the increase is with time, yet it is not a pragmatic measure to estimate time since death. The value of protein increases in the postmortem interval in CSF and the increase is with time. It is not a helpful to measure

postmortem duration. The glucose decreases in the postmortem interval with time, but the fall is not regular and many times, it is precipitous and at times erratic. It is not trustworthy indicator to estimate time since death.

Table No. 1 Table showing values of the sodium, potassium, and chloride, inorganic phosphorus, lactate, protein, and sugar in control subjects. The values are in range, mean, & standard deviation

Table No. 2 Table showing postmortem values in CSF of potassium, sodium, chloride, inorganic phosphorus, lactate, protein, & glucose (range, mean & standard deviation).

Constituents 6 hour 12 hour 18 hour

REFERENCES

1) Coe J.I.: Postmortem chemistry update, The American Journal of Forensic Medicine & Pathology, Vol.14, No.2, 1993, 91-117.

2) Cooper E.S., Lechner E., & Bellet S.: Relation between serum and CSF electrolytes under normal and abnormal conditions, American Journal of Medicine, Vol. 18, April 1955, 613-621.

3) Fraschini F., Muller E., & Zanoboni A.: postmortem increase of Potassium in human CSF, Nature, Vol.198, June 1963, 1208.

4) Hansen A.J.: Effects of anoxia on ion distribution in the brain, Physiological Reviews, Vol.65, No.1, January 1985, 101-148.

5) Karkela J.T., Pasanen M., Kaukinen S., & Morsky P.: Evaluation of hypoxic brain injury with spinal fluid enzymes, lactate, and pyruvate, Critical Care Medicine, Vol. 20, No.3, March 1992, 378-386

6) Karkela J.T.: Critical Evaluation of postmortem changes in human autopsy Cisternal fluid. Enzymes, electrolytes, acid-base balance, glucose & glycolysis, free amino acids and ammonia. Correlation to total brain ischemia,

Journal of Forensic Sciences, Vol.38, No.3, May 1993, 603-616.

7) Madea B., & Henbge C.: electrolyte concentration in CSF and Vitreous humor, in Henssge C., Knight B.,Madea B., & Nokes L. (Eds.) estimation of time since death in early postmortem interval, Edward Arnold London, 1993.

8) Meyer J.S., Kanda T., Shinohard Y., & Fukuuchi Y.: Effects of anoxia on CNS Sodium & Potassium concentrations, Vol.21, September 1971, 889-895.

9) Naumann H.N.: Studies on postmortem chemistry, American journal of Clinical Pathology, VOL.20, 1950, 314-324.

10) Naumann H.N.: CSF electrolytes after death, Proceedings of the society for Experimental Biology and Medicine, Vol.98, No.1, May 1958, 16-18.

11) Paulson G.W. & Stickney D.: Cerebrospinal fluid after death, Confinia Neurologica, Vol.33, No.3, 1971, 149-162.

12) Schoning P. & Strafuss A.C.: postmortem biochemical changes in Canine Cerebrospinal fluid, journal of Forensic Sciences, Vol.25, No.1, January 1980, 60-66.

Original Article

TRANSCATHETER EMBOLIZATION IN MANAGEMENT OF HAEMOPTYSIS.

Dr. Kishor Taori *

Dr. Atul Rewatkar **

Dr. Rajesh Mundhada **

Massive haemoptysis is defined as expectoration of more than 600 ml of blood in 48 hours ( 1 ). Tuberculosis is by far the most common cause of haemoptysis in India. Bronchietasis, aspergiloma, pneumoconiosis, bronchogenic carcinoma, pulmonary artery aneurysm & pulmonary AVM etc. accounts for the other commoner causes of haemoptysis. Massive haemoptysis can be life threatening when treated conservatively with mortality rate approaching 75% usually due to asphyxiation (2). Aggressive surgical procedures can considerably reduce the mortality rate (2- 4) but most of these patients cannot sustain this major surgery due to extensive pulmonary disease. These patients are best managed by embolization of bronchial and non bronchial collaterals supplying the inflammed lung.

Anatomy

Bronchial artery most commonly arise from the descending aorta between superior end plate of 5^th thoracic vertebra and the inferior 6^th

thoracic vertebra. In approximately 45% there is single bronchial artery on one side usually on right and two on the other side. While in 30% there is single bronchial artery on each side. The right intercosto-bronchial trunk is seen in 80% of individuals (5). Bronchial artery may vary in their site of origin which can be inferior aspect of aortic arch (15%), internal mammary artery, thyro-cervical trunk and inferior phrenic artery. Besides supplying the bronchi, bronchial arteries also contribute to the blood supply of oesophagus, pleura, myocardium, vasa vasorum of the aorta and pulmonary artery and occasionally the spinal cord.

Pathophysiology of haemoptysis

Chronic inflammation of the lung when reaches the pleura, the diseased lung also derives its supply from non bronchial arteries like intercostals, internal mammary arteries, thyrocervical & costocervical trunks, branches of axillary, inferior phrenic & left gastric arteries.

* Professor & Head

** Lecturer, Department of Radiodiagnosis _ Interventional Radiology Unit

Government Medical College & Hospital, Nagpur.

Chronically inflammed lungs

Abnormal broncho pulmonary shunts in inflamed lung in peribronchial tissue

Bronchial & non bronchial systemic collaterals dilate to increase flow

Small fragile vessels in inflammed tissue are exposed to systemic arterial pressure

They rupture and cause massive bleeding.

What is done in embolization?

Bronchial and Non bronchial collaterals are embolized mainly at the broncho pulmonary shunt levels so as to decrease the systemic blood pressure in the inflammed area causing cessation of bleed. Bronchial and Non bronchial collaterals are not to be blocked only at the origins because though it can cause temporary cessation of bleeding, the chances of rebleed are significantly high due to revascularization of broncho pulmonary shunts.

Technique

The procedure is done by retrograde trans femoral approach. Arch aortogram is done for mapping the bleeders, and then the culprit vessels of haemoptysis are selectively catheterized and embolized using various embolic agents. The commonest embolic agent used is gelfoam particles. At times poly vinyl alcohol particles (PVA) & coils can be used for embolization.

Imaging spectrum of abnormal bronchial arteries  

á

á

á

á

* Hypertrophied & tortuous

* Psuedoaneurysm formation

* Areas of hypervascularity in lungs

* Visualization of pulmonary artery or vein

* Early draining vein

* Active extravasation of contrast

The end point of embolization is reached when there is contrast stasis in abnormal artery with cessation of forward flow.

