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Editorial Is health a commodity?
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But health is not a consumer good on the supermarket shelf! To prevent consumerism in health, it is to be made a fundamental justiciable constitutional right. All private parties seeking subsidised land and infrastructure from government should establish units in rural areas with modern amenities on a no profit no loss basis and have no less than 20% of beds free and reserved for the economically backward population for treatment without condescension. Consumerism has reached the medical education arena, too. The governments economic constraints, coupled with huge demands for medical graduates, paved the way for private medical institutes. Politicians and entrepreneurs became aware of the new huge profit area and many regional governments actually promoted private medical colleges by specific minority or, ethnic groups. As a result, India became the single country with most medical colleges (335, with 40,485 MBBS seats). This, per se, is not objectionable, if quality were maintained. Stiff competitions allow only the meritorious to get enrolled in a government medical college in both UG and PG levels. The rich leftovers, and also the not-so-rich ones then by-pass the screening examination and enroll into private institutions with questionable infrastructure, usually patronised by political big shots/entrepreneurs, and obscene amounts of money change hands, some overt, but most covert. The not-so-rich ones are put through extreme hardships to arrange the money. All these graduates will be driven by the need to recover the money as quickly as possible, a consideration that can easily make them morally and ethically susceptible to unfair practices in the professional life. Problems of private medical colleges include part-time appointments, no assurance of regular payments, no long term security and no pension schemes, resulting in high staff attrition. Two other issues are paucity of clinical teaching material owing to reduced length of stay of patients due to high cost, and a narrow sociocultural milieu of the students coming from privileged backgrounds. This interferes with cultural competence and will affect patient care. The famous Flexner Report (1910) gave a stinging remark about 14 medical schools in Chicago a disgrace to the state whose laws permit their existence!, recommending: the way to get them (better doctors) is to produce few. His report resulted in reducing the number of medical Schools from 166 in 1910 to 96 in 1915 and by 1930 there were only 76 schools! In India, already more than 200 applications to start new medical colleges are in queue. Privatisation has, of course, has its own uses today for
rivatisation is the contractual transfer of a combination of ownership, operation, or responsibility for government functions to private actors. It introduces market principles in the public sector viz, user fees, contracting out and private insurance, and leads to the growth of the for profit sector. The irrefutable logic of total government responsibility for peoples health and healthcare raises questions about privatisation requiring urgent attention from government agencies, health policy formulators and, most importantly, doctors from all disciplines across our country. Up to late seventies, public investment in health was meagre, but a network of services in both rural and urban areas was created. From then till late eighties outlay cutbacks and concessions to private sectors took place. Then loans from IMF and World Banks began, which many states received for reforming the government health services. Those reforms called for sustainability of state services and institutions, by making them generate funds. But sustainability has in it the seed of profit. Public financial crunch and rise of new middle class and a rich peasantry, thanks to the green revolution, led to the growth of the market forces in health sector. While prevention remained a typically state preoccupation, curative and rehabilitative medicine caught the fancy of private sector as they are more individualised, time consuming, and technology dependent and, of course, profit-yielding,. Healthcare improved, but expenditure multiplied. As everybody needs to earn from a patient, medical practice became just another white collar profession and not a service to mankind. Then there is Private-Public Partnership (PPP), a suddenly popular management buzz-word for sick health units; land and infrastructures are provided to private players who are also allowed to operate sick health facilities. This, without adequate regulatory mechanisms, actually may force the rural poor to spend more to get even basic medical services. All this cannot be the goal of any civilised, democratic society. The right to health was first articulated in the 1946 Constitution of the WHO, followed by the 1948 Universal Declaration of Human Rights (Art 25), and the 1966 International Covenant on Economic, Social and Cultural Rights. In the Constitution of India, however, civil and political rights are fundamental and justiciable, but health is not. Since 2002, in a paradigm shift in policies, government resources are mandated only to be used for the deserving section of the society, while the affording population is expected to purchase medical care services from the private sector. 868
