(a) (i) Enlist conditions having an increased risk of malignant disease in bone and cartilage. (ii) Briefly mention…

(a)(i) Conditions with an increased risk of malignancy in bone and cartilage

• Paget's disease of bone: secondary (Pagetic) osteosarcoma in about 1%, mainly in long-standing polyostotic disease.
• Multiple hereditary exostoses (EXT1/EXT2): chondrosarcoma in roughly 1–5%, compared with under 1% for a solitary osteochondroma.
• Enchondromatosis (Ollier disease; Maffucci syndrome with haemangiomas): a high lifetime risk of chondrosarcoma, commonly quoted at 25–50%.
• Hereditary cancer syndromes: hereditary retinoblastoma (germline RB1), Li–Fraumeni syndrome (TP53), and the Rothmund–Thomson, Werner and Bloom syndromes predispose to osteosarcoma.
• Prior irradiation of bone: radiation-induced sarcoma after a latency usually longer than 5–10 years.
• Fibrous dysplasia (including McCune–Albright syndrome): rare malignant change (under 1%) to osteosarcoma or fibrosarcoma, often after radiation.
• Bone infarcts and chronic osteomyelitis: undifferentiated pleomorphic sarcoma or fibrosarcoma in old infarcts; squamous cell carcinoma in long-standing draining sinus tracts (Marjolin ulcer).

The risk is higher with long-standing and multiple lesions. New pain, rapid growth or a cartilage cap over 2 cm in an adult osteochondroma should prompt evaluation for malignant change.

(a)(ii) Classification of bone tumours

The WHO Classification (5th edition, 2020) groups tumours by line of differentiation. Each group is subdivided into benign, intermediate (locally aggressive or rarely metastasising) and malignant.

• Chondrogenic: osteochondroma, enchondroma, chondroblastoma and chondromyxoid fibroma (benign); atypical cartilaginous tumour (intermediate); chondrosarcoma grades 1–3 and its dedifferentiated, mesenchymal and clear-cell forms (malignant).
• Osteogenic: osteoma and osteoid osteoma (benign); osteoblastoma (intermediate); osteosarcoma, including conventional, telangiectatic, small-cell, parosteal, periosteal, high-grade surface and secondary types (malignant).
• Fibrogenic: desmoplastic fibroma (intermediate); fibrosarcoma (malignant).
• Vascular: haemangioma (benign); epithelioid haemangioma (intermediate); epithelioid haemangioendothelioma and angiosarcoma (malignant).
• Osteoclastic giant cell-rich: aneurysmal bone cyst and non-ossifying fibroma (benign); giant cell tumour of bone (intermediate); malignant giant cell tumour.
• Notochordal: benign notochordal cell tumour; chordoma (malignant).
• Other mesenchymal tumours of bone: simple bone cyst, fibrous dysplasia, osteofibrous dysplasia and lipoma (benign); adamantinoma, leiomyosarcoma and undifferentiated pleomorphic sarcoma (malignant).
• Haematopoietic neoplasms of bone: plasmacytoma or multiple myeloma, primary lymphoma of bone and Langerhans cell histiocytosis.
• Undifferentiated small round cell sarcomas (a separate WHO chapter): Ewing sarcoma, and CIC- and BCOR-rearranged sarcomas.

Clinically, tumours are also divided into primary and secondary. Metastases (from breast, prostate, lung, kidney and thyroid) are the commonest malignant bone tumours in adults, and myeloma is the commonest primary malignancy of bone. The Enneking (MSTS) surgical staging guides resection margins. It stages benign lesions 1–3 (latent, active, aggressive) and malignant lesions IA–III by grade, compartment and metastasis.

(b) Complications of subtotal gastrectomy for carcinoma stomach

Early complications (within about 30 days)

• Haemorrhage: intraperitoneal bleeding (short gastric vessels, splenic injury) or intraluminal bleeding from the anastomosis.
• Anastomotic leak or duodenal stump blow-out (Billroth II or Roux-en-Y): usually on days 3–7, causing peritonitis, sepsis or a fistula.
• Complications of D2 lymphadenectomy: pancreatic fistula or pancreatitis, intra-abdominal abscess and chylous leak.
• Delayed gastric emptying (gastric atony).
• Acute afferent loop obstruction: a closed loop with pain and raised amylase that threatens stump blow-out; efferent loop obstruction causes vomiting of food.
• General complications: atelectasis and pneumonia, wound infection or dehiscence, DVT/PE and cardiac events.

