Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareDentists - An Extended Arm during COVID-19
English0101Dr. Little MahendraEnglishEnglishCOVID-19, Health care system, Dental personnel, PPEhttp://ijcrr.com/abstract.php?article_id=2884http://ijcrr.com/article_html.php?did=2884Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareChanges in Haematological Parameters among COVID-19 Patients
English0204Haytham DahlawiEnglishCorona Virus Disease 2019 (COVID-19) is the pandemic world crisis that causes the most dangerous health and economic disaster since the second world war. The world health organization (WHO), in February 2020 has announced about the new epidemic disease caused by 2019-nCoV: 2019 Coronavirus Disease (COVID-19). Several health problems were associated with COVID-19 infection including; dry cough, fever, fatigue, headache, haemoptysis, diarrhoea, dyspnoea, and lymphopenia COVID-19 infection was associated with death especially among older patients. Coronaviruses can infect bone marrow cells leading to abnormal blood production and synthesis (haematopoiesis). Thus, several changes have been reported in haematological parameters among COVID-19 patients. Yet, the mechanisms by which this virus delays and inhibit the hematopoietic system are not clear. This review was aimed to focus on the most common laboratory changes within the haematological parameters including; white blood cells, lymphocytes, platelets and other.
English COVID-19, Haematologicalparameters, WBCs, Lymphocytes, ThrombocytopeniaIntroduction
Corona Virus Disease 2019 (COVID?19) is the pandemic world crisis that causes the most dangerous health and economic disaster since the second world war. The world health organization (WHO), in February 2020 has announced about the new epidemic disease caused by 2019-nCoV:2019 Coronavirus Disease (COVID-19)1. The COVID-19 was reported as a very highly spread virus, however, some transmission method between patients and healthy person is still unclear2. It has been estimated that the median incubation period (the period from exposure to the appearance of the symptoms) for COVID-19 is between 2 and 14 days3. Several health problems were associated with COVID-19 infection including; dry cough, fever, fatigue, headache, haemoptysis, diarrhoea, dyspnoea, and lymphopenia4,5. Moreover, rhinorrhoea, sneezing, and sore throat was found as unique clinical features7. COVID-19 infection was associated with death especially among older patients. Many studies were reported that the period from onset of symptoms among COVID-19 infected patient to death ranging from 6 to 41 days. Whereas this period is varying according to many factors such as the patient’s age and patient's immune system status. Patients aged 70-years old and more were reported with a shorter period between the onset of COVID-19 symptoms and death8.
Coronavirus and total white blood cells level
Clinical laboratory investigations are essential to confirm COVID-19 infection and also to follow up patient’s health status. It has been found that coronaviruses can infect bone marrow cells leading to abnormal blood production (hematopoiesis)9. Thus, several changes have been reported in haematological parameters among COVID-19 patients. Yet, the mechanisms by which this virus delays and inhibit the hematopoietic system are not clear.
From day one to fourteen while the incubation period and none of the symptoms are presented, the total white blood cell (WBC) count is normal or slightly decrease10. Following the incubation period, Ding and colleagues, reported low white blood cell count (leukopenia) in more than 25% of hospitalized patients with COVID-1911. The result of a retrospective study performed on asymptomatic patients under 18 years old in the recovery period showed a low level of white blood cells among 20% of patients1. Within the same study, an increase in lymphocytes in 18.75% of patients was reported1. Another study done to investigate the level of WBCs among hospital admitted patients with COVID-19 and showed that leukopenia developed in 20% of patients12. A more recent study in Hanchuan City People's Hospital showed decreased WBCs account among the vast majority (99%) of COVID-19 infected patients11.
Coronavirus and lymphocytes level
Regarding the level of lymphocytes in COVID-19 infected patients, normal or slightly low level was reported among patients during the incubation time10. However, low level of lymphocytes was detected in 83.2% of hospital admitted patients10. A significant association between low lymphocytes count and requirement of intensive care unit (ICU) admission was reported by Wu and his colleagues13. In Washington state, decreased level of lymphocytes was highly reported with seriously ill COVID-19 patients in ICU14. Also, low lymphocytes count was more commonly reported in ICU patients compared to the non?ICU patients. Thus, low lymphocytes level might be considered as an important indicator for early admission for supportive ICU care. Neutrophils are one of the immune cells which, protecting human bodies during bacterial or fungal infections by phagocytosis15. Huang et al. highlighted an increased level in neutrophils in patients with COVID-19 who is admitted in ICU4. High risk of development of acute respiratory distress syndrome (ARDS) and the mortality rate was significantly (P < .001) associated with high neutrophils level13.
Coronavirus and thrombocytes level
In Beijing, 72.5% of COVID-19 patients developed thrombocytopenia among 13 patients from three hospitals, however, the reduction on platelet count did not reach to the level at which bleeding happens16. Low platelets level (thrombocytopenia) was noted among COVID-19 patients on admission and ICU patients in 552 hospitals in 30 different provinces in China17. On the other hand, another study reported non-significant differences in platelets level between ICU patients and non- ICU patients8. Similarly, no significant changes in platelets level between COVID-19 patients with ARDS and patients without ARDS as reported in Wu’s study13. Xu and colleagues were reported three hypothesized mechanisms causing thrombocytopenia. The first mechanism by causing direct viral infection of bone marrow cells and impairing of platelet synthesis. Also, the decrease of platelet synthesis indirectly as a result of lung injury. The second mechanism is through the body’s immune system. The third hypothesized mechanism is by aggregation Of platelet in the lungs, leading to platelet consumption and microthrombi18.