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EDITORIAL
All India Advisory Board Dr A K Pancholi (MP) Dr A Marthanda Pillai (Kerala) Dr A Murugganathan (Tamilnadu) Dr Abhoya Kar (Orissa) Dr Ajay Kumar Singh (Jharkhand) Dr Akula Sailaja (AP) Dr Anil Pachnekar (Maharashtra) Dr Dipak Dhar Choudhury (Uttarakhand) Dr G K Thakur (Bihar) Dr Gulab Aggarwal (Uttar Pradesh) Dr Hazie Dara Kapadia (Maharashtra) Dr M Balasubramanian (Tamilnadu) Dr Mahadev Desai (Gujarat) Dr Manabendra Goswami (Assam) Dr Miland Nayak (Maharashtra) Dr Mohan Gupta (Chhattisgarh) Dr Om Prakash Singh Kande (Punjab) Dr P M Gobinda Rajulu (Karnataka) Dr Pramathesh Das Mahapatra (West Bengal) Dr P Saikumar (AP) Dr Purshotam Nema (MP) Dr R A Sharma (Chhattishgarh) Dr R K Agarwal (Rajasthan) Dr S K Mittal (Delhi) Dr S S Agarwal (Rajasthan) Dr Sahajanand Prasad Singh (Bihar) Dr Sraddhanand Prasad Sinha (Bihar) Dr Srijit M Kumar (Kerala) Dr Srijoy Patnaik (Orissa) Dr Sudipto Roy (West Bengal) Dr T K Thusso (Faridabad) Dr V C Velayudhan Pillai (Kerala) Dr V S Prashad (AP) Dr Zora Singh (Chandigarh) Prof Asim De (West Bengal) Prof N Damayanti (Imphal) Prof N K Pal (West Bengal) Prof Sudhir Singh (Imphal) Prof Tamal Biswas (West Bengal)
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addressing some of the problems intriguing the medical education, and it also serves to enlarge the health manpower resources. Private funding has been an important impetus for research that ultimately enriches life. In the field of education, however, two distinct kinds of medical graduates will result as a result of privatisation: The ones from government schools chosen by merit, and those from private schools chosen by other considerations. Such a mix does not bid well for the future society. A glaring example of what greed can do to private enterprises operating on subsidised land is the case of Icare Medical College, Haldia, West Bengal, which was fraudulently established on premises occupied by the same groups dental college; when the fraud came to light, the college was scrapped by the MCI, plunging the fate of 88 students into uncertainty. The recent tragic fire which smothered 94 hapless patients admitted for treatment at the AMRI Hospitals, Calcutta, established on hugely subsidised land is another shocking example of the private operator who blatantly disregarded safety regulations. Consumerism ushers a radical change in the age-old mindset of philanthropism in which, for example, land was donated by a rich philanthropist, and the hospital built by the government. Such was the case of Medical College, Bengal, the first medical college in Asia for which the land was donated by Baboo Mutty Lal Seal. In a shameful reversal, we now see private hospitals springing up in lands obtained from government subsidy! If we have sense enough to resist a premature foreign fund entry in retail business, why cant we raise a collective demand for a fundamental justiciable right status for health which, to the majority of people, is a retail and personal matter, and never wholesale? Professor of Surgery, Nilratan Sircar Medical College, Kolkata 700014 and Hony Editor, JIMA, Kolkata 700014
NEMAI C NATH
C O N D O L E N C E We, from the family of IMA& JIMA, deeply mourn the deaths caused in the horrific fire that gutted theAMRI Hospitals, Dhakuria, Kolkata in the wee hours of the 9th of December, 2011. Our sympathies lie with the grieving families of those deceased and injured in the fire. We also express our sympathy to the families of the two nurses who lost their lives working to save the patients even after the fire broke out, not shying away from their duty even in the face of such adversity. We express our gratitude to the fire-fighters, other rescuers and the local people, without whose active help, the death toll in this incident could have catapulted to higher proportions. Their selfless act stands as another precedent showing that no adversity can ever rise above humanity. Our heartiest thanks go to the Chief Minister of Bengal, Sreemati Mamata Banerjee, for her untiring and unprecedented efforts throughout the day for being beside the families of the affected, arranging for rapid disbursement of the bodies to the family members and supervising the rescue and disaster management activities. She has also promised for financial help to the bereaved families.