Late complications (months to years)

• Postgastrectomy syndromes: early dumping (10–30 minutes after meals, hyperosmolar fluid shift with vasomotor and gut symptoms) and late dumping (1–3 hours, reactive hypoglycaemia); chronic afferent loop syndrome (postprandial pain relieved by bilious vomiting); bile (alkaline) reflux gastritis; Roux stasis syndrome; post-vagotomy diarrhoea.
• Marginal (stomal) ulcer and anastomotic stricture.
• Nutritional and metabolic effects: weight loss; iron-deficiency anaemia; vitamin B12 deficiency from loss of intrinsic factor; folate deficiency; fat malabsorption; osteoporosis or osteomalacia from impaired calcium and vitamin D absorption.
• Other effects: small-bowel bacterial overgrowth, and gallstones after vagal branch division.
• Oncological: locoregional or peritoneal recurrence, and gastric remnant (stump) carcinoma many years later.

(c)(i) Fibroid uterus in a 25-year-old infertile woman with menorrhagia

Evaluation

• History and examination: duration of infertility; menstrual blood loss (for example, a pictorial blood-loss chart); symptoms of anaemia or pressure; pallor and uterine size.
• Bleeding work-up: haemoglobin and ferritin, thyroid function, and a coagulation screen if indicated.
• Fibroid mapping by FIGO leiomyoma subtype (0–8): transvaginal USG, saline-infusion sonohysterography or 3D USG, and hysteroscopy to assess the cavity. MRI helps when fibroids are numerous or adenomyosis is suspected.
• Complete infertility work-up of the couple: ovulation; ovarian reserve (AMH, antral follicle count); tubal patency (HSG, or laparoscopy with chromopertubation, which also detects endometriosis); and the partner's semen analysis. This matters because the fibroids may not be the cause of infertility.
• Endometrial sampling: not routinely needed at 25 unless risk factors are present.

Management (fertility-preserving)

• Medical treatment: correct anaemia. Tranexamic acid or NSAIDs during menses reduce bleeding without affecting fertility. COCs, LNG-IUS and GnRH analogues or antagonists control bleeding but prevent conception, so they serve only as temporary bridges.
• Submucous fibroids (FIGO 0–2): hysteroscopic myomectomy treats the heavy bleeding and improves pregnancy rates.
• Intramural fibroids of about 3 cm that do not distort the cavity: surgery is generally not advised for infertility alone; fertility treatment proceeds instead. Myomectomy (laparoscopic or open) is considered for cavity-distorting or larger (over 4–5 cm) fibroids, or after repeated IVF failure. Subserosal fibroids do not impair fertility.
• Pre-operative GnRH agonist (about 3 months): used when needed to correct anaemia and shrink fibroids.
• Options to avoid: uterine artery embolisation and MR-guided focused ultrasound are not first choices when pregnancy is desired, because of adverse pregnancy outcomes; hysterectomy is contraindicated.
• After myomectomy: conception is advised after 3–6 months; caesarean delivery is advised if the cavity was breached; IUI or IVF is offered as the work-up indicates.

(c)(ii) Classification of Abnormal Uterine Bleeding (AUB) and endometrial patterns

FIGO AUB System 1 (2011, revised 2018) standardises terminology. It uses heavy menstrual bleeding (HMB) and intermenstrual bleeding in place of terms such as "menorrhagia" and "metrorrhagia".

FIGO AUB System 2, PALM-COEIN, classifies causes:

• PALM (structural): Polyp, Adenomyosis, Leiomyoma (with submucous/other subclassification, types 0–8), Malignancy and hyperplasia.
• COEIN (non-structural): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, and Not otherwise classified.

The 2018 revision moved anticoagulant-related bleeding into AUB-C. It also placed drugs that disturb ovulation under AUB-O.

