Letters to the Editor Gastric Stromal Tumour presenting as Upper Gastrointestinal Bleed Dear Editor,

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e read with interest, the case report titled "Gastric Stromal Tumour presenting as Upper Gastrointestinal Bleed" published in April 2008 issue of MJAFI. Gastro-intestinal stromal tumours (GIST), till 1998, consisted of a heterogeneous group of mesenchymal tumours primarily involving the wall of the bowel. Subsequent to the seminal work of Hirota et al [1], the term GIST seized to be an all encompassing non-committal term and the diagnosis of a GIST now mandates the demonstration of the KIT gene or its expression as CD117 (c-kit) for which 95% of GISTs are positive. Subsequently two large studies, one addressing all GISTs [2] and another, only gastric GISTs [3] have clearly stated that all GISTs harbour an uncertain biological behaviour and should be stratified as very low risk, low risk, intermediate risk and high risk on the basis of tumour size and mitotic index per 50 high power fields. Implicit in this classification is that rarely a very low risk GIST may demonstrate aggressive behaviour. GISTs are no longer classified as benign or malignant. The case report has omitted essential information such as tumour mitotic count, tumour size at histopathology (this is always more accurate then the estimation prior to resection) and presence of

necrosis, if any. Expression of KIT has not been mentioned. Consequently the case report has not fulfilled current criteria for the diagnosis and risk stratification of gastrointestinal stromal tumours. References 1. Hirota S, Isozaki K, Moriyama Y, et al. Gain-of-function mutations of c-kit in human gastrointestinal stromal tumours. Science 1998; 279: 577-80. 2. Fletcher CD, Berman JJ, Corless C, et al. Diagnosis of gastrointestinal stromal tumours: a consensus approach. Hum Pathol 2002; 33:459-65. 3. Miettinen M, Sobin LH, Lasota J. Gastrointestinal stromal tumours of the stomach : a clinicopathologic, immunohistochemical and molecular genetic study of 1765 cases with long term follow up. Am J Surg Pathol 2005;29: 52-68. Contributed by Col SS Gill Associate Professor (Department of Pathology), AFMC, Pune.

Reply Dear Editor At the outset the authors wish to thank the reader for the keen interest shown in the article. I fully agree with the author that the diagnosis of a GIST now mandates the demonstration of the KIT gene or its expression as CD 117 (c-kit) for which 95% of GISTs are positive. CD 117 (c-kit) was done by IFC method at AFMC Pune in our patient and was found positive fulfilling the criteria for diagnosis. At histopathology the specimen measured 4.5 x 3.5 x 3 cm and had mucosa on one aspect. As the size was already mentioned

in preoperative finding and legend of Figure 1, it was omitted in text to avoid duplication. Cut surface showed areas of cystic degeneration and hemorrhages as shown in Figure 1. No necrosis was noted. Contributed by Col SP Rai Senior Advisor (Medicine & Respiratory Medicine), MH (CTC) Pune-40.

Pediatric Nephrology Experience in Afghanistan Dear Sir,

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fghanistan is a war torn country with third highest under five mortality rate in the world [1], due to political unrest and lack of primary health facilities. India is supporting Afghanistan in various ways one of which is by establishing Indian Medical Mission since 2001. Currently there are five teams working at five different parts of Afghanistan. One of the most frustrating part of working here is losing a child for want of basic modalities of treatment which we tend to take for granted in India. One such example of managing a child with acute renal failure due to a reversible cause is presented. A child was brought to Indira Gandhi Institute of Child Health, Kabul with complaint of anuria for four days and coma of one day duration. Clinically the child was having acidotic breathing and was not dehydrated. Investigations revealed high blood urea (197mg/ dl)and creatinine(9.7mg/dl), Hb (11gm%), total leukocyte count (9000/mm3). Ultra sonography showed bilateral hydronephrosis and hydroureter with multiple calculi and complete obstruction. ECG showed tall T waves. No other investigation was available.

Initially empiric treatment to reduce hyperkalaemia in the form of salbutamol inhalation, glucose insulin infusion and sodium bicarbonate infusion was initiated. The only way to stabilize the child prior to surgery was to perform peritoneal dialysis (PD). So far peritoneal dialysis was not performed in this place and dialysis fluid is not available anywhere in the country. We had one PD catheter brought by author during one of the trips to India. As we were sure baby would not survive if no action was taken, we decided to make dialysis fluid by mixing 2 parts of normal saline with 1 part of a mixture made of 5% dextrose and sodium bicarbonate in ratio of 22:3 [2]. In place of normal ‘Y’ tubing, two three ways with three intravenous (IV) sets were used to make in and out channels. After taking informed consent from parents, the first ever PD of this hospital was started. The procedure was successful and by 7th cycle, child’s breathing had become normal and ECG had reverted back to normal. Child regained consciousness after short while and after 20 cycles, PD was stopped and child transferred to another hospital for surgery. The child is presently doing well. This case highlights the fact that all physicians practicing in field conditions should be conversant with peritoneal dialysis since

198 this procedure can salvage many patients of renal failure before definitive therapy can be offered. References 1. UNICEF. The State of the World Children 2008:Child Survival. New York:UNICEF;2008. Available at http://www.unicef.org/ swoc2008.Accessed Aug 07,2008.

