Title:
A ganglion cyst at the foot causing tarsal tunnel syndrome detected by magnetic resonance imaging.
Abstract
Tarsal tunnel syndrome is often misdiagnosed as clinical symptoms of tarsal tunnel syndrome vary and physician must keep this in mind whenever unexpected paresthesias are present in the planter aspect of the foot, in the toes, or over the medial distal calf. . Failure to diagnose and treat neuropathies effectively can cause permanent neuropathic pain and functional disability. We report a case of a ganglion cyst detected by MRI in a 31-year-old man who complained of rapidly aggravating pain, numbness and paresthesia on the great toe and the first metatarsal area in the sole, symptoms that resembled tarsal tunnel syndrome confined to the medial planter nerve. Surgical treatment could be performed early with no permanent sequelae. We could also avoid repeated steroid injections or prescription medications.
Key words: Tarsal tunnel syndrome; Ganglion cyst; Medial planter nerve.

Introduction
Tarsal tunnel syndrome (TTS) is caused by compression of the posterior tibial nerve as it passes through the posterior tarsal tunnel. It is much more common in the posterior tarsal tunnel than in the anterior by compression of the deep peroneal nerve as it passes beneath the superficial fascia of the ankle [1]. TTS may be associated with exacerbation of symptoms at night, by exercise or rest, or by elevating or lowering the extremity, and symptoms confined to the lateral planter nerve, medial planter nerve, or medial calcaneal nerve [2]. Failure to diagnose and treat neuropathies effectively can cause permanent neuropathic pain and functional disability In most cases, TTS develops from unknown causes and can be treated conservatively. However, early surgical intervention is mandatory when neuropathy arises from a progressing occult pathology to avoid, repeated steroid injections, prescription of several medication for neuropathic pain, and to prevent permanent neuropathic pain. MRI and electromyography, together with clinical history and physical examination, can help to make the differential diagnosis.

Case history:
The patient was a 31-year-old man with a 6-month history of pain, numbness, and paresthesia on the left great toe and the first metatarsal area in the sole. The pain was constant and burning. Symptoms were aggravated by pressure on the sole such as walking and weight bearing. Symptoms had initially localized in the great toe and sole but gradually extended to the second and third toes. Patient had been prescribed lot of local steroidal injections but had no permanent relief.
A physical examination did not reveal specific abnormalities except a local tenderness just below and down to the medial malleolus over the foot. There was no palpable swelling. We then performed an MRI which revealed a unilocular, ganglion cyst around the medial planter nerve in the digitorum muscles of the foot. [Fig.1 and 2]. Nerve-conduction studies showed that conduction velocity was reduced in the right medial plantar nerve. There was no apparent weakness of the intrinsic muscles of the right foot, but a subtle T2 high signal change in the abductor hallucis and flexor digitorum brevis muscle was seen on MRI. We suspected subacute muscle denervation and planned the patient for surgery. Intra-operatively, ganglion cyst was found close to the medial planter nerve and after meticulous dissection nerve was freed from the ganglion cyst [Fig. 3 and 4]. After surgery two weeks later, the patient had dramatic response with improved symptoms.



Discussion
The most common cause of compression of the posterior tibial nerve around the tarsal tunnel is trauma to the ankle, but any occult pathology, such as a space-occupying lesion like a ganglion cyst, can cause similar neuropathic pain [3]. Tarsal tunnel syndrome is an entrapment neuropathy caused by compression of the posterior tibial nerve and its branches, between the calcaneum and the medial malleolus under the cover of the flexor retinaculum [4, 5]. TTS can be misdiagnosed as ankle arthritis and lumbar radiculopath [6]. However, patients with ankle arthritis have radiologic evidence of it. TTS can be distinguished from lumbar radiculopathy because patients suffering from TTS have no reflex changes, and motor and sensory changes are localized to the distribution of the distal posterior tibial nerve and its branches. Secondary TTS by a ganglion is unusual,[4,5] but it can occur. Kirby and colleagues [7]) found that ganglion cysts were the most common benign lesion of the foot, accounting for nearly one-third of all cases. The size and location of the ganglion cyst is influences entrapment neuropathy because the volume of the tarsal tunnel compartment ranges from 18 cm3 to 21 cm3 in normal individuals [8]). In addition, Takakura and colleagues (9[] mentioned that a large ganglion can easily be diagnosed by MRI, but is difficult if it is smaller than 0.5 × 0.5 × 0.5 cm. A cystic and completely anechoic fluid collection around the ankle detected by USG commonly represents a ganglion cyst [10].