Endometrial patterns in different types of AUB

• AUB-O (anovulatory): proliferative or disordered proliferative endometrium with stromal breakdown (oestrogen breakthrough or withdrawal bleeding). Prolonged unopposed oestrogen leads to hyperplasia without atypia.
• Ovulatory dysfunction with luteal defects: inadequate secretory change (irregular ripening), or irregular shedding from a persistent corpus luteum, seen as mixed proliferative and secretory endometrium beyond day 5 of menses.
• AUB-E (ovulatory HMB): a normal secretory endometrium with a primary disorder of local haemostasis (prostaglandin and fibrinolytic imbalance); chronic endometritis shows plasma cells.
• AUB-P: an endometrial polyp with thick-walled vessels and fibrous stroma.
• AUB-M: atypical hyperplasia (endometrial intraepithelial neoplasia) or endometrial carcinoma.
• AUB-I: a progestogen or COC effect, with decidualised stroma and inactive atrophic glands ("pill endometrium"); inflammatory change with an IUD.
• AUB-C and AUB-A: the endometrium is usually normal and cyclical.
• Atrophic endometrium: bleeding in hypo-oestrogenic or postmenopausal states.

(d)(i) Contraception for a young newly married couple

The aim is to delay the first pregnancy with a reversible method that allows a quick return of fertility. The couple is counselled on a "basket of choices" guided by the WHO Medical Eligibility Criteria (MEC) and the national family planning programme.

• Condoms (male "Nirodh"; female condom): hormone-free and the only method that protects against STI/HIV. Typical-use failure is about 13%, so dual protection with another method is advised.
• Combined oral contraceptives (for example, Mala-N): perfect-use failure is about 0.3% and typical-use failure about 7%. They regulate cycles and fertility returns immediately. MEC screening covers migraine with aura, hypertension, thrombophilia and heavy smoking.
• Centchroman (ormeloxifene, "Chhaya"): a non-steroidal pill taken twice weekly for 3 months and then weekly. It has few side effects, although some women have delayed periods, and fertility returns quickly.
• Progestogen-only pill: used when oestrogen is contraindicated, but requires strict timing.
• Copper IUD (Cu-T 380A, Cu 375) and LNG-IUS: long-acting reversible methods, usable in nulliparous women (WHO MEC category 2), with fertility returning promptly on removal.
• Injectable DMPA ("Antara", 150 mg every 3 months): highly effective, but return of fertility is delayed by about 7–10 months, so it suits the couple less if they want a child soon.
• Fertility-awareness methods (Standard Days Method with CycleBeads, symptothermal method): no side effects but a higher failure rate, and they need regular cycles.
• Emergency contraception: levonorgestrel 1.5 mg within 72 hours, or a copper IUD within 5 days, as a backup.

Permanent methods are not appropriate at this stage.

(d)(ii) Methods of female sterilisation and complications of tubectomy

Methods

• By timing: interval (6 weeks or more after delivery), postpartum (within 7 days), post-abortal, or at caesarean section.
• Minilaparotomy: suprapubic, or subumbilical when postpartum.
• Laparoscopic sterilisation: Falope (Yoon) ring, the method most used in Indian camps; Filshie or Hulka clips; bipolar electrocoagulation.
• Rarer routes: vaginal (colpotomy or culdoscopy), and hysteroscopic occlusion with Essure, which has now been withdrawn.
• Tubal occlusion techniques: Pomeroy and modified Pomeroy, Parkland, Irving, Uchida and fimbriectomy (Kroener). Bilateral salpingectomy is increasingly preferred because it also lowers the risk of ovarian cancer.

Complications of tubectomy

• Immediate: anaesthesia-related events (the leading cause of death); haemorrhage from the mesosalpinx; injury to bowel, bladder or major vessels; gas embolism or surgical emphysema at laparoscopy; conversion to laparotomy.
• Early post-operative: wound or pelvic infection and haematoma.
• Late: failure (about 0.5%, higher with clips and in young women), a high proportion of which are ectopic pregnancies; regret, especially in women under 30; menstrual disturbance or post-tubal ligation syndrome (contested); psychological sequelae. In India, the Family Planning Indemnity Scheme compensates for failure, complications and death.

