Predictive Determinants for Gastro-oesophageal Malignancy in Dyspeptic patients with Alarm features.

INTRODUCTION : Dyspepsia is a nonspecific term to denote upper abdominal discomfort that is thought to arise from the upper-GI tract. Dyspepsia may encompass a variety of more specific symptoms, including epigastric discomfort,bloating, anorexia, early satiety, belching or regurgitation, nausea, and heartburn. Symptoms of dyspepsia most commonly result from 1 of 4 underlying disorders: peptic ulcer disease, GERD, functional disorders (nonulcer dyspepsia),and malignancy: malignancy is present in 1% to 3% of patients with dyspepsia and peptic ulcer disease in another 5% to 15%. The estimated annual prevalence in western countries is approximately 25% to 40% accounting 2-5% of all primary care consultations. In India almost one-third of the population has symptoms. Endoscopy is the procedure of choice for the diagnostic evaluation of this common, longterm, symptom shifting, expensive disorder.It offers the potential for early diagnosis of structural disease.Yet, given the large numbers of patients with dyspepsia, it is not practical to perform endoscopy in all patients with dyspepsia. Age and alarm features have been used in an attempt to identify those patients with dyspepsia who harbor structural disease. Patients with a new onset of dyspepsia after 45 to 55 years of age and those with symptoms or signs (unintended weight loss, Upper Gastrointestinal bleeding or iron deficiency anemia, progressive dysphagia, persistent vomiting, palpable mass, lymphadenopathy, jaundice) that suggest structural disease are advised to undergo initial endoscopy. Patients with alarm features and dyspepsia have significantly worse outcomes than the population at large. In a prospective questionnaire study, patients with alarm symptoms and dyspepsia had a significant increase in both GI cancer and mortality over a 3-year period. Even though alarm features predict relatively poor patient outcomes, they have a low predictive value for GI cancer. In a meta-analysis of 15 studies that evaluated more than 57,000 patients with dyspepsia, alarm symptoms showed a positive predictive value for GI cancer of <11% in all but 1 of these studies. The negative predictive value of alarm symptoms was much higher, at > 97%, because of the low prevalence of GI cancer in that population. A second meta-analysis of 26 studies that totaled more than 16,000 patients with dyspepsia showed similar results: the positive predictive value of alarm symptoms for upper-GI cancer was only 5.9% and the negative predictive value was >99%. Unfortunately, clinical impression, demographics,risk factors, history items, and symptoms also do not adequately distinguish structural disease from functional disease in patients with dyspepsia who are referred for endoscopy. It is worth noting that one fourth of patients with malignancy and dyspepsia have no alarm symptoms. AIM OF THE STUDY : 1.To determine the predictive factors of gastroesophageal malignancy in dyspeptic patients presenting with alarm features. 2.To arrive at or to refine indications for Upper Gastrointestinal Endoscopy in patients with dyspepsia. CONCLUSIONS : The alarm features like dysphagia(p=0.003), persistent vomiting(p=0.02), anemia(p=0.01), age>45 years(p = 0.02) and weight loss(p = 0.008) were identified as significant predictors for Gastroesophageal malignancy in dyspeptic patients. No gender difference observed to influence the malignant outcome(p = 0.3). The duration of alarm inversely correlates with malignant outcome(p<0.0001). Presence of alarm combination do not significantly increase the chances of malignancy (p=0.3) Alarm features in age > 45 years predict more significantly(p=0.008) the malignant outcomes than younger age group with alarm. Alarm features like Upper GI bleed(p=0.8), early satiety(p=0.2), anorexia(p=0.1), easy fatiguability(p=0.13), mass abdomen(p=0.6) do not predict significantly Gastroesophageal malignancy. Based on the results of the present study,we recommend the following guidelines that can be followed in our set up: 1.Irrespective of age group, any dyspeptic patient with alarm should be subjected to Upper GI endoscopy to rule out malignancy as per the recommendation.But the urgency of endoscopy can be prioritised. (a) In Age > 45 years presenting with alarm,Upper GI endoscopy should be done urgently/at the earliest without even waiting for the baseline investigations. (b) In Age > 45 years without alarm & younger patients with alarm,Upper GI scopy can be done in an elective basis or after undergoing baseline investigations. 2.Patients presenting with dysphagia,vomiting ,weight loss,anemia should be done endoscopy in an urgent basisThe above indications may minimize the workload to the endoscopist and at the same time identifies the malignancy at the earliest

Health Seeking Behaviour, Infant (0-12 Months) Rearing Practices and Nutritional Status of Migrant Population Near Metropolis