Originals and Papers Impact of learning nutrition on medical students : their eating habits, knowledge and confidence in addressing dietary issues of patients Shama Shaikh1, Shraddha Dwivedi2, Maroof A Khan3 Nutrition is an important component in the treatment of acute and chronic diseases and is a cornerstone in strategies for disease prevention and health promotion. Despite the acknowledged importance of nutrition, there is evidence to indicate that the nutrition training of medical students is inadequate in both quality and quantity. The study aimed to know the dietary/eating habits of medical students, assess their knowledge on nutrition and to assess their confidence in addressing the dietary issues of patients. It was a cross-sectional study conducted on final year medical students, interns and postgraduate students of Moti Lal Nehru Government Medical College, Allahabad. The sampling was purposive and a total of 218 participated in the study voluntarily. Overall 55% of the students were less knowledgeable and only 45% of them were more knowledgeable. Most (62%) postgraduates were more knowledgeable (p0.340). Only 45.4% of them were confident in assessing the diet of patients and 44% of them were confident in recommending change of diet in patients. However this study shows no association between increase in the level of knowledge and confidence levels of the students (p>0.339 and p>0.109) suggesting that we need to incorporate innovative teaching methods to increase their confidence. Most students (79%) said that the medical curriculum was either just enough or not enough in preparing them to deal with the dietary issues of patients and 55% of them were of the opinion that the faculty should be trained in nutrition. The study results intend to stimulate active consideration of proper role of nutrition learning in medical education. [J Indian Med Assoc 2011; 109: 870-2]
Key words : Nutrition training, knowledge, eating habits, confidence.
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utrition interfaces significantly and relevantly with every field of medicine1. Nutrition is an important component in the treatment of acute and chronic diseases and is a cornerstone in strategies for disease prevention and health promotion2. Nutrition intervention is a component of first-step therapy for many common diseases including cardiovascular disease, diabetes mellitus, and obesity. To exclude or ineffectively approach the nutrition correlates of disease presentations is to risk an increase in morbidity, mortality, from many potentially preventable diseases and healthcare costs of hospitalised patients1,2. The students at medical colleges learn nutrition and health as a part of their curriculum. The curriculum in nutrition includes dietary recommendations, dietary assessment, common nutritional diseases (eg, obesity), and nutrition in chronic diseases. Despite the acknowledged importance of nutrition, there is evidence to indicate that the nutrition Department of Community Medicine, MLN Medical College, Allahabad 211001 1 MD, Lecturer 2 MD, Professor and Head of the Department 3 PhD (Stat), Lecturer (Biostatistics) Accepted December 22, 2010 870
training of medical students is inadequate in both quality and quantity1. Most curricula do not provide a clearly identifiable period of training in nutrition and many medical schools lack adequate curriculum on these topics3. In some ways nutrition and other subjects involved in health promotion and disease prevention are relegated to the back burner2. How then, given the present state can our future doctors be prepared to counsel patients about diet? The solution to the above dilemma is to increase awareness through the training of medical students and residents regarding the importance and practical significance of the concepts and principles of nutrition. This study evaluates the impact of learning nutrition on students, their knowledge, and eating patterns and confidence for addressing these topics of dietary issues with patients. MATERIAL AND METHOD It was a cross-sectional study conducted on final year medical students, interns and postgraduate students of Moti Lal Nehru Government Medical College, Allahabad which is one of the renowned medical colleges of Uttar Pradesh. The participants aged between 22 and 32 years who were enrolled for the study. The sampling was purposive. We included all the final year medical students, in-