Coronavirus and coagulation parameters
Other common alterations in haematological parameters in patients with COVID-19 are including; prolonged activated partial thromboplastin time (APTT) as well as elevated D-dimer levels. Such coagulation parameters were markedly higher among COVID-19 patients compared with healthy controls individuals. On the other hand, the majority of patients with COVID-19 infection were investigated with normal prothrombin time (PT)19. Several studies have been reported abnormality in D-dimer levels19,20. It has been shown that 28.6% of COVID-19 patients investigated with high D-dimer levels in the University of Hong Kong-Shenzhen Hospital21. Additionally, the complications and severity of the disease among patients with community-acquired pneumonia was significantly associated with D-dimer elevated levels22. Thus, higher D-dimers level is associated with patients WHO requiring ICU treatment and more severe cases20.
Conclusion:
In conclusion, since the World Health Organization announced virus Corona is a global pandemic the virus is still spreading strongly affecting and killing thousands of people around the World. Currently, scientific information about the disease and the nature of its spread is still not well known. Thus understanding pathophysiology of the disease to develop an effective treatment for the virus is still a challenge for the human being. Laboratory tests are an important factor in the diagnosis and treatment of the disease. According to the literature review, haematological parameters are changeable according to the course of COVID-19 infection and that some of them can be a sign of poor outcomes that may lead to death. Leukopenia, thrombocytopenia, lymphopenia, and coagulation abnormalities are the most notable haematological manifestations. However, this review article has some limitations. Because COVID-19 is considered a recent pandemic.
ACKNOWLEDGEMENT
I acknowledge the help and support of Dr Rana Zaini from clinical laboratory science department.
Englishhttp://ijcrr.com/abstract.php?article_id=2885http://ijcrr.com/article_html.php?did=28851. Zhang W, Yuan Y, Yang Z, Fu J, Zhang Y, Ma M, et al. Leukopenia of Asymptomatic COVID-19 Infections under 18 Years Old in Recovery Stage. medRxiv. 2020;4682
2. Rothan HA, Byrareddy SN. The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak.Journal of Autoimmunity. 2020.109,102433
3. Linton NM, Kobayashi T, Yang Y, Hayashi K, Akhmetzhanov AR, Jung S, et al. Incubation Period and Other Epidemiological Characteristics of 2019 Novel Coronavirus Infections with Right Truncation: A Statistical Analysis of Publicly Available Case Data. J Clin Med. 2020;9(2).
4. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223).
5. Lu H. Drug treatment options for the 2019-new coronavirus (2019-nCoV). Biosci Trends. 2020;14(1).
6. Garg N, Kothandaraman K, Jeyaraman M. Optimization of the response to nCOVID-19 pandemic in pregnant women – An urgent appeal in Indian scenario. Vol. 12(9), International Journal of Current Research and Review. 2020.
7. Assiri A, Al-Tawfiq JA, Al-Rabeeah AA, Al-Rabiah FA, Al-Hajjar S, Al-Barrak A, et al. Epidemiological, demographic, and clinical characteristics of 47 cases of Middle East respiratory syndrome coronavirus disease from Saudi Arabia: A descriptive study. Lancet Infect Dis. 2013;13(9).
8. Wang W, Tang J, Wei F. Updated understanding of the outbreak of 2019 novel coronavirus (2019-nCoV) in Wuhan, China. J Med Virol. 2020;92(4).
9. Yang M, Ng MHL, Chi KL. Thrombocytopenia in patients with severe acute respiratory syndrome (review). Hematology. 2005;10(2).
10. Terpos E, Ntanasis-Stathopoulos I, Elalamy I, Kastritis E, Sergentanis TN, Politou M, et al. Hematological findings and complications of COVID-19. Am J Hematol. 2020;95:834–847
11. Li R, Tian J, Yang F, Lv L, Yu J, Sun G, et al. Clinical characteristics of 225 patients with COVID-19 in a tertiary Hospital near Wuhan, China. J Clin Virol. 2020;127:104363.
12. Li YX, Wu W, Yang T, Zhou W, Fu YM, Feng QM, et al. Characteristics of peripheral blood leukocyte differential counts in patients with COVID-19. Zhonghua nei ke za zhi. 2020;59:E003--E003.
13. Wu C, Chen X, Cai Y, Zhou X, Xu S, Huang H, et al. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China. JAMA Intern Med. 2020;180(7):934-943
14. Arentz M, Yim E, Klaff L, Lokhandwala S, Riedo FX, Chong M, et al. Characteristics and outcomes of 21 critically ill patients with COVID-19 in Washington State. Jama. 2020;323(16):1612–4.
15. Németh T, Sperandio M, Mócsai A. Neutrophils as emerging therapeutic targets. Vol. 19, Nature Reviews Drug Discovery. 2020;19,253–275
16. Chang D, Lin M, Wei L, Xie L, Zhu G, Cruz CS Dela, et al. Epidemiologic and clinical characteristics of novel coronavirus infections involving 13 patients outside Wuhan, China. Jama. 2020;323(11):1092–3.
17. Guan W, Ni Z, Hu Y, Liang W, Ou C, He J, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020;382(18):1708–20.
18. Xu P, Zhou Q, Xu J. Mechanism of thrombocytopenia in COVID-19 patients.Annals of Hematology. 2020. 99:1205–1208
19. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395(10223).
20. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical Characteristics of 138 Hospitalized Patients with 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA - J Am Med Assoc. 2020;323(11).
