malignant neoplasm ovary - Dysgerminoma

Germ cell tumours constitute about 15-20 per cent of all ovarian neoplasm and they are the second common ovarian tumours. For classification see p. 281. They have got varying degrees of malignant potentiality. About 3 per cent of these tumours are malignant. Germ cell tumours occur predominantly in children and young adults. They arise from embryonic germ cells.

Dysgerminoma

                       Dysgerminoma is the commonest (30-40%) malignant germ cell tumour. It arises from undifferentiated form of germ cells. It is often (5%) associated with dysgenetic gonad (see Ch. 27). The counter part of dysgerminoma in male is seminoma. ‘Majority (75%) of the tumours occur before the age of 30 years.

hCG assays are often positive, confusing the diagnosis with pregnancy. It may coexist with pregnancy (20-30%). Dysgerminoma may be associated with choriocarcinoma or endodermal sinus tumour. Tumour markers a-fetoprotein (AFP) and hCG may be positive in that situation. Karyotyping is needed specially when a premenarcheal girl presents with a pelvic mass.

Pathology: The shape is usually round or oval and is usually 5-15 cm in diameter; feel is boggy, at times it is firm rubbery. It may be bilateral (10%). Cut section shows pink or yellow colour. Microscopic appearance reveals uniform large round cells (monotonous pattern), arranged in cords or clumps with abundant clear cytoplasm. Nuclei are large, irregular and hyperchromatic with varying degree of mitosis. There is intense infiltration of lympho~ Cytes and plasma cells in the fibrous septum (Fig. 23.25). In more than 50 per cent, they are potentially malignant.

Clinical features are not specific for the tumour.

Treatment: Majority (75%) of dysgerminomas are Confined to one ovary and are stage I at the time of diagnosis.

In a young patient where preservation of fertility is desired, laparotomy for surgical staging and unilateral salpingo-oophorectomy’ is' done. If there is any suspicion of involvement to the other ovary, bisection of the contralateral ovary, and excisional biopsy should be done. The tumour is sensitive to both chemotherapy and radiotherpy

Medications for hiv treatment

Treatment:

• Preventive          
• Definitive
  

Preventive measures include:

•  Safer sex’ practice by health education. Use of latext condoms and spermicides will prevent HIV.
• Use of blunt tipped needles to avoid needle stick injury during surgery. 
•  HIV negative blood transfusion (screening of 'donors).
•  HIV negative frozen semen to use for artificial donor insemination.
• 'To maintain protocols for correct handling of all body fluids 
• 'Postexposure prophylaxis with zidovudine and lamivudine is advisable.
• 'Termination of pregnancy in HIV positive women.
• Avoiding breastfeeding -in the developing world, avoidance of breastfeeding may not be possible. Mother needs to be counselled
• as regard the risks and benefits of breastfeeding. She is helped to make an informed choice. . ' .'
• 'Wide spread voluntary counselling and testing
• 
  

Definitive

HIV treatment protocols change frequently.

Antiretroviral therapy

: Antiretroviral drugs are grouped into -

 (A) Nucleoside Reverse Transcriptase Inhibitors (NRTIS) : Zidovudine, Zalcitabine, Lamivudine, Stavudine.

 (B) Non-Nucleoeide ReverseTranscriptase Inhibitors (NNRTIS) : Delvirdine, levirapine, Efavirenz.

 (C) Protease Inhibitors (PI) : Indinavir, Saquinavir, Ritonavir, Amprenavir

. D) Fusion inhibitor : Enfuvirtide. The combinations of these drugs are effective in increasing CD4 counts and reducing viral load. Monotherapy is not used as it hastens drug resistance. Combination therapy is known by the acronym HAART (Highly Active Antiretroviral Therapy).

Drug combinations :

• Up to date treatment recommendations available at: www.A.IDSinfo.nih.gov.
•  Two from Gr. A (NRTIs) plus one from Gr. 8 OR 2 from Gr. A (NRTls) plus one from Gr. C (PI).
• Plasma HIV RNA levels indicate the degree of viral replication and CD4 + T cell count indicate level of immune competence.
• Important side effects of drugs - lactic acidosis, anemia, granulocytopenia, pancreatitis, peripheral neuropathy, hepatic dysfuncction and carbohydrate intolerance

. 

When to start therapy: 

• Acute HIV infection syndrome. 
• Symptomatic HIV infection.
• Asymptomatic but CD 4 cell count < 350cells/id or with viral load HIV RNA 50,000 copies/ml.
•  Post-exposure prophylaxis 
• With effective treatment viral load should reach 'undetectable’ levels (< 50 copies/ml) and CD4 count should rise.
•  Patients with CD 4 count < 200/ Ml should also receive trimethoprim and aulphamethoxazole combination ( carinii prophylaxis).
•  Opportunistic infections (mycobacterium) should be treated simultaneously with specific drugs when CD4 + T cells < 50/ul.
•  Colposcopy and cervical cytology screening should be routinely done.
• Zidovudine is given in a dose of 200 mg every 8 hours. Nevirapine is found to reduce the viral transmission to breastfed infants.

