Basic and clinical research results that were incorporated in medical decision making was found to be subjective in earlier times, and there was no formal process for determining the extent of research evidence. Many studies done from 1960 to 1972, found that there were a lack of controlled trials supporting many practices which had previously been assumed to be effective. Towards the end of 1980, it was seen that larger numbers of procedures performed by physicians were considered inappropriate and not up to medical standards. The absence of comparative research, undermined medical decision-making at the level of individual patients and population at large, and this paved the way for the introduction of evidence based medicine (EBM). Now EBM has a considerable impact on modern day healthcare practices.
Through this case study, we can observe and understand the very prevalent setbacks in the Indian healthcare system. It is important to note however, that while the Indian healthcare system has its faults, it has its strengths as well. Treatment is effective, waiting periods are fast moving or non-existent, doctors are highly trained and experienced, and drugs and various medications are relatively affordable to the masses. While options for surgical procedures are limited to the common man, the middle and upper class has access to world-class facilities. One aspect that needs prompt review is its outlook on mental health, palliative care, and the awareness of diseases such as Neurofibromatosis Type 1, which require an extensive social and psychological support framework.
As stated above, this story is representative of thousands of lower-middle class Indians, seeking treatment in urban tertiary care centers, from all over the country. It is important to note, that no amount of facial reconstructive surgery will ever render this patient’s face close to what was its previous morphology. Her treatment is still in progress, a process that could have been made much easier if she could benefit from the support of an organization in her community. The importance of these initiatives simply cannot be understated. They are imperative in teaching patients that there is life beyond neurofibromatosis, one that is not worth living in recluse. Patients with neurofibromatosis, even Type 1, that suffer drastic disfiguration in their appearance, are almost always capable of living fulfilled, functional, and working lives. Through the ages, in a society where people are different, because of the color of their skin, sexual orientation, or mental stability, they tend to lead isolated lives. However, what catalyzes their integration into a community is an awareness of their disorder, and support from others who share their experiences. Thus, for patients who suffer from the psychological and social trauma of living with a pNF, the aid of a local, community based support organizations is crucial to improving their quality of life.
Malocclusion being an issue, the orthodontist must deliberate how to deal with the dental arch ‘vacancies.’ Condensing large toothless spans of long standing in adults where the cortical plates have collapsed and shrunken alveolar ridge forms a barrier, especially in the mandibular posterior region is a formidable challenge, assertively vetoed by some investigators. When such a daunting task is embarked upon, one must be wary of the perils of root resorption, gingival dehiscence, periodontal defects and improper root parallelism owing to heavy force exertion. Corticotomy, alveolar ridge expansion and the ‘regional acceleratory phenomenon’ (rapid localized bone turn overand swift orthodontically-induced tooth movement) engendered by bone damage are facilitative protocols indicated in such a circumstance. Even when space closure is technically feasible and there are no obvious impediments, executing this plan is tantamount to modifying the patient’s existing occlusal scheme with fixed orthodontic hardware and prolonged care.
A 71-year-old asymptomatic male was referred to a cardiologist for a treadmill stress test. The patient’s primary care physician sent him for this test after observing that patient had sinus bradycardia (heart rate of 44beats per minute). Results of the test revealed a ST segment depression at peak exercise. In response to these abnormal results, the patient was referred to us for an exercise gated sestamibi SPECT (single photon emission computed tomography) study. This revealed normal left ventricular systolic function and no evidence of ischemia. Stress testing is not indicated for asymptomatic arrhythmias. Therefore, we believe that the initial treadmill stress testing in this case was unnecessary and led to further superfluous testing.
A total number of 10,591 surgical specimens were received during the 3 years period from 1982 to 1984 out of these 556 lymph node biopsies were recorded giving an incidence of 5.25% and an average of 185 lymph node biopsies per year.
The youngest case in the present series was a child of 6 months and the oldest case was an 80 year old male.
The largest number of lymph node enlargement was seen in 2nd and 3rd decades (255 cases) accounting for 45.9% followed by 15.8% (88 cases) in the 4th decade and 11.3% (63 cases) in the 5th decade.
The commonest cause of lymphadenopathy was tuberculous lymphadenitis (42.1%) followed by reactive hyperplasia (33.8%) and metastasis in lymph node (15.1%). The commonest type of metastasis was Adenocarcinoma, Squamous Cell Carcinoma, Infiltrating duct Carcinoma, and Carcinoma of thyroid in that order.