21. Chan JFW, Yuan S, Kok KH, To KKW, Chu H, Yang J, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet. 2020;395(10223).
22. Snijders D, Schoorl M, Schoorl M, Bartels PC, Van Der Werf TS, Boersma WG. D-dimer levels in assessing severity and clinical outcome in patients with community-acquired pneumonia. A secondary analysis of a randomised clinical trial. Eur J Intern Med. 2012;23(5).
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareKnowledge, Attitude and Practice of Mothers for Administration of Medicaments to Their Children and its Correlation with Dental Caries
English0508Nilima Ramdas ThosarEnglish Sphurti Pramod BaneEnglish Nandinee HakeEnglish Suruchi GuptaEnglish Sudhindra Baliga M.English Nilesh RathiEnglishAim: The study was conducted to assess the awareness among parents especially the mothers regarding liquid medication among children and its relation to caries progression. Materials and Method: Around 230 mothers were included in the study. The mothers were asked to fill a validated questionnaire and her offspring were assessed for presence or absence of dental caries. Results: The data revealed that 80.4% of mothers preferred medication in syrup form, 63.5%administered medication twice daily while none of the mothers performed oral hygiene measures post medication. Around 78.7% of mothers were unaware of the relation between liquid medication and caries. Conclusion: The Pediatric dentists should create awareness among the mothers regarding liquid drug administration and oral hygiene measures.
English Liquid medication, Pediatric drugs, Dental Caries, Parental Knowledge, Oral Hygiene PracticesINTRODUCTION
Oral health is considered to be an important factor in a child’s overall growth and development. Dental caries being one of the major threats to children is multifactorial. It leads to decalcification of the teeth due to acid production caused by oral bacteria. The reaction between sugars in drinks, foods and bacteria in the dental biofilm present on the tooth surface causes the production of acid which is responsible for the initiation of dental caries.1,2
Analgesics and antibiotics along with various multivitamin supplements are commonly prescribed to children. These medications are widely available in syrup or suspension form and sweetened to increase patient compliance. Along with acceptance by the pediatric age group, medication in syrup form has good absorbability and flexibility with dosage.3 However, long term usage of sweetened oral medication can cause amplification of risks by making patients more susceptible to dentinal caries.4
High sucrose, fructose and glucose content in these medications along with other contributing factors like low pH, the duration and frequency and time of administration leads to an increase in caries in children. The incidence of caries can be reduced if proper precautionary and preventive measures are taken by the child’s parent or guardian. Poor attitude of parents towards the oral health of children is one of the reasons for the increase in caries prevalence.
Thus, this study is scheduled to assess the knowledge and awareness of mothers about cariogenicity of pediatric syrup medications and its correlation to dental caries.
MATERIALS AND METHODS
The study was a prospective study conducted in the Department of Pediatrics and Preventive Dentistry, Sharad Pawar Dental College and Department of Pediatrics, Acharya VinobaBhave Rural Hospital, Sawangi(Meghe), Wardha. Institutional Ethical Approval (DMIMS (DU)/IEC/2018-19/7172) was obtained from Datta Meghe Institute of Medical Sciences ethical committee.
The study included 230 mothers of children aged between 4 to 8 years of age and mothers of immunocompromised children or those having systemic medical history were excluded from the study. A validated short questionnaire consisting of 4 multiple choice questions were used for the study. (Table 1) The questionnaire was framed in local language about awareness regarding the administration of medication to their children.
The oral cavity of children of participated mothers was examined for dental caries and recorded in the study.
STATISTICAL ANALYSIS
The data obtained was calculated using descriptive statistics employing absolute distribution, percentage of measures and techniques of interferential statistics. Frequency analysis was done using SPSS software version 22.0.
RESULTS
Amongst the 230 mothers who participated in the study, 80.4% mothers preferred syrup and 1.7% mothers preferred tablets for their child while 17.8% mothers preferred medication in both forms for their children (Graph 1). 63.5% of mothers revealed that they administered medication twice daily while 34.8% of mothers used to administer medication thrice for their children (Graph 2). None of the participated mothers made their child brush post medication, however, 93.9% mentioned that their child drinks water after intake of medication and 6.1% mothers took oral hygiene measures and made their child gargle with water post medication intake (Graph 3).
The relationship between frequent consumption of medications and dental caries was not known to 78.7% mothers while 19.1% of mothers thought that these medications could not cause dental caries (Graph 4). The dental caries status of children having one carious lesion is among 33.9% whereas only 3.5% of children had more than 6 carious teeth in the mouth (Graph 5).
DISCUSSION
Lokken et al. and Imfeld et al. mentioned the presence of sucrose in medicines having cariogenic potential. This sucrose amount varied from 0-67% in pediatric liquid medication.5 Agrawal et al.6 observed a range of 20.62 – 68.26% sucrose in Indian Pediatric liquid medication.6 Commercially available medications for pediatric age group are mainly in sucrose based syrup forms as the liquid preparation for drug delivery are popular and easily accepted by children.7
Historically, Roberts and Roberts first documented harmful effects on the oral health of a child due to oral medication in 1979.8 Physicians including the Pediatricians prescribe medications for cough, fever along with medications for overall growth and well-being. Pediatric dentists are well aware of the relationship between liquid medication and dental caries. However, due to parental preference and lesser knowledge about the of non-sweetened pediatric medications availability in the market, they tend to prescribe the medication in liquid syrup form.