Imaging spectrum of inflammed collateral responsible for haemoptysis

Observations -

The study was carried out at the Department of Radiodiagnosis, Government Medical College, Nagpur from January 2000 to January 2003. Of the 80 patients treated for massive haemoptysis, 52 were male and 28 were female (M: F:: 1.9 : 1) with their age ranging from 12 to 48 years. Immediate control

of haemoptysis was obtained in 79/80 patients (98.75 %). Only 1/80 patient of fungus ball rebleed within 24 hours who was then treated by thoracotomy.

Of the 65 patients of tuberculosis treated by embolization, 37 patients (56.92%) were

defaulters while 28patients (43.08%) were non defaulters.

In all135 bronchial arteries were embolized in 80 patients. Their distribution is as follows.

Right broncho-intercostal angiogram pre and post embolisation

Haemoptysis due to arteriovenous malformation - pre and post embolisation

The distribution of all the 260 non bronchial collateral embolized in 80 patients is as follows

All patients were followed up for at least 6 months. All 4 of them who rebleed were defaulters and were reembolized. 3/4 had new collaterals while 1/4 had reopened collateral, as a cause of rebleed. Late rebleed is generally due to disease progression and can be successfully treated by repeat embolization (1). 6 patients died due to the on going end stage lung disease.

Complications

Only one patient (1.25%) had complication in the form of quadriparesis which was due to the embolization of the right broncho-intercostal trunk. This patient on steroids and AKT recovered completely in 1 ½ years.

Results and conclusion :

The success rate of embolization was 98.75%.

On an average five vessels were embolized in patients with life threatening haemoptysis.

Haemoptysis is common in defaulters (56.92%)

Failure rate and complication rate were very low (1.25%)

Take home message : "Transcatheter embolization is safe & effective measure in treating life threatening haemoptysis". 

In 80 patients with massive life threatening haemoptysis in total 395 vessels were embolized including 135 bronchial and 260 non bronchial collaterals, with an average of 5 bleeders in each patients

After the embolization, the patients were given adjuvant treatment in the form of medical and / or surgical line. In all 67 patients (83.75%) required medical line of treatment in the form of anti tubercular regime and 13 patients (16.25%) were treated surgically.

The distribution of management is as follows.

References

1) Marshall TJ, FlowerCDR, Jackson JE. Review: The role of radiology in the investigation and management of patients with haemoptysis. Clinical Radiology 1996; 51: 391- 400.

2) Crocco JA, Rooney JJ, Fankrushan et al Massive haemoptysis. Arch Intern Med 1968; 122: 495

3) Sehat S, Oreize M, Moinedine K. Massive pulmonary haemorrhage:

surgical approach as a choice of treatment. Ann Thorac Cardiovasc Surg 1978; 25 : 12

4) Garzon AA, Govrin A. Surgical management of massive haemoptysis: a 10- year experience. Ann Surg 1978; 187 : 267

5) Marshall TJ, Jackson JE. Vascular interventions in thorax: bronchial artery embolization for haemoptysis. Eur Radiol 1997; 7; 1221 - 1227

Original Article

evalUation of letrozole versus high dose tomoxifen along with chemotherapy in downstaging locally advanced breast cancer

Dr. V. N. Sagdeo, Dr. M. V. Khubalkar, Dr. Jambhulkar, Dr. P. Giri, Dr. Nagdeve,

Dr. Borkar, Dr. Bhagat, Dr. N. Kale,
Department of Surgery, Govt Medical College - Nagpur.

Abstract

Background : In developing countries like India, Breat cancer is the second commonest cancer in Females, next to carcinoma uterine cervix. In India most of these patients belong to locally advaned Breast cancer. Most centres treated this by surgery or irradiation with the results that most patients succumbed to metastatic disease. Chemohormonal therapy has been used to deownstage the locally Advaned Breast Cancer since long-time. Addition of Tamoxifen, an antiestrogen, has shown to decrease the local recurrence as well as distant metastasis in different clinical trials. Now the discovery of Aromatase inhibitors has been an achievement in the management of advanced breast cancer. Recently several studies have reviewed the efficacy of aromatase inhibitors as the first line agents in post-menopausal woman. Letrozole a non-steroidal third generation Aromatase inhibitor has been found to be equivalent or superior to Tamoxifen as first line therapy in advanced breast cancer, and it has been shown that Letrozole has produced higher clinical benefit.

Meterial and Methods : Preliminary trial carried out on Locally Advanced Breast Cancer patients at Government Medical College and Hospital, Nagpur between Jan 2002 to Dec 2003. 16 patients were given Letrozole 2.5 mg OD and 15 patients were given tablet Tamoxifen 50 mg BD alongwith chemotherapy.

Results : Mean age at diagnosis was 55 years in group I and 54.7 years in group II. 16 (100%) patients in group I and 15 (100%) patients in group II aer state T_4b 15 (9.3.75%) patients in group I and 11 (73.33%) patients in group II had axillary nodes only. One (6.25%) in group I and 01 (6.67%) patients in group II had ipsilateral supraclavicular nodes also. 3 (20%) patients in group II had no clinically detectable nodes. Seven (43.75%) patients in group I and 7 (46.67%) patients in group II had maximum response in preoperative 3 cycles. Three (18.75%) patients in group I and (6.67%) patient in group II had complete response. Nine (56.25%) patients in group I and 13 (86.67%) patients in group II had partial response. Two (12.5%) patients in group I had progressive disease. Two (12.5%) patients in group I and 1 (6.67%) had static disease. All the patients in group I and group II had one of the toxicities

that Letrozole has produced higher clinical benefit. However no significant difference has been shown in the duration of overall response or in overall clinical benefit. So in this study letrozole has been compared with tamoxifen in locally Advanced Breast Cancer as a Neo-Adjuvant treatment in addition to chemotherapy (Cyclophosphamide + Methotrexate + 5 flurouracil). In this study the Tamoxifen used is high does (50 mg BD).

Materials and methods

This is a preliminary trial carried out on locally advanced breast cancer patients who were treated at Government Medical College and Hospital Nagpur, between January 2002 to December 2003. 16 patients were given tablet Letrozole 2.5 mgOD and 15 patients were given tablet Tamoxifen 50 mgBD.

Eligibility Criteria :

1. No Age Limit

2. Locally Advanced Breast Cancer (LABC) patients i.e. state III B (AJCC-1992) i.e. patients with tumor of any size with any one or moer of the following.

a. Skin involvement : ulceration, peaud'orange, satellite nodules.

b. Fixity to chest wall

c. Ipsilateral supra clavicular lymph nodes.