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terns and postgraduate students and the sample size ac- knowledgeable as presented in Table 1. It was observed cording to their strength worked out to be 314. A total of that among the study groups, postgraduates (62%) were 218 participated in the study voluntarily. A pretested ques- more knowledgeable followed by interns (34.7%) and final tionnaire was used to assess their nutrition knowledge, year students (29.4%). This was found to be statistically their eating habits and confidence in their ability to assess significant (p0.340). a pretested self-administered questionnaire and informaThe results of confidence levels in Table 1 shows that tion on their eating habits and knowledge concerning nu- only 45.4% of them were confident in assessing the diet of trition was obtained. It also included students general patients and 44% of them were confident in helping painformation and assessed confidence in their ability to tients to change their diet as per requirement. Among the address dietary issues of patients. students, 54.3% of the postgraduates were confident to The questionnaire contained multiple choice questions. assess the diet and 52.2% of them were confident to change It contained questions such as habit of eating breakfast, the diet of patients and this was found to be statistically consuming milk, fruits and green leafy vegetables. Each significant (p0.109). This means that only knowledge eating habits replies classified as frequent were "consumes cannot increase their confidence in dealing with the didaily or almost every day" and as infrequent were "con- etary issues of patients. Most students (79%) as shown in Table 2, said that the sumes once in a while or does not consume". More frequent the habit of eating breakfast, consuming milk, fruits medical curriculum was either just enough or not enough and greens and the less frequent the habit of consuming in preparing them to deal with the dietary issues of pasoft drinks and snacks then the eating habits were consid- tients; 55% of them were of the opinion that the faculty ered healthy. Otherwise the eating habits were considered should be trained in nutrition and 39% suggested a separate department to improve learning in nutrition and 5.5% less healthy. The level of knowledge in nutrition was qualified by of the students recommended practical sessions and inmeans of questions on knowledge concerning foods which crease in teaching hours. are sources of fibres, fats, vitamins, minerals and energy, DISCUSSION as well as on knowledge concerning healthy foods. In reThe knowledge in nutrition was assessed among mediply to these questions, aside from the alternative "I don't cal students and it was observed that 55% were less knowlknow", there was choice from multiple answers. Each quesedgeable and 45% of them were more knowledgeable. Simition answered correctly was awarded one point. Wrong lar findings on the knowledge of doctors in Hissar answers and "I don't know" did not receive scores. The (Haryana) were observed by Suneja and Bhat5 in which scores varied from zero to 15. The variable level of nutrithe correct responses in therapeutic nutrition ranged from tional knowledge was categorised in "more knowledge38% to 66% in government doctors and 18% to 49% in able" when the score was equal to or above the 75th perprivate doctors. A study on 528 senior medical students centile (>12 correct replies) and "less knowledgeable" when from nine medical colleges in Taiwan examined a higher the score was below the 75th percentile (11 20 ß2 microglobulin 7.2 1.6-27.3 8 36
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tein levels and percentage of bone marrow plasma cells. thalidomide treatment are shown in Table 5. Most adverse The response rate was categorised into three groups viz, effects were due to thalidomide and were mild to moderate complete response, partial response and no response. in nature. The most common (60%) adverse effect noted in The overall response rate was 72%. All patients with a this study was drowsiness. We noted that drowsiness was response had a complete bone marrow response (90% second most common adverse effect was constipation folreduction in the serum M protein level from the baseline, lowed by oedema and tremor. with bone marrow plasma cells of < 5%. Three patients All the 7 who did not respond, died, two of them while (16%) had more than 75% but less than 90% reduction in in hospital. M protein levels but with a complete bone marrow reStatistical analysis : With the help of graph pad Instat sponse. More than 50% but less than 75% reduction of M 3 software programme the appropriate mean and median protein level was noted in 5 patients (28%). was calculated. Paired t test was used to compare the There was a significant reduction in the bone marrow effect of serum M protein and ß2microglobulin levels beplasma cells following the thal-dexa regimen. The mean fore and after treatment. Repeated measures ANOVA were bone marrow plasma cells percentage at the end of therapy used to compare the haemoglobin, total count and platelet was 2% compared to 56% at baseline with significant p- count at base line and the end of every 28 days chemovalue (p< 0.0001). All of the