Mothers are unaware of the hidden sugar components in liquid medicaments and their implication on the oral and dental health of the child. Liquid medications can lead to rampant dental decay and it can be considered as one of the major etiologic factors.9 Literature suggests an increase in caries incidence in children consuming liquid medication. It has been noted that in children consuming liquid medications, the incidence of dental caries is also increased.10,11,12 Also, low endogenous pH of these medications is responsible for erosive and cariogenic potential in children.13,14
Nowadays, it is seen that there is an increased usage of non-prescription and over the counter liquid medicaments for cough and cold in children. But many studies have shown that there are adverse effects associated with non-prescription drug administration.15 Walimbe et al.16 through his study stated that about 50% paediatrician prescribed medication in the form of syrup, whereas more than 80% parents stated that their children preferred medication in the liquid form as stated in the present study.
Mothers are often responsible for the administration and care related to the use of pediatric medicines. The medical practitioners should encourage the parents to restrict the intake of the medication to mealtimes and avoid administrating medication before sleeping.17 In the present study, around 63.5% of parents administered medications twice daily while only 0.4% administered it four times a day. The duration has a major impact on dental caries, as Girish Babu et al.5 stated that syrups given in 2-3 divided doses especially during the night have a deleterious effect on enamel. This can be attributed to the fact that the saliva rate decreases during the night and the oral muscular co-ordination is less leading to decrease in the oral clearance process and reduced ability to eliminated the retained particles from the mouth.
Pediatric dentists emphasize parents on seeking regular preventive oral care for their children along with a routine oral hygiene recommendation post medication administration.7 The frequency of consumption of sugar is proportional to the experience of caries. Consumption of these liquid medicines increases the number of sugar exposure in the child’s normal diet thereby increasing the risk of caries.18 About 33.9% of children had only one carious lesion while only 3.5% has carious lesion more than six carious teeth. This can be attributed to the fact that majorly 91% of mothers mentioned that they made the child drink water post medication. This was a major oral hygiene factor practised by the mothers unknowingly, flushing the liquid medication of the teeth surface and decreasing dental caries incidence.
It is important to spread awareness amongst parents about the potential risk of inadvertent and injudicious use of these medications in which Pediatricians and Pedodontists play an important role. They should inform the parents about the sugar content of these medications, recommend limited use whenever possible, use of tablets be encouraged, advice brushing after administration, medication to be given at mealtimes rather than between meals and avoid administration at bedtime.19Pediatricians, Pediatric dentists and Physicians should prescribe non-sucrose medicaments and advice adequate preventive and oral hygiene measures for children on the long term use of liquid medicines.20
Conclusion
The Pediatric dentist and Pediatricians should create awareness among the parents regarding caries incidence due to liquid medication. They should be encouraged to take adequate post medication measures in their children.
Financial support
Nil
Conflict of interest
There are no conflicts of interest.
Englishhttp://ijcrr.com/abstract.php?article_id=2886http://ijcrr.com/article_html.php?did=28861. Gaidhane, A.M., M. Patil, N. Khatib, S. Zodpey, and Q.S. Zahiruddin. “Prevalence and Determinant of Early Childhood Caries among the Children Attending the Anganwadis of Wardha District, India.” Indian Journal of Dental Research 24, no. 2 (2013): 199–205. https://doi.org/10.4103/0970-9290.116677.
2. Kriplani, R., R. Bahadure, and N. Thosar. “Full Mouth Rehabilitation of Early Childhood Caries: A Case Report.” Journal of Datta Meghe Institute of Medical Sciences University 7, no. 1 (2012): 51–53.
3. Nunn T, Williams J. Formulation of medicines for children. Br J Clin Pharmacol. 2005 Jun;59(6):674–6.
4. Roberts IF, Roberts GJ. The relation between medicines sweetened with sucrose and dental disease. Br Med J. 1979 Jul 7;2(6181):14–6.
5. K. L. Girish Babu, Geeta Maruti Doddamani, L. R. Kumaraswamy Naik, K. N. Jagadeesh J Int Soc Prev Community Dent. 2014 May-Aug; 4(2): 108–112.
6. Agrawal N, Shashikiran ND, Vanka A, Thakur R, Sandhu SS. Cariogenic potential of most commonly prescribed liquid oral medicines for children. Peo J Sci Res. 2010;3:7–10.
7. Jehan Al Humaid. Sweetener content and cariogenic potential of pediatric oral medications: A literature. Int J Health Sci Qassim. 2018 Jun;12(3):75–82.
8. Bhandary S, M. R P, Shetty UA. Paediatricians Perceptions towards the Use of Sweetened Liquid Medications and its Relationship to Oral Health of Children. J Evol Med Dent Sci. 2019 Oct 14;8(41):3070–3.
9. Feigal RJ, Jensen ME, Mensing CA. Dental caries potential of liquid medications. Paediatrics. 1981 Sep;68(3):416–9.
10. Roberts IF, Roberts GJ. The relation between medicines sweetened with sucrose and dental disease. Br Med J. 1979 Jul 7;2(6181):14–6.
11. Bigeard L. The role of medication and sugars in pediatric dental patients. Dent Clin North Am. 2000 Jul;44(3):443–56.
12. Shaw L, Glenwright HD. The role of medications in dental caries formation: need for sugar-free medication for children. Pediatrician. 1989;16(3–4):153–5.
13. Passos IA, Sampaio FC, Martínez CR, Freitas CHS de M. Sucrose concentration and pH in liquid oral pediatric medicines of long-term use for children. Rev Panam Salud Publica Pan Am J Public Health. 2010 Feb;27(2):132–7.