When to change

 (i) Failure to reduce viral load.

 ii) Persistently declining CD43 + T cell count.

 (iii) Clinical deterioration.

Postexposure Prophylaxis 

          A combination of2 NRITs is given for 4 weeks. Prophylactic use zidoudine (300 mg bid) and lamivudine (150 mg bid) for a period of 4 weeks immediately followig an exposure may reduce the  risk of seroconversion (CDC-2001).

.‘

Head massage

Abhyanga (massage) procedure performed on head (siras) is called sirobhyanga. It is the first procedure among the murdha tailas and has the less effect of all of them according to Acarya. In our common practice, prior to whole body massage,head massage is done routinely.

It can be done as a preventive procedure and as a therapeutic procedure.

Depth of penetration is about 3 mm.

'Reference seen in Ayurveda  samhitas

.

Benefits of head massage

• .     Massage on temples improves eyesight and creates a well centred state of awareness.
•       Massage of the temples, eye brows relaxes the whole body and is especially beneficial for the eyes and            nervous system.
•       Massage of the forehead increases sight and power of concentration.
•       Scalp massage cures dryness, loss of hair and premature baldness. 
•       Head massage increases the supply of fresh oxygen and glucose to the brain. It increases blood                      circulation and normal functioning of hormones.

 Indications: 

            Hair fall,  Psychological diseases, headache spectrum, hair ailments, scalp diseases, degenerative and demyelinating brain diseases, ear and eye diseases etc

Pre operative procedure: 

             It can be done at any time of the day, before bath. Morning time is most ideal. Patient is asked to take moderate warming up exercise and do clear his bowel.

Procedure: 

         Patient is made to sit on a cushioned knee high chair / stool. His body is covered with a cloth below the neck. Therapist standing behind the patient is ideal position to carry out massage. Oil is to be made Luke warm by keeping in boiling water before application. The oil is then poured in the hands of therapist,held over the head or the patient, then spread all over the head including the neck and ear pinna with palmar surface of the therapist. Then start to massage gently over these areas. Movement should be done in linear direction or  in circular fashion. 

Amount of oil to be used is till the head gets wet with oil (50 ml-lOO ml)

Duration: 30 min to 45 min. 

Medicine Pet

PET is based on the tissue uptake of 18F-fluro-2 deoxyglucose. FDG-PET can measure the difference between the normal tissue and cancerous tissue. Cancer tissues process this glucose analog differently compared to that of normal tissues. This glucose analog is given IV. FDG-PET scan is then done and the images are interpreted.

FDG-PET scan is more sensitive for detection of metastatic disease and recurrence of ovarian malignancy. It is also useful to assess the response following tumour therapy. FDG-PET scan is found to be more sensitive and specific compared to CTor MRI.

Tumour makerbreast

A tumour marker is a substance that is selectively graduated by the neoplastic tissue. It is then released into the blood where from it can be detected.

Ideal tumour marker should fulfil. the following criteria:

• .It should be produced only by the tumour cells.
•  If Should be Specific.
• Its measurement either in the blood or urine should be sensitive enough to detect microscopic or sub clinical disease.
•  Tumour markers are used to monitor the response of therapy. Ideally the antigen (tumour marker) level should represent the tumour volume correctly. Progressive rise in marker value indicates ineffective chemotherapy.
•  The assay should be inexpensive and acceptable.

The tumour marker should not only indicate the presence but also the site of tumour origin

.

      Tumour marker is useful in screening, diagnosis and management of a case and for follow up. However, the detection of tumour marker is seldom made before the cell population becomes 1010.

(The role of serum CA-125 in the evaluation of disease (ovarian carcinoma) progression and regression is invaluable. Similarly, serum BhCG is useful in the diagnosis, management and follow up of cases with GTN.)

Asianet news investigation about alapuza incidents

Internal controls of audit

DEFINITION AND MEANING OF AUDlTING OR AUDIT

Auditing in the Literal Sense:

The term ‘audit’ is derived from the Latin word ‘audire’, which means ‘to hear’.

in ancient times, whenever trauds were suspected. the proprietors of business firms used to appoint some experienced and impartial persons, ordinarily judges. to check the correctness of the accounts of their firms prepared by their book-keepers (i .e., the persons who had maintained the books of accounts). The persons appointed to check the correctness of the accounts used to only hear from the book‘keepers alt the accounts relating to the business, and, on the basis of the hearing of accounts, would express their opinion about the correctness or otherwise of the entries made In the books of accounts.