Conclusion
In conclusion, neuropathy arising from progressing occult pathology should be diagnosed early with high degree of suspicion by modern imaging facilities and treated adequately to avoid permanent neuropathic pain and functional disability. When a suddenly exacerbated case of neuropathy is encountered, a space-occupying lesion such as a ganglion cyst should be considered and clinicians must try to detect it as soon as possible. MRI may be a helpful device for this effort. The unique clinical symptoms and signs of our diagnosis of a ganglion causing medial plantar nerve compression were confirmed by MRI and then operative findings.

Consent
"Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal."

Competing interests
“The author(s) declare that they have no competing interests’'.
Authors' contributions
“IHWand SS analyzed and interpreted the patient data regarding the disease. YK discussed the case with radiology and pathology experts and formulated the investigative and treatment plan. AQS and SS performed the biopsy. IHW was responsible for followup and prepared the manuscript. All authors read and approved the final manuscript.”



References

1. Waldman SD: Posterior tarsal tunnel syndrome. In: Atlas of Common Pain Syndromes. 2nd ed. Philadelphia,Saunders Elsevier. 2007,pp 337-9.
2. Greer Richardson E.:From Neurogenic disorders: Tarsal Tunnel syndrome. In Campbell’s operative orthopaedics. Volume 4th. Elevanth Edition.Edited by S. Terry Canale, James H. Beaty 2008; 83: 4717-4721.
3. Ferraresi S, Leidi P, Leidi M, Ubiali E, Bortolotti G, Cassinari V: Tarsal tunnel syndrome. Report of a case and review of clinical and surgical aspects. Ital J Neurol Sci 1992; 13: 47-51.
4. Taguchi Y, Nosaka K, Yasuda K, Teramoto K, Mano M, Yamamoto S: The tarsal tunnel syndrome: report of two cases of unusual cause. Clin Orthop Relat Res 1987; 217:247-52.
5. Brown RJ: Tarsal tunnel syndrome due to a ganglion: a case report. Ulster Med J 1982; 51: 127-9.
6. Lam SJ: Tarsal tunnel syndrome. J Bone Joint Surg Br 1967; 49: 87-92.
7. Kirby EJ, Shereff MJ, Lewis MM: Soft-tissue tumors and tumor-like lesions of the foot. An analysis of eighty-three cases. J Bone Joint Surg Am 1989; 71:621-6.
8. Bracilovic A, Nihal A, Houston VL, Beattie AC, Rosenberg ZS, Trepman E: Effect of foot and ankle position on tarsal tunnel compartment volume. Foot Ankle Int 2006; 27: 431-7.
9. Takakura Y, Kumai T, Takaoka T, Tamai S: Tarsal tunnel syndrome caused by coalition associated with a ganglion. J Bone Joint Surg Br 1998; 80: 130-3.
10. Chhem RK, Beauregard G, Schmutz GR, Benko AJ: Ultrasonography
of the ankle and the hindfoot. Can Assoc Radiol J 1993; 44: 337-41.


Figure legends’:
Fig. 1: MRI showing unilocular hyperintense cystic lesion in digitorum muscles of foot.

Fig.2: MRI showing ganglion cyst.
Fig. 3: Ganglion cyst pressing on a medial planter nerve detected intraoperatively.