3. FNAC - proved

Exclusion Criteria

Prior treatment elsewhere, Inflammatory Breast Cancer, Cardiac disease, Pergnancy, Any other malignancy.

like venous thrombosis and increased endometrial thickness (only with tamoxifen) were not found in any case and followup of the cases role as first-line therapy in downstaging locally advanced breast cancer (LABC) and it is equally effective as that of Tamoxifen (high dose) if not more effective with better patient compliance. However, larger studies with large sample size will give a conclusive evidence about the efficacy of either of these two (Letrozole or Tamoxifen).

introduction

In developing countries like India, Breast cancer is the second commonest cancer in Females, next to carcinoma uterine cervix. In India most of these patients belong to locally advanced Breast cancer. Management of locally advanced Breast cancer remained disappointing till 1985. Most centres treated this by surgery or irradiation with the results that most patients succumbed to metastatic disease. Chemohormonal therapy has been used to downstage the locally Advanced Breat Cancer since long-time. Addition of Tamoxifen, an antiestrogen, has shown to decrease the local recurrence as well as distant metastasis in different clinical trials.

Now the discovery of Aromatase inhibitors has been an achievement in the management of advanced breast cancer. Recently several studies have reviewed the efficacy of aromatase inhibitors as the first line agents in postmenopausal woman. Letrozole a non-steroidal third generation Aromatase inhibitor has been found to be equivalent or superior to Tamoxifen as first line therapy in advanced breast cancer, and it has been shown

The patients were divided into two groups i.e. I & II. Group I comprises 16 patients and group II comprises of 15 patients of age between 40 and 70 years and of post menopausal states.

The treatment protocal for each group is as follows: Group I : Consisted of 16 LABC patients treated by Unit Surgery at GMCH, Nagpur with

Ø Inj. Cyclophosphamide in the dose of 600 mg/m² body surface area.

Ø Inj. Methotraxate in the dose of 50 mg/m² body surface area

Ø Inj. 5-Flurouracil 600 mg/m² body surface area

This treatment was started on the very first day of histopathological diagnosis. Cycle of CMF was given on day 1 and 8 of every 3 weeks interval until maximum response is reached (usually 3 cycles). This was followed by Modified Radical Mastectomy. Oral Letrozole 2.5 mg OD was given from the day of diagnosis upto first three months. After Letrozole, Standard Dose Tamoxifen (SDT) was advised to continue upto 5 years from the date of diagnosis.

Group II : Consisted of 15 patients treated at unit I Surgery, GMCH, Nagpur, They were given

Ø Inj. Cyclophosphamide in the dose of 600 mg/m² body surface area.

Ø Inj. Methotraxate in the dose of 50 mg/m² body surface area

Ø Inj. 5-Fluorouracil 600 mg/m² body surface area

From the first day of histopathological diagnosis upto maximum response (Usually 3 Cycles). This was followed by Modified Radical Mastectomy. Oral high dose Tamoxifen (50mg BD) was given daily from day of diagnosis upto the completion of locoregional treatment After high dose tamoxifen, standard dose tamoxifen was advised to continue upto 5 years from the date of diagnosis. Complete haematocrit evaluation was done before every cycle of chemotherapy. Response to chemohormonal therapy was documented before every cycle of chemotherapy using UICC criteria.

CR Complete response No clinical evidence of disease

PR Partial response - 50% regression as calculated by the area of the tumor, largest dimension multiple by the dimension perpendicular to the largest dimension.

SD Static disease / Progression Less than 50% regression or actual incease in the area of primary tumor.

In case of partial response the chemohormonal therapy was continued till two consecutive assessments revealed no chage i.e. till maximum response is achieved and then locoregional management. In case of complete response, patient was taken for locoregional management after three weeks of chemotherapy regimen. In case of static disease or progressive disease patients were offered palliative locoregional treatment, radiotherapy or surgery. Absence of overt distant metastasis was based on complete physical examination, chest X-ray, skeletal metastasis survey by X-rays, abdominal

3 (20%) patients in group II had no clinically detectable nodes Seven (43.75%) patients in group I and 7 (46.67%) patients in group II had maximum response in preoperative 3 cycles. Mean no. of preoperative cycles in group I and group II was 3 cycles. Three (18.75%) patients in group I and 1(6.67%) patient in group II had compete response. Nine (56.25%) patients in group I and 13 (86.67%) patients in group II had partial response. Two (12.5%) patient in group I had progressive disease Two (12.5%) patients in group I and 1 (6.67%) had static disease. All the patients in group I and group II had one of the toxicities like nausea, vomiting, loss of appetite, alopecia, hot flushes. Therapeutic continuity was not broken in any case due to these toxicities. Toxicities like venous thrombosis and increased endometrial thickness (only with tamoxifen) were not found in any case and followup of the cases is continued for the same.

comments : This is a preliminary study about the evaluation of letrozole 2.5mg OD against tamoxifen 50mg BD along with chemotherapy in downstaging the locally advanced breast cancer. (LABC). Haagensen and Stout illustrated the difficulties in the management of locally advanced breast cancer (LABC). The retropective analysis of their series of such patients who underwent radical mastectomy; approximately half the patietns had local recurrence within five years and only 3% survived upto five years. It is, therefore, not surprising that other treatment options have been examined. Radiotherapy alone, although studies of Mouridsen, S. Paepke, Ellis were also belonging to postmenopausal status. The median number of cycles of chemotherapy required to achieve complete response were 3

ultrasonography, LFT and KFT. A detailed clinical history is taken and examination of breast and axillary gland is done as per proforma given below.

follow up : Patients in both groups were followed every three months for initial one year and then, six monthly thereafter. In follow up visit, all patients had to undergo detailed clinical examination, complete blood counts, LFT and abdominal and pelvic ultrasound. X-ray chest was done on each 6 monthly follow up. Symptomatic bony secondaries patietns were advised bone scan. All the toxicities of the Tamoxifen & Letrozol were observed carefully and accordingly the investigations like pelvic ultrasound for endometrial thickness and tests for visual acuity were done. The data collected was used for analysis of observations and documented in the next chapter.

results : In this study patients were distributed according to the age at diagnosis between 40 to 70 years. Patients below 40 years and above 70 years were not included. Age group 40-50 included 5 (31.25%) in group I and 8 (53.33%) in group II. Age group 50-60 included 8 (50%) in group I and 3 (20%) in group II. Age group 60-70 included 3(18.75%) in group I and 4 (26.67%) group II. Mean age at diagnosis was 55 years in group I and 54.7 years in group II. 16 (100%) patients in group I and 15 (100%) patients in group II are state T_4b the patients in this study had local invasion extension of stage T_4b. i.e. skin involvement overlying the tumor. 15 (93.75%) patients in group I and 11 (73.33%) patients in group II had axillary nodes only. One (6.25%) in group I and 01 (6.67%) patients in group II had ipsilateral supraclavicular nodes also.