responded patients had more therapy cycle. than 90% reduction in the bone marrow plasma cells, comDISCUSSION pared with the baseline. During follow-up there was signifiIn a study conducted by Mayo Clinic9, reviewing 1027 cant improvement of the haemoglobin level from the baseline patients with newly diagnosed myeloma, 2% were younger and between each cycle. We than 40 years, and 38% were found that there was a mean inTable 3 Parameters Showing Poor Prognostic Markers 70 years or older. The median crease of 3.4 g/dl of haemoglo- Parameters No of Median age was 66 years. To compare cases (%) (range) bin compared with the baseline with this landmark study, the (p-value < 0.0001). None of the Hb 50% sented at a much earlier age Advanced osteolytic lesion (> 3 sites) 12 (48%) tropenia or thrombocytopenia Serum creatinine >1.5 mg/dl 8 (32%) 1.4 (0.5-3.7) than in the western populaduring treatment. From the ß 2 microglobulin >4µg / ml 20 (80%) 7.2 (1.6-27.3) tion. The most common cliniabove parameters, the present Immunoglobulin levels IgG >5 g/dl 16 (64%) 4.2 (0.6-5.5) cal presentation in this study study demonstrated that thali- Salmon Durie stage III 20 (80%) was bone related. Fourteen domide is devoid of patients (56%) presented with myelosuppression and that Table 4 Showing Comparison of the Parameters at Baseline bone related problems. The and at the End of Chemotherapy there is significant improvement other less common clinical Mean at Mean at end P-value* in the anaemia status even in Parameters manifestations noted in this baseline of therapy the presence of marrow infiltrastudy were easy fatigability, Haemoglobin (g/dl) 8.2 11.6 < 0.001 tion and renal failure. Serum IgG level (g/dl) 4.2 0.7 < 0.0001 renal impairment and pneumoThere was a significant reß 2 microglobulin (µg/ml) 8.6 2.7 0.0002 nia. To compare with the westduction in the serum M pro- Bone marrow plasma cell (%) 5 6 2 < 0.0001 ern study, the clinical presentein (4.2 versus 0.7 g/dl, p *All p-values are statistically significant tation is almost similar but the 4 µg/ml. In the Dimopoulous et al10 study only 29 % of the patients had ß2 microglobulin of >6 µg/ml, while the Mayo Clinic review9 revealed that only 21% presented with levels >4 µg/ml. These findings showed again that the patients in this study presented in late stages of the disease with poor prognostic markers for survival. The skeletal survey remains the standard method for radiological screening at diagnosis; there is a clear association between the extent of disease (in terms of the number of lytic lesions at presentation) and tumour load at diagnosis11. Eighty eight per cent of the patients had at least one radiological evidences of disease activity. From the skeletal survey the most common site of bone involvement was vertebrae in 60% of patients, followed by the skull in 52%. In the new International Classification (International Myeloma Working Group 2003)7, patients with bone disease are classified as symptomatic and requiring treatment even in the absence of clinical symptoms. The osteolytic lesions were persistent in all of the patients of this study even after 4 cycles of thalidomide based therapy. It is worthnoting that lytic bone lesions seldom show evidence of healing on plain radiographs and sequential skeletal surveys have limited value to assess the treatment response12. In this study, 8 (40%) out of 25 patients had renal involvement with serum creatinine elevation of more than 1.5 mg/dl. All multiple myeloma patients with renal involvement need to be treated very aggressively, because the presence of renal involvement in multiple myeloma is one of the poor prognostic markers13. Renal failure is one of the most common causes of death, second only to infection. Among the 8 multiple myeloma patients with renal involvement in this study only 3 responded to the thaldexa regimen. In the 1950s, thalidomide was introduced in clinical practice for the treatment of insomnia and morning sickness and it was withdrawn from the market in 1961 after the teratogenic effects. Increased angiogenesis is one of the important pathogenic mechanisms in disease progression of multiple myeloma. Despite its teratogenecity thalidomide has re-entered into clinic practice because of its immunomodulatory and anti-angiogenic properties. The antitumour activity of thalidomide-dexamethasone combination is higher than with a single agent of either thalidomide or dexamethasone. From various studies, the response rate of thal-dexa in newly diagnosed and refrac-
