Jabalpur: M/S Banarsidas Bhanot. Publisher. 302 10. 2. Development of An Atlas of Cancer in India. First All India. Report 2001 2002. Nandakumar A, Gupta PC, ...
Fig. 3 : Maculopapular rash over abdomen and arms.
recommended as first-choice agents for inclusion in an expanded PEP regimen.1 This type of reaction (maculopapular rash) is well known with the use of nevirapine especially in individuals with normal CD4 count. During 1997·2000, a total of 22 severe adverse events in persons who had taken nevirapine-containing regimens for occupational or nonoccupational postexposure prophylaxis were reported to FDA. 2 Severe hepatotoxicity occurred in 12 (one requiring liver transplantation), severe skin reactions in 14, and both hepatic and cutaneous manifestations occurred in four. Because the majority of occupational exposures do not lead to HIV infection, the risk for using a nevirapine-containing regimen for occupational PEP outweighs the potential benefits. The same rationale indicates that nevirapine should not be used for PEP. The idea behind publishing the case was to highlight the ignorance on the part of prescribing physician regarding the CDC/NACO guidelines for PEP for HIV. The present case also pleads for creating awareness among health care professional, especially the doctors, as what needs to be done after occupational exposure to HIV, so that unnecessary investigations and unwarranted treatment can be avoided. A Mahajan*, H Sharma**, Aruna Bhagat**, VR Tandon***, R Sharma, S Sharma+
Fig. 1 : Maculopapular rash over face and neck
Fig. 2 : Maculopapular rash over back
replication cycle (e.g., nucleoside analogues with a PI) theoretically could offer an additional preventive effect in PEP, particularly for occupational exposures that pose an increased risk of transmission. CDC or NACO guidelines for PEP recommend a 4 week course of lamivudine (150mg) + zidovudine (300 mg) twice a day (Basic regimen) and the addition of a third drug for PEP following high-risk exposures (expanded regimen) is based on demonstrated effectiveness in reducing viral burden in HIV-infected persons. Indinavir (800mg 8hrly) or nelfinavir (750mg TDS) or efavirenz (600mg OD) are © JAPI VOL. 55 MARCH 2007
*Asst Professor, Post Graduate Department of General Medicine and Consultant HIV Clinic; **Postgraduate student; ***Senior Resident/Demonstrator; +Professor, Post Graduate Department of General Medicine and Post Graduate Department of Pharmacology and Therapeutics, Govt. Medical College, Jammu (J and K) India - 180 001. Received : 8.5.2006; Revised : 18.8.2006; Accepted : 24.8.2006
REFERENCES 1.
2.
CDC. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for postexposure prophylaxis. MMWR Recomm Rep 2001;50(RR-11):1-52. CDC. Serious adverse events attributed to nevirapine regimens for postexposure prophylaxis after HIV exposures·worldwide, 1997-2000. MMWR Morb Mortal Wkly Rep 2001;49:1153-6.
Epidemiologic Features of Gastric Cancer
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in a Railway Population in Eastern India Sir, In India, gastric cancer is a disease of the underprivileged and poorer sections of society, particularly in elderly males above 50 years of age [M: F::7:1]. It is more prevalent in urban areas and South India.1-3 Population serving in different zones of Indian Railways is well defined and has some special attributes -- [1] At least one earning member per family who thus have a fixed source of monthly income. [2] Better living standards and literacy rate than the average Indian population. [3] A well coordinated tertiary care [central railway hospital] referral system for complex diseases, which makes the central hospital cancer registry a reasonable source of epidemiologic data in this population.3 We conducted this study to see whether these attributes brought any difference in the epidemiology of gastric cancer in this population. The profile of 50 consecutive patients {mean (SD) [Range] age : 59.26(13) [20-78] years; 35 males; all Hindus} diagnosed to have gastric cancer by upper GI endoscopy (Pentax FG 29V) and biopsy in this unit between January 2002 and May 2005 were compared to 50 patients of nonulcer dyspepsia [NUD] undergoing upper GI endoscopy [controls]. Both groups were matched for age, sex, religion, literacy rate and monthly income. Demography, clinical history and examination, endoscopic and histological findings and a detailed pre illness dietary history regarding the risk factors of gastric cancer were recorded. Odds ratio and 95% confidence interval was calculated using Epi Info version 6. p < 0.05 was considered significant. An audit of the cancer registry of this hospital for the
last 4 years revealed gastric cancer to comprise 2% 3% of all new cancer cases/year and to be the 2nd commonest GI cancer [15% - 25%] with an annual incidence of approximately 2/lakh population. It is diagnosed in 1.5% 2% of all NUDs undergoing upper GI endoscopy in a year. 11[22%] cases were ≤ 50 years age (lowest 20 years). 84% belonged to lower income group. Mean time to presentation (S.D.) [range] was 3-14(2) [1-12] months. Symptoms were anorexia [100%], anemia [100%] (mean {S.D.} HB = 7.8 {1.2} gm/dl), significant weight loss [90%], abdominal pain [34%], gastric outlet obstruction [24%], hematemesis [20%], dysphagia [8%]. 80% had distant metastasis at presentation [liver 40%, ascites 36%, abdominal mass 32%] where only palliation could be done. Site : antrum [78%], body [14%], cardia [8%]. Histomorphology was ulceroproliferative [86%], polypoid [6%], infiltrative [8%], adenocarcinoma 96%, leiomyosarcoma 4%, signet ring type in 8% [well differentiated 16%, moderate 52% and poor in 32%]. Risk factor analysis (Table 1) confirms the usual ones with addition of high intake of fried food. However proper dietary history recording is limited by inappropriate recall and variation in pattern daily and also over time. With westernization of diet in India, there is increased consumption of fast food and non veg items (mostly fried). Frying not only destroys the anticarcinogens in food but also increase fat intake and produce nitrosamiones, increasing cancer risk. To conclude, the clinicoepidemiologic features of gastric cancer in this population are mostly similar to the general population of eastern and other parts of India (including the Railways)1-3 with some notable differences viz [a] A much lower M:F ratio (in spite of M: F of 1000:828 in the general population in this region),2
Table 1 : Risk factors predisposing to gastric cancer Risk factors [1] [2] [3] [4] [5] [6] [7] [8]
Smoking^ Alcohol^ Betel leaf chewing Chewing tobacco Gastrojejunustomy$ Family history of cancer# Tube well water drinking Food Items * Mixed diet * Low intake of fruits and veg (≤ twice/week) * Non veg [fish, meat, eggs] (daily or alternate day) * Fried food (> thrice/week) * Increased salt intake (extra salt apart from that used in cooking) * Tea (≥ 4 cups/day) * Chillies and pickles
Cases
Controls
OR [95% CI]
p value
21 18 19 9 3 4 23
10 4 9 4 0 6 22
2.9[1.09-7.81] 6.5[1.86-28.24] 2.8[1.02-7.78] .5 [0.64-10.61] · 0.82 1.02 [0.46-1.57]