Fig. 4: Removed ganglion cyst

Avoidable Tragedy: Spurious Liquor


With more than half of all alcohol drinkers in India falling into the criteria for hazardous drinking, alcohol abuse is emerging as a major public-health problem in the country. The problem becomes more compounded especially where we find the urban poor and rural peasants flocking to the liquor shops with a 10 rupee note and buying death in a sachet as seen in the recent Calcutta tragedy India's reputation as a country with a culture of abstinence especially in matters regarding alcohol is underserved, say experts. The country, which has seen a rapid proliferation of city bars and nightclubs in recent years, is fast shedding its inhibitions about alcohol as a lifestyle choice.
This situation has led to fears of an undocumented rise in alcohol abuse not only among poorer classes but also in sections of society that were previously considered dry. The entire policy regarding the pricing and trading of state sponsored liquor outlets with singular aim of generating revenue needs to be questioned by concerned citizens. The increasing production, distribution, and promotion of alcohol have already seen drink-related problems emerging as a major public-health concern in India. Sales of alcohol have seen a growth rate of 8% in the past 3 years. Officially, Indians are still among the world's lowest consumers of alcohol—government statistics show only 21% of adult men and around 2% of women drink. But up to a fifth of this group—about 14 million people—are dependent drinkers requiring “help”.

The concern, say experts, is that there has been a rapid change in patterns and trends of alcohol use in India. Chief among them is people are beginning to drink at ever-younger ages. The percentage of the drinking population aged less than 21 years has increased from 2% to more than 14% in the past 15 years, according to studies in the southern state of Kerala by Alcohol and Drugs Information Centre India, a non-governmental organization (NGO). Alarmingly, the study found that the “average age of initiation” had dropped from 19 years to 13 years in the past two decades.
The centre points out that a “powerful international and domestic alcohol lobby” is purposely targeting young Indians. The local industry has introduced flavored alcohol drinks to attract previously non-drinking women and young men. Multinational companies have identified India with its vast unexploited markets as one of the worlds most sought after places for investment.
Many alcohol adverts now feature spirited groups of young people having a good time. Although alcohol advertising is banned in the electronic and print media, surrogate advertising is rife, “Drinking water and apple juice is packaged by alcohol companies. It's all about getting young people to start early and be life-long consumers. Bollywood films now glorify alcohol where the good guys drink.”
The shifting composition of Indian drinkers has seen a rise in the number of Indian women drinking regularly and heavily. One recent study in the southern state of Karnataka found young women consumed similar amounts of alcohol to young men on any typical drinking occasion.
What is of particular concern—and an important indicator of health risks—is that the signature pattern of alcohol consumption in India is frequent and heavy drinking. More than half of all drinkers fall into the criteria for hazardous drinking, which is characterized by bingeing and solitary consumption to the point of intoxication. Moreover, spirits account for 95% of the beverages drunk in India.
There is evidence even to suggest that the poor are beginning to drink more than they earn—a deadly spiral of alcohol and debt. Although the Indian constitution includes the prohibition of alcohol among its directive principles, alcohol policy is devolved to individual states—as is the levying of taxes on it. Since most states derive around a fifth of their revenue from alcohol taxation—the second largest source after sales tax—they are generally ambivalent towards stemming its flow. Moreover, there is a long history in India of a powerful alcohol lobby with industry figures influencing the political process, both in the form of party donations and as representatives. But experts argue that Indian society is losing considerably more than it gains.
According to a recent study by researchers from NIMHANS it is shocking to know that the direct and indirect costs attributable to alcohol addiction is more than triple the profits of alcohol taxation and several times more than the annual health budget of Karnataka. These included the tangible costs of health care, occupational, financial, social, and legal factors.
Indian Alcohol Policy Alliance, an NGO aiming to prevent alcohol-related harm through evidence-based policy intervention, says that the key is to break the stranglehold of state revenue departments who see increasing consumption of alcohol as a boon to treasury coffers.
In less than a week after more than 90 women, men, and children died in a calamitous fire at the AMRI hospital in Kolkata, illicit brew has claimed the lives of about 150 people, at Sangrampur in the South 24 Parganas district of West Bengal. The hooch was sold in sachets, priced between Rs.7 and Rs.20, virtually opposite a police post in the area. Starting with a couple of deaths early in the morning, the toll kept rising through the day and touched 80 by daybreak next day. Most of the victims complained of body pain, stomach cramps, vomiting, and a burning sensation. The recurrence of heart-rending tragedies caused by the killer brew only lends credence to the thinking among political parties and State governments that it might be better to introduce legal sale of licensed liquor than let addicts go for the illicit stuff. There is a demand from sections in government to suggest monopolizing sale of government controlled liquor as the Tamil Nadu Model .Of course the protagonist will feel that this step might be catastrophic. But the evidence from across India shows that prohibition just doesn't work; in fact, it brings on all sorts of ill effects, social as well as medical. Although States that still implement prohibition, full or partial, have set up separate wings in the police department to handle cases arising out of prohibition offences and illicit brewing, it is common knowledge that connivance between the brewers and sections of the police makes the hooch flow, particularly in festival season. Most, if not all, victims tend to be poor laborers, and the families end up paying a terrible price. Alcoholism is a social menace that needs to be tackled in a sensitive, intelligent, multi-pronged way. Driving it underground, to dangerous devices, is clearly not the way.