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tory myeloma varies from 55% to 72%. The high response rate suggests that a synergistic effect exists between thalidomide and dexamethasone. Singhal et al14 first demonstrated that thalidomide has significant activity in one-third of patients with refractory myeloma. This activity was subsequently confirmed by several independent studies. In the present study, the overall response rate following the thal-dexa regimen was 72%. Eighteen patients responded to the thal-dexa regimen. Out of those who responded, 10 patients (56%) had complete response and 8 patients (44%) had partial response. A study conducted by Rajkumar et al5 in Mayo Clinic demonstrated that thal-dexa combination therapy had a response rate of 64% (32 out of 50) in newly diagnosed multiple myeloma. In a study conducted by Weber et al6 to evaluate the response rate in multiple myeloma between the thalidomide alone and combination of thal-dexa in previously untreated myeloma, the response rate was 36% for patients treated with thalidomide alone and 72% for patients treated with thal-dexa combination. In the study conducted by Dimopoulous et al10 in Greece, the effect of thal-dexa regimen in refractory myeloma demonstrated that 24 (55%) out of 44 patients achieved a partial response. Even though many of the patients presented with more severe disease and poor prognostic markers compared with western population, the response rate was similar in both groups. All patients tolerated the thalidomide based treatment without any major adverse effects. In this study there was a mean increase of 3.4 g/dl haemoglobin compared with the baseline and none of the patients
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developed neutropenia or thrombocytopenia. From the above parameters, this study demonstrated that thalidomide was devoid of myelosuppression and that there is significant improvement in the anaemia status even in the presence of marrow infiltration and renal failure. Response to therapy was also accompanied by improvement of symptoms. Since the study interval was only two years and the sample size was small. The survival benefit of the thal-dexa regimen also could not be studied due to the above reasons. Although multiple myeloma has remained an incurable disease to date, presently available thalidomide based combination chemotherapy represents an active inductive regimen to improve the outcome and achieve eventual cure. ACKNOWLEDGMENT The authors wish to gratefully acknowledge the DST FIST sponsored clinical immunology laboratory (Division of Clinical Immunology), Department of Medicine, JIPMER and Professor VS Negi MD, DM, (Immunology), for their constant help to assess the various laboratory parameters during the study. REFERENCES 1 Kumar A, Loughran T, Alsina M, Durie BG, Djulbegovic B — Management of multiple myeloma: a systematic review and critical appraisal of published studies. Lancet Oncol 2003; 4: 293-304. 2 Child J, Morgan G, Davies F — High dose chemotherapy with hematopoietic stem cell rescue for multiple myeloma. N Engl J Med 2003; 348:1875-83. 3 Rajkumar SV, Dispenzieri A, Fonseca R — Thalidomide for previously untreated indolent or smoldering multiple myeloma. Leukemia 2001; 15: 1274-6.
4 Rajkumar SV, Fonseca R, Dispenzieri A — Thalidomide in the treatment of relapsed multiple myeloma. Mayo Clin Proc 2000; 75: 897-902. 5 Rajkumar SV, Hayman S, Gerz MA, Diapenzieri A, Kyle RA — Combination therapy with thalidomide plus dexamethasone for newly diagnosed myeloma. J Clin Oncol 2002; 20: 4319-23. 6 Weber D, Alexanian R, Gavino M — Thalidomide alone or with dexamethasone for previously untreated multiple myeloma. J Clin Oncol 2003; 21: 16-9. 7 International Myeloma Working Group — Criteria for the classification of monoclonal gammopathies, multiple myeloma and related disorders: a report of the International Myeloma Working Group. Br J Haematol 2003; 121: 749-57. 8 Durie BG — Staging and kinetics of multiple myeloma. Semin Oncol1986; 13: 300-9. 9 Kyle RA, Gertz MA, Witzig TE, Lust JA, Lacy MQ, Dispenzieri A, et al — Review of 1027 patients with newly diagnosed multiple myeloma. Mayo Clin Proc 2003; 78: 21-33. 10 Dimopoulos MA, Zervas K, Kouvatseas G, Galani E — Thalidomide and dexamethasone combination for refractory multiple myeloma. Ann Oncol 2001; 12: 991-5. 11 Durie BG, Salmon SE — A clinical staging system for multiple myeloma: correlation of measured myeloma cell mass with presenting clinical features, response to treatment, and survival. Cancer 1975; 36: 842-54. 12 Wahlin A, Holm J, Osterman G, Norberg B — Evaluation of serial bone x-ray examination in multiple myeloma. Acta Med Scand 1982; 212: 385-7. 13 Augustson BM, Begum G, Dunn JA, Barth NJ, Davies F, Morgan G, et al — Early mortality after diagnosis of multiple myeloma: analysis of patients entered onto the United Kingdom medical research council trials between 1980 and 2002: Medical Research Council Adult Leukaemia Working Party. J Clin Oncol 2005; 23: 9219-26. 14 Singhal S, Weber D, Mehta J, Desikan R — Antitumor activity of thalidomide in refractory multiple myeloma. N Engl J Med 1999; 341: 1565-71.
