Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524162EnglishN-0001November30General SciencesSTUDIES ON MICROBIOLOGICAL QUALITY OF IDLI FORTIFICATION WITH WHEY PROTEIN CONCENTRATES
English0105Alka YadavEnglish Ranu PrasadEnglishThe present study was undertaken with the objectives to determine the shelf life of the prepared product and to estimate the cost of the production. Four different ratio of WPC @ 5%, 10%, 15%, 20% and different holding times 10, 15, 20, 25 minutes for fermentation of batter were used in the present study. Product was tested for yeast and mould count, standard plate count, coliform count and cost of the product was also worked out for different treatment combinations. The data obtained during investigation were statistically analysed by using two way classification and Critical Difference (CD) technique between treatments. The highest average yeast and mould count/gm of idli samples 37.83 was recorded on day fifteen. The highest average SPC/103gm of idli samples 52.61 was recorded on day fifteen. The coliform count is negative which means that strict hygienic practice was observed during preparation of idli. The highest cost of the idli sample T4H3 is Rs. 26.70 as compared to the other treatments. Result revealed that the microbial analysis of the prepared product is equally good, free from yeast and mould, standard plate count and coliform and is safe for consumption.
Englishbatter, fermentation, Whey Protein Concentrate, fortification, idliINTRODUCTION
Idli a fermented, steam cooked breakfast food is popular all over India. Extremely scrumptious, light, fluffy and nutritious and it is an ideal breakfast dish. Made of rice and urad daal, making idli is not difficult at all, though its preparation takes a little time as the batter for idli requires fermentation. As it is a steamed food with minimum oil and no spices, it is very healthy food for all age group peoples (Blandino et al., 2003). Idli is also known as “Rice cake” is a traditional food of India. Rava idli or rave idli is a variation of idli, made with Rava / sooji instead of the usual rice and urad daal. The fermentation process breaks down the starches so that they are more readily metabolized by the body. The term semolina is derived from the Italian word “Semola” which is derived from the ancient Latin Simila, meaning “Flour”. Semolina is made from hard durum wheat. It is the starchy endosperm part only which is separated from the bran and the wheat germ and then milled into flour. In south India, semolina is used to make savory foods like rava dosa, upma and puddings like “Kesari” or “Sheera”. In North India it is used for sweets such as “Suji halwa”. Whey Protein Concentrate (WPC) is a co- product of the cheese making process and it is pure, all natural, high quality product that contains little to no fat, lactose or cholesterol. Whey protein concentrate (WPC) is a white to light cream coloured product with a blend, clean flavour and it is as a source of amino acids and its effect on reducing the risks of diseases such as heart disease, cancer and diabetes (Krissansen, 2007). Whey protein concentrate (WPC) is an abundant source of branched chain amino acids (BCAAs), which are used to fuel working muscles and stimulate protein synthesis. It contains more leucine then milk protein, egg protein and soy protein and it stabilize blood glucose levels by slowing the absorption of glucose into the bloodstream (Patel, 2003).
MATERIALS AND METHODS
Preparation of idli Whey protein concentrate (WPC) was purchased from Mahan Protein Limited in New Delhi for each replications. Other ingredients such as Semolina, Eno powder and salt were collected from local market of Allahabad. Four different ratios of whey protein concentrate (5%,10%,15%,20%) were used for making idli and four different holding times (10,15,20,25 minutes) were used in the present experimental work. Idli prepared from different treatment combinations were compared with each other.
Microbial analysis Yeast and mould count
It was determined as per the procedure laid down in IS: 1479, Part- III (1962) of Manual in Dairy Bacteriology, ICAR publication
Standard plate count (SPC)
It was determined as per the procedure laid down in IS: 1479, Part- III (1962) of Manual in Dairy Bacteriology, ICAR publication.
Coliform count
It was determined as per the procedure laid down in IS: 1479, Part- III (1962) of Manual in Dairy Bacteriology, ICAR publication.
Determination of cost of the product
The cost of the prepared product was calculated at the prevailing prices of raw materials purchased from the local market of Allahabad
Statistical analysis
The data obtained for various parameters were analyzed statistically by using two way classification and Critical Difference (CD) technique (Imran and Coover, 1983).
RESULTS AND DISCUSSION
Yeast and mould count Therefore, it is concluded that the highest average yeast and mould count/gm of idli samples 37.83 was recorded on day fifteen followed by day twelve (25.58), day nine (16.49) and day six (8.22). The lowest average yeast and mould count/gm of idli samples 2.83 was recorded on day third. This result indicates that the yeast and mould count/gm of idli samples was obtained less than the range indicated 100 cfu/gm (B.I. Standards) till day fifteen, so prepared idli could be stored for fifteen days under refrigerator temperature. As the time period in number of days increases the yeast and mould count also increases.
Standard plate count (SPC)
Therefore, it is concluded that the highest average SPC/103 gm of idli samples 52.61 was recorded on day fifteen followed by day twelve (36.59), day nine (25.02) and day six (14.8). The lowest average count for SPC/103 gm of idli samples 7.06 was recorded on day third. This result indicates that the standard plate count/gm of idli samples was obtained less than the range indicated 30 × 103 cfu/gm (B.I. Standards) till day nine, so from this point of view prepared idli could be stored for nine days under refrigerator temperature. As the time period in number of days increases the standard plate count also increases.
Coliform count
Table–3 shows that the coliform negative which means that strict hygienic practice was observed during preparation of idli fortification with whey protein concentrate.
Cost of the product
Figure – 1 shows that the highest total cost of idli sample in Rs. 26.70 was obtained in T4H2 sample and the lowest cost of idli sample in Rs.16.69 was recorded for T0H0 sample. The cost of the ingredient is very important factor besides other factors in determining the cost of the production. It is considered as a basis for price fixation and determining the profit. The price of a product is dependent on the cost of production.
CONCLUSION
From the findings of this study, can be concluded that the microbial analysis of the prepared product is equally good, free from yeast and mould, standard plate count and coliform and is safe for consumption. The highest cost of the idli sample T4H3 is Rs. 26.70 as compared to the other treatments combinations. Its cost is low and the lower cost of the product will be more affordable by a larger segment of the population. Storage of idli at refrigerator temperature will increase its shelf life.
Englishhttp://ijcrr.com/abstract.php?article_id=964http://ijcrr.com/article_html.php?did=964REFERENCES
1. Blandino, A.; Al – Aseeri, M.E.; Pandiella, S.S.; Cantero, D. and Webb, C. (2003). Cereal based fermented foods and beverages. International J. of Food Research, 36: 527 – 543.
2. Krissansen, G.W. (2007). Emerging health properties of whey proteins and their clinical implications. J. Am Coll Nutr., 26 (6): 713 – 723.
3. Imran, R.L. and Coover, W.B. (1983). A modern approach to statistics. New York: John willy and sons inc, 497.
4. Indian Standards Specification: 4883, (1968). Bureau of Indian Standards for dairy products. Indian Standards Institution, Manak Bhavan, New Delhi.
5. Indian Standards: (Part 3). (1947). Manual in dairy bacteriology. ICAR publication 1972.
6. Patel, G.R. (2003). Research and product development needs of dairy sector. 55 (3): 56 – 62.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524162EnglishN-0001November30HealthcarePRAGMATIC APPROACH TOWARDS THE ROLE OF HIJAMAT IN IRQUNNASA (SCIATICA) - A REVIEW
English0612Mohammed SheerazEnglish Zaheer AhmedEnglish Mirza Ghufran BaigEnglish Mohd Aleemuddin QuamariEnglishUnani scholars managed certain ailments since antiquity by regulating the metabolic process through various modes of treatment. Ibnesina (Avicenna) has advocated certain principles of treatment. Regimenal therapy is one such core method of treatment through which the morbid matter is eliminated, its excessive production is checked or its spread is arrested and resolved by certain special techniques and there by restoring humoral equilibrium. One such procedure is Hijamat (Cupping).Hijamat is an Arabic word derived from the term ?Hajm‘ which stands for volume, but technically used for sucking. It also means ?to minimize?, ?to restore to basic size? or ?to diminish the volume?.Neuralgic pains of lower limbs are one of the commonest manifestations of Irqunnasa (Sciatica). The overall incidence of this condition is projected to be between 13% and 40% with the malady has the potential to become chronic and obstinate with large socioeconomic ramifications. Irqunnasa is mostly managed by the mainstream therapists either by medication or surgical intervention or sometimes both. The consequence of evidence based medicine in terms of high cost, disease centric management and its associated side effects warrantsaviable alternative.A meticulous attempt has been made to explore the utility of this age old regimen in the management of Irqunnasa (sciatica).
EnglishHijamat, Cupping, Irqunnasa, Sciatica, Unani medicineINTRODUCTION
Unani system of medicine has grown out of fusion and thoughts of diverse knowledge and experiences. Its origin can be traced back to the fourth and fifth century B.C when it was first propounded by Bukhrat (Hippocrates) in Greece. According to its principles and philosophy, maintenance of health, disease and its manifestations are innate process, hence proper and normal functioning of the bodily process must be ensured to maintain health. Any disturbance in the normal humoral balance whether it is excess, diminution or blockage leads to disease. Unani scholars managed certain ailments since antiquity by regulating the metabolic process through various modes of treatment. According to Ibne sina1 (Avicenna) the principles of treatment are: 1. Ilaj bit tadbeerwaTaghzia (Regimenal and Dieto therapy) 2. Ilaj bid dawa (Drug therapy) 3. Ilajbilyad (Surgery) Regimenal therapy is one such core method of treatment through which the morbid matter is eliminated, its excessive production is checked or its spread is arrested and resolved by certain special techniques and there by restoring humoral equilibrium. One such procedure is AlHijamah
Al Hijamah
Hijamah is an Arabic word derived from the term ?Hajm‘ which stands for volume, but technically used for sucking. It also means?to minimize?, ?to restore to basic size? or ?to diminish the volume?. Hij?mat is an ancient method which was particularly used among the Chinese, Babylonians, Egyptians and Greeks etc. The pottery cups, hollowed out animal horns and bamboo cups were used commonly for the purpose.2, 3.The importance of this regimen can be gauged from the noble saying of blessed messenger of Islam Hazrat Mohammed ?Indeed the best of remedies you have is Hijama.?4 Basically Hijamat is of two types, but procedurally it is of three types: 5, 6 1. HijamatBilShart (Wet Cupping / Cupping with scarification) 2. HijamatBilaShart (Dry Cupping / Cupping without scarification) 3. Hijamat Bin Nar (Fire Cupping)
Hijamat Bil Shart (Wet Cupping / Cupping with
scarification) It is truly a regimen for Tadbeer Istefragh (bloodletting technique) where Damavi Madda (Sanguinous matter) is involved as a cause of the disease and needs elimination. Accordingly several places in human body are specified for application of Hijamah.