cycles in our study. Also the median number of cycles of chemotherapy required to achieve complete response in the studies of Mouridsen, S. Paepke, Ellis was 3 cycles. In our study ER/PR receptor status was not done in any of the patients due to non affordability of the patients. Still our patients responded to chemohormonal therapy. While in the studies of Mouridsen, S. Paepke, Ellis most of the patients had tumors of known receptor status and they responded. In a retrospective review from the Harvard Joint Center for Radiation Therapy. 41 patients with stage III breast cancer, who received post irradiation adjuvant therapy with either chemotherapy alone or combined with an endocrine-ablative procedure, had a significantly better relapse free survival and improved local control at four years (51% and 85% respectively) as compared to a matched group of patients not receiving adjuvant therapy (29% and 63% respectively)⁴⁰. Combination chemotherapy prior to Local therapy was introduced by the Milan group. In 110 patients they achieved 70% objective response rate (15% CR) with four cycles of AV chemotherapy prior to Local therapy and reported overall three years survival of 53% compared to 41% for a historical control group receiving radiation along.⁴¹ In our study the overall response rate in 31 patients is 84.17% with 12.71% complete response rate which is comparable to the above studies. A similar treatment strategy was used in 52 non inflammatory stage III patients at the M.D. Anderson hospital in which 3 cycles of FAC plus Bacillus Calmette-Guerin (BCG) were administrated prior to local therapy with either radiation alone or surgery followed by radiation. An objective response rate to chemotherapy of

82% (15% CR) was achieved with 40% actuarial 5 years survival. Thus, induction chemotherapy for a fixed number of cycles prior to local therapy resulted in a considerable tumor regression that enhanced the ability to either perform a surgical resection or deliver a tumouricidal dose of radiation.⁴² In our study also we achieved objective response rate of 84.17% with 12.71% of complete response rate with median 3 cycles of neoadjuvant chemotherapy. Hence our result are comparable with this study. Study of s. m. Swain, R.A. Sorace et al³⁷ (1987), showed 93% objective response rate to induction chemotherapy, 49% patients showed complete response and 44% patients showed partial response and 7% no change. They had used Clyclophosphamide, Doxorubicin, Methotrexate, 5-fluorouracil, Tamoxifen (40mg/day) or Premarin and Leucovorin upto maximum objective response. The median number of cycles of chemotherapy use to Achieve CR and PR are five and three respectively, while in our study we have got maximum response in 3 cycles of chemohormonal therapy. In the study of Mouridsen H, Gershanovic M, Sun Y³⁶ the overall response rate in Letrozole group was 30% and in Tamoxifen group it was 20%. Complete response was 8% and partial response was 23% in Letrozole group. While in Tamoxifen complete response was 3% and partial response was 17%. In the study carried out by Eisermann, S. Paepke, J. Appfelstaedt, J. Eremin³⁸ the overall response rate in Letrozole group was 55% and in Tamoxifen group it was 36%. Complete response rate was 10% and partial response rate was 45% in Letrozole group. While in Tamoxifen group complete response rate was 4% and partial

response rate was 32%. In the study carried out be Ellis et al⁴⁷ Letrozole group showed 88% of overall response rate and Tamoxifen group showed 21% of overall response rate. In the study of Eisermann, S. Paepke, J. Appfelstaedt, J. Eremin³⁸ 24% patients of Letrozole group, and 35% patients of Tamoxifen group had static disease. While 12% patients of Letrozole group and 17% patients of Tamoxifen group had disease progression. In our study 12.5% patients of Letrozole group and 6.67% patients of Tamoxifen group had static disease. While 12.5% patients of Letrozole group had disease progression. In our study, group I showed a 75% of overall response rate with 18.75% complete response and 56.25% partial response. Group II showed 93.34% of overall response rate with 6.67% complete response and 86.67% partial response which is comparable to the studies of Ellis et al⁴⁷ and Eisermann, S. Paepke, J. Appfelstaedt, J. Eremin³⁸. In our study the sample size is small (16 patients in Letrozole group and 15 patients in Tamoxifen group). In the study carried out by Ellis et al⁴⁷ also the sample size was less (17 patients in Letrozole group and 19 patients in Tamoxifen group). In our study all the patients had side effect like nausea, vomiting, alopecia. But therapeutic continuity was not broken due to these toxicity. In the studies of Mouridsen, S. Paepke, Ellis also the nature and frequency of adverse effects were similar in both the groups. In our study the overall response rate in Letrozole group is not statistically significant than in Tamoxifen group. (p=0.153) While in all these studies (Mouridsen, S. Paepke, Ellis) the overall response rate in Letrozole group was statistically significant than in Tamoxifen group

(p<0.05). The Tamoxifen used in all these reference studies was standard dose (20mg OD). While in out study we have used high dose Tamoxifen (50mgBD). Complete response and partial response patients were advised locoregional therapy like modified radical mastectomy. Patients with static disease were offered other modalities like radiotherapy and adriamycin/epirubicin based chemotherapy in afforable patients. Patients with progressive disease were subjected to debulking surgeries followed by radio therapy and combination chemotherapy (adriamycin/epirubicin based) in affordable patients. After comparing our study with other studies it is found that the results of our study are comparable in terms of overall response rate, complete response rate, partial response rate and adverse effects. In our study Letrozole (2.5mgOD) is shown to be equally effective as that of high dose Tamoxifen (50mgBD) along with chemotherapy in downstaging the locally advanced breast cancer in postmenopausal women irrespective of ER/PR receptors status. The adverse effects in both the groups are similar and there is no discontinuation of treatment in any of the patients due to adverse effect. Literature says Letrozole given in a post menopausal women with ER/PR positive status is more effective as compared to Tamoxifen (20mg OD).^{43,44,45,46,47,48} In our study group II patients were given high dose Tamoxifen (50mg BD) and the results were equivalent to that of Letrozole (2.5mg OD) in terms of overall response rate, complete response rate, partial response rate and adverse effect. Our study being a preliminary trial is restricted to the patients registered in unit I surgery, Government

Medical College and Hospital, Nagpur and the sample size in each group is small (15 patients). In our study ER/PR receptor status was not done in any of the patients as most of the patients were belonging to low socio-economic status and could not afford it. In spite of that most of our patients in both the groups responded to chemoharmonal therapy. High dose Tamoxifen (100mg/day) works independently of ER/PR receptor status hence it is quite useful in all patients. With the use of high dose Tamoxifen, the results are equivalent to that of Letrozole. In Letrozole the patient's compliance is better due to single daily dose. However as the number of patients in this study are small, larger studies will be required to give a conclusive evidence about the efficacy of Letrozole over high dose Tamoxifen.