(Prof Gourishankar Patnaik is a senior Consultant in orthopedics based in Bhubaneswar. He can be contacted at drgsp66@yahoo.com)

Kikuchi's Disease though usually a relatively benign and self-limiting entity, if mistaken for other more serious conditions would result in many avoidable psychological, physical and financial strains for the patients and all others concerned with their care.
Kikuchi’s Disease or histiocytic necrotizing lymphadenitis, a self-limiting entity of varied manifestations including prolonged fever and cervical lymphadenitis at times poses diagnostic problems because of presently non-available specific laboratory tests for its definitive diagnosis. It should be considered in the differential diagnosis of un-explained fever with cervical lymphadenitis in young adults with varied sign and symptoms such as sore-throat, cough, rhinorrhea, chills, cephalgia and non-specific myalgias. Histopathological reports of fine needle aspiration or excision biopsy of accessible lymph node together with immune-histo-chemistry if available, is the means presently available for making a definitive diagnosis of Kikuchi’s disease. It usually runs a benign course, recurrences are very rare and over-all prognosis is generally favorable. Treatment is primarily symptomatic.

J Otolaryngol Head Neck Surg. 2011 Apr;40(2):131-6.

Audiometric profile in patients with chronic renal failure.
Pandey S, Gore G, Valame D, Mehta K.

Abstract

OBJECTIVES:

To determine the occurrence of hearing loss and to establish audiometric profiles and patterns of hearing impairment in patients with chronic renal failure (CRF).
METHODS:

A retrospective study examined the relationship between the different stages of CRF and corresponding audiologic findings in those patients. Twenty-three subjects (46 ears) in the age range of 25 to 60 years were included in the study. These subjects were arranged into groups ranging from the second to fifth stages of CRF. Audiologic assessment in each subject was performed using a battery of tests, which included pure-tone audiometry, transient otoacoustic emission (TOAE), distortion product otoacoustic emission, and brainstem evoked response audiometry (BERA).
RESULTS:

Significant differences in the degree of hearing loss were observed among patients with different stages of CRF. It was noted that almost all (95.65%) patients with CRF did not pass the TOAEs. It was important to notice that none of the patients with CRF showed findings on BERA that pointed to retrocochlear involvement. Thus, the present study found that most patients (65.21%) had a cochlear pathology.
CONCLUSIONS:

We observed that (a) there is a high incidence of hearing loss among patients with CRF; (b) the methods of treatment (hemodialysis and conservative treatment) may not influence the impact of the disease on hearing; (c) levels of serum electrolytes and biochemical constituents of blood do not seem to correctly reflect the audiologic status of a CRF patient; and (d) hearing loss in patients with CRF has a distinct audiologic pattern. Given that CRF involves hearing loss, routine audiologic assessment in patients with this condition is essential.

PMID:
21453648
[PubMed - indexed for MEDLINE]