Hijamat Bila Shart
(Dry Cupping) It is a technique through which vacuum is created by applying cups / horn / clay pot etc. by placing over muscular surface of the human body. This procedure can be carried out by two methods: 1. Hijamat Bila Naar (Cupping without fire) 2.Hijamat Bin Naar / Mehjama Nariya (Fire Cupping)
Hijamat Bila Naar (Cupping without fire)
This procedure can be performed by several methods: 1. By placing horn and sucking orally 2. By placing cups and suctioned manually 3. By placing cups and sucked through suction machine 5, 6
Hijamat Bin Naar / Mehjama Nariya (Fire
Cupping) This procedure also can be done by different techniques. 1. Flamed alcohol soaked cotton at the base of brass / steel / ceramic / clay material 2. Flamed paper / cotton / cloth / wooden piece poured into the glass and applying 3. Flamed camphor / spirit soaked cotton kept over coin and placing glass / cups / clay material etc.5, 6, 7
General Principles of Hijamat
Ibne Sina has discussed about Hij?mat b eside its description in detail and has pointed out certain important principles which are as follows: 1. It should be carried out in the mid of lunar month because the humours are fully agitated at this time. 2. It should be done in after noon because this is the most moderate time of the day. 3. It should be done preferably in summer season because the consistency of the humours remains thin so it easily enters the microvasculature and can easily be eliminated through Hijamat. 4. It should be performed in those whose blood is less viscous. 5. The person should be given stomachic tonic and divergent beverages prior to Hij?mat. 6. It should be avoided in obese persons for the fear of Kasrat-e-Tahallul (excessive resolution). 7. It should be avoided below two years and above sixty years of the age since the humours are viscid in these age groups. 8. It should be avoided immediate after bath because the skin becomes thicker so it needs deeper incision to take out the blood, which causes severe pain and leads to weakness and the persons having viscid blood should be exempted as they need a deep incision. 9. It should be avoided after coitus. 10.It should be avoided after vigorous exercises for fear of dehydration and general weakness with the exception of thick blood (increased haematocrit).1,2
METHOD / PROCEDURE
The patient is made comfortable as indicated position for Hij?mat (sitting or lying position) and the required area to be cupped are exposed. If the area is hairy then shaving is required in order to fix the cups firmly on the body. Otherwise their adhesion with the skin will not be complete and air can infiltrate into the cups and adhesive force of cup fails. Thereafter, the area is sponged with warm water to increase the blood circulation towards it. Then the piece of paper which is made in the form of cone is burned with the help of candle or lamp. After wards the burning paper is inserted into the cup and opening of the cup is placed on the skin of the particular area. In turn, the burning paper will burn a big quantity of air inside the cup, as a negative pressure inside the cup will be created making firm adhesion of the cup over the area. Ultimately there will be increased circulation locally making the area highly congested. The pulling effect over the skin and the increased temperature inside the cup is responsible for superficial vaso dilatation which in turn further increases the vascular circulation. Due to this plethora of blood cups tend to pull the skin for a while and prevents the assembled blood from mixing with the circulation to a certain degree. After fifteen to twenty minutes cup is removed from the body. The cup is removed by holding its belly between the thumb and forefinger of one hand and simultaneously depressing the skin of adjacent area by the other hand. This is the method of Hij?mat-e-NariyaBilaShart, when its purpose is to increase the blood flow or to divert the humours towards the site of Hij?mat. In case of Hij?mat-e-Nariya bil- Shartafter the above procedures, the area is disinfected with medical antiseptics. Thereafter few nicks are given on the congested area of the skin by the edge of a sharp sterile blade and the cup is again fixed on the site quickly which starts sucking the blood. Cups remain fixed until the process of sucking gets completed then the cup filled with blood is removed as mentioned above and area is properly cleaned with anti-septic and sterile dressing is done finally. Hij?mat-e-Ghair-Nariyais also done in the same manner but the method of fixing and removing the cups is different. With the advent of new techniques and tools, cups have become highly modified and sophisticated. Such modified cups are provided with a valve at the top and a hand operated pump. To fix the cup on an area its edges are kept over the skin and the air inside the cup is sucked out with the help of suction pump so as to create the vacuum. Similarly when the cup is needed to be removed the valve is simply pulled up with the help of thumb and fore finger. This pulling of valve will permit the air in the cup and it will be detached by itself.8,9
Essential Tools/Kit
G lass cups, Vacuum pump, Medical antiseptics, Lamp or Candle, Small paper, Sterilized gloves, Sterilized medical scalpel,Cotton roll, Sterilized gauze, Micro pore tape, Razor to remove the hair of the site if needed.8,9
I Indications
? To prevent the passing of food from stomach before digestion as in the case of Zalaq -ulAm’?, Hijamat is applied on epigastrium to aid the digestion. ? To divert the material from one place to another, as in case of menorrhagia where cups are applied below the bust line. ? When the abscess is deep and contains excessive pus and difficult to drain completely, cup is placed on the opening of the abscess to suck out the pus completely. ? When the swelling is in any important viscera thencups are applied ona relatively less important organ to divert the morbid material from the visceral organ.
? When there is any indication to warm up any particular organ, which has become cold, in Mehjama -Nariya is preferable. ? When the air accumulates in any part of the body the application of Hij?mat on the same part is beneficial, in particular, Hij?mat-eNariya is more effective in intestinal colic due to flatulence. ? Hij?mat is also done to relieve severe pain in any part of the body. This purpose is achieved either due to the diversion of materials away from the site of pain or removal of trapped air.Therefore Hij?matis indicated in sciatica on medial and dorsal aspect of thigh. ? Hij?mat is supportive in restoring the normal size of an atrophied organ ? Hij?mat is also helpful in restoring the normal size of hyper trophied organ. The purpose is achieved by applying the cups in the surrounding area which diverts the material to the site of the Hij?mat and leads to reduction in size of organ.1, 2, 8
Utility of Hij?mat in the Treatment of Irqunnasa R?zi stated in his book, Al-H?wi, under the treatment of Irqunnasa (Sciatica), and Waja-ul Mafasil(Arthritis) ?In case of Irqunnasa‘ enema is more useful than purgation, but if thick humors are collected in hip joint then Hij?mat becomes mandatory and has a big advantage over other methods?. In case of Irqunnasa’R?zi further states, ?Hijamat-bil-Shart and Hij?mat-Bila-Shart will be done over hip when disease starts from the site of pain.? He further states, ?If the humors become thick in the affected joint due to improper treatment Hij?mat (cupping) becomes very useful for this condition.10? In Kaamil-us-Sana‘a, pertaining to the treatment of Irqunnasa it is written, ?When the disease becomes chronic and there is no relief in using the drug treatment, then it is essential to use Hij?mat
e-Nariya as it sucks the material from the joints towards the skin?.11 Ibne Sina writes under the treatment of Irqunnasa that if the drug treatment is unable to treat the problem then Hij?mat (cupping) with and without scarification over the hip will be helpful.1 ? Ismail Jurjani has elaborated Hij?mat under the treatment of Waja-ul- Warik and Waja-ul-Aqab. He states it is preferable to keep the patient on fast and advise him exercise after the general evacuation, if his lifestyle is sedentary. If these Tadabeer (measures) are unable to relieve the disease then only morbid humors are to be taken out towards the surface of affected area. This purpose is attained by Hijamat-e- Nariya (cupping with fire). Repeated attempts of Hij?mat by sucking of liberal amount of blood generally relieve the condition by eliminating morbid materials from the joints.12 In the management of Irqunnasa, Azamkhan quotes, ?Lastly those Tad?beer(measures) should be carried out which have Muhallil (Antiinflammatory) and Mulattif (Demulcent) effects and take out the deep seated materials to the body surface. Hijamat (Cupping), Muhammir (rubifacient) paste and the Tila of garlic, onion, Nargis, Baladur and Fig are included in these Tad?beer, but along with these, some laxative drugs should also be added otherwise there may be dryness inthe joints.?13 This reveals that Hijamah not only induce evacuation and diversion but it has antiinflammatory and demulcent effect as well. According to Kabeeruddin ?The treatment of Irqunnasa’ is similar to that of Waja-ul-Mafasil and Waja-ul-Warik in few aspects, thus the Hij?mat and T?leeq can also be regarded useful in the treatment of Waja-ul-Mafasil.? The above quotation reveals that Hij?mat is useful in the treatment of Irqunnasa, Waja-ul-Mafasil as well as Waja-ul-Warik.14
DISCUSSION
Though Hijamah has been in practice since centuries to treat various types of pain in Unani medicine, this review paper is a concerted attempt to bring it to medical domain for the larger benefit. In our study which has been carried out in the National Institute of Unani medicine, India as part of M.D(Unani) thesis, scientific validation of the regimen ? Mehjama Nariya and Hijamat Bila Shart was undertaken in cases of Irqunnasa. The study has revealed that both the regimen are equally effective in alleviating the symptoms of Irqunnasa with statistical significance (p>0.001)8 . Various theories are put forth as to the benefits of the Hijamat Bila Shart; one theory suggests that with the increase in circulation over the area of procedure, the morbid matter is eliminated from the desired area. Another theory which is proposed is the Unani concept of Imaale mawaad (diversion of matter) from one place to other. Placebo effect of cupping is also proposed by some physicists. From a biophysical point, the negative pressure created by physical stimulation in the cup triggers local metabolism, promotes phagocytosis resulting in pain alleviation. The site of cupping not only improves circulation but also provide nutrition.5, 6, 15 Cupping without bloodletting works on the principal of Imaale-mawaad.i.e. diversion of morbid humours from one site to another. In case of Mehjama Nariya, due to combustion of air inside the cups, the air becomes warm, and helps in retracting the muscular surface, causing pulling of the area beneath the cups immediately after its application resulting in relief of pain.16 Blood cupping has a neuro modulating input into central nervous system activating CNS multiple analgesia systems and stimulating pain modulation system to release neuro transmitters such as endogenous opioids.17 These substances including β-endorphin pain signals in the spinal cord and emotional aspect pain by acting on the limbic system.18 Another possible mechanism that may explain the analgesic effect of cupping therapy is that vigorous sensory stimulation can produce a sharp decrease in pain for varying periods of time due to blocking of messages from sensory nerves carrying pain impulses by faster moving impulses, this mechanisms is called ?gate control theory.19 Bloodletting cupping might exert effects on inflammation in that injury to the skin leads to release of β-endorphin and adreno cortical hormone into circulation. Both are helpful in blocking the inflammation in arthritis.20 The physiological mechanism through which wet cupping might function remains unknown. It has been suggested that the effects of wet-cupping can be divided into several components, including neural, hematological, immune and psychological effects. In particular, the ??pain suppression‘‘ mechanism of wet-cupping might be through influence on three neurological systems: (a) the ??analgesia‘‘ system in the brain and spinal cord (including the periaqueductal gray and periventricular areas, the Raphamagmus nucleus, the Nucleus reticularis and Paragigantocellularis); (b) the brain‘s opiate system (endorphins and enkephalins), and (c) most influential, through inhibition of pain transmission by simultaneous tactile sensory signals. Moreover, diffuse noxious inhibitory controls (DNICs) might contribute partially to the pain-relieving effect witnessed.21, 22 An alternate hypothesis also plausible is that wet cupping may function in a manner similar to acupuncture. Finally very few studies have been carried out on these procedures, hence the need to analyze thoroughly the literary aspect of the regimen to explore new vistas.
CONCLUSION
Hijamat plays a vital role in the management of Irqunnasa provided the regimen is judiciously used with all the given facts taken in to consideration. Besides the fundamental importance of this therapeutic methodology there is a problem of lack of uniform standard operative procedures. It therefore apparently seems essential to standardize it and to develop certain scientific parameters for evaluation of the efficacy of this therapy as it is cost effective, user friendly devoid of adverse effects. Hence scientific studies are being under taken to validate this age old regimen in different Unani research institutions of India so that the benefits may be reaped by large section of society. This therapy must also be evaluated for prophylactic use so that some of the impending attacks / bouts of disease can be averted.
ACKNOWLEDGEMENT
The Authors duly acknowledge the coordination and cooperation extended by the library staff of Central library, National Institute of Unani Medicine, Bangalore in collecting the literature pertaining to the manuscript, authors whose references quoted and the journal reviewers for pointing out certain discrepancies. There is no any conflict of interest.
Englishhttp://ijcrr.com/abstract.php?article_id=965http://ijcrr.com/article_html.php?did=965REFERENCES
1. Ibne Sina. Al Qanoon Fit Tib (Urdu translated by Kantoori GH). Vol 3. New Delhi: Idara Kitabushifa; 2007.p. 1120-21.
2. Nayab Md. Clinical study on effects of Hijamat (Cupping therapy) in the management of Waja-ul Mafasil [dissertation].Bangalore: NIUM.RGUHS;2007.p. 33-57.
3. GhassanJ. Tib-ul-Hijamah. Beirut: Dar-ulHarf-il-Arabi; 2005.p. 14, 54-55.
4. Bukhari AAMBI. Sahih Bukhari sheriff (Urdu translation). Vol3. New Delhi: Farid Book Depot; 1990. 314: 5371.
5. Akhtar J, Siddiqui MK. Utility of cupping therapyHijamatin Unani medicine. Indian journal of traditional knowledge. 2008. Oct; 7(4): 572- 4.
6. Huang Shixi, Cao Yu. Cupping Therapy, Journal of Chinese Medicine. 2006 Oct. 82:52-7.
7. Maseehi AAFIQ. Kitab ul Umda Fil Jarahat (Urdu translation). Vol 1. New Delhi: CCRUM; YNM.p.200.
8. Sheeraz MD. A comparative clinical study on the effects of Mehjama Nariya and Hijamat Bila Shart in Irqunnasa (Sciatica).[Dissertation].Bangalore:NIUM.RG UHS;2013.61-65, 70-95
9. Sheeraz MD, Zaheer Ahmed, Mohd Aleemuddin Quamri. Concept and Management of Irqunnasa (Sciatica) in Unani system of Medicine – A Review. AARJMD.2013.Volume-1, Issue-13:205-18.
10. R?zi ABMBZ. Al Havi Fit Tib. Vol.11. New Delhi: CCRUM; 2004.p. 75-77, 84, 88, 96, 99, 114, 129, 174.
11. Majusi AHAIA. Kamilussanaa. New Delhi: Idarae kitabushifa; 2010.p.543, 574.
12. Jurjani MI. Zakheerae Khuwarizm Shahi (Urdu translation of Hakim Hadi Hussain). New Delhi: Idare kitabushifa; 2010. p. 637, 649, 650.
13. Khan MA. Al Ikseer. (Urdu translation by Hakim Kabeeruddin). Vol.2. New Delhi: Ejaz publishing house; 2003.p.1451- 53.
14. KabeeruddinM. Tarjuma waSharhKulliyatee-Nafeesi. Vol2.New Delhi: Idara-e-Kitab ulShifa; 1954.p. 453-54.
15. Khan HA. Majmaul Bahrain. Lucknow: Matba Munshi Naval Kishore; 1294. p. 523.
16. Ali M, Shukla VD, Dave AR, Bhatt NN. A clinical study of Nirgunda Ghana Vati and Maatra Basti in the management of Gridhrasi with special reference to sciatica. AYU Journal. 2010. 31(4):456.