conclusion

After the study of 31 cases of Locally Advanced Breast Cancer (LABC) treated with Letrozole 2.5mg OD + CMF/CEF (16 cases) and high dose Tamoxifen 50 mg BD + CMF/CEF (15 cases) in unit I surgery at the Government Medical College and Hospital, Nagpur, many conclusions can be drawn. Mean age of presentation of locally advanced breast cancer (LABC) patients in this study is 54.85 years. Mean age at diagnosis is 55 years in patients treated with Letrozole 2.5 Mg OD and 54.7 years in patients treated with Tamoxifen 50 mg BD. All the patients in our study are of postmenopausal status. Overall response rate is comparable in Letrozole as well as Tamoxifen group. Maximum patients treated with Letrozole

and high dose Tamoxifen achieved maximum response in 3 cycles of CMF chemotherapy regimen. Toxicities of both the therapies are comparable and none of it required discontinuation of therapy or hospitalisation for management. With availability of newer anti-emetic like ondansetrone, the Incidence of Nausea/vomiting was less in patients belonging to both the Letrozole and Tamoxifen group. No special toxicity of Tamoxifen like endometrial Carcinoma, optic retinopathy etc. was observed. Serial follow up of these patients receiving Tamoxifen is being done for the same. Complete response and partial response patients were advised locoregional therapy like modified redical mastectomy. Patients with static disease were offered other modalities like radiotherapy and adriamycin/epirubicin based chemotherapy in affordable patients. Patients with progressive disease were subjected to debulking surgeries followed by radio therapy and combination chemotherapy (adriamycin/epirubicin based) in affordable patients. Letrozole 2.5 mg OD has a definite role as first-line therapy in downstaging locally advanced breast cancer (LABC) and it is equally effective as that of Tamoxifen (high dose) if not more effective with better patient compliance. However, larger studies with large sample size will give a conclusive evidence about the efficacy of either of these two (Letrozole or Tamoxifen). The only limitation is the cost of Letrozole, which limits the use as most of the patients registered in Government Medical College and Hospital, Nagpur belong to poor socio-economic group.

references

1. Mouridsen H. Gershanovic M, Sun Y, et al : Superior efficacy of Letrozole versus Tamoxifen as first line therapy for post-menopausal women with Advanced Breast Cancer : Results of phase III Study of the Internation Letrozole Breast Cancer group. J. Clin. Oncol. 19 : 2596-2606, 2001.

2. S. M. Swain et al : Neoadjuvant chemotherapy in the combined modality approach of locally advanced non metastatic breast cancer. Cancer Res 47:3889-94; 1987.

3. Eisermann, Paepke S, Apffelstaedt J, Eremin J et al : Preoperative treatment of postmenopausal breast cancer patients with letrozole : A randomized double-blind multicenter study. Annals of Oncology 12:1527-1532; 2001

4. Dembermouesky P, Smith I, Falleson G et al : Letrozole, a new oral aromatase inhibitor for Advanced Breast Cancer; Double blind randomozed trial showing a close effect and improved efficacy and tolerability compared with megesterol acetate. J. Clin. Oncol 16: 453-461, 1998.

5. Bruckman JT et al : Results of treating stage III carcinoma of breat by primary radiation therapy. Cancer : 43:985-93, 1979.

6. Delena M et al : Combined chemotherapy and Radiotherapy approach in LABC : Cancer chemother. Pharmacol 1 :53-59, 1978.

7. Hartobagyi GN et al : Multimodal treatment of locoregionally advanced

breast cancer : Cancer (Phila) 51: 763-68, 1983.

8. Mouridsen H, Gershanovich M, Monnier A et at : Letrozole is superior to tamoxifen as first line hormonal treatment of post menopausal women with locally advanced or metastatic breast cancer. Ann Oncol 2000; 11:155.

9. Mouridsen H : Superior efficacy of Letrozole versus Tamoxifen as first line therapy for post-menopausal women with Advanced Breast Cancer. Results of phase II study of international Letrozole Breast cancer group. J. Clin. Oncol 18: 3758-3767, 2000.

10. Mouridsen H, Perez-Carrion R, Becquart D, et al : Letrozole (Femara) versus Tamoxifen preliminary data of a first line clinical trial in post-menopausal women with locally advanced or metastatic Breast Cancer Eur J. Cancer 36: 588, 200 (Suppl 5, Abst 220).

11. Paepke S, Apttelstadet J, Eremin J. et al : Neo-Adjuvant treatment of post menopausal breast cancer patients with letrozole (Femara) : A randomized multicenter study versus tomoxifen. Eur J. Cancer 36:576, 2000 (Suppl 5, Abst 179).

12. Ellis MJ, Loop A, Singh B et al : Letrozole is more effect neo-Adjuvant endocrine therapy than Tamoxifen for Erb 131 and or Erb B₂ positive, estrogen receptor positive primary Breast Cancer, Evidence from a phase 3 randomized trial J. Clin Oncol 2001, 19(18): 3808-16.

13. Hortobagyi G.N. et al : Management of stage III primary Breast Cancer with Primary chemotherapy. Surgery and radiation therapy. Cancer 62: 2507-15, 1988.

Original Article

OSPE IN MICROBIOLOGY

Dr. Suresh V Jalgaonkar M.D. *

Dr. Supriya S. Tankhiwale M.D. **

Dr. Gopal Agrawal M.D. **

Abstract

Objective structured practical examination (OSPE) is a tool to evaluate various aspects of the practical exercises in a planned or structutred manner with emphasis on objectivity of evaluation. An eight station OSPE in Microbiology consisting of 2 procedure stations, one observation station and 5 question Stations was structured and implemented as a part of formative assessment of students. Performance of students in OSPE was found to be less satisfactory than the traditional practical examination. Post-test questionnaire to assess the attitude of students towards new examination pattern revealed that the OSPE was found to be a better evaluation method for skill testing, observation and practical questions than the traditional examination. Majority of students graded the examination from .good to excellent and were convinced that it is objective and devoid of personal variation and bias.