14. Lökken P, Birkeland JM, Sannes E. pH changes in dental plaque caused by sweetened, iron-containing liquid medicine. Scand J Dent Res. 1975 Sep;83(5):279–83.
15. Yang M, So T-Y. Revisiting the safety of over-the-counter cough and cold medications in the pediatric population. Clin Pediatr (Phila). 2014 Apr;53(4):326–30.
16. Walimbe H, Bijle MNA, Nankar M, Kontham U, Bendgude V, Kamath A. Knowledge, Attitude and Practice of Paediatricians toward Long-Term Liquid Medicaments Associated Oral Health. J Int Oral Health. :4.
17. Nirmala SV, Popuri VD, Chilamakuri S, Nuvvula S, Veluru S, Minor Babu MS, et al. Oral health concerns with sweetened medicaments: Pediatricians’acuity. J Int Soc Prev Community Dent. 2015;5:35–9.
18. Girish Babu KL, Doddamani GM, L.R KN. Knowledge, attitude, and practice of paediatricians regarding pediatric liquid medicaments. Eur J Dent. 2017 Jan;11(01):106–10.
19. Durward C, Thou T. Dental caries and sugar-containing liquid medicines for children in New Zealand. N Z Dent J. 1997 Dec;93(414):124–9.
20. Bradley MB, Kinirons MJ. Choice of sugar-free medicines by a sample of dentists, doctors and pharmacists in Northern Ireland: the views of parents and health professionals. Community Dent Health. 1998 Jun;15(2):105–8.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareHow Logical and Mathematical Games Treat Patients and Adults Suffering from Dementia
English0913Vinothini KasinathanEnglish Akansha MandhanaEnglish Aida MustaphaEnglish Nur Sarah Adha AdamEnglishResearch in recent years has proven the effectiveness of brain games for staving-off the onset of dementia as people we age. This is because games offer both social and mental stimulation especially old people with dementia. Games are good to exercise the brain and to slow down worsening cognitive capacity. Five types of games that are especially suitable for dementia lovers include card games, Bingo, visual games, word puzzles, and video games. To capitalize on this aspect, this paper reviews the potential of logical and mathematical games to induce mental health among the public in general, and old people as well patients of dementia in particular.
English Mathematical game, Dementia, Mental simulation
Introduction
According to the Merriam-Webster dictionary, the noun ‘game’ means an activity engaged in for diversion or amusement. In the existence of mankind, humans play certain games to lighten up their mood, have fun, or to distract themselves from other issues. In this era, however, games have become digitalized. It is a fact that every single person’s normal life can include a normal or high rate of playing computer or video games even conventional non-digitalized games1. Since the existence of phones, we have now come to a time when everyone has a mobile device, be it a laptop or a mobile phone. The mobile phones that we use are increased in quality every year as well as an increase in functionalities and features. It is because of this that the gaming industry has skyrocketed, especially with mobile phones now sometimes having better Graphics Processing Units (GPUs) than average laptops. Laptops, on the other hand, have become affordable items that can be deemed as necessities for our everyday lives.
Gaming addiction is also a prevalent issue at present times as many teens and children waste their time on games that do not increase their problem-solving skills and mental state. With gaming addiction, our youth has succumbed to it, with ongoing technological advancements making it easier for anybody with a tablet, mobile device, television, notebook computer or desktop to be able to play a game whenever boredom strikes2
Over 90% of children in the United States play video games, and quite a high amount of time is used playing them 3. The problem is that with gaming addiction, the games that our youth sometimes play have no benefit to the brain or hardly give any increase in knowledge.
Aside from gaming addiction, it is also a known fact that social media can sometimes bring negative effects to its users, causing depression and other forms of negative emotions4. Both our youth, adults, and senior citizens can agree that not only does social media can spread positivity, but it can also spread negativity in the form of media, news, and posts that contain harsh, violent, and negative content that can disrupt moods and affect its readers. Public users must be educated with the types of games that can enhance critical thinking and problem-solving skills, not necessarily confined to educational materials for school children only.
As today’s generation grows old in the future, the culture of playing video games has been long rooted in their behavioural routine. Health deterioration and complications will persist and we must prepare for technology or platform that could contribute to the mental health of senior people. To capitalize on this aspect, this paper reviews the potential of logical and mathematical games to induce mental health among the public in general, and old people as well patients of dementia in particular.
The remaining of this paper proceeds as follows. Section 2 reviews in-depth two mental application games in the market. Section 3 discusses the findings and concludes the paper with some indication of future projects.
Review of Mental Games
This paper reviews in detail two highly popular mind games promoting problem-solving skills, which are Peak and Nonograms Katana. The main criterion of choosing the applications to review is based on the suitability of the concept
to be adopted by different audience altogether, which is older people or patients with dementia. A study by O. Anderson5 reported the following key findings when researching attitudes and habits of adults age 50-plus in playing video games from a nationally representative sample of 2,964 adults ages 50-plus (gamers, n = 1510; non-gamers, n = 1454). The key findings are as follows:
38% of adults aged 50-plus are gamers (every four in ten adults).
59% of the senior gamers use computers/laptops and 57% use the phone/other mobile devices.
59% of senior gamers say they play games online. 37% of 50-59 year-olds play video games weekly but
43% of 60-plus say they play every day.
22% of the senior gamers have made any video game-related purchases in the past 6 months.
77% bought for themselves, while 52% bought for others. Half of the online gamers report playing games online more today than they did five years ago.
Relative to this review, the top three favourite types of video games among the respondents are moreover, the main reason gamers say they are playing video games is to have fun (26 % say that's a very important factor and 52 % say it's very important).