17. Bowsher D. Mechanisms of acupuncture. In: Filshie J, White A, eds. Medical acupuncture: a Western scientific approach. London, England: Churchill Livingstone ; 1998. p. 69- 82.
18. Petti F, Bangrazi A, Liguori A, Reale G, Ippoliti F. Effects of acupuncture on immune response related to opioid-like peptides. J Tradit Chin Med.1998. Mar; 18(1): 55-63.
19. Baldry. Trigger point acupuncture. Medical acupuncture a Western scientific approach, New York: Churchill Livingstone; 1988. p. 38.
20. Sack K E, Fye K H. Rheumatic Diseases, Ch. 33, in Medical Immunology by Stites D P, Terr A I, Parslow T G, Applen and Lang; Shealy C N; 1996.p. 456-479,
21. Sahbaa M Ahmed, Nour H Madbouly, Soheir S Maklad and Eman A Abu-shady. Immunomodulatory effects of bloodletting cupping therapy in patients with rheumatoid arthritis. The Egyptian journal of immunology. 2005; 12 (2): 39-51.
22. Khosro Farhadi, David C Schwebel, Morteza Saeb, Mansour Choubsaz, Reza Mohammadi, Ali reza Ahmadi. The effectiveness of wetcupping for nonspecific low back pain in Iran: A randomized controlled trial. Complementary Therapies in Medicine.2009; 17: 9—15.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524162EnglishN-0001November30HealthcareA CASE OF LINEAR VERRUCOUS EPIDERMAL NEVUS
English1316Arun Kumar S. BilodiEnglish S. VidyaEnglish SethuramanEnglishAim: The objective of the present study is to report a case of linear verrucous epidermal nevus that was seen in 18 years old female. Place of study: This case was seen in outpatient department of dermatology at Velammal Medical College Teaching Hospital, Anuppanadi Madurai. Period of Study: This case was studied during the month of June 2013 Case Study: A female aged 18 years came with history of islands of pigmentations over her right lower limb presence since birth. There were no islands of pigmentation in her other parts of the body. She was thoroughly examined after detailed history and relevant investigations. Discussion: This case was well compared and correlated with available literatures. Conclusion: This is case of congenital disorder of skin which may or may not run in the family, but has clinical importance, hence it has been reported
Englishcongenital disorder of skin, linear verrucous epidermal nevus, islands of pigmented patchesIntroduction
Linear verrucous epidermal nevus is also known as Linear epidermal nevus and "Verrucous epidermal nevus"[1] . It is lesion of the skin giving rise to verrucous skin-colored papules which may be dirty grey or brown.[2,3] When the nevus covers extensive area of the body or diffuse distribution, then it is known as Nevus, On the other hand, when there is distribution in only one half of the body, then it is known as Nevus Unis Lateralis. [2] The islands of papules when present they coalesce in the form of serpiginous plaque.[3]
Case Report
A eighteen years old female trainee staff came with history of black velvety linear lesion in the right leg gradually increased in length since birth. Intially lesion was small behind knee, which gradually became more prominent to the extent of involving thigh and leg. There was no history of discomfort, itching, redness, pain, oozing from the lesion except for the cosmetic disfigurement. There was no history of trauma.
On Examination
Islands of Hyper pigmented verrucous Lesion was present in poster lateral aspect of right thigh extending down to the leg in a serpigenous fashion. No similar complaints in the other members in the family. She had tried topical creams where verrucous lesions shaded and became flat only to recur in the similar fashion.
Discussion
Inflammatory linear verrucous epidermal nevi are skin lesions characterized histologically by hypergranulosis with orthokeratosis and parakeratosis with agranulosis. Very frequently they are raised, flakey or scabby It is called inflammatory because, the affected region will be warmer, inflamed than the rest area of the skin.Lesion is long and thin, hence they are known as 'Linear' Since the lesions are wart like they are known as. 'Verrucous' .These patients are treated with C02 Laser Surgery so as to give appearance of skin as flat, smoother and more normal resurface4,5 Epidermal nevi are congenital malformations of skin derived from embryonic ectoderm. They are also known as Haemarthomas.According to the predominant epidermal structure involved, their clinical appearance, distribution, and the extent of their involvement, they are classified into variants6,7 These lesions which are observed at birth or during infancy usually do not run in the family(non-familial)8 . Prevalance rate of this congenital lesion is estimated to be 1:1000 live births. These anomalies can be associated with anomalies of musculoskeletal and central nervous system (CNS). There is documentation of oral mucosal lesions. Clinically they appear as veracious papules and plaques observed in a linear pattern following Blaschko's lines (purported embryonic lines of ectodermal cleavage). Their extent is variable may be unilateral known as Nevus Unis Lateralis or bilateral which is very extensive (ichthyosis hystrix)9 . Inflammatory Linear Verrucous Epidermal N evus (ILVEN) is of rare variety of epidermal verrucous nevus commonly seen in females. This condition is clinically characterized by the appearance of recurrent inflammatory chronic eczematous or psoriasiform conditions which may be commonly unilateral in distribution associated with severe itching10,11 A female patient aged 23-year-old came to Department of Oral Medicine and Radiology with the history of gums bleeding for past 6 months. There was no significant history of medical and family history. On examination, she had scoliosis associated with shorter right foot and leg, hence she was limping There was a patch of loss of hair (alopecia) over the right fronto-parietal region of scalp. She also had papules which were dark brown in colour with severe itching. The type of distribution was linear over the right upper part of her body, also seen in the cervical region axilla,over the pectoral region (chest), back, shoulder and over the extensor surface down to up to nails of little finger and thumb The lesion were also found on the face, external ear, over the pre auricular region and extending over the right cheek. Papules were observed on the forehead, extending from the scalp adjacent to midline, linearly down to the root of the nose, right nostril, to the vermillion border of the upper lip on the right side. There was diffuse, sessile, linear papillary lesion intra orally12 Verrucous epidermal nevi are seen in the form of circumscribed patches or in the form linear streaks or whorls occur in circumscribed patches or more often, in linear streaks or whorls following Blaschko's lines13. The lesions are commonly seen over the trunk, extremities, cervical region & over the face. 14 Papillomatous nevi are found in the new born children have flat velvety soft lesions, while in adolescence, they occur as hard keratotic, verruciform lesions. 14,15 The lesion colour may vary from the coloured type to brown colour. Acanthosis, orthohyperkeratosis, papillomatosis, and an expanded papillary dermis are characteristic features of verrucous epidermal nevi histologically .They can be well demarcated from the surrounding healthy normal skin They are also known as keratinocytic, epidermal nevi15 A study was done on 167 biopsy specimens of epidermal nevi patients. The study showed in 160 out of 167 biopsy specimens, the features of verrucca was observed in 2% along with dilatation of blood vessels16
Present Study:
Showed Linear verrucous epidermal nevus in a eighteen years old female trainee staff with history of black velvety linear lesion in the over the right leg. To start with, it was found as a small lesion behind the right knee, & gradually increased in size and attained present size. No history of discomfort of itching, redness, pain, oozing and other signs of inflammation from the lesion. There was also no history of trauma On examination, hyper pigmented Verrucous Lesions were found as Islands on the poster lateral aspect of right thigh extending down towards the right leg in a serpigenous fashion..There were no history similar lesions of skin in the other members of family. Topical creams were applied over the verrucous lesions, where they became flat but it has tendency to recur it again. She had no scoliosis, no shortening of right leg, no limping, no patch of alopecia over the right frontoparietal region of scalp. There was no distribution upper part of her body, nor in the cervical region axilla, the pectoral region (chest), back, shoulder and not over the extensor surface down to up to nails of little finger and thumb
Conclusion
The present case is of rare variety of congenital lesion of the skin which has paramount clinical importance. Hence it has been studied, compared correlated with available literatures and reported. Since this anomaly is congenital, after taking proper history and after relevant investigations, proper awareness of the skin lesion has to be given by health workers, NGOs. Health education should be given and prevention of recurrences in the community has to be encouraged. To avoid drugs during first trimester, consanguineous marriages, consumption of alchohol, and smoking has to be stressed by voluntary workers & NGOs
Acknowledgements
Our sincere thanks to our respected Chairman, Dean of RMO for allowing us to study the above case and for publishing it.
Englishhttp://ijcrr.com/abstract.php?article_id=966http://ijcrr.com/article_html.php?did=966REFERENCES
1. Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. (2007).Dermatology: 2-Volume Set. St. Louis: Mosby. p. 851(831). ISBN 1-4160- 2999-0.
2. Freedberg MD, Arthur Z. Eisen, MD, Klauss Wolff, MD, K. Frank Austen, MD, Lowell A. Goldsmith, MD, and Stephen I. Katz, MD, PhD, . Fitzpatrick's Dermatology in General Medicine. (6th ed.).- Journal of the American Academy of Dermatology, Volume 51, Issue 2, New York, 2003, McGraw-Hill. ISBN 0- 07-138076-0.
3. James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology. (10th ed.). Saunders. ISBN 0-7216-2921-0.
4. Odom, Richard B.; Davidsohn, Israel; James, William D.; Henry, John Bernard; Berger, Timothy G.; Clinical diagnosis by laboratory methods; Dirk M. Elston (2006). Andrews' diseases of the skin: clinical dermatology. Saunders Elsevier. ISBN 0-7216-2921-0.
5. Freedberg, et al. (2003). Fitzpatrick's Dermatology in General Medicine. (6th ed.). McGraw-Hill. ISBN 0-07-138076-0
. 6. Rogers M. Epidermal nevi and the epidermal nevus syndromes: A review of 233 cases. Pediatr Dermatol. 1992;9:342–4.[PubMed]
7. Rogers M, McCrossin I, Commens C. Epidermal nevi and the epidermal nevus syndrome - a review of 131 cases. J Am Acad Dermatol. 1989; 20:476–88.[PubMed]
8. Naylor MF. Benign epithelial tumors and hamartomas. In: Sams WM, Lynch PJ, editors. Principles and practice of dermatology. 2nd ed. New York: Churchill Livingstone; 1996. pp. 215–6.
9. Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ. In: Fitzpatrick's Dermatology in general medicine. 5th ed. Vol. 1. New York: McGraw Hill, Inc; 1999. Epidermal nevus; pp. 876–8.
10. Solomon LM, Fretzin DF, Dewald RL. The epidermal nevus syndrome. Arch Dermatol. 1968;97:273–85.[PubMed]
11. Gon AS, Minelli L, Franzon PG. A case for diagnosis. Ann Bras Dermatol. 2010;85:729– 31.[PubMed]
12. C. Anand Kumar, Garima Yeluri, and Namita Raghav: Inflammatory linear verrucous epidermal nevus syndrome with its polymorphic presentation - A rare case report: Contemp Clin Dent. 2012 Jan-Mar; 3(1): 119– 122.doi: 10.4103/0976-237X.94562: PMCID: PMC3341748
13. Bolognia JK. Lines of Blaschko's. J Am Acad Dermatol 1994; 31: 157.
14. Vujevich JJ, Mancini AJ. The epidermal nevus syndromes: Multisystem disorders. J Am Acad Dermatol. 2004; 50: 957- 961.
15. Pierson D, Bandel C, Ehrig T et al. Benign epidermal tumours and proliferations. In: Bolognia JL, Jorizzo JL, Rapini RP, eds. Dermatology. Philadelphia: Mosby, 2003: 1697- 1720.15.
16. Su WP: Histopathologic varieties of epidermal nevus. A study of 160 cases. Am J Dermatopathol 1982; 4: 161- 170.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524162EnglishN-0001November30HealthcareOUTCOME OF PHYSICAL REHABILITATION IN PATIENTS WITH SPINAL CORD INJURY
English1725Devangi S. DesaiEnglishIntroduction: Spinal Cord Injury (SCI) results in long-term disability and can dramatically affect quality of life. The effects of SCI have an impact not only on the lives of the client and family but also on society as a whole. Patients with SCI need a well coordinated, specialized rehabilitation program consisting of a team of physicians and health care professionals to provide the tool necessary to develop a satisfying and productive post injury life style. Objective: To assess effectiveness of physical rehabilitation in patients with spinalcord injury (SCI) and also to assess the functional improvement in patients with SCI with physical therapy. Methodology: In this study 30 paraplegic patients were selected, whose fracture level was below D9 vertebrae. Physical rehabilitation was started depending on the patient’s assessment. In general physical rehabilitation includes ROM exercises and positioning, strengthening, mat activities, transfer training, wheelchair skills, gait training, etc. Patients were reevaluated after six weeks of rehabilitation. Outcome measures were ASIA motor score, ASIA sensory score and FIM to assess motor function, sensory function and level of independence respectively. Result: The result shows highly significant improvement in ASIA motor score, ASIA sensory score, motor score of FIM following six weeks of physical rehabilitation in paraplegics at 5% significance level except cognitive score of FIM. Conclusion: The conclusion of the study is that physical rehabilitation plays very important role in improving physical capacity of patients as well as in making them functionally as much independent as possible.