Breast feeding has been the most natural response of a mother to satisfy the emotional and nutritional needs of her infant. That this can even serve as a natural barrier to infections and even save us money is perhaps not thought of. The effectiveness of the breast milk has long been established for reducing diarrhea, pneumonia, improved child nutrition and development along with its potential as Eco-friendly.
Breastfeeding benefits all sectors of society economically, ecologically and socially. However, over the last decades, women's self confidence in their capacity to nourish their infants has been undermined by many factors, including the power of the infant formula industry and a lack of social support. The major reasons for decline in breast feeding practices in India (50.9% by 3 months) are 1.rapid urbanization. 2. commercial pressure by marketing companies giving false messages. 3. lack of self confidence in mothers & dislike for breast feeding with the fair of loosing charm and beauty. 4. Practical problems of working mothers. 5.Most important improper technique and positioning while breast feeding leading to cracked nipples, engorgement of breasts and thus lactational failure a common problem faced by young mothers.
6. Delayed initiation of first feed leading to failure of lactation reflex.
7. Starting bottle or pacifiers along with breast feeding thus confusing the baby while sucking.
These and many other factors lead to failure to initiate breast feeding and an excuse for the mother to say I don’t have enough milk which is absolutely a myth because nature has been kind enough to provide milk to all the mammals to feed their young ones even to multiple ones at a time.
Benefits of breast feeding:-
There are many positive reasons for women to breastfeed their babies: breast milk is the best and most nutritious food, protecting them from illness and ensuring healthy physical and psychological development. For mothers, breastfeeding provides several health benefits such as reduction in the risk of breast and ovarian cancer, with the decrease in breastfeeding over the past several years one could daily hear the bad news of breast cancer in very young ladies attributed to hormonal imbalance led by stopping breast feeding their babies, a protective mechanism provided by nature. Breast feeding also helps in diminishing post-partum bleeding and iron deficiency anemia, and a natural means of spacing children by delaying ovulation. Breastfeeding also empowers women by increasing their self-confidence in their capacity to nourish and protect as well as nurture their babies and by decreasing their dependence on commercial products.
Millions of babies fall ill every year because they are not breastfed. The World Health Organization (WHO) estimates that more than 1.5 million infant deaths could be avoided every year if all babies were breastfed. It has been observed that infants under 2 months of age are nearly six times more likely to die if not breastfed.
A study from Ghana on 10947 breastfed babies concluded that we could save 22 %( 2.5 lakh) neonates from death if breastfeeding was initiated within one hour of birth.
In Botswana in 2005/06, infant formula feeding was given to all the babies with the aim to prevent transmission of HIV infection fro their mothers suffering from AIDS. This led to increase in diarrheal disease in these children with the increase in national under five mortality by 18%.also hospital admissions increased by 50%. Breast milk being free of contamination, adulteration and available at desired temperature has been proven best anti-infective. This property is being attributed to certain immunoglobins, compliments, macrophages, lysozymes present in breast milk particularly during first few days (colostrum).

Incidence of atherosclerosis and various related heart ailments are on lower side in people, those who are exclusively breast fed in childhood .breast fed babies have also proven highly intelligent than artificially fed babies .