Key words : Practical examination, objectivity

Introduction

Validity, reliability and objectivity are the necessary criteria for an ideal evaluation system. These criteria are effectively introduced at the theory examination in the form of multiple choice questions (MCQs) and short answer questions (SAQs). There is a need to introduce objectivity in practical examination. Medical council of India in its regulations has also stressed the introduction of objectivity in evaluation system. The traditional practical examination (TPE) has been rightly criticized for its lack of objectivity. The particular practical, which the examinee performs on the day of examination, is subject to subjective evaluation. More importantly the examiner hardly gets the chance to assess the skill acquired by the students, the examination invariably ends in theoretical discussion. The TPE also has the major disadvantage of monotonous evaluation of the large number of students which is frustrating for the examiner. In an era where competence based medical education is

* Professor & Head

** Professor & Head, Department of Microbiology

Indira Gandhi Medical College, Nagpur-4400 18

necessary, it is imperative that evaluation strategies need a closer scrutiny. It is in this context that the "Objective Structured Practical Examination (OSPE)" is a tool to assess the competence acquired by the students in various aspects of the practical exercise in a planned or structured manner with due attention being paid to the objectivity of the examination. The OSPE measures practical skiIls better, has a wide discrimination index and eliminates examiner bias.^{1, 2, 3}

An attempt was made to structure OSPE in microbiology as a part of formative assessment and to study the attitude of the students towards new pattern of examination.

MATERIALS AND METHODS

Second M. B. B. S. students of 2001. regular batch in their second term, who were already exposed to traditional practical examination, were assessed by OSPE.

Structuring the OSPE:

Detailed instructions were given to students regarding the pattern of examination and the course to be covered. The students were divided into two batches of 30 and 29 each. The students were assessed at a series of 8 stations with one or two aspects of competence being tested at each station.

Three types of stations were included.

1. Procedure stations: Here the students were required to demonstrate practical staining techniques of Gram's and Ziehl. Neelsen stain.

2. Observation stations: Here the students had made observations from the experimental set -up (eg. Focused gram stained smear, colonies on culture medium) and answer the questions on an answer sheet.

3. Question stations: Here the students had to answer technical and applied questions on an answer sheet

Generally the observation stations were related to and followed the procedure stations and the question stations followed the observation stations. The students were rotated round the stations spending 3 minutes at each station. The time was decided taking into consideration the time required for performing procedure and the number of questions to be answered at the observation and question stations.

The observer in the procedure station was an examiner who was provided with a check-list. The examiner observed the students as he/she perfonned the procedure and awarded marks for each step.

Following are the examples of three types of stations.

Procedure Station:

Question- First two steps of Gram's stain (ie. Primary staining and pouring of gram's iodine) are done on a given smear. Complete the procedure.

The check-list for marking the steps of procedure is given in Table-I.

the range of marks obtained was between 10.5 to 38 out of 5 8.

Thirty two (54.25%) students secured less than 40% marks, 26 (44.07%) students between 40% -60% marks and only one student could get more than 60% marks. The result indicated that the performance of the students was not satisfactory as compared to traditional examination wherein 25.97% students were in the 40%-60% range and 72.73% students secured more than 60% marks.(Table 4).

Students' attitude:

Students were given a post test questionnaire to indicate their views on the TPE and OSPE and grade the examinations in a scale of 4. with 4 as excellent. 3 as very good, as satisfactory and as poor.

All the students irrespective of their score in the examination felt that OSPE pattern of the examination is better than the traditional examination. The attitude of the students ranged from grading the OSPE as good to very good with some students marking it as excellent. All students graded the OSPE to be better than TPE in all the exercises. More than 80% students were convinced that the examination was objective. (Table 5)

DISCUSSION:

As this was a formative assessment examination, the whole pattern of the OSPE was discussed with the students. The positive feed-back during discussion was in relation to critical execution of each step of the staining procedures. As the steps were assessed by the

Observation Station:

Question- A Gram stained smear is focused Observe the focused field and answer the questions.

The questions and the marking pattern is given in Table-2

Question Station:

This is in the form of direct questions to be answered by the student. The example is given in Table-3.

The 8 station OSPE was structured as follows:

Station 1. Gram's staining procedure

Station 2. Observation and questionnaire on focused gram smear

Station 3. Ziehl-Neelsen staining procedure.

Station 4. Questions on Mycobacteria

Station 5. Culture medium with questionnaire

Station 6 Observation and questionnaire on culture medium with growth.

Station 7. Instrument with questionnaire

Station 8. Serological test with questionnaire

Two procedure stations, 2 observation stations and 4 question stations were included in this 8 station OSPE. The observation and question stations were different sets on the two days tor different batches. Station-wise marks were allotted depending on the number of check-list points or objective questions asked. The total marks for 8 stations OSPE were 58.

RESULTS:

Performance of students in OSPE:

Fifty nine students appeared for OSPE. Mean score of students was 22.69 ± 6.1 and

examiner in the check-list, the importance of correct procedure could be emphasized in this feed back session. As all the students were required to answer the same set of questions, and are assessed by the same examiner, in a methodical way, the subjective bias of the examiner and the element of the chance are considerably minimized.

On the similar pattern of this 8 station OSPE which served the purpose of formative assessment, an extended OSPE can be structured to include all the components of practical evaluation as prescribed in the curriculum. Thus this objective pattern of examination can be introduced in the summative examination.

In view of its influence on learning behaviour of students, OSPE is distinctly a better method of formative evaluation. The very nature of OSPE makes it imperative that the educational objectives of practical training have to be clearly defined from the, beginning.

OSPE is thus a relia.ble, valid and an objective method of practical evaluation. It has a unique advantage over TPE in the form of transparency in the examination system. However, with the distinct advantages, a serious thought needs to be given to the question of whether it can completely replace the traditional examination. Dedicated efforts are required for structuring an OSPE; it is also time consuming.

Table No. 1

Procedure station on Gram stain Check-list with the examiner.

Table No. 2

Questions and marking of the observation station on focused gram stained smear

Table No. 3

Example of question station

* This station follows the procedure station on Ziehl-Neelsen stain.

Table No. 4

Showing comparison of results of OSPE & TPE

Table No. 5

Showing student attitude score : Grading of OSPE & TPE on scale of 1-4

2. Sandila MP, Ahad A, Khani ZK. An objective structured practical examination to test students in experimental physiology. J Pak Med Assoc. 200 I; 51: 207-210

3. Nayar U, Malik SL and Bijlani RL. Objective structured practical examination: A new concept in assessment of laboratory exercises in preclinical sciences. Medical education 1986; 20: 204-209

Acknowledgements

The authors are grateful to Dr. Mrs. P. S. Pendharkar, Dean, Indira Gandhi Medical College, Nagpur for the permission to conduct the study.