EnglishRehabilitation, Paraplegia, FIM, ASIA, Physical TherapyINTRODUCTION
Spinal Cord Injury (SCI) typically results in impaired motion and loss of function, both of which are associated with a decrease in quality of life. 1 Spinal Cord Injury (SCI) is a low incidence, high cost disability requiring tremendous changes in an individual lifestyle.2 The effect of SCI have an impact not only on the lives of the client and family but also on society as a whole.3 Spinal injury units now exist worldwide and international symposia on the treatment of those with spinal cord lesions take place regularly.4 Improvements in administering care at the time of accident, technological advances in diagnosis and in management have contributed to a continuing fall in mortality and morbidity rates over recent years.5 Spinal cord injuries can be grossly divided into two broad etiological categories: Traumatic injuries and non-traumatic damage.2 Statistics from the NSCID (National Spinal Cord Injury Database) indicate that accidents involving motor vehicles are the most frequent cause of traumatic SCI (45.6%), followed by falls (19.6%), acts of violence (17.8%), recreation sports injuries (10.7%) and other etiologies (6.3%).6 Non-traumatic conditions that damage spinal cord are vascular malfunctions, vertebral subluxations secondary to rheumatoid arthritis, transverse myelitis, spinal neoplasm etc. They account for 30% of all spinal cord injuries. The areas of spine that demonstrate the highest frequency of injury are between C5 and C7 in cervical region and between T12 and L2 in the thoracolumbar region.2 The International Standards for Neurological and Functional Classification of Spinal Cord Injury (ISNCSCI) provide a straightforward, internationally accepted procedure for classifying spinal cord injury based on a systematic motor and sensory examination of neurological function.7 Functional Independence Measure (FIM) is devised to measure function for any disability. Each area of function is evaluated in terms of independence using a seven point scale.4 Patients with SCI need a well coordinated, specialized rehabilitation program consisting of a team of physicians and health care professionals to provide the tool necessary to develop a satisfying and productive post injury life style.8,9 The rehabilitation team for SCI is composed of the physician, orthopedic surgeons, physical therapist, occupational therapist, orthotist, nurses, speech language pathologist, dietician, psychologist, vocational counselor, social worker, engineer etc.10,11,12,13 The patients, their family members and NGOs are also the important part of rehabilitation team. A coordinated system of care shortens hospital stays and improves efficiency of functional gains during rehabilitation.14, 15 SCI usually happens to active, independent people who at one moment are in control of their lives and in the next moment are paralyzed, with loss of sensation and loss of body function and dependence on others for their basic needs so this study was chosen to assess effectiveness of physical rehabilitation in patients with spinal cord injury and also to assess the functional improvement in patients with SCI with physical therapy.
MATERIAL AND METHODOLOGY Study Design:
Prospective longitudinal follow up study
Study Setting: Physiotherapy department of Govt. Physiotherapy College, Ahmedabad. DURATION OF STUDY: 4 months. The duration of treatment program for each subject was 6 weeks. INCLUSION CRITERIAS Traumatic Spinal Cord Injury Operated cases Fracture below D9 vertebrae Duration since injury not more than 2 months Age 18 – 50 years Sex: Both males and females Willing to participate
EXCLUSION CRITERIA
Non traumatic cause of spinal cord injury Fracture above D9 vertebrae Patients treated conservatively Any other associated major neurological, musculoskeletal or cardiopulmonary condition Subject mentally unstable in the judgment of the investigator Subjects whose Modified Ashworth Scale is 3/4 or 4/4 at hip or knee at any time during the study
DATA COLLECTION AND PROCEDURE: MATERIALS
Plinth, Tilt table, Push up blocks Medicine ball, dumbbells Floor Mat, Wheelchair Parallel bars with mirror Posterior knee guard and Toe raising splint Walker, stick Evaluation format including ASIA motor form, ASIA sensory form, FIM Hammer, cotton, pin, pen
OUTCOME MEASURES
? American Spinal Injury Association (ASIA) motor score ? American Spinal Injury Association (ASIA) light touch score ? American Spinal Injury Association (ASIA) pinprick score ? Functional Independence Measure (FIM)
PROCEDURE For this study, a convenient sample of 30 paraplegic patients was taken from Paraplegia Hospital, Civil Hospital, Ahmedabad. All of them took part in the study on a voluntary basis after signing consent form. All the subjects were assessed as per the evaluation format. Those who fulfilled inclusion criteria were taken up for the study. The procedure was explained to all the subjects. Physical rehabilitation program was tailored for each subject depending on their evaluation. Orientation to vertical position was given by use of tilt table and by slowly elevating the head of the bed. Vitals were monitored during this period.2 To maintain R.O.M. in lower limbs, passive movements were given to hip, knee, ankle joints. Stretching exercises were also used mainly for gastro soleus and hamstring muscle. Hamstring stretching is given more emphasis to achieve a straight leg raise of 100 degrees. All upper extremity muscles were strengthened by progressive resistive exercises using manual resistance, weight cuffs or dumbbells. Mainly emphasis was given to shoulder depressors, triceps, and latissimus dorsi, which are required for transfers and ambulation. All the muscles of trunk and lower extremity which remain innervated were strengthened in similar manner.2 Mat activities2 constitute a major component of treatment during rehabilitation phase. Following activities were taught on mat. Rolling, Prone on forearm (photograph 1), Prone-on-hands position , Supine on elbows position, sitting, Balance exercises in sitting, Sitting push-ups using push-up blocks (photograph 2), Quadruped position (photograph 3) and Kneeling. Basic movements within the wheelchair like to manipulate the brakes, to remove the armrest, to pick up objects from the floor, to reach down to the foot plates; to lift the buttocks forward in the chair were taught. 10 to 15 seconds of pressure relief for every 10 minutes of sitting should become part of the patient’s daily routine. Techniques include wheelchair push-ups, hooking elbow or wrist around the push handle and leaning toward the opposite wheel.4 Transfer training was initiated after achievement of good sitting balance. Training was given on different surfaces such as bed, toilet, and chair to floor etc (Photograph 4-6). For standing and walking, basic requirements are to fix the knee joints and to hold the feet in dorsiflexion.4 To fix the knee joints and to maintain dorsiflexion of feet, posterior knee guard and toe raising splint were used respectively. With the use of necessary orthoses, standing between the parallel bars (Photograph 7) was given. Balance exercises in standing were given in parallel bar. Patient should learn to tilt his pelvis by using latissimus dorsi. Even pelvic side tilting was taught. Gait training was also given in parallel bars. Progression was made by making pt. walk with walker. Balance exercises in walker (Photograph 8) were also given. Patients were reevaluated after six weeks of rehabilitation for ASIA motor score, ASIA light touch score, ASIA pin prick score, Functional Independence Measure. In FIM, score of self care, sphincter control, transfers, and locomotion were considered as motor score and score of communication and social cognition were considered as cognitive score.
RESULTS
In this study 30 paraplegic patients were selected and evaluated by the physical therapist. Then physical rehabilitation was started depending onthe patients’ assessment. Patients were reevaluated after six weeks of physical rehabilitation. Here paired t-test was used for statistical analysis of outcome measures. Outcome measures were ASIA motor score, ASIA light touch score, ASIA pin prick score, motor score of FIM and cognitive score of FIM. Results of ASIA motor score (Table–1), ASIA sensory score (Table–2 and 3), motor score of FIM (Table–5) showed highly significant improvement after six weeks of physical rehabilitation at 5% level of significance. Results of cognitive score of FIM (Table–6) showed no statistically significant improvement after 6 weeks of physical rehabilitation.
DISCUSSION
Data collected through this study showed highly significant improvement in ASIA motor score, ASIA sensory score, motor score of FIM following six weeks of physical rehabilitation in paraplegics except cognitive score of FIM. In this study, standing and Gait training was given with the use of posterior knee guard and toe raising splint than Knee Ankle Foot Orthosis (KAFO) because of their cost effectiveness. Walker was used for gait training than forearm crutches because it increases base of support so patient feels secure. The other important reason is that all patients were coming from towns and residing on ground floor so they don’t have to climb stairs in their routine. In FIM transfer to bath, shower was taken as whether pt was able to transfer from wheelchair to floor because patients take bath on floor. Transfer to toilet was taken as whether pt was able to transfer to same level stool or chair because they didn’t have facility of western commode so they are going to use such modification. In this study 22 patients were men and 8 were women so 73% were men and 27% were women. This finding is nearer to finding of National Spinal Cord Injury Database in which 81% pts were men.6 The age of patients was ranging from 18-50 years with mean age of 27.83 years. At the starting of the study ASIA impairment scale was A for 17 patients, B for 7 patients, C for 7 patients so 53.33% had A scale, 23.33% had B scale and 23.33% had C scale. The mode of injury was fall from ht. in 13 pts. (43.33%), fall of heavy wt on back in 10 pts (33.33%), RTA in 7 pts. (23.33%). Muslumanoglu L, Aki S, Ozturk Y, et al 1997, Bode RK, Heinemann AW 2002, Jongjit J, Sutharom W, et al 2004, Hall KM, Cohen ME, et al 1999 , all these studies support the results found in this study but the follow up of pts was for a long duration. All these studies have shown improvement in ASIA motor score, ASIA light touch score and FIM motor score. They also didn’t find improvement in cognitive score of FIM.17, 18, 19, 20 M J De Vivo, J S Richards, S L Stover et al 1991 also found improved independence in activities of daily living following acute care and rehabilitation in pts with spinal cord injury.21 Sandy Stevens, Don Morgan, Ph.D.2 et al 2008 found strong positive association (r = .75; pEnglishhttp://ijcrr.com/abstract.php?article_id=967http://ijcrr.com/article_html.php?did=967REFERENCES
1. Boswell B, Dawson M, Heininger E. Quality of life as defined by adults with spinal cord injuries. J Rehabilitation 1998; 64:27-32
2. Susan B O’Sullivan, Thomas J Schmitz. Physical Rehabilitation. In: George D. Fulk,Thomas J Schmitz, Andrea L. Behrman, editors. Traumatic Spinal Cord Injury. 5th edition. Jaypee Brothers, F.A.Davis Company, Philadelphia; 2007.p.937-990.
3. Darcy A Umphred. Neurological Rehabilitation. In: Myrtice B. Atrice, Sarah A Morrison, Shari L. McDowell, Betsy Shandalov, editors. Traumatic Spinal Cord Injury. 4th edition. Mosby; 2001.p. 477-528.
4. Ida Bromley. Tetraplegia and Paraplegia A Guide for Physiotherapists. In: Ida Bromely, editor. Spinal Cord Injury. 5th edition. Churchill Livingstone;2006.p.1-9.
5. Jennifer A Pryor, S Ammani Prasad. Physiotherapy for Respiratory and Cardiac Problems Adults and Paediatrics. In: Trudy Ward, athryn Harris, editors. Spinal Cord Injury. 3rd edition. Churchill Livingstone;2005.p.537-547
6. Jackson AB, Dijkers M, Devivo MJ,et al. A demographic profile of new traumatic spinal cord injuries: Change and stability over 30 years. Arch Phys Med Rehabil 2004; 85:1740 – 1748.
7. American Spinal Injury Association. International Standards for Neurological Classification of Spinal Cord Injury. Chicago: ASIA; 2002
8. Brown DJ. Spinal Cord Injuries: The last decade and the next. Paraplegia 1992; 30:77- 82.
9. Whiteneck GG, et al. Mortality, morbidity and Psychological outcomes of persons spinal cord injured more than 20 years ago Paraplegia1992; 30:617-630.
10. DeLisa JA, Martin GM, Currie DM. Rehabilitation medicine: past, present, and future. In DeLisa JA (ed). Rehabilitation Medicine Principle and Practice. Philadelphia: Lippincott; 1993. p. 3-27.
11. Dollfus P. Rehabilitation following injury to the spinal cord. J Emerg Med 1993;11:57-61.
12. Nickel VL. The rationale and rewards of team care. In Nickel VL, Botte MJ(eds). Orthopaedic Rehabilitation, 2nd ed. New York, Churchill Livingstone, 1992.p. 243-256.
13. Randall L. Braddom. Physical Medicine and Rehabiliation. In: Thomas N. Bryce, Kristjan T. Ragnarsson, Adam B. Stein, editors. Spinal Cord Injury. 3rd edition.Saunders;2007.p.1285- 1350.
14. Apple DF, Hudson LM, (eds).Spinal Cord Injury: The model. In proceedings of the National Consensus Conference on Catastrophic Illness and Injury, December 1989. Atlanta: Shepherd Center for treatment of spinal injuries, 1990.
15. Frost FS: Role of rehabilitation after spinal cord injury. Urol Clin North Am 1993;20:549- 559.
16. Hamilton BB, Anne Deutsch, Carol Russell,Roger C. Fiedler, Carl V Granger. Relation of disability costs to function: Spinal cord Injury. Arch Phys Med Rehabil 1993; 80: 385-391.
17. Hall KM, Cohen ME, et al. Characteristics of the Functional Independence Measure in traumatic spinal cord injury. Arch Phys Med Rehabil 1999; 80:1471-6.
18. Muslumanoglu L, Aki S, Ozturk Y, et al. Motor, sensory and functional recovery in patients with spinal cord lesions. Spinal Cord 1997; 35:386-9.