(e)(i) The 'yellow' category of biomedical waste (BMW Management Rules, 2016, amended 2018 and 2019)

Types of waste

• Human anatomical waste: tissues, organs, body parts and placenta.
• Animal anatomical waste.
• Soiled waste: dressings, plaster casts, cotton swabs, and bags containing residual blood or body fluids.
• Expired or discarded medicines, including cytotoxic drugs and items contaminated with them.
• Chemical waste: chemicals used in the production of biologicals, and discarded disinfectants.
• Chemical liquid waste: laboratory reagents, used formalin and film developer.
• Discarded linen, mattresses and bedding contaminated with blood or body fluids.
• Microbiology, biotechnology and other clinical laboratory waste: cultures, stocks, specimens, and live or attenuated vaccines.

Bags and containers

• Solid waste: yellow, non-chlorinated plastic bags of at least 50 microns, labelled with the biohazard or cytotoxic symbol and bar-coded, and segregated at source.
• Chemical liquid waste: a separate collection system leading to an effluent treatment plant (ETP).
• Laboratory waste: pre-treated on site before it is bagged.

Treatment and disposal

• Human and animal anatomical waste and soiled waste: incineration, plasma pyrolysis or deep burial. Deep burial is allowed only in rural or remote areas without access to a common biomedical waste treatment facility (CBWTF), with SPCB approval. Where incineration or plasma pyrolysis is unavailable, soiled waste may be autoclaved, microwaved or hydroclaved and then shredded, with the treated residue sent for energy recovery.
• Expired and cytotoxic medicines: returned to the manufacturer or incinerated at over 1200 °C.
• Solid chemical waste: incineration, plasma pyrolysis or encapsulation at a hazardous-waste treatment, storage and disposal facility (TSDF).
• Liquid chemical waste: neutralisation and pre-treatment in the ETP before discharge.
• Contaminated linen and mattresses: non-chlorinated chemical disinfection, then incineration or plasma pyrolysis.
• Laboratory waste: on-site sterilisation (autoclave) or disinfection as per WHO/NACO guidelines, then incineration.

(e)(ii) Incineration as a method of biomedical waste management

Incineration is controlled high-temperature oxidation that converts organic waste into ash and flue gases.

Standards (BMW Management Rules, 2016, Schedule II)

• Design: a double-chamber incinerator, with the primary chamber at 800 ± 50 °C and the secondary chamber at 1050 ± 50 °C with a gas residence time of at least 2 seconds; combustion efficiency of at least 99%; a stack at least 30 m above ground.
• Emission limits: particulate matter 50 mg/Nm³, HCl 50 mg/Nm³, NOx 400 mg/Nm³, mercury 0.05 mg/Nm³, and dioxins and furans 0.1 ng TEQ/Nm³.
• Ash: disposed of in a secure landfill (TSDF).
• Siting: no new on-site facility may be set up where a CBWTF is available within 75 km.

Advantages

• Complete destruction of pathogens.
• Anatomical waste is rendered unrecognisable.
• Volume is reduced by about 90%.
• The only practical route for anatomical, cytotoxic and pharmaceutical waste.
• Energy can be recovered.

Limitations

• Toxic emissions: dioxins and furans form from chlorinated plastics such as PVC (hence the ban on chlorinated bags), and heavy metals such as mercury from broken thermometers are released.
• Unsuitable waste: pressurised containers, radioactive waste, halogenated plastics and heavy metals should not be incinerated.
• Cost and operation: high capital and running costs; toxic ash; small, poorly run hospital incinerators; public opposition.
• International commitment: India's obligations under the Stockholm Convention on persistent organic pollutants.

Judgement. Incineration remains necessary for anatomical and cytotoxic yellow-category waste. It should be centralised at CBWTFs with online emission monitoring by CPCB and SPCBs, while non-burn technologies (autoclaving, microwaving, hydroclaving, plasma pyrolysis) handle the bulk of infectious plastic (red-category) waste.