References

1. Feroze M and Jacob AJ. OSPE in pathology. Indian J Pathol Microbiol 2002; 45: 53-57

Review Article

HYPERLIPIDEMIA IN NEPHROTIC SYNDROME : PATHOGENESIS AND

TREATMENT MODALITIES

Vikrant S. Deshmukh ***
Dr. V. L. Gupta **
Dr. Vijay Thawani *

Abstract

The pathogenesis, clinical significance, and treatment options of the disturbances in lipid metabolism in children with persistent nephrotic syndrome have been reviewed. The pathophysiology of nephrotic dyslipoproteinemia is multifactorial, including increased hepatic synthesis and diminished plasma catabolism of lipoproteins. The persistence and severity of lipid changes in serum correlate well with the duration and frequency of the relapses, even during the remission in patients of the nephrotic syndrome. Understanding the distribution of cholesterol among the plasma lipoproteins is important as persistent hyperlipidemia may predispose to premature atherosclerosis in children. There is

overall raised level of serum LOL, serum VLOL, serum triglycerides that are highly atherogenic. Along with lipid lowering mechanism, statins are reported to be reno-protective in nephrotic

syndrome. Hence there is sound rationale of using statins when lipid abnormalities are persistent, to prevent development of premature atherosclerosis in pediatric age group. Further long-term studies are required to assess safety and efficacy of statins for treatment of hyperlipidemia in these children.

Introduction

Nephrotic syndrome is clinically a complex condition, characterized by proteinuria >3.5 gm per 1.73 m2 per 24 hr, hypoalbuminemia <2.5 gm/dl, edema, hyperlipidemia, lipiduria and hypercoaguability. About 80% of the nephrotic syndrome patients are under 16 years of age group and it affects, 20 % adults, ' with peak incidence between 6 to 8 years. Most of these patients are primarily steroid sensitive. The clinical course of syndrome is marked with peaks and troughs due to relapses and remissions.

*** MBBS, Intern, Government Medical College, Nagpur

** MD, Associate Professor in Pharmacology, Govt Medical College, Nagpur

* MD, PhD, Head Of Department of Nephrology, Super Specialty Hospital,

Govt Medical College, Nagpur.

Hyperlipidemia is believed to be due to increased hepatic lipoprotein synthesis, which is triggered by fall in the plasma oncotic pressure¹. This is compounded by increased urinary loss of lipoprotein lipase, the enzyme which otherwise catabolizes lipoproteins. The role of dyslipidemia in premature development of atherosclerosis and progression of renal disease remains debatable².

Pathogenesis

Hyperlipidemia is a common feature of the nephrotic syndrome but the mechanism of increased lipid synthesis in liver and distribution of lipoproteins in plasma is not well understood. The pathogenesis being multifactorial ³, various hypotheses have been proposed about hyperlipidemia in the nephrotic syndrome. It has been suggested that hepatocytes may be the signaling pathway in stimulating lipogenesis. Low plasma oncotic pressure due to low plasma albumin has been attributed to trigger hepatic lipogenesis¹. For predicting the. future implications, it is important to assess the lipoprotein distribution in the plasma to predict the risk of premature atherosclerotic heart disease and future end stage renal damage⁴.

The lipoprotein lipase is lost in urine in the nephrotic syndrome leading to decreased catabolism of lipoproteins, which in turn causes hyperlipidemia. The urinary loss of high-density lipoprotein (HDL) and other liporegulatory factors may be contributing to decreased lipolytic enzyme activity and altered metabolism of plasma lipoproteins ⁵. These alterations result in variation of lipid profile in the nephrotic syndrome patients.

Interventions aimed at reducing the proteinuria, like angiotensin converting enzyme (ACE) inhibitors cause reduction in lipid levels in animals as well as in nephrotic patients even when plasma albumin concentration is unchanged, suggesting that proteinuria may be one of the factors causing reduced catabolism of lipoproteins ⁶. In-vitro experimentation has shown that low plasma viscosity might be the major signal detected by hepatocytes rather than low plasma oncotic pressure in the nephrotic syndrome. Significant inverse correlation has been found between the total cholesterol concentration and both the plasma albumin concentration and the plasma oncotic pressure, but no such correlation has been found with plasma viscosity. Enhanced hepatic synthesis of lipoprotein lipids might be stimulated by low plasma albumin concentration or oncotic pressure but did not seem to be due to changes in the plasma viscosity ².

To validate the hypothesis of low plasma oncotic pressure in genesis of hyperlipidemia, correction of oncotic pressure with infusion of dextran or human albumin in the patients of the nephrotic syndrome was done which resulted in fall of plasma lipid level ⁷. This supported the suggestion that low plasma oncotic pressure acts as a signal for generation of Hepatic lipogenesis in the nephrotic syndrome.

Conflicting and inconsistent results have been reported when correlation between proteinuria and hyperlipidemia in the nephrotic syndrome was studied. In relapse cases, even in absence of proteinuria, the abnormalities of plasma lipids were persistent. However the persistence and severity of lipid changes in the plasma correlated well with the duration and

In one short-term study lovastatin showed favorable effects on the lipoprotein profile of the nephrotic syndrome by decreasing the total cholesterol by 30 to 40%, with few side effects ¹³. Thus it appeared to be an effective drug. However long-term prospective studies to demonstrate the efficacy and safety of lipid lowering agents in children are lacking ⁴.

Pravastatin was found to be effective in reducing total cholesterol and LDL. It increased LDL clearance by 16.7% and did not affect production of apoB containing lipoproteins¹⁴. Similarly, Simvastatin produced a fall in cholesterol, LDL while HDL and triglyceride serum lipoprotein a [Lp(a)] was not affected. No major adverse events were encountered with simvastatin. Minor events included elevations in serum creatine kinase without clinical symptoms. Otherwise simvastatin was found to be effective and safe^15,16.

Probucol had beneficial effects on lipoproteins and lipid peroxidation, but did not improve proteinuria or GFR. The drug was generally well tolerated, but needed discontinuation because of a prolonged QT interval in some patients ¹⁷. Its use has been recommended in low doses, in combination with other lipid lowering agents. In a clinical controlled trial two such drugs viz. constipol and probucol were tried in patients of unremitting nephrotic syndrome, both drugs were well tolerated ¹⁸.

The effect of the gemfibrosil on hyperlipidemia in the children with persistent nephrotic syndrome was studied. At the end of the fourth months, gemfibrosil reduced total cholesterol by 34%, LDL by 30%, apo B 21 % and triglycerides by 53%, which was significant.

frequency of the relapses ⁸. These lipid abnormalities may persist during the remission also. Hence proteinuria may not be a sensitive indicator for hyperlipidemia in the relapsed cases of the nephrotic syndrome. Even though there is no single mechanism implicated in the pathogenesis of nephrotic hyperlipidemia, both hypoalbuminemia and proteinuria play distinct role, individually or synergistically⁹. In frequent relapses or unremitting cases of the nephrotic syndrome, the lipoid abnormalities persist and may be associated with increased levels of lipoprotein-A, increased levels of very light density lipoprotein (VLDL) and reduction in HDL. All of these may contribute to higher risk for atherosclerosis.