19. Bode RK, Heinemann AW. Course of functional improvement after stroke, spinal cord injury, and traumatic brain injury.Arch Phys Med Rehabil 2002; 83:100-6.
20. Jongjit J, Sutharom W, et al.Functional independence and rehabilitation outcome in traumatic spinal cord injury. Southeast Asian J Trop Med Public Health 2004; 35:980-5.
21. M J De Vivo, J S Richards, S L Stover et al. Spinal cord injury. Rehabilitation adds life to years. West J Med 1991; 154: 602–606.
22. Sandy L Stevens,Jennifer L Caputo, Dana K Fuller, Don Morgan. Physical Activity and Quality of Life in Adults with Spinal Cord Injury. J Spinal Cord Med 2008; 31:373-378.
23. Ota T, Akaboshi K, Nagata M, et al. Functional assessment of patients with spinal cord injury: measured by the motor score and the Functional Independence Measure. Spinal Cord. 1996; 34:531-5
24. Ditor DS, Latimer AE, Ginis KA, Arbour KP, McCartney N, Hicks AL.Maintenance of exercise participation in individuals with spinal cord injury: Effects on quality of life, stress and pain. Spinal Cord 2003; 41:446-50. 2
5. Bizzarini E, Saccavini M et al Exercise prescription in subjects with spinal cord injuries. Arch Phys Med Rehabil. 2005 Jun;86(6):1170-5.
26. Scelza WM, Kalpakjian CZ et al Perceived barriers to exercise in people with spinal cord injury.Am J Phys Med Rehabil. 2005 Aug;84(8):576-83.
27. Catz A, Itzkovich M, Agranov E et al. SCIM– –spinal cord independence measure: A new disability scale for patients with spinal cord lesions. Spinal Cord 1997; 35:850-6.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524162EnglishN-0001November30HealthcareAN EXTREMELY RARE REPORT OF TUBERCULOUS COLD ABSCESS OF THE RIGHT ANTERIOR CHEST WALL PRESENTING AS AN EXTREMELY HARD AND IMMOBILE LUMP MIMICKING CARCINOMA BREAST
English2634Govindarajalu GanesanEnglish Krishnapillai AyyappanEnglishTuberculous cold abscess usually presents as soft swelling and occurs commonly in the neck, axilla and inguinal regions due to the presence of lymph nodes in these regions. But tuberculous cold abscess of the anterior chest wall is quite rare. Also tuberculous cold abscess of the anterior chest wall presenting as an extremely hard and immobile lump is extremely rare and is so far not reported in the literature and hence is reported here. Due to the extremely hard and immobile lump, the lesion was initially thought to be due to carcinoma breast. But after detailed investigations, the lump was finally diagnosed to be due to tuberculous cold abscess. The exact reasons for the extreme hardness and immobility of the lump are discussed here in detail. The role of ultrasonography in distinguishing between solid and fluid filled lesions of the anterior chest wall and in showing clearly the exact anatomical relation of the fluid filled lesion to the breast and ribs is discussed here. The importance of doing incisional biopsy before starting antituberculous drugs and its role in excluding malignancy is discussed here. The importance of doing prompt surgical drainage and complete evacuation of the cold abscess inorder to prevent the disastrous complication of rupture of the cold abscess into the underlying pleural cavity and lungs is also discussed here.
EnglishTuberculous cold abscess, anterior chest wall, extremely hard and immobile lump, ultrasonography, incisional biopsy, prompt surgical drainage.INTRODUCTION
Tuberculous cold abscess of the chest wall is quite rare. Tuberculous cold abscess can occur in the anterior chest wall or lateral chest wall or in the posterior chest wall (1,11). Tuberculous cold abscess of the anterior chest wall is commonly reported to occur in association with tuberculosis of the underlying ribs (6,27) or tuberculosis of the underlying lungs (5,.6,7,10,11,21,29). But in the patient reported below the cold abscess of the anterior chest wall was neither associated with tuberculosis of the underlying ribs nor associated with tuberculosis of the underlying lungs. Tuberculous cold abscess of the anterior chest wall lying parasternally is reported to occur mainly due to tuberculous caseation of the internal mammary lymph nodes (3,8,10,18,21,22). Hence the most probable cause of the cold abscess which was lying parasternally in this patient was tuberculous caseation of the internal mammary lymph nodes. Tuberculous cold abscess of the anterior chest wall occurring without tuberculosis of the underlying ribs or lungs is very rare and is hence reported here.
Case report:
A 55 year old female patient presented with history of painless lump of the right breast, gradually increasing in size for two months. There was no history of fever, loss of appetite or loss of weight. She was non diabetic, human immunodeficiency virus (HIV) negative immunocompetent patient. Local examination revealed an extremely hard, immobile, nontender, smooth lump measuring about 6x3cms in the region of right upper medial quandrant of the right breast (fig 1). Due to the extremely hard and immobile lump, the lesion was initially thought to be due to carcinoma breast and the patient was immediately subjected to ultrasound examination of the right breast. But very interestingly ultrasound examination revealed normal right breast and an abundant amount of collection of dense fluid deep to the right breast (fig 2) extremely close to the ribs (fig 3 ). The collection was also seen to extend in between the ribs by ultrasound examination (fig 4) Mantoux test revealed 29x24mm induration at the end of 48hours. Hence the patient was strongly suspected to have tuberculous cold abscess. But X-ray chest was normal without erosion of the underlying ribs and also revealed normal lung fields. While doing fine needle aspiration cytology (FNAC), aspiration showed pus like material and microscopic examination revealed neutrophils, macrophages and degenerated cells in a necrotic background and the smear for acid fast bacilli was also negative. Despite very strong Mantoux test, since X-ray chest and Fine needle aspiration cytology were inconclusive of tuberculosis, it was decided to do incisional biopsy inorder to get accurate tissue diagnosis. Hence under short general anaesthesia, an incision was made deep into the lesion. About 250 ml of pus was found deep to the right breast and deep to the pectoralis major and minor muscles extremely close to the ribs. After complete evacuation of the pus, an incisional biopsy was done from the wall of the abscess. Histopathological examination revealed epitheloid cell granuloma with langhans giant cells, caseating necrosis and lymphocytes indicating tuberculosis (fig 5,6). Epitheloid cell is identified under light microscope by its lightly stained pale elongated or oval nucleus, lightly stained eosinophilic (pink) cytoplasm and indistinct cell border (fig 5). Due to the indistinct cell border, the outline of one epitheloid cell appears to merge with the outline of the adjacent epitheloid cell (fig 5) (29 to32). Langhans giant cells are huge cells with multiple nuclei arranged as horseshoe pattern in the periphery of the cell (fig 5) (29to32). Caseating necrosis is identified by acellular pink areas of necrosis under light microscope (fig 6) (29). Lymphocytes are cells almost completely filled with haemotoxylin stained blue coloured nucleus. Hence a final diagnosis of tuberculous cold abscess of the right anterior chest wall was made for the patient. The patient was immediately started on 6 months daily course of antituberculous drugs with daily dose of Isoniazid 300mg, Rifmpicin 450mg, Ethambutol 800mg and Pyrazinamide 1500mg for an intial period of two months followed by daily dose of Isoniazid 300mg and Rifmpicin 450mg for the next four months. After completion of three months of antituberculous treatment, the operative wound has healed completely, the patient has become completely asymptomatic and has recovered completely
DISCUSSION
Tuberculous cold abscess of the anterior chest wall usually presents as soft and mobile swelling (1,2,3,9,13,14,16,18,20,32) . But tuberculous cold abscess of the anterior chest wall presenting as an extremely hard and immobile swelling, as in this patient, is extremely rare. The cold abscess of this patient was lying between the strong pectoral muscles in front and the bony ribs behind and was extremely hard and immobile. The exact reasons for the extreme hardness and immobility of this cold abscess are discussed here in detail. Tuberculous cold abscess is a type of false cyst. A cyst is a swelling having fluid inside it. A cyst is of two types- true cyst and false cyst. A true cyst has fluid inside it and is lined by epithelium. A false cyst has fluid inside it but is not lined by epithelium. An abscess is a false cyst as it has pus inside it but is not lined by epithelium. Both pyogenic abscess and tuberculous cold abscess are examples of false cyst. Tuberculous cold abscess is a false cyst as it has caseating material or tuberculous pus inside it but is not lined by epithelium. A false cyst like tuberculous cold abscess has all the clinical features of a true cyst except for the fact that it is not lined by epithelium. A cyst is soft, firm or hard depending upon the tension of the fluid present inside the cyst. A cyst will be hard in consistency if the fluid inside the cyst is under tremendous tension. Being a false cyst, tuberculous cold abscess will also be hard in consistency if the tuberculous pus inside the cold abscess is under tremendous tension. The cold abscess of this patient was filled with abundant amount of tightly packed collection of dense caseating material or tuberculous pus. As the disease progresses, the extent of caseation increases and the tuberculous pus also increases in amount. But this increasing amount of tuberculous pus of this patient could not expand freely both anteriorely and posteriorely due to the highly unyielding extremely strong pectoralis major muscle present anteriorely and the strong bony ribs present posteriorely producing tremendous tension of the tuberculous pus inside the cold abscess. Since the tuberculous pus inside the cold abscess of this patient was under tremendous tension due to the highly unyielding strong pectoralis major muscle present anteriorely and the strong bony ribs present posteriorely, the cold abscess was extremely hard in consistency. Any deep swelling arising from bone or attached to bone is immobile. The cold abscess of this patient was lying extremely close to the ribs and was also seen to extend in between the ribs both by ultrasound examination and during the operation and hence it was immobile. Ultrasonography, with its advantages of being radiation-free, is an extremely useful diagnostic tool for evaluation of chest wall lesions (16) Ultrasonography is a cost-effective and an extremely useful modality to demonstrate rib destruction in a chest wall cold abscess. Ultrasonography shows abscesses as hypoechoic areas and bone fragments due to rib destruction appears as echogenic foci within these hypoechoic collections (15). But in this patient ultrasonography did not show any evidence of rib destruction. Thus ultrasonography shows chest wall cold abscess as hypoechoeic collection (28, 29). Hence ultrasonography in this patient also has shown an hypoechoeic collection deep to the right breast adjacent to the ribs (fig 2,3). Thus ultrasonography is extremely useful to distinguish between solid and fluid filled lesions of the anterior chest wall, shows the exact anatomical relation of the fluid filled lesion and its relation to the breast and ribs (fig 2,3) and can also show clearly the extension of the fluid filled lesion in between the ribs (fig 4). Incisional biopsy is generally avoided in tuberculous cold abscess of cervical, axillary and inguinal lymph nodes due to the fear of occurrence of non-healing sinus or ulcer (33). But in most cases of cold abscess of the anterior chest wall, fine needle aspiration cytology is inconclusive of tuberculosis (2,7,8,9,11,19,24,34). Hence incisional biopsy from the wall of the cold abscess is absolutely mandatory inorder to get accurate tissue diagnosis and to rule out any underlying malignancy(1,2,8,9,18, 20,23,24,29,32). Incisional biopsy is also absolutely necessary since rare organisms other than Mycobacterium tuberculosis like Burkholderia pseudomallei causing melioidosis and even Staphylococcus aureus were reported to cause cold abscess of the anterior chest wall (33,35) Biopsy and histopathological examination facilitates prompt diagnosis of chest wall cold abscess (20). Histologic proof by biopsy facilitates prompt treatment of chest wall cold abscess (20). Such prompt diagnosis and treatment is extremely important to prevent serious bone and joint destruction underlying the chest wall cold abscess (1,18). In this patient, within one week of her clinical presentation, X-ray chest, Mantoux test, ultrasonography and fine needle aspiration cytology was done immediately followed by incisional biopsy from the wall of the abscess after complete surgical evacuation of the abscess. Within few days after doing incisional biopsy, histopathological examination revealed tuberculous granuloma and the patient was immediately started on antituberculous drugs. Hence within two weeks of her clinical presentation, complete surgical drainage of the cold abscess was done, histological diagnosis of tuberculosis was made and antituberculous drugs was started for the patient. Because of such prompt diagnosis and treatment, serious complications like destruction of the adjacent ribs and rupture of the cold abscess into the underlying pleural cavity and lungs was avoided in this patient. Hence prompt histological diagnosis and prompt surgical and medical treatment of the cold abscess of the anterior chest wall is extremely important to avoid the above mentioned serious complications. Tuberculous cold abscess of cervical, axillary and inguinal lymph nodes are generally managed by antigravity or non-dependent wide bore needle aspration along with antituberculous drug treatment (33). But wide bore needle aspration is not adequate for the deep seated cold abscess of the anterior chest wall as it has high risk of incomplete evacuation of the cold abscess. But complete evacuation of the cold abscess of the anterior chest wall is extremely important as the cold abscess can easily rupture into the underlying pleural cavity or lungs with disastrous consequences if not completely evacuated. However complete evacuation of this cold abscess is possible only through open surgical drainage and not by wide bore needle aspration. Cold abscess of the anterior chest wall cannot rupture anteriorely due to the highly unyielding extremely strong pectoralis major muscle present anteriorely. Hence the only way for the cold abscess to rupture is through the space between the ribs into the underlying pleural cavity or lungs with disastrous consequences (24,27). Hence prompt open surgical drainage and complete evacuation of the cold abscess without any undue delay is extremely important inorder to avoid the disastrous consequences of rupture of the cold abscess into the underlying pleural cavity and lungs. The cold abscess of the anterior chest wall of this patient was not associated with tuberculosis of the underlying ribs or lungs. The cold abscess was located deep to the right upper medial quadrant of the right breast just by the side of sternum which is the exact location of the internal mammary lymph nodes. Tuberculous cold abscess of the anterior chest wall lying parasternally is reported to occur due to tuberculous caseation of the internal mammary lymph nodes (3,8,10,18,21,22). Since the underlying ribs and lungs were normal and due to its parasternal location the most probable cause of the cold abscess of this patient was tuberculous caseation of the internal mammary lymph nodes.