The hearing from the book-keepers all the accounts relating to the business came to be known as audit or auditing, and the persons who heard from the book-keepers all the accounts relating to the business came to be known as auditors. So, literally, 'audit’ or ‘auditing’ means hearing, and 'auditors' mean ‘hearers’.

Auditing in the General Sense:

Now, let us consider the meaning of the term ‘audit’ or ‘auditing’ in the ordinary or general sense. Initially, the term ‘audit‘ or ‘auditing’ was taken to mean examination of the books of accounts of a business to ascertain whether the persons in charge of receiving and paying cash and maintaining the books of accounts had properly accounted for all the cash receipts and cash payments on behalf of their principal

'(i.e., the owners of the business). In other words, initially, the term 'audit’ or ‘auditing’ was taken to mean checking of the books of accounts of a business to find out whether cash had been embezzled (is, misappropriated), and if so, who had embezzled it (is. the cash) and how much of cash had been embezzled. In short, in the beginning, the term 'audit' or ‘auditing meant only ‘cash audit' (is. examination or checking of the cash receipts and cash payments).

Modern Concept 01‘ Auditing:

However, over the years, the meaning of the term ‘audit’ or ‘auditing’ has undergone a considerable change. Today, audit or auditing (is, audit or auditing in its modern concept) means Thorough and critical examination of all the books of accounts any records of a business by an independent person or body of persons Qualified for the lob to verify the arithmetical accuracy of the account as well as the authenticity and the truth of the transactions recorder, in the books of accounts and in the financial statements, and try report to the owners of the business whether the profit and ice; account gives a true and fair view of the profit or loss of the business for the financial period, and the balance sheet gives a true and far, view of the slate of affairs of the business at the end of the financial period.

The above meaning of audit or auditing in its modern concern (i.e., modern audit or auditing) is borne out by the definitions given. by several writers on the subject ‘auditing'. So, let us consider some of the important definitions of ‘audit’ or ‘auditing’, and understand how far the above meaning of modem audit or auditing is borne out by these definitions.

Spicer and Pegler have defined audit as “such an examination of the books, accounts and vouchers of a business as will enable the auditor to satisfy himself that the balance sheet is properly drawn up, so as to give a true and fair view of the state of affairs of the business and whether the profit and loss account gives a true and fair view of the profit or loss for the financial period, according to the best of his information and the explanations given to him and as is shown by the books, and if not, in what respects he is not satisfied.” According to this definition, auditing is the systematic and scientific examination of the books of accounts and the records If the business to verify whether the balance sheet and the profit and loss account are properly drawn up, and to report whether the balance sheet gives a true and fair view of the financial position the business, and the profit or loss account gives a true  view of the profit or loss of the business.

in the words of F.R.M.De Paula, “An audit denotes the examination of a balance sheet and profit and loss account prepared by all together with the books, accounts and vouchers relating thereto such a manner that the auditor may be able to satisfy himself at honestly report that in his opinion, such balance sheet is proper drawn up so as to exhibit a true and correct view of the state affairs of the particular concern, according to the information a

epla dons given to him and as shown by the books 

lust endorses the View of Spicer and Pegier. To be specific, according to this definition also, auditing is the systematic and scientific examination of the books of accounts and the records of a business for the purpose of ascertaining and reporting whether the financial statements are properly drawn up and whether they give a true and correct view of the profits and the financial position of the business.

According to  Dicksee, “Auditing can be understood as an examination of accounting records undertaken with a View to establishing whether they correctly and completely reflect the transactions to which they purport to relate. in some instances, it may be necessary to ascertain whether the transactions are supported by authority." According to this definition, auditing is the examination of the accounting records to establish whether the transactions of the business have been undertaken with proper authority, and whether the accounting records correctly and completely reflect the transactions to which they relate, and also to report whether the financial statements (i.e., the balance sheet and the profit and loss account) prepared from the accounting records portray a true and fair picture of the business.

Montgomery defined auditing as ‘a systematic examination of the books and records of a business or other organisation in order to ascertain or verify and to report upon the facts regarding the financial operations and the results thereof.” According to this definition, auditing is the systematic examination of the books of accounts and the records of a business organisation or any other organisation to verify and report upon the facts regarding the financial operations and the financial results (i. e., the profit or loss and the financial position)

R Batiiboi defined audit as “an intelligent and critical scrutiny of the books of accounts of a business with the documents and vouchers for which they are relied upon for the purpose of ascertaining Whether the working results for a particular period as shown by the profit and loss account and also the exact financial condition of the business as reflected in the balance sheet are truly determined and presented by those responsible for their compilation.” According to this definition, auditing is a critical examination 'of the books at accounts of a business with the vouchers and other documents for a purpose of ascertaining whether the working results (Le, the refit or toss) of the business tor a particular period.