Interventions

Studies report that the patients of nephrotic syndrome have the potential risk of development of premature coronary artery disease, glomerular sclerosis and thrombosis^10,11. So, should hyperlipidemia be decreased with the lipid lowering agents like statins, or resins in children is a matter of discussion.

Ideally the treatment should start with dietary modification, because diet is an important independent protective factor for this disease. Low fat diet has been shown to be well-tolerated and effective in children ¹². There are no major long-term studies demonstrating harmful beneficial results with lipid-lowering drugs. Nevertheless, concerns about the psychological and metabolic effects of long- term lipid lowering continue to haunt. Use of lipid lowering medicines in children has been generally restricted to genetic disorders of lipid metabolism.

Gemfibrosil therapy did not show any side effects and had favourable effects on the lipoprotein profile of the nephrotic patients¹⁹.

Lipopheresis may be beneficial in nephrotic patients with focal segmental glomerulosclerosis. Long-term effects of low-density lipoprotein cholesterol (LDL- C) removal using the Kaneka Liposorber system, which binds LDL-C to dextran sulfate, have been studied in a controlled trial. Lipopheresis was found to be safe and effective method for the control of LDL in nephrotic syndrome. Early clamping of total cholesterol in the normal range resulted in a prolonged and significant reduction of LDL compared with control ²⁰.

Treatment of hyperlipidemia has a rationale. If left untreated, it may contribute to the development of atherosclerosis and premature progression of chronic renal failure⁴. Even though the benefits of treatment with lipid lowering agents have not been proven in children, the efficacy and safety of statins in lowering hyperlipidemia in adults has been documented. The important side effects of statins are increase in serum transaminase and myopathy with an incidence of 0.1 %. Although the prevalence of mild elevation in creatinine phosphokinase (CPK) may be 5% to 10%, myositis is rarely seen²¹. Recent studies indicate actions of statins other than lipid lowering mechanism in the nephrotic syndrome. One study supports the observation that lowering serum cholesterol in the nephrotic syndrome reduces proteinuria and increases serum albumin levels. No difference in the rate of decline in renal function could be demonstrated when compared with control group²². Larger trial is needed to show if potent

lipid-lowering therapy slows progression of hypercholesterolemic protein uric diseases. Statin therapy was found to have improvement of dyslipidemia and brachial artery endothelial function in patients with nephrotic syndrome. Improvement in brachial artery endothelial function may in part be related to a non-lipid effect of statins²². Thus there is sound rationale for using statins in treatment of hyperlipidemia in the nephrotic syndrome.

Conclusion

The clinical evidence for use of lipid-lowering agents in hyperlipidemia in nephrotic syndrome is growing. If dietary modification and lifestyle changes fail to adequately control the blood lipids, lipid-lowering medicines may be utilized to achieve the treatment goal. For optimal management of these patients, evaluation of the patient's health and risk status, estimation of hyperlipidemia, definition of treatment goals and clear understanding of the mechanisms and effects of lipid-regulating agents are necessary. Considering the documented safety of lipid lowering agents, the use in children should not be withheld, which otherwise may lead to premature atherosclerosis, renal failure and deterioration in quality of life. The best policy will be to reverse the pathological mechanism responsible for generation of hyperlipidemia. Till we are able to pinpoint the exact trigger for hyperlipidemia, the beneficial effects of statins may be encashed for improving lipid profiles of the children. Long-term assessment of the potential benefits of lipid-lowering medicines in children suffering from nephrotic syndrome will validate this suggestion.

serum lipid abnormalities in children with idiopathic nephrotic syndrome. J Pediatr (1984) 104 (1): 61- 64.

9. Joven J, Espinel E, Simo JM, Vilella E, Camps J, Oliver A. The influence of hypoalbuminemia in the generation of nephrotic hyperlipidemia. Atherosclerosis (1996) 126 (2): 243-252.

10. Yang X, Wang K, Zhu Z, Deng A. Serum lipoprotein (a) concentration in patients with nephrotic syndrome and its clinical implication. : J Tongji Med Univ (1998) 18 (4): 236-238.

11. Saland JM, Ginsberg H; Fisher EA. Dyslipidemia in pediatric renal disease: epidemiology, pathophysiology, and management. Curr Opin Pediatr (2002) 14 (2): 197-204.

12. Tonstad S. Role of lipid-lowering pharmacotherapy in children. Paediatr Drugs (2000) 2 (1): 11-22.

13. Kasiske BL, Velosa JA, Halstenson CE, La Belle P, Langendorfer A, Keane WF. The effects of lovastatin in hyperlipidemic patients with the nephrotic syndrome. Am J Kidney Dis (1990) 15 (1): 8-15.

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References:

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Special Article

LABORATORY INVESTIGATIONS AND VIRAL EPIDEMICS

Dr. D. A. Gadkari

Emeritus Medical Scientist, National Institute of Virology, Pune

Summary

Infectious diseases are on rise. One can attribute this to population explosion and concomitant drop in hygienic conditions. Air, water and soil pollution, behavioral and ecological changes are also important factors associated with spread of infectious diseases.

A question is often raised about the utility of rapid viral diagnosis since most viral diseases have no anti-viral treatment. However, a treating clinician is certainly benefited if the viral etiology is known. Supportive treatment can be initiated. Such immediate responses help in saving patient's life and reducing severity of the disease. For some viral infections antiviral treatment is available, e.g acyclovir for herpes, reverse transcriptase or protease inhibitors for HIV, possible use of ribavirin or amantadine for influenza. In some cases passive transfer of antibodies also helps in reducing the mortality e.g. hepatitis A or rabies virus infections.

Once the viral etiology is known, certain assumptions can be made on its route of transmission. In aerosol infections, patients can

be segregated; adequate precautions could be taken by medical and paramedical staff to control the spread of disease. In case of water-borne diseases source of water contamination can be traced and treated adequately to prevent further spread of virus. In case of vector-borne diseases, (dengue or Japanese encephalitis) immediate vector control measures help in subsequent spread of disease. Essentially, rapid viral diagnosis is also of immense importance to health care providers and policy makers.

Field investigations and rapid viral diagnosis reveal many epidemiological facets that give us more opportunities for appropriate interventions. The diagnosis also helps in keeping a watch on new and emerging diseases. Sometimes the same virus presents different clinical features over a period of time. Once the virus is identified long-term studies could be undertaken to understand the pathogenesis, develop an animal model, stu