CONCLUSION
Six extremely important features of tuberculous cold abscess of the anterior chest wall of this patient are highlighted in this article 1. The cold abscess was extremely hard due to the tremendous tension of tuberculous pus inside the cold abscess due to the highly unyielding strong pectoral muscles in front of it and the bony ribs behind it. 2. The cold abscess was immobile since it was lying extremely close to the ribs and was also extending in between the ribs. 3. Ultrasonography is extremely useful to distinguish between solid and fluid filled lesions of the anterior chest wall and shows clearly the exact anatomical relation of the fluid filled lesion to the breast and ribs. 4. Incisional biopsy from the wall of the cold abscess is absolutely mandatory inorder to get accurate tissue diagnosis and to rule out any underlying malignancy. 5. Prompt open surgical drainage and complete evacuation of the cold abscess without any undue delay is extremely important inorder to avoid the disastrous consequences of rupture of the cold abscess into the underlying pleural cavity and lungs. 6. Since the underlying ribs and lungs were normal and due to its parasternal location the most probable cause of the cold abscess of this patient was tuberculous caseation of the internal mammary lymph nodes
ACKNOWLEDGEMENT
Both the authors gratefully acknowledge with utmost respect Professor Dr. N. Anantha Krishnan, the greatest guru for both of us, whose constant guidance, encouragement and advice has helped us to publish this manuscript. Both the authors also acknowledge with extreme thankfulness Professor Dr.Thirupurasundari, Head of the dept of gynaecology, Aarupadai Veedu Medical College And Hospital, Puducherry for doing thorough gynaecological examination of the patient and ruling out gynaecological pathology in the patient.
Englishhttp://ijcrr.com/abstract.php?article_id=968http://ijcrr.com/article_html.php?did=968REFERENCES
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3. Prasoon D.Tuberculosis of the intercostal lymph nodes.Acta Cytol. 2003 JanFeb;47(1):51-5
4. Rivo V J, Fernández V A, Cañizares C M. (2004). Cold abscess of the chest wall 58 years after thoracoplasty Arch Bronconeumol. 2004 Nov; 40(11):540-1.
5. Zhang Y, Li H, Li T, Zhang WQ.A tuberculous abscess of the chest wall in a renal allograft recipient.J Thorac Dis. 2013 Aug;5(4):E133-6
6. Sakuraba M, Sagara Y, Komatsu H.Surgical treatment of tuberculous abscess in the chest wall.Ann Thorac Surg. 2005 Mar;79(3):964-7.
7. Kim YT, Han KN, Kang CH, Sung SW, Kim JH.Complete resection is mandatory for tubercular cold abscess of the chest wall.Ann Thorac Surg. 2008 Jan;85(1):273-7.
8. Kuzucu A, Soysal O, Günen H.The role of surgery in chest wall tuberculosis.Interact Cardiovasc Thorac Surg. 2004 Mar;3(1):99- 103.
9. Aghajanzadeh, M., Pourrasouli, Z., Aghajanzadeh, G., and Massahnia, S. Surgical Treatment of Chest Wall Tuberculosis. Tanaffos, 2010; 9(3): 28-32.
10. Morris BS, Maheshwari M, Chalwa A.Chest wall tuberculosis: a review of CT appearances.Br J Radiol. 2004 May;77(917):449-57.
11. Deng B, Tan QY, Wang RW, He Y, Jiang YG, Zhou JH, Liang YG.Surgical strategy for tubercular abscess in the chest wall: experience of 120 cases.Eur J Cardiothorac Surg. 2012 Jun;41(6):1349-52.
12. Ero?lu A, Kürkçüo?lu C, Karao?lano?lu N, Kaynar H.Breast mass caused by rib tuberculosis abscess.Eur J Cardiothorac Surg. 2002 Aug;22(2):324-6.
13. Bekci, T. T., Ya?ar, B. T. S., Kesli, R., Maden, E. Tuberculous Abscess of the Chest Wall. Eur J Gen Med, 2010; 7(3) : 326-329
14. Chang JH, Kim SK, Kim SK, Chung KY, Shin DH, Joo SH, Choe KO. Tuberculosis of the ribs: a recurrent attack of rib caries.Yonsei Med J. 1992 Dec;33(4):374-8.
15. Grover SB, Jain M, Dumeer S, Sirari N, Bansal M, Badgujar D. Chest wall tuberculosis - A clinical and imaging experience.Indian J Radiol Imaging. 2011 Jan;21(1):28-33
16. Huang CY, Su WJ, Perng RP.Childhood tuberculosis presenting as an anterior chest wall abscess.J Formos Med Assoc. 2001 Dec;100(12):829-31.
17. Ekingen G, Guvenc BH, Kahraman H.Multifocal tuberculosis of the chest wall without pulmonary involvement. Acta Chir Belg. 2006 Jan-Feb;106(1):124-6.
18. Jain S, Shrivastava A, Chandra D.Breast lump, a rare presentation of costochondral junction tuberculosis: a case report.Cases J. 2009 Sep; 9(2):7039
19. Koul PA, Ashraf M, Jan RA, Shah S, Khan UH, Ahmad F, Qadri BA, Bazaz SR.An elderly male with tubercular osteomyelitis of the chest wall.BMJ Case Rep. 2011 Mar ; 8:2011
20. Hossain M, Azzad AK, Islam S, Aziz M.Multiple chest wall tuberculous abscesses.J Pak Med Assoc. 2010 Jul;60(7):589-91.
21. Faure E, Souilamas R, Riquet M, Chehab A, Le Pimpec-Barthes F, Manac'h D, Debesse B.Cold abscess of the chest wall: a surgical entity?.Ann Thorac Surg. 1998 Oct;66(4):1174-8.
22. Paik HC, Chung KY, Kang JH, Maeng H.Surgical treatment of tuberculous cold abscess of the chest wall. Yonsei Med J. 2002 Jun;43(3):309-14.
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25. Tanaka S, Aoki M, Nakanishi T, Otake Y, Matsumoto M, Sakurai T, Tada K, Ikeda A.Retrospective case series analysing the clinical data and treatment options of patients with a tubercular abscess of the chest wall.Interact Cardiovasc Thorac Surg. 2012 Mar;14(3):249-52.
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32. Aribas OK, Kanat F, Gormus N, Turk E.Cold abscess of the chest wall as an unusual complication of BCG vaccination.Eur J Cardiothorac Surg. 2002 Feb;21(2):352-4.
33. Vishnu Prasad NR, Balasubramaniam G, Karthikeyan VS, Ramesh CK, Srinivasan K.Melioidosis of chest wall masquerading as a tubercular cold abscess.J Surg Tech Case Rep. 2012 Jul;4(2):115-7.
34. Hsu HS, Wang LS, Wu YC, Fahn HJ, Huang MH.Management of primary chest wall tuberculosis.Scand J Thorac Cardiovasc Surg. 1995;29(3):119-23.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524162EnglishN-0001November30HealthcareFNAC STUDY OF MALE BREAST MALIGNANCY
English3539Parikh U.R.English Dave P. NEnglish Barot H.P.English Goswami H.M.English Jani H.U.English Gonsai R. N.EnglishIntroduction: Although breast carcinoma is the second most common cause of death in female patients, male breast carcinoma is rare. The incidence for male breast carcinoma is about 1 % in all breast carcinoma. Clinicians also reported that the incidence of male breast carcinoma is increase day by day. Aims and Objectives: The present study was undertaken to determine the efficacy of FNAC in the diagnosis of these lesions. Material and Method: The present study was undertaken over a period of five months in one of the tertiary care teaching hospital. After detailed clinical history and examination, fine needle aspiration is performed in all the five patients. Result: Our 60 % of the patients are present in 7th decade. Total five male patients having malignant breast lesion on cytological examination. The cytological diagnosis is confirmed by histopathological examination. Discussion: Fine needle aspiration cytology is considered as a rapid diagnostic tool as well as it is reliable and less traumatic and is also able to differentiate non neoplastic and neoplastic breast lesions. This procedure is technically easy to apply in small breast lesions. FNAC is most accurate when experienced cytologists are available. The size and extent (stage) of tumors are the most important factors in the prognosis for male breast cancer. Conclusion: FNAC is outdoor patient procedure with high diagnostic accuracy, sensitivity and specificity.
EnglishFine Needle Aspiration Cytology (FNAC), Male Breast CancerINTRODUCTION
The role of fine needle aspiration cytology (FNAC) in male breast lesions has been reported in literature and is as reliable as in female breasts.1 Indeed, FNAC is the first line investigation in the clinical evaluation of breast lumps in males because it is a fast and cost effective method. It can be performed as an office procedure, requires little special equipment, causes minimal morbidity and has excellent patient acceptance. Breast cancer is the most common type of cancer in women, age 40 – 50 years. It is the second leading causes of cancer deaths i.e about 250,000 women die of this disease every year. 2 Men also possess a small amount of nonfunctioning breast tissue (breast tissue cannot produce milk) that is concentrated in the area directly behind nipple on the chest wall. Like breast cancer in women, cancer of the male breast is the uncontrolled growth of the abnormal cells of this breast tissue. 3 Male breast cancer is a rare condition, accounting for only about 1 % of all breast cancers.3 Most of the cases of male breast cancer are detected in men between the age of 60-70 years.3 The incidence of malignant neoplasia of male breast is on the rise. The apparent significant increase in the incidence is most probably attributable to an increase in screened cases and to increase awareness. The statistical significance coupled with decreased morbidity and mortality associated with early detection of malignant tumours. 2
MATERIAL AND METHOD
A detail study of five cases over a period of five months i.e. from April, 2012 to August, 2012 was carried out to determine the diagnostic accuracy of FNAC for male breast carcinoma, in pathology department of our tertiary care teaching hospital. After detailed clinical history and physical examination, aspiration was carried out using 22 gauge needle and standard precautions. Smears were immediately fixed in 95% ethyl alcohol. Smears were stained with May Graunwald Geimsa (MGG), Hematoxylin and Eosin stain (Hand E) and Papanicolaou (PAP) stain. Cytopathological diagnosis had been recorded in each case. Results of FNAC are confirmed by histopathological examination
RESULTS A
total of five patients with male breast lump have been diagnosed and treated at our tertiary care hospital over a period of five months i.e. from April, 2012 to August, 2012 are taken into consideration. In all the cases, detailed clinical examination and pre-operative FNAC has been done and diagnosis has been recorded. The FNAC report has been confirmed by histopathological examination in all the five case. Out of all patients, one of the patients is in 6th decade, three patients are in 7th decade and one patient is in 8th decade (Table I and Chart I). One of the patient (patient is in 6th decade) has history of ulceration and reddening of overlying skin with serous discharge from it. Four of our patients has lump of about 2 X 2 cm diameter, firm, well defined, immobile, non-tender and fixed to chest wall. Only one patient in 8th decade has lump of about 0.8 X 0.8 cm, firm, well defined, immobile, non-tender and fixed to chest wall. Axillary lymph nodes are not palpable in any of the above patients. No history of mumps orchitis in their younger age, testicular trauma or prostatic lesion has been found out. After taking consent, fine needle aspiration (FNA) is performed in all the five patients from two different sites and cytological examination is performed in H and E stained smears. The smears are hypercellular showing loosely cohesive three dimensional clusters, syncitial grouping of cells with absence of bipolar naked nuclei (Figure I). The individual cells show hyperchromasia, pleomorphism, anisocytosis, irregular nuclear border, small prominent nucleoli, and scant amount of coarsely granular basophilic cytoplasm with presence of abnormal mitotic figures (Figure II). Cytological diagnosis of malignant breast lesion is concluded in all the five cases. The diagnosis is confirmed by histopathological examination
DISCUSSION
Fine needle aspiration of the breast is a rapid, relatively atraumatic and accurate method for the diagnosis of breast disease.4 The real challenge for FNA cytologist is in their ability to translate cytological patterns into histological ones that have diagnostic meaning. Early diagnosis of cancer is crucial, a delay in the diagnosis of breast cancer is unfortunately common because of economic and social reasons in our society, with a poor impact on the management of such patients, it is therefore, important that a reliable cost effective and easy to perform investigation like FNAC should be done in such circumstances. A definite diagnosis sometimes cannot be made by FNAC either due to inherent limitations of cytological examination or by inability to obtain adequate material for diagnosis. The rate of sampling error and inadequacy for lesion < 1 cm can be attributed to deep location of the lesions.2 Male breast carcinoma represents 1% of all breast carcinomas in USA, but in countries like Egypt, the incidence raises to nearly 10%.5,6 One report from King Faisal Hospital in Taif KSA, breast carcinomas constituted 8.3%.6 A similar higher incidence of male breast carcinoma has been reported by Koriech.7 Though there are no recognizable etiological reasons and the higher incidence may be related to the higher incidence of liver cirrhosis following hepatitis B, leading to hyperestrinism and malignancy in susceptible males. 6 Our 60 % of the patients were in seventh decade which was correlated with Wick MR8 et al. A study published from the US Virginia Medical School calculated the mean age for ductal carcinoma in males at 64 years and they found that 60% of these patients were obese.8 Most of the breast carcinoma are treated by surgery. A modified radical mastectomy is most common surgical treatment for male breast cancer. After surgery, adjuvant therapies are often prescribed. Adjuvant therapies include chemotherapy, radiation therapy, targeted therapy, and hormone therapy.3 The prognosis of male breast cancer is similar to female breast cancer. As in women, the size and extent (stage) of tumors are the most important factors in the prognosis for male breast cancer. Overall survival rates for each tumor stage are similar for men and women. Since men have least breast tissue than women, it is more common for breast cancers in men to have spread beyond the breast when they are identified, resulting in a more advanced tumor stage at diagnosis.3 Disease-specific five-year survival rates (meaning the percentage of patients who do not die of the disease for at least five years following diagnosis) reported for male breast cancers by stage is as follows: ? Stage 0 – 100% ? Stage I - 96% ? Stage II – 88% ? Stage III – 60% ? Stage IV – 23% These survival rates were calculated using historical data, and it is likely that current treatments will lead to even greater survival rates for those recently diagnosed. FNAC is an efficient tool for diagnosing male breast lesions with high sensitivity and specificity and should be used confidently as an investigation of choice for diagnosing male breast lesions.