Results
Peak
The peak is a mobile application developed by PeakLabs. It is a comprehensive collection of exercises designed to hone the player’s memory, sharpen their problem-solving skills, and enhance their mental agility. Figure 1 shows the screenshot of Peak and the user profile in Peak. Peak has a sleek logo design, showing how tech-savvy the organization deems to be. Vibrant colours often attract consumers to download your application.
In the profile page, the interface shows a user who bought a yearly subscription, during January 2019 and has full access to the application until the eighth of February, 2020. At the top half part, Peak curates a collection of games for users to play daily, and they change every single day. The amount of time that it would take for users to complete the curated playlist of games is stated there, as well as how many mental agility games are available in the said playlist. At the bottom half part, are games categorized with their purpose, which are The Total Workout, Coffee Break, High Rank, Language, Problem-Solving, and Memory? Figure 2 shows the problem-solving category and the summary of scores. Before the game begins, a summary of the player’s score will be shown. The best rank, Legend is the highest rank available.
Figure3 shows the gameplay. The game begins with a countdown timer on the top part of the game. At the bottom part of the game, there are tutorials which pop up now and then to remind users how to play. This game works in such a way that users have to fill boxes with black ink to confirm the placement of the answer. The horizontal and vertical sides have numbers to state how many boxes should be filled in. On the top right-hand corner of the game, is the score count. On the bottom left-hand corner of the game is the clue button, which will take away user’s time should you choose to use it. The slash (/) symbol on the boxes is used when the user knows the box will never be filled in due to user calculations and logical assumptions.
Once the puzzle is done, it will show the shape that the developer has created; this time, it is in the shape of a heart, with the caption ‘Love Message’ as shown in Figure 3.
Nonograms Katana
Nonograms Katana is developed by user ‘devs’. The game has Japanese-like visuals, which makes it feel exclusive to
the user. Figure 4 shows the landing page and the menu in Nonograms Katana. The options include Black-and-White Nonograms, Coloured Nonograms, Nonograms Sent by Users, and an option for My Nonograms, which are puzzles already completed by the user.
The mobile application, there are options to choose how big the player wants their Nonograms to be. Players generally choose the 10x10 option, while beginners can choose the 5x5. A tutorial is also provided by the application for users who do not know how to play. This is great for players who do not want to search online for the rules of the game.
Figure 5 shows the gameplay of Nonograms Katana. Puzzles are solved by using calculations and logical assumptions. On the top, left-hand corner of the game, a small, rough drawing of the ‘picture’ so far is shown, awaiting for the player’s completion and accomplishment. Users can use the X tool to fill that in, in boxes that the developer confirms would not be filled. The developer continues the puzzle. When a grave mistake has been made, it will be highlighted in red to show the illogicality of it as shown in Figure 6. The user will be encouraged to change their answer.
Finally, Figure 7 shows the completed nonogram. Note that a nonogram corresponds to a puzzle game with the objective is to an image on a grid by checking the certain cells. Those cells have to satisfy some rules associated with each row and column6. In this figure, the 10x10 Nonogram is complete, its X-filled boxes disappeared due to the completion of the puzzle. Here, a house is shown.
Conclusions
According to to7, 8 maze and puzzle games train long term memory, spatial cognition, and analytical thinking. With this literature review as well as comparisons of similar gaming the application that exists in the market, many issues in regards to the prospectus, gaming application can be discovered and prepared for. By comparing similar systems, we can plan what kind of features most important or has not been offered in the market when preparing for a mental game application.
With this review, this project is set to embark on developing a problem solving and critical thinking games that are tailored for senior people target market, preferably within the age range of 60 to 70 years old. Such games are hoped to promote brain activities among the old people to safeguard them from having dementia. Dementia, although its not a fatal illness, is counted as a disability by the Equality Act 2010 and the UN Convention on the Rights of Persons with Disabilities (UNCRPD) as it causes long-term impairments of physical, mental, intellectual, as well as sensory9. It is imperative that our community is prepared with technology-based instruments for encouraging mental health in Malaysia.
ACKNOWLEDGEMENTS
The authors also wish to express gratitude to the management of Asia Pacific University of Technology & Innovation
(APU) for their support.
Conflict of Interest
The authors involved in the current study does not declare any competing conflict of interest.
Funding and Sponsorship
No fund or sponsorship in any form was obtained from any organization for carrying out this research work.
Englishhttp://ijcrr.com/abstract.php?article_id=2887http://ijcrr.com/article_html.php?did=28871. M. H. Al-Bayed and S. S. A. Naser, “An intelligent tutoring system for health problems related to the addiction of video game playing,” 2017.
2. C. Atkinson, G. Dileo, B. Erdik, J. Gleason, V. Hazzard, O. Hernandez, M. Laflamme, L. Romig, and H. Shafir, “Nokia has just updated the bud-get Nokia 3 to android 9.0 pie,” https://www. addictions.com/video-games/Fig. 6: More gameplay for Nonograms Katana alarming-video-game-addiction-statistics/, 2018.
3. D. A. Gentile, K. Bailey, D. Bavelier, J. F. Brockmyer, H. Cash, S. M. Coyne, A. Doan, D. S. Grant, C. S. Green, M. Griffiths et al., “Internet gaming disorder in children and adolescents,” Pediatrics, vol. 140, no. Supplement 2, pp. S81–S85, 2017.