Letters to the Editor 2. Srivastava RN, Bagga Arvind. Renal replacement therapy. In: Srivastava RN, Bagga Arvind ,editors. Pediatric Nephrology. 3rd ed. New Delhi: Jaypee Brothers 2001; 256. Contributed by Lt Col AK Simalti Graded Specialist (Paediatrics), 155 BH, C/o 99 APO.

Iatrogenic Amputation of the Great Toe Dear Sir,

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pre-term, second-born triplet female baby weighing 1.4 kilograms was delivered in a private hospital at a metro city. The baby developed features of hyaline membrane disease. She was on ventilator and intensive monitoring at neonatal intensive care unit (NICU) just after birth. The pulse oximeter probe was wrapped around the great toe of the left foot and for three days, the position of the probe was not changed (This was as told by mother, not confirmed by personal communication or verification). Meanwhile, parents could not afford the cost of treatment at the private hospital, hence baby was transferred to a government hospital for further management. Baby was shifted in a transport incubator with oxygen and ventilatory support. On arrival at the government hospital, the pulse oximeter probe was removed. The great toe that was completely hidden under the broad strap of pulse-oximeter probe had totally become gangrenous! The probe was very tight at base of the toe as evidenced by a constriction ring and clear demarcation between viable and non-viable zone. Over the next few days, the gangrenous toe shrank and fell off on its own. (Fig. 1). The baby made uneventful recovery is presently 20 month old and thriving well. This case highlights the need for careful monitoring for complications related to devices used in medical care. Our heart sank for a while when the mother said “ Sir, God was kind to us, it was not thumb, it was only a toe which does not matter much”. Every parent may not be as forgiving as this in the present era of consumer protection act !

Fig. 1 : Picture showing amputated great toe of the left foot due to a constricting pulse oxymetry monitoring probe. Contributed by Surg Cdr KM Adhikari*, Wg Cdr V Venkateshwar+, Gp Capt D Singh# * Classified Specialist (Pediatrics), INHS, Asvini, Colaba, Mumbai. ,+ Reader (Dept of Pediatrics) AFMC, Pune, # Senior Advisor (Pediatrics & Neonatology), Command Hospital (AF), Bangalore

Mid- Clavicular Fractures- A Change in Treatment Strategies? Dear Editor,

infraclavicular structures [2].

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The author has used reconstruction plates for fixation when they do not offer adequate biomechanical stability and strength. Contoured LC-DCPs would offer a biomechanically better implant choice [3]. The use of postoperative drains is also extremely controversial. It has been proven beyond doubt that use of postoperative drain increases the risk of infection. There is no firm basis for the use of drain available in literature [4].

he author of the original article “Primary Plating of Displaced Mid-shaft Clavicular Fractures” published in July 2008, must be congratulated and commended for drawing the attention of the Armed Forces medical community to the rapid changes occurring in the well established traditional treatment of one of the commonest fractures of upper limb. However, I have my concerns about the author’s technique of superior placement of plates in clavicle fractures. The main blood supply of middle third of clavicle is periosteal which is predominantly from superior and anterior borders [1]. Superior plating is likely to disturb this already tenuous blood supply increasing risk of non-union. In addition, the serving soldiers have to wear shoulder straps and the prominent hardware irritates the overlying skin and soft tissues leading to frequent requirement of another surgery for implant removal. Antero-inferior placement of the plate will offer an alternative in form of stable bony fixation, relatively much lower incidence of implant prominence problems and sharp instrumentation directed away from potentially risky

I do not agree with the author’s contention that the literature relating to pin fixation of clavicle fractures is rare. There is enough emerging literature that supports intra-medullary fixation as an alternative to plate or screw fixation or nonsurgical treatment, as it produces excellent cosmetic and functional results regardless whether patients suffered from isolated clavicular fractures or polytrauma [5 - 7]. It may be noted that these studies have much larger patient groups and longer follow-ups. I would not be in a hurry to reach a conclusion based on this study in view of the small study group i.e. only 20 patients. The MJAFI, Vol. 65, No. 2, 2009