CONCLUSION
In this era of economic constraints, low allocation of health budgets in developing countries, lack of screening programs and increasing cost of diagnostic procedures, patients are invariably at a disadvantage and present late for medical assistance. It is, therefore recommended that FNAC should be used as a routine diagnostic procedure in rare lesions due to its cost effectiveness, thus maximizing the availability of health care to patients. Palpable breast lesions can definitely be diagnosed by a combination of physical examination and FNAC which when performed by a dedicated cytopathologist should be an integral part of a breast screening service. Thus, FNAC is useful to diagnose carcinoma in early stages which also improve the prognosis of the patients.
Englishhttp://ijcrr.com/abstract.php?article_id=969http://ijcrr.com/article_html.php?did=969REFERENCES
1. Ibrahim Mansoor, Awatif Jamal; The Value of Fine Needle Aspiration Cytology in the Diagnosis of Male Breast Lesions; Kuwait Medical Journal; 2001; 33 (3): 216-219.
2. Rakhshindah Bajwa And Tariq Zulfiqar; Association of fine needle aspiration cytology with tumor size in palpable breast lesions; Biomedica Vol.26, Jul. – Dec. 2010; P. 124 – 129
3. Chapter in book: Carcinoma of the Male Breast. Paul Peter Rosen; Rosen’s Breast Pathology; 2nd Edition; Lippincott Williums and Wilkins: 713-728.
4. McManus DT and Anderson NH. Fine needle aspiration cytology of the breast. Current Diagn Pathol 2001; 7: 262-271.
5. El Gazareyli M, Abdel Aziz AS. On bilharziasis and male breast cancer in Egypt. A preliminary report and review of literature. Br J Cancer. 1963; 17:566-571.
6. Ram Kumar G, Al Misiri S. (Letter to editor) Pattern of breast diseases in Saudi Arabia. Saudi Medical J 1997; 20:200-201.
7. Koriech OM, Profile of cancer in Riyadh Armed Forces Hospital. Annals Saudi Med 1994; 17:187-194.
8. Wick MR, Sayadi, Ritter JH, Hill DA, Reddy VB, Gattuso P. Low-stage carcinoma of the male breast. A histological, immunohistochemical, and flow cytometric comparison with localized female breast carcinoma. Am J Clin Pathol. 1999; 111:59- 69.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524162EnglishN-0001November30HealthcareNOSOCOMIAL PNEUMONIA IN MECHANICALLY VENTILATED - A MULTIVARIATE ANALYSIS
English4047Rashmi M.English Shaik Mohammed UsmanEnglishBackground: The most frequent infection in ICUs, Ventilator-associated pneumonia (VAP); potentially life threatening, stands for another challenge in medicine. Earliness in diagnosis is pivotal. Constant surveillance is crucial to confront the issue by defining expedient strategies. Purpose: The study intended to present our experience in the intensive care units (ICUs) of causative organisms of VAP and their antimicrobial susceptibility profile, with the effect of different variables; utilising this data to devise more pertinent empirical therapy. Methodology: A prospective clinico-microbiological review of patients mechanically ventilated for ?48 hrs and in agreement with a clinical criteria, at a tertiary care set up, from multidisciplinary ICUs was undertaken by standard microbiological techniques. Antimicrobial resistance was patterned. Results: Occurrence of VAP was 49.07%. Late onset type (65.28%) was more frequent. Majority (85.95%) were caused by Gram Negative bacteria (GNB). Acinetobacter baumannii (30.58%) was most regular, followed by Pseudomonas aeruginosa (27.27%). 15 isolates (4 Escherichia coli, 9 Klebsiella spp., 2 Enterobacter spp.) produced ESBL (Extended Spectrum beta lactamase). 1 MRSA (Methicillin resistant Staphylococcus aureus) was isolated. Cases of OP (Organophosporous) poisoning- 31.48%; associated advancing age (>60 years) - 45.28%, Diabetes mellitus - 26.39% and COPD - 22.68% were pre-eminent. Conclusions: Monitoring trends of drug profile of the causative agents is of cardinal benefit for restricting the use of empiric broad spectrum antimicrobials which predisposes to colonization. Constant evaluation of current practice on basis of antibiotic consumption patterns, timely availability of data and programs to reduce or alter antibiotic-prescribing practices is crucial to avert the terrible impact of antimicrobial resistance.
EnglishVentilator associated pneumonia, Intensive care units, Gram negative bacteria, Acinetobacter baumannii, Pseudomonas aeruginosa.INTRODUCTION
Due to the high vulnerability of critically ill patients, and the use of procedures (invasive), the intensive care unit (ICU) is the focal point of nosocomial infections. These infections are associated with an important rise in morbidity, mortality and healthcare cost. The widespread use of tracheal intubation and mechanical ventilation in the ICUs has defined a set of cases who are at risk of nosocomial pneumonia (NP). Patients who are intubated and require mechanical ventilation have a 6 to 20 fold increased risk of pneumonia.1 Ventilatorassociated pneumonia (VAP) is defined as pneumonia that develops more than 48 hours after initiation of mechanical ventilation (MV). Conceptually, VAP is defined as an inflammation of the lung parenchyma caused by infectious agent/s not present or incubating at the time, mechanical ventilation was started.1 VAP may be caused by an array of bacterial pathogens. The etiology may be polymicrobial and rarely due to anaerobic bacteria, viruses or fungi. The etiological agents differ from that of the more common community-acquired pneumonia (CAP). In particular, viruses and fungi are uncommon causes in people who are immunocompetent. Prevalence of pathogens causing VAP may vary by hospital, patient population. Early diagnosis and initiation of appropriate antimicrobial(s) is of immense importance. The supplementary problem of multidrug-resistant pathogens boosts the impact of infections in ICUs. Several factors contribute to the rapid spread of multidrug-resistant pathogens in the ICU. These are new mutations, selection of resistant strains and suboptimal infection control. NP is categorized by the American Thoracic Society (ATS)2 as Early-onset NP (Nosocomial pneumonia occurring within 4 days after hospital admission) and Late-onset NP (Nosocomial pneumonia occurring 5 or more days after hospital admission). This categorization helps predict the implicated pathogens directing empiric therapy. Early-onset pneumonia commonly results from aspiration of endogenous community acquired pathogens colonizing the oropharynx. Conversely, late-onset VAP may be caused by more unusual or multidrug-resistant (MDR) pathogens following aspiration of oropharyngeal and gastric secretions.3 Oropharyngeal or tracheal colonization with Pseudomonas aeruginosa or enteric Gram negative bacilli is common in ICU patients, increases with length of hospitalization.4 Rosenthal et al showed the incidence of VAP in eight developing countries to vary between 10%- 52.7%.5 The incidence was reported to be around 45% by some south Indian Prospective studies.6,7 GNB including Pseudomonas aeruginosa, Acinetobacter baumannii and Enteric Gram negative rods are implicated in majority of the VAP episodes (41-92%) with predominance of either Pseudomonas aeruginosa or Acinetobacter baumannii in majority of the studies and Gram positive cocci particularly Staphylococcus aureus accounting for 6-58% of the isolates.8 For diagnosis, bacteriologic strategy requires quantitative cultures of lower respiratory specimens (Endotracheal aspirate-ETA, Bronchoalveolar lavage-BAL or Protected specimen brushPSB collected with or without a bronchoscope). Growth above a threshold concentration is used to diagnose VAP and to determine the causative microorganism(s). Growth below the threshold is assumed to be due to colonization or contamination. Quantitative cultures have been demonstrated to have good diagnostic utility for the presence of pneumonia, especially in patients with a low or equivocal clinical suspicion of infection.1,9 The consensus threshold values of quantitative culture is 105 cfu/ml for ETA secretions, 104 cfu/ml for BAL specimens and 103 cfu/ml for PSB material.1,10 This study tends to highlight the trend of this clinical condition with a keen focus on the antibiogram of the causative agents.
MATERIALS AND METHODS
A prospective study was done undertaking 216 cases, intubated and mechanically ventilated for more than 48hrs with a clinical suspicion of pneumonia10,11 (a new/progressive/persistent infiltrate on the chest radiograph and at least one of the following: leucocytosis >12×109 /ml, fever >38.3°C, or the presence of purulent tracheobronchial secretions) between January 2013 and October 2013 from the multidisciplinary ICUs of a tertiary care set up (M S Ramiah memorial hospital, Bangalore). Patients with preexisting pneumonia were excluded. Personal details and data such as date of admission into intensive care unit, chief complaints, risk factors Rashmi M. et. al. NOSOCOMIAL PNEUMONIA IN MECHANICALLY VENTILATED - A
involved, duration of mechanical ventilation, clinical signs was obtained. Data related to general physical examination, a battery of routine investigations- radiological and haematological investigations was collected. The VAP group was classified into two groups, early-onset type (60 years (45.28%) was predominant. [Table-1] Male dominance (68.98%) was identified. [Figure- 1] The frequently predisposing clinical condition was OP poisoning (31.48%). The associated conditions which are considered as important risk factors were advancing age (>60 years)- 45.28%, Diabetes mellitus- 26.39% and COPD- 22.68%. Majority of the VAP episodes were of late onset type (141/216-65.28%). ETA and BAL cultured from 89 and 12 cases respectively showed significant growth and no organism was isolated from 85 cases. [Table-2] [Figure-2] The isolates were polymicrobial in 14.85% (15/101) of the samples showing significant growth. Out of the total isolates (121) obtained, 5 were fungi (4- Candida albicans, 1- Aspergillus fumigatus). [Figure-3] The presence of Aspergillus fumigatus as an invasive pathogen was further confirmed by a positive Serology (IgG/Galactomannan). Gram negative bacilli were significantly isolated in largest number (104/121) accounting for 85.95% of the total isolates. Acinetobacter baumannii (30.58%) was the preponderant organism isolated followed by Pseudomonas aeruginosa (27.27%), former being predominant in late onset variety and the latter in the early type. The Streptococcus pneumoniae isolate was observed to be sensitive to all the drugs tested. All isolates of Streptococcus viridans (7/7) were sensitive to Vancomycin and Linezolid; while only 5 isolates (71.42%) showed susceptibility to Pencillin-G, Oxacillin, Ampiclox, Ceftriaxone and Levofloxacin and only 4 (57.14%) were sensitive to Erythromycin and Doxycycline. None of the Staphylococcus aureus (0/2) isolate was resistant to Cotrimoxazole, Vancomycin, Linezolid and Teicoplanin; while 1 was resistant to rest of the drugs tested (Amoxyclav, Cloxacillin, Cephalexin, Cefoxitin, Pencillin-G, Ciprofloxacin, Erythromycin, Clindamycin and Doxycycline). The antibiogram of the isolated GNB (with Nonfermenters) is depicted in Tables-3A, 3B, with low susceptibility in bold numbers. There were altogether 15/104 isolates (4 Escherichia coli, 9 Klebsiella spp., 2 Enterobacter spp.), which exhibited ESBL production accounting for 14.42% of the GNB tested. Methicillin resistance was encountered in 1 isolate (50%) of Staphylococcus aureus.