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Originals and Papers Non-cirrhotic portal fibrosis among children admitted in a tertiary care hospital of Kolkata : a search for possible aetiologies Abhik Sinha1, Tryambak Samanta2, Sarmila Mallik3, Dipak Pal4, Sutapa Ganguly5 Non-cirrhotic portal fibrosis (NCPF) is reported to be a very infrequent cause of portal hypertension (PHT) in paediatric population, but a number of cases of NCPF were found in the paediatric ward of NRS Medical College and Hospital, Kolkata which prompted us to do a study with objectives to find out the proportion of NCPF cases among the study population (the total number of PHT cases admitted in the study period) and their sociodemographic profile with special reference to residence in arsenic affected areas. It was a clinic-based retrospective study. All children below 12 years during the study period (August 2005 to July 2008) with clinical features suggestive of PHT were screened for NCPF. Relevant investigations were done and guardians of all the PHT patients were interviewed with a predesigned pretested questionnaire. Among the total 134 cases of PHT, 29(21.64%) were due to NCPF and the remaining 105(78.36%) cases were due to other causes of PHT other than NCPF. Among the sociodemographic variables studied significant association was found with residency in arsenic affected areas. The study highlights the need of extensive studies to validate the association in the paediatric population. [J Indian Med Assoc 2011; 109: 889-91]
Key words : Non-cirrhotic portal fibrosis (NCPF), portal hypertension (PHT), arsenic.
N
on-cirrhotic portal fibrosis (NCPF) is a syndrome of obliterative portovenopathy leading to portal hypertension (PHT), massive splenomegaly and repeated well tolerated episodes of variceal bleeding1. The term noncirrhotic portal fibrosis was first coined by Basu et al2 in Kolkata in 1967 which was later accepted universally in a workshop organised by ICMR in New Delhi in 19693. Though aetiology of the syndrome is obscure but association with significant past illness in the form of umbilical sepsis, diarrhoeal episodes in infancy and childhood have been described4. Chronic arsenic ingestion has also been implicated in the causation of the disease5. The possible reason in this case being progressive reduction of hepatic glutathione and anti-oxidant enzymes (eg, catalase, gluDepartment of Paediatric Medicine, NRS Medical College and Hospital, Kolkata 700014 1 MBBS, MD Postgraduate Trainee; At present: MD, Assistant Professor of Community Medicine, Calcutta National Medical College, Kolkata 700014 2 MD (Paediatr), RMO cum Clinical Tutor; At present : Assistant Professor 3 MD (Commun Med), Assistant Professor of Community Medicine, Medical College, Kolkata 700073; At present: Associate Professor of Community Medicine, Midnapur Medical College, Paschim Medinipur 721101 4 MD (Commun Med), Associate Professor of Epidemiology, All India Institute of Hygiene and Public Health, Kolkata 700073; At present : Professor 5 MD (Paediatr), Professor and Head of the Department Accepted October 1, 2010 889
tathione peroxidase, etc ), leading to significant increase in lipid peroxidation and protein oxidation in the liver which eventually leads to fibrosis. Lymphocytopenia might also be related. Jaundice, ascites and hepatic encephalopathy are rare. Hepatic parenchymal functions are nearly normal. Morbidity and mortality in this condition is related to variceal bleeding, most commonly from oesophageal varices. As per literature, NCPF is a rather rare cause of PHT in paediatric age group7. But we came across a substantial number of cases of NCPF in the paediatric ward of NRS Medical College and Hospital, Kolkata which prompted us to do this study with the following objectives: (1) To find out the proportion of NCPF cases among the study population. (2) To study the sociodemographic profile of the study population with special reference to residence in arsenic affected areas. MATERIAL AND METHOD All children below 12 years of age admitted in the paediatric medicine ward of NRS Medical College, Kolkata with history and clinical features suggestive of PHT were screened and considered for study population. The diagnosis of NCPF was confirmed by patent splenoportal axis on Doppler ultrasonography along with liver biopsy showing characteristic histopathology with no evidence of cirrhosis6 confirmed from the pathology department of NRS Medical College, Kolkata. Study period was August 2005 to July 2008. Out of 134 cases with PHT studied over a