4. M. Anderson, J. Jiang et al., “Teens, social media & technology 2018,” Pew Research Center, vol. 31, p. 2018, 2018.
5. O. Anderson, “Video games: Attitudes and habits of adults age 50-plus,” https://doi.org/10.26419/res.00125.001, 2016.
6. R. Soto, B. Crawford, C. Galleguillos, and E. Olgu´?n, “Solving nonogram using genetic algorithms,” in 2016 11th Iberian Conference on Information Systems and Technologies (CISTI). IEEE, 2016, pp. 1–4.
7. P. M. Kato, “Video games in health care: Closing the Gap,” Review of general psychology, vol. 14, no. 2, pp. 113–121, 2010.
8. I. Spence and J. Feng, “Video games and spatial cognition,” Review of General Psychology, vol. 14, no. 2, pp. 92–104, 2010.
9. S. Fraser Butlin, “The UN Convention on the Rights of Persons with Disabilities: Does the Equality Act 2010 Measure up to UK International Commitments?” Industrial Law Journal, vol. 40, no. 4, pp. 428–438, 12, 2011. [Online]. Available: https://doi. org/10.1093/indlaw/dwr015
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcarePlasma Homocysteine Concentration in Acute Coronary Syndromes
English1419A. T. PardesiEnglish Dilip P. PatilEnglish Nitin B. JadavEnglish Pramod KulkarniEnglish Dany JohnEnglishIntroduction: The high plasma or serum concentrations of total homocysteine are associated with an increased risk of atherothrombotic disease. Aim- a study to assess Plasma Homocysteine Concentration in Acute Coronary Syndromes. Methods: Total 60 patients with the diagnosis of coronary artery disease and non-hemorrhagic stroke are included in this study. Results: In the present study, the plasma homocysteine level is significantly elevated in patients with CAD and non-hemorrhagic stroke. The elevated plasma homocysteine level is an independent and traditional risk factor for CAD. This is turn may revolutionise the development of new strategies of treatment for primary prevention of CAD and non-hemorrhagic stroke in those individuals who do not have traditional risk factors. In absence of the established major atherogenic risk factors like hypertension, diabetes mellitus, hyperlipidemia and smoking, atherosclerotic occlusive vascular events are known to occur. This indicates that there may be an additional independent risk factor such as elevated plasma homocysteine. There is increasing evidence that, linked hyperhomocysteinaemia as a risk factor for the pathogenesis of atherosclerosis. To confirm this concept, 60 cases of occlusive atherosclerotic vascular events (45 coronary artery disease and 15 non-haemorrhagic cerebrovascular diseases), without other risk factors are studied, for plasma homocysteine levels. Conclusion: Homocysteine levels are studied in control subjects without clinical vascular diseases. The data is analysed to demonstrate the correlation of homocysteine levels with vascular events.
English Homocysteine, Acute coronary syndromes, Non-Haemorrhagic strokeINTRODUCTION
The first to hypothesise that hyperhomocysteinaemia is a risk factor for atherothrombosis. More recently, many but not all cross-sectional and prospective studies have shown that high plasma or serum concentrations of total homocysteine are associated with an increased risk of atherothrombotic disease. High total homocysteine concentrations can be lowered by treatment with folic acid and vitamin B12. So assessment of whether such treatment lowers the risk of atherothrombosis is important.1,2
Hyperhomocysteinaemia as a Risk Factor:
Hyperhomocysteinaemia is an independent risk factor for Coronary Artery Disease (CAD).3 Elevated plasma homocysteine concentration is found in almost one-third of all patients with atherosclerosis. Elevation by 12% above the upper limit of normal (15 micromoles per litre) is associated with a three-fold increase in the risk of acute myocardial infarction (AMI). Homocysteine concentration is determined by genetic and nutritional factors.4 vitamin B12 and folic acid are essential co-factors for the remethylation of homocysteine to methionine and dietary supplementation with these vitamins lowers plasma homocysteine by up to 30 %. These observations have formed the basis of large scale intervention trials that are seeking to determine whether lowering homocysteine concentration through vitamin-B supplementation can improve survival in patients with CAD.22 Increasing evidence suggests that adverse vascular effects of elevated homocysteine are mediated through endothelial dysfunction which is an early manifestation of atherosclerosis.4
So, far studies investigating the effects of lowering homocysteine concentrations on vascular endothelial function have yielded conflicting results.5 In primates, folate supplementation is reported to reduce plasma homocysteine concentration but not to affect vascular function.34 In healthy human subjects, folate supplementation is associated with reduced homocysteine concentration and improved vascular endothelial function. Though in these studies there was no relation between homocysteine concentration and endothelial function implying that the effects of B vitamins on endothelial function may not be mediated through homocysteine lowering.6
India is on the threshold of an epidemic of cardiovascular disease (CVD). The country is going through an epidemiological transition. Infectious and nutritional diseases are receding as the cause of adult mortality, while non-communicable diseases assume more menacing proportions.7
MATERIALS & METHODS
All cases of acute coronary syndromes including acute myocardial infarction and non-hemorrhagic stroke admitted in the Intensive Care Unit, Dept. of Medicine, Krishna Hospital, Karad.
A total of 60 patients with the diagnosis of coronary artery disease and non-hemorrhagic stroke are included in this study.
Exclusion Criteria:-
The following patients were excluded from the study
Diabetes mellitus
Hypertension
Renal Disease
Chronic Smokers
Hyperlipidemia
Inclusion Criteria:-
Acute coronary syndromes including acute myocardial
Infraction (STEMI, NSTEMI), unstable angina, and cardiac enzyme abnormalities.
Non-hemorrhagic stroke.