Ayurvedic treatment Udwarttanam

It is the external application of medicated curna or pastes on the body with affordable pressure massage generally in pratiloma/ retrograde direction (massage in the direction opposite to that of hair).A type of ruksha kriya (bahya karma) which is more specific to tvak and medho dhatu. It may be equated a therapeutic passive exercise

. It aims to bring about rukshana at the level of superficial dhatus especially at the level of twak (rasa rakta, mamsa and médas.

. Most of drug having katu, tikta, kashaya rasatmaka & ushna, laghu, ruksha, viéada, lékhana, kathii guna dravyas are useful for udwarttana.

Properties and benefits: kapha hara, médasazpravilayana (reduce excess fat), sthirikaranamangana: wakprasadakaram, kantikrt, dourgandhya hara, gouravam hanti, tantra hara, kandughna, imprc irajakagni etc

Cleanses the body, increase brightness, increases circulation, expansion & dilatation of the vessels. ’Udvartana procedure enhances channel as well as cellular level circulation and transportation of fluids.

and nutrients. It helps to eliminate waste products & influences general metabolism. It also helps for reabsorbing of inflammatory products.

.Preventive aspect and curative effect:it can be used as a preventive measure to stop the progression fro médovrddhi to médoroga or ati sthaulya. It is an effective therapeutic procedure for the management of médovrddhi/ ati stoulya.

>Udvartan in combination with internal medication and paneakarmas forms effective treatment for stablished sthaulya/ metabolic-X syndrome.

>udvarthana has a cosmetic value as it imparts good complexion and has a stress relieving  property.

>It destroys the itching and removes the waste products by stimulating their excretion through sweat

.

 >By udwarttana/ udgharshana there will be dilatation of tiryakgata siras which are present in twak and this stimulates the bhrajaka pitta with the help of ushna guna. Then kapha, méda vilayana (lékhana) takes Ilace by khara and ushna guna. This is followed by kshalana (cleanching) of formed sweda over the body urface by visada guna, Then by the roksha property there will be soshana of swéda which leads to  laghu guna. Finally appearance of drdhata in body by kathina guna.

INDICATIONS

Most commonly kapha pradhana, médho dhatu dushtijanya rogas likes sthoulya, praméha, praméha pitakas, .Some type of kushthas, dhamani praticaya etc, pés’i s'aithilyavastha, firustambha, sometimes sosha/yaksh muscle wasting (AH-Ci) etc

>Umada, apasmara & rajayakshma (by Caraka)

>MND/ Demyelination diseases (at their first stage), acute neuropathy, TAO, obesity, sensory motor neuropathies, peripheral vascular disease, fasciluations etc

>If the child is emaciated utsadana can be done and that may provide controlled rukshna.

>Especially in vasanta rtu, udwartana is indicated. Because of previous seasonal influence on aggravation )of kapha dosha (which are accumulated in s'is'ira rtu). Various kaphaja rogas may manifest because of heat )reduced in vasanta rtu (which liquifies saneita kapha dosha).

CONTRA INDICATIONS

Paittika / rakta pradhana rogavastha, dhatukshayajanya vita prakopavastha, nflammation sites, cellulitis, wounds, deep vein thrombosis, children, senile persons etc . 3" Durbala, kaéya, garbhini, vrddha, bala etc.

TYPES OF UDWARTTANA 

Vi) Depending upon the nature of medicines used

Ruksha udwarttana if dry powdrer (medicated powder) alone is used (for kapha pradhana / médo dhatu dushtajanya rogas).

 Snidha udwarttana if there is taila / oil substance is used in this procedure (if there is slight vata kepa  with the kapha, medho') dushti). 

Oil / medicine should be selected according to the prakrti of the patient & condition of the disease. 

Ruksha udwarttana is most commonly practiced. 

ii) Depending upon the nature of the medicine during the procedure

Udvarthana (the above said procedure) 5Udgharshana dry medicine (powder) is rubbed against the body (asnéha oushadha curn ‘bhigharsanam). Almost same as that of udwarttanam.

3. Utsadana ~ it is a type ofbahya snéhana (snigdha-rdkshahather than ruksha kriya, in which a paste of powdered medicine kalkka is moistened with taila/ oil (sneha kalkéna utgharshanam)

MATERIALS REQUIRED

Abhyanga table                     

Powderd medicine / taila

Attendant

Rasnadi coorna

 Preoperative procedure: preparation of the patient usually done in the morning time. Evacuate the bowel and bladder. It should be done alter sun rise, in empty stomach. Patient should use minimum dress Talam may or may not be done with suitable medicines/ oil. Patient is advised to lay down in the dhroni.

 Procedure

apply powder /oily powder on the body and massage in a direction opposite to that of hair (pratiloma) with a moderate pressure /affordable pressure to the patient. Simultaneously on the both leg the process is continued in upward direction. Usually done in 4 positions supine, rt lateral, lt lateral & prone position.