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span of 3 years, 29 children were diagnosed as NCPF. The by skilled labour (27.92% and 24.35% respectively). So far study was a clinic-based retrospective descriptive study. the literacy status of the head of the family is concerned Relevant bits of information was collected by necessary labo- most of them were below primary (41.23%) and middle ratory tests of the study population and interviewing the school completed (29.56%) in both the groups. There was guardians of the said population by a predesigned and pre- unusually high clustering of the cases in Murshidabad tested questionnaire. Study variables included important vari- district. Though the district contributes 18.1% of total adables like residence, socio-economic status, clinical features, missions in paediatric department as available from the history of past infection and illness, lymphocytopenia. Chi- departmental records in this disease it was as high as square test and Z-test were used in data analysis. 58.6%. To find out the possible associated factor it was checked whether these patients were residing in docuOBSERVATIONS mented arsenic affected areas or not. Quite interestingly, Out of 29 children of NCPF the age ranged from 3.1 to 25 (86.2%) of the NCPF children were from these arsenic 11.9 years with a mean age of 7.6 ± 1.18 years. The male: affected areas (Table 2). female ratio was 16:13. These children came from 6 districts Other implicating agents like contributory past illness of South Bengal. The highest number of cases 17 (58.6%) and lymphocytopenia (defined by count of less than 2SD were from Murshidabad, 6 cases (20.7%) were from Nadia for that age)8 were present in 5 (17.2%) and 3 (10.3%) cases district, 2 patients (6.9%) each came from districts of North respectively. Table 2 showed the association of and South 24 Parganas. Table 1 Distribution of Cases of NCPF possible aetiological factors of NCPF as found in Malda and Bardhaman dis- according to Residency in Arsenic Affected the study. Analysing the data, it was noted that trict contributed 1 case (3.4%) Areas (n=29) the mean age of NCPF (7.6 ± 1.18 years ) is greater each (Table 1). District No of cases than of non-NCPF causes of portal hypertension Presenting complaints from arsenic affected blocks (%) (6.92 ± 0.87 years), but difference was not statistiwere mainly haematemesis cally significant. Residence in arsenic affected area 16 (94.1%) and melaena (82.7%) and Murshidabad (n=17) had the only significant association with NCPF. Nadia (n=6) 6 (100%) abdominal distension North 24 parganas (n=2) 1 (50%) No other study variable was found to have signifi(79.3%). Splenomegaly was South 24 Parganas (n=2) 1 (50%) cant association with NCPF. almost universal (96.6%). Malda (n=1) 1 (100%) DISCUSSION Hepatomegaly was present Bardhaman (n=1) Total (n=29) 25 (86.2%) 9 Dutta et al were the first Indian authors to rein 37.9% of the children, but port a relation between arsenicosis and NCPF. Submild icterus was seen in one patient only. Three children developed transient minimal sequently in 1988 Guha Majumdar et al11 demonstrated free fluid in abdomen after bouts of heamatemesis which very high level of arsenic in the liver of 12 patients of could be detected only after ultrasonography. No other NCPF who were drinking arsenic contaminated water in features of chronic liver disease indicative of decompen- Kolkata. High arsenic was also demonstrated from hairs sation was noted in any other case. Features of hyper- and nails of these patients. However, all these publicasplenism were present in 6 children (20.7%). The mean tions in our region were on adult population only and litpresenting total serum bilirubin was 1.1 mg/dl, alanine erature in paediatric age group are very scarce. Literatures aminotransferase alanine (ALT, SGPT) 43 U/l and ami- from the West as well as other parts of India6 showed that notransferase aspartate (AST, SGOT) 62U/l. All patients NCPF contributed about 1 to 5 % of all causes of PHT in were managed by conservative means and were found well children, but it was found as 21.64 % in this study. This remarkable high incidence is possibly due to arsenic toxicin varying 3 to 26 months follow-up. Analysing the socio-economic status of the study ity. The arsenic affected children in West Bengal reside in population measured by Prasad scale7 it was Table 2 Distribution of the Study Population according to the Variables found that majority of the children of NCPF beunder Study (n=134) longed to the social class III ie, 15(51.7%), folVariable No of portal hypertension cases P-value lowed by class V5 (17.2%), social class IV NCPF Non-NCPF 4(13.8%), social class I2(6.9%) and social class (n=29) (n=105) II3 (10.3%). Children belonging to the social Low socio-economic status 9 (31.03) 38 (36.19) NS 19 (18.1) NS classes of IV and V were taken as to be from low Contributory past illness for NCPF 5 (17.2) Residence in arsenic affected areas 25 (86.2) 41 (39) χ2=20.14, socio-economic status. df=1, p