Artificially fed babies have to bear extra financial burden for purchasing milk, bottle, fuel etc., which amounts to almost Rs 1500-2000/month, which is beyond the capacity of average middle class family, which compels them to over dilute the milk, thus leading to malnutrition. at the national level almost Rs 15000-20000 crores (estimated cost of marketed milk)can be saved by breast feeding approximately 22 million babies born per year.
Perhaps the least known of all the advantages of breastfeeding are the ecological benefits. Breast milk is a natural and renewable resource which is often overlooked. Breastfeeding protects the environment by reducing the demands made on it and eliminates sources of waste and pollution. Artificial baby milks and processed baby foods are non-renewable products which create ecological damage at every stage of their production, distribution and use.
Breastfeeding is unique - it causes no pollution and is the best example of how humanity can sustain itself through provision of the first and most complete food for human life. It is vital to increase our efforts to support, protect and promote breastfeeding. All sectors of society need to learn about the advantages of breastfeeding and how to support the natural rights of mothers to breastfeed and babies to be breastfed. All women should have access to information and support in order to be able to make truly informed choices about these natural rights.
The breastfeeding culture is culture of peace, balance and harmony. It involves trusteeship and global responsibility towards our young, and seeks accountability from governments and various spiritual traditions to support families in nurturing children. Almost all great world religions recognize breastfeeding as a essential nurturing the young and respect women's role in doing so.
Processing artificial baby milks wastes energy
Baby milk consists of a mixture of factory-processed substances which may be then added to cow's milk and converted into powder at high temperatures. This wastes a lot of electrical energy. This energy usually comes from hydro-electric or nuclear power plants that are expensive and cause a lot of damage to the environment. Breast milk is naturally produced. A mother's normal low-cost diet is transformed into a natural, invaluable and specialized food for her baby! This is the most energy efficient food production system ever known!
________________________________________
Breast milk needs no extra-packaging
The packaging of manufactured baby milk wastes tin plate, paper and plastic. Bottles, teats and other feeding equipment use plastic, rubber, silicon and glass. To bottle feed all US babies, the 550 million tins sold each year, stacked end to end would circle the earth one and a half times. In 1987, 4.5 million feeding bottles were sold in Pakistan alone. These feeding bottles stacked end to end would reach the top of Mount Everest.
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Disposal methods pollute air, land and groundwater
The packages used for baby foods, along with feeding bottles, teats and pacifiers, are commonly thrown away after use. Normally these are not biodegradable. Plastic feeding bottles, teats and pacifiers take 200 to 450 years to break down when disposed in landfills. Glass feeding bottles take an undetermined amount of time to break down. Landfill and incineration are the most common disposal methods. Landfill sites can pollute groundwater, and there is a shortage of suitable sites in some countries. Incineration releases pollutants into the air: if plastic bottles are burned, the fumes may contain dioxin and other toxic substances. The beauty of breast milk is that one need not worry about disposal and it is immediately available without any need for packaging and preparation. Breastfeeding is waste free.
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Transportation pollutes and wastes fuel
The fresh cows' milk, grains and additives used in making baby food travel long distances even before processing, and additional long distances on the way to central, then regional warehouses, and finally, retail outlets. Many countries import baby food and feeding bottles from the other side of the world. This means a great waste of fuel and contributes to air pollution everywhere. Breast milk does not have to be shipped around the world; every mother has a ready supply wherever she goes...
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Preparation - more waste
A 3 month old bottle-fed baby needs a liter of water per day to mix with the formula powder. Another two liters are needed to sterilize the bottles and teats. If the water is boiled over a wood fire, more than 73 kg of wood are needed to prepare a year's feeds. In many parts of the world, water and fuel are so scarce that few mothers have the luxury of keeping the bottles and teats clean and of using only boiled, cooled water to make up the feeds. Breast milk is ready to use at the right temperature, does not need to be sterilized and causes no pollution.
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Processed baby milks maybe contaminated
Baby milk is an industrially manufactured food which undergoes multiple processing, additions and alterations as it is converted from cows' milk plus additives to a can full of powder. No wonder that it has proved vulnerable from danger to contamination by harmful bacteria like E. Sakazakii and Salmonella, radio-activity, chemicals, foreign bodies and insect pests. Furthermore, the water mixed with the powder poses another danger of contamination, while problems have also arisen from teats breaking during use. Breast milk is a living substance. Each woman's milk is individually tailored for her own baby. What's more, her milk changes constantly - both during a feed and day by day - to meet her baby's evolving needs. When a mother is exposed to pathogens in the environment, she produces antibodies to combat them. The mother's antibodies are then passed on to her baby via her breast milk.
The dangers of Donations
Many violations of the code have been observed in emergencies with the donations of breast milk substitutes. During earthquake in Indonesia 2006, distribution of donated formula to children under 2 years led to increased prevalence of diarrheal disease to 25%, compared to 12% in breastfed babies.
Similarly in 2005 tsunami in Pondicherry, the occurrence of diarrhea was three times more among children who were fed with free breast milk substitutes than in those who were not fed with the same. These figures clearly show the misuse of these donations.

IMS Act and breast feeding:
To encourage and promote breast feeding various organizations like BPNI,IBFAN etc have been playing a commendable job by providing training people including health personnel ,highlighting benefits and objectives of breast feeding through printed and electronic media and interacting with various government officials for strict implementation of IMS (infant milk substitution act)1992 and amended in 2003 through the act of parliament and as per this act it is illegal:
1. To promote infant milk substitutes and feeding bottles intentionally /unintentionally on pretext of distribution of educational material
2. To make advertisement or exhibition of these products.
3. To sponsor any health official or related to child welfare to any tour, conferences etc.
4. To provide gifts or monitory benefit.
5. To distribute literature which directly or indirectly helps in promotion of their products and thus undermining breastfeeding?
DR.NIYAZ AHMAD BUCH
PROFESSOR (pediatrics).
SKIMS MEDICAL COLLEGE
SRINAGAR.
National trainer for infant and young child feeding
Niyaz_buch@yahoo.co.in