Diagnostic Criteria:
The diagnosis of coronary artery disease was based on clinical history, ECG change(ST-elevation according to nomenclature, ST depression with enzyme abnormalities), cardiac enzyme estimation, and two Dimensional Echocardiography.
The diagnosis of non-hemorrhagic stroke patients was based on clinical history, clinical findings, and CT scan of the head.
OBSERVATIONS AND RESULTS
In the Department of Medicine, Krishna Hospital, Karad 133 patients were diagnosed as CAD.
Total of 358 patients presented with stroke out of which 263 patients were diagnosed as non-hemorrhagic stroke patients.
A total of 45 patients of CAD and 15 patients of non-hemorrhagic stroke fulfilled the criteria for the present study.
Randomly selected, age-matched 25 patients of other medical problems were taken as a control for this study.
SEX DISTRIBUTION
Out of a total of 60 patients with coronary artery disease and cerebrovascular disease, 34 (56.67%) are male and 26 (43.33%) are female shown in table 1
Out of 26 patients with acute myocardial infarction,12 (46.12%) have anteroseptal MI, 6 (23.08%) have inferior wall MI,2 (7.69%) have transaction MI, 2 (7.69%) have trans ant + inf MI,1 (3.85%) has anteroseptal + Hi lat MI and 3 (11.54%) have extensive anterior MI.
Out of total 19 patients with the acute coronary syndrome, 9 (47.37%) have anteroseptal MIsc, 8 (42.11%) have inferior MIsc, 1 (5.26%) has trans ant + inf MIsc, 1 (5.26%) has extensive anterior MIsc and none in trans ant MIsc as well as in anteroseptal + hi lat MIsc. (Table 2)
Disease distribution location of non-hemorrhagic infarctions
Out of a total of 15 patients with non-hemorrhagic stroke 7 (46.67%) have RMCA area infarction and 8 (53.33%) have LMCA area infarction.
In this group, there were no patients of vertebrobasilar territory infarction.
Plasma homocysteine levels in the study group
Out of a total of 60 patients of the study group 2 (3.3%) have normal Hcy level, 13 (21.66%) have moderate Hcy level, 16 (26.66%) have intermediate Hcy level and 29 (48.33%) have severe Hcy level.
Plasma homocysteine levels in different MI groups.
Out of a total of 12 patients with anteroseptal MI 1 (8.33%) has a normal Hcy level, 1 (8.33%) has a moderate Hcy level, 6 (50.00%) have intermediate Hcy level and 4 (33.33%) have severe Hcy level.
Plasma homocysteine levels in different MI groups.
Out of a total of 6 patients with an inferior wall, MI 2(33.33%) have moderate Hcy level, 2 (33.33%) have intermediate Hcy level, 2 (33.33%) have severe Hcy level and none has normal Hcy level.
Plasma homocysteine levels in different MI groups.
Out of 2 patients with transanterior MI 2 (100%) have severe Hcy level and none has normal, moderate, and intermediate Hcy level.
Plasma homocysteine levels in different MI groups.
Out of a total of 2 patients with transanterior + inferior wall, MI 2 (100%) have severe Hcy level and none has normal, moderate, intermediate Hcy level.
Plasma homocysteine levels in different MI groups.
Out of a total of 1 patient with anteroseptal + high lateral MI 1 (100%) has a moderate Hcy level and none has normal, intermediate, severe Hcy level.
Plasma homocysteine levels in different MI groups.
Out of a total of 3 patients with extensive anterior MI 3 (100%) have severe Hcy level and none has normal, moderate, intermediate Hcy level.
Plasma homocysteine levels in different acute coronary syndrome groups.
None of the patients had transanterior myocardial ischemia.
Plasma homocysteine levels in different acute coronary syndrome groups.
Out of a total of 1 patient with transanterior + inferior MIsc 1 (100%) has an intermediate Hcy level and none has normal, moderate, severe Hcy level.
Plasma homocysteine levels in different acute coronary syndrome groups.
None of the patients had anteroseptal + high lateral myocardial ischemia. (Table 20)
Plasma homocysteine levels in different acute coronary syndrome groups.
Out of a total of 1 patient with extensive anterior Misc 1 (100%) has a severe Hcy level and none has a normal, moderate, intermediate Hcy level.
Cardiac Enzymes
Out of a total of 45 patients with coronary artery disease, 18 (40%) have CPK-MB elevated in the range of 20-40 IU/Iit and 27 (60%) have CPK-MB elevated by more than 40 IU/It.
Plasma homocysteine levels in different Non-hemorrhagic stroke groups.
Out of a total of 8 patients with LMCA area infarction, 2 (25%) have moderate Hcy level, 1 (12.50%) has intermediate Hcy level, 5 (62.50%) has a severe Hcy level and none has a normal Hcy level. (Table 23)
Plasma homocysteine levels in different Non-haemorrhagic stroke groups.
Out of a total of 7 patients with RMCA area infarction, 3 (42.86%) have moderate Hcy level, 1 (14.26%) has intermediate Hcy level, 3 (42.86%) have severe Hcy level and none has a normal Hcy level. (Table 24)
Plasma homocysteine levels in the control group.
Out of the total of 25 patients in the control group, 24 (96%) have normal Hcy level, 1 (4%) has moderate Hcy level and none has intermediate, severe Hcy level.
DISCUSSION
Out of total 45 patients are with CAD and 15 patients with non-hemorrhagic stroke are included in this study.
Age and sex distribution:
The age group of the male is 23-70 yrs. Age group of the female is 35-70 years. Male to female ratio in this study is 1.3