DISCUSSION
This prospective study has addressed the occurrence, clinical peculiarities and microbiology of VAP at a tertiary care set up. There is a fluctuating incidence of VAP, as reported in different studies, and varies from 7% to 70%.15,16,17 Our study showed occurrence of VAP to be around 50%, which is in accordance to various studies.6,7,18,19 The predominance of patients in the age group of 51-60 years could be attributed to the increasing number of hospital admissions occurring in this age group and to their high association with comorbid conditions. This type of age dominance is documented in other studies too.6,7 The male gender dominance identified here is also observed in some studies.6,20 The predisposing conditions identified may cause colonisation and pneumonia due to disease associated impairment in host defense function and are considered as important risk factors by various studies.6,7,19 Majority of the VAP episodes were of late onset type. This data simulates the findings of other studies done.20,21 The report of high incidence of aerobic gram negative bacteria (87.60%) is consistent with some prior reports.5,22 This can be attributed to oropharyngeal colonization of aerobic GNB, to which the critically ill patients in ICU are more susceptible.23 The incidence of the polymicrobial isolates, though less, is well comparable to some studies performed.22,24 Most of the Gram positive cocci isolated were susceptible to antibiotics tested, while majority of GNB were multi-resistant with considerable ESBL production. The results represent the experience from a single centre, and may not be generalizable to other areas with different epidemiologic or clinical settings. Intuitiveness into trends of the causative agents responsible for this burdensome condition with their drug resistance is of cardinal benefit for restricting the use of empiric broad spectrum antibiotics which predisposes to colonization.
CONCLUSION
VAP creates a havoc in ICUs with its soaring incidence and due to detrimental effects of the upsurging antimicrobial resistance. Individuals with advancing age and associated co-morbid conditions in ICUs are more prone to develop VAP. Aerobic gram negative bacilli are the most common isolates found, Acinetobacter baumannii and Pseudomonas aeruginosa being the most regular. Auxiliary efforts are much needed to curtail the perinicious outcome of antimicrobial resistance. Constant evaluation of current practice on the basis of trends in drug resistance and antibiotic consumption patterns, timely availability of data and programs to reduce or alter antibioticprescribing practices is pivotal to avert the terrible impact of antimicrobial resistance.
ACKNOWLEDGEMENTS
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed.
DECLARATIONS -
Funding: None Competing interests: None declared
Englishhttp://ijcrr.com/abstract.php?article_id=970http://ijcrr.com/article_html.php?did=970REFERENCES
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2. Campbell GD, Niederman MS, Broughton MA, Craven DE, Fein AM, Fink MP et al American Thoracic Society. Hospital-acquired pneumonia in adults: diagnosis, assessment of severity, initial antimicrobial therapy, and preventive strategies. A consensus statement. Am J Respir Crit Care Med 1995;153:1711- 25.
3. Ewig S, Bauer T, Torres A. The pulmonary physician in critical care: Nosocomial pneumonia. Thorax 2002;57:366-71.
4. Bergmans DC, Bonten MJ, van Tiel FH. Cross-colonization with Pseudomonas aeruginosa of patients in an intensive care unit. Thorax 1998;53:1053-58.
5. Rosenthal VD, Maki DG, Salomao R, Moreno CA, Mehta Y, Higuer F et al. Deviceassociated nosocomial infections in 55 intensive care units of 8 developing countries. Ann Intern Med 2006;145:582-91.
6. Arindam Dey, Indira Bairy. Incidence of multidrug resistant organisms causing ventilator- associated pneumonia in a tertiary care hospital: A nine months prospective study. Annals of thoracic medicine 2007;2:52- 7.
7. Girish L. Dandagi. Nosocomial pneumonia in critically ill patients. Lung India 2010;27:149- 53.
8. Yaseen Arabi, Nehad Al-Shirawi, Ziad Memish, Antonio Anzueto. Ventilatorassociated pneumonia in adults in developing countries: a systematic review. International journal of infectious diseases 2008;12:505-51.
9. Heyland DK, Cook DJ, Marshall J, Heule M, Guslits B, Lang J et al. Canadian Critical Care Trials Group. The clinical utility of invasive diagnostic techniques in the setting of ventilator-associated pneumonia. Chest 1999;115:1076-84.
10. Fabregas N, Ewig S, Torres A, El-Ebiary M, Ramirez J, Puig de la Bellacasa et al. Clinical diagnosis of ventilator associated pneumonia revisited, comparative validation using immediate post-mortem lung biopsies. Thorax 1999;54:867-73.
11. Johanson WG, Pierce Ak, Sandford JP. Nosocomial respiratory infections with gramnegative bacilli: the significance of colonization of the respiratory tract. Ann Intern Med 1972;77:701–6.
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13. Jagadish Chander, Textbook of medical mycology 3rd ed. (Mehta Publishers, New Delhi) 2009. p.no. 53-67.
14. CLSI. Performance Standards for Antimicrobial Susceptibility Testing: TwentyThird Infromational Supplement. CLSI Document M100?S23. Wayne PA: Clinical and Laboratory Standards Institute; 2013.
15. Cook DJ, Walter SD, Cook RJ, Griffith LE, Guyatt GH, Leasa D et al. Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Ann Intern Med 1998;129:433-40.
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8. Trivedi TH ,Shejale SB, Yeolekar ME. Nosocomial pneumonia in Medical intensive care unit. JAPI 2000;48:1070-73.
19. Panwar Rakshit P, Nagar VS, Deshpande AK. Incidence, clinical outcome and risk stratification of ventilator-associated pneumonia: a prospective cohort study. Indian J Crit Care Med 2005;9:211-6.
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22. Mukhopadhyay C, Bhargava A, Ayyagari A. Role of mechanical ventilation and development of multidrug resistant organisms in hospital acquired pneumonia. Indian J Med Res 2003;118:229-35.
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24. Nidhi Goel, Uma Chaudhary, Ritu Aggarwal, Kiran Bala. Antibiotic sensitivity pattern of gram negative bacilli isolated from the lower respiratory tract of ventilated patients in the intensive care unit. Indian J Crit Care Med 2009;13:148-51.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524162EnglishN-0001November30HealthcareNARROWING OF JUGULAR FORAMEN DUE TO BONE GROWTH AT JUGULAR FOSSA IN THREE DRIED SKULLS - A CASE REPORT
English4851Udaya Kumar. P.English Chandra Mohan. M.English Murali Krishna S.English Kalpana. T.English Rajesh. V.English Naveen Kumar. B.EnglishVariations in the size and shape of jugular foramen are of considerable importance. An abnormal and partial obliteration of jugular foramen by a bony growth were observed in three skulls during osteology demonstration classes for medical undergraduates. Jugular foramen transmits important cranial nerves (IX, X, XI), internal jugular vein and inferior petrosal sinus. So, narrowing of the jugular foramen might result in neurovascular symptoms, a condition called Vernet’s syndrome, which is discussed along with the case. The knowledge of this bony abnormality is of great importance to neurologists, radiologists, anthropologists and neurosurgeons.
EnglishJugular Foramen, Jugular Fossa, Skull Base, Vernet’s SyndromeINTRODUCTION
The jugular foramen is an irregular hiatus, which lies at the posterior end of the petro-occipital suture between the jugular process of the occipital bone and the jugular fossa of the petrous part of the temporal bone1 . A fibrous or osseous bridge divides the foramen into two compartments. The anteromedial compartment, the pars nervosa, transmits glossopharyngeal (IX) nerve and inferior petrosal sinus. The pars vascularis, posterolateral compartment, contains the jugular bulb and transmits vagus (X) and spinal accessory (XI) nerves2 . Tekdemir I, et al reported that a dural septum separates the IX cranial nerve from the X and XI cranial nerves3 . Vernet’s syndrome is characterized by loss of taste sensation over the posterior 1/3rd of the tongue, paralysis of vocal cords along with dysphasia and weakness of sternocleidomastoid and trapezius muscles, which are due to involvement of cranial nerves IX, X and XI respectively.
CASE REPORT
During routine osteology demonstration classes for the undergraduate medical students, an unusual narrowing of jugular foramen was observed in 3 dried skulls. Measurements of jugular foramen of the three skulls are mentioned in the table – 1 and are shown in the figure 1, 2 and 3. The jugular foramen was reduced to less than half of its size on one side in specimens 2 and 3 when compared to their counter side, where as specimen 1 showed marked narrowing bilaterally. No other abnormalities were observed in the skulls.
DISCUSSION
The jugular foramen of the skull transmits the sigmoid sinus, inferior petrosal sinus, ninth, tenth and eleventh cranial nerves. The jugular fossa lodges the superior bulb of the internal jugular vein. In a morphometric analysis by Lang and Schreiber4 (as quoted by Thomas J. Vogl et al4 ) showed that the mean dimensions of jugular foramen are 14.5 × 7 mm at the internal skull base and 9 × 17 mm at the outer surface. Sturrock, et al5 ; Hatiboglu MT, et al6 and Hakuba A, et al7 observed in their individual studies, that the pars vascularis is usually larger on the right side causing asymmetry of the jugular foramina. In a study on 300 dried skulls Hatibo?lu MT, et al6 , observed a bony dome in jugular foramen, bilaterally in 49%, on the right only in 36%, on the left only in 6%; it was absent bilaterally in 10.3 % specimens. A Complete septation by a bone growth occurred in 5.6% on the right and in 4.3% on the left side, partial septum was observed in 2.6% on the right and in 19.6% on the left side. Danny R. Sawyer, et al8 , observed bridging of jugular foramen in 8.1% of cases. S Nayak9 and Rakhi Rastogi, et al9 observed a slit like jugular foramen, due to partial obstruction of jugular foramen by an abnormal bony growth at jugular fossa, In the present case also such abnormal slit like jugular foramen were observed in three dried skulls. One out of the three specimens showed bilateral narrowing and the remaining two showed narrowing on one side only. Reduced size of jugular foramen and jugular fossa might cause neurovascular symptoms which can mimic the symptoms caused by hyper vascular glomus jugulare tumors, neural sheath tumors like schwannomas, jugular meningiomas or nodules reducing the size of foramen in Varicella zoster infection. Superior bulb of internal jugular vein may be compressed by the bony growth in the jugular fossa which can result in venous congestion in the cranial cavity. The compression of glossopharyngeal, vagus and spinal accessory nerves might result in vernet’s syndrome which is characterized by paralysis of pharynx, larynx and palate.
CONCLUSION
The anatomical variations like reduced size of jugular foramen and jugular fossa warrant a careful attention during clinical diagnosis, as the
structures of this region may be at risk during micro surgical procedures. So the knowledge of this bony abnormality is of great importance to neurologists, radiologists, anthropologists and neurosurgeons. Competing Interests The authors declare that we have no competing interests. Ethical committee clearance As the study included only human dried bones, ethical committee clearance was not taken into consideration. Authors will take the responsibility of any further allegations regarding ethical clearance that arise from the study.
ACKNOWLEDGEMENTS
Authors acknowledge the immense help received from the scholars whose articles are cited and included in the references of the manuscript. The authors are also grateful to scholars / authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=971http://ijcrr.com/article_html.php?did=971REFERENCES
1. Standring S, Borley NR, Collins P, Crossman AR, Gatzoulis MA, Healy JC, et al. Gray’s Anatomy. 40th Ed. London: Churchill Livingstone, 2008.
2. Daniels DL, Williams AL, Haughton VM. Jugular foramen: anatomic and computed tomographic study. AJR Am J Roentgenol. 1984; 142: 153–158.
3. Tekdemir I, Tuccar E, Aslan A, et al. The jugular foramen: a comparative radioanatomic study. Surg Neurol.1998; 50: 557–562.
4. Lang J, Schreiber T. Uber form und lage des foramen jugular (fossa jugularis), des canalis caroticus und des foramen stylomastoideum sowie deren postnatale lageveränderungen. HNO. 1983; 31: 80–87. As quoted by Thomas J. Vogl, Sotirios Bisdas. Differential Diagnosis of Jugular Foramen Lesions. Skull Base. 2009 January; 19(1): 3– 16.
5. Sturrock RR. Variation in the structure of the jugular foramen of the human skull. J Anat. 1988; 160 227–230.
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7. Hakuba A, Hashi K, Fujitani K, Ikuno H, Nakamura T, Inoue Y. Jugular foramen neurinomas. Surg Neurol. 1979; 11: 83–94.
8. Danny R. Sawyer, Michael L. Kiely. Jugular foramen and mylohyoid bridging in an Asian Indian population. American Journal of Physical Anthropology. 1987; 72: 4; 473 – 7
9. Nayak S. Partial obstruction of jugular foramen by abnormal bone growth at jugular fossa. Internet J Biol Anthropol. 2007; 1: 2.
10. Rakhi Rasthogi, Virendra Budhiraja, slit like jugular foramen due to abnormal bone growth at jugular fossa, International Journal of anatomical variations (2010) 3: 74-75.