INTRODUCTION: Migration along with mortality and fertility is considered to be one of the vital population processes influencing the size, composition and distribution of population. Migration can either depopulate or overpopulate an area depending upon the level of economic activities and is an important process of urbanisation and social change. Historically it has been a force to the democratization of society. For example, the great nations like US and Australia are the products of the streams of migration. In the Indian context, it powered the way for the lower caste groups1 to free themselves from the oppression and subjugation of traditional caste system if they mould to the urban areas2. Migration is a process of cultural evolution also. Migrants bring new ideals, skills and host of cultural practices related to food, dance and music and other life styles as well. Sometimes, they are easily absorbed in the host culture, but in several times they are thought to be a source of conflict and the cultural differences are exploited to increase the tension between the migrant and not communities. However the conflict between the migrant and host communities is rooted in the competition for jobs between these two groups of people. Thus the politicization of migrants and also of the migration policy is a logical outcome. OBJECTIVES OF THE STUDY: 1. To assess the health status of infants of migrant population residing in brick kilns. 2. To understand the health seeking behaviour and infant rearing practices of the migrant population. DISCUSSION: Women and children constitute vulnerable segment of the population with respect to health care and utilisation of health care services, more so in poorer sections of society like migrant population. This migrant population forms a separate group who suffer more than that of General population and is connected to the need to increase their income. In the process, health and health seeking behaviour are grossly affected. They serve as pockets of source of infections or epidemic outbreaks. Not many studies were done about their health status and about their health seeking behaviour. This study is an attempt to identify the factors in maternal health seeking behaviour and infant rearing practices among the migration population. Brick kiln population constitute one of the largest migrating population in Chennai Corporation. This study was done in one segment of the Brick kiln population near Chennai i.e. Poonamallee 10 - 15 kms away from Chennai. This study basically focuses on health seeking behaviour of migrant population esp. pregnant mother and infants. The questionnaire was developed to bring out the health seeking behaviour of the pregnant mothers, their impact on neonatal deaths, health seeking behaviour during infant illness and infant rearing practices. In the present study, pregnant mothers did not receive adequate antenatal care. Antenatal care was confined to confirmation of pregnancy in majority of cases. It has a direct bearing on the infant and neonatal mortality rates in this migrant population i.e. very high neonatal / infant mortality rates. Even the primi mothers are aware of immunisation. This is evident that majority had received 1st dose of TT. Indeed this turned them away from health seeking behaviour in the form of further checkups. This factor calls for a rethink on strategies of immunisation and improvement of health seeking behaviour of this population. Significant antenatal mothers of this migrant population had home deliveries on account of a single antenatal visit. Motivation in institutional deliveries has not occurred. This has resulted in significant, unsupervised home deliveries. Consequent to this home delivery, the study has revealed a High Birth Asphyxia rate, high neonatal mortality rate secondary to Birth Asphyxia. This again indicates that programmes to reduce Neonatal mortality have not reached this migrant population. CONCLUSION: 1. The study show that the migrant population face a number of barriers to the use of maternal health services. The availability of services, illiteracy, cost and prevailing traditional attitudes towards child birth, all act to prevent women from utilising maternal health care. 2. Only 57.1% mothers had antenatal visits and 61.5% of mothers had only one antenatal checkup. This is statistically significant. 3. FST / FAT consumption in this migrant population is 57.1% only 53.3% had taken 2 months of FST / FAT. 17.2% had taken 3 months which is statistically significant. 4. About 39.7% deliveries are at home whereas institutional deliveries constitute 30.8% in this migrant population. 5. Exclusive Breast feeding rate is 81.5% in less than 6 months of age which is statistically significant. 6. Underweight, stunting and wasting are 77.2%, 57% and 37.6% in infants >6 months of age compared to infants < 6 months of Age (26.2%, 21.5% and 13.8% respectively). P value less than 0.001 which is significant. 7. Statistically significant association observed between late introduction of semisolid and prevalence of underweight, stunting and wasting. 8. Frequency of occurrence of Respiratory infection / Diarrhoea in infants >6 months (Mean 3.35 and 3.52 respectively) is increased with significant P value < 0.001. 9. Statistically significant association is present between the early introduction of artificial feeds and underweight, stunting but not with wasting. Infant mortality rate is 80 / 100 live births whereas Neonatal mortality rate is 81 / 1000 live births. Neonatal deaths constitute 95.5% of infant deaths. Birth Asphyxia form the major etiological factor (45.4%). 10. About 75.7% of infants were immunised for Age. * Regarding the type of treatment given to common ailments 72.2% of infant had taken native medicine. About 50% and 30.8% of infants had received nasal blowing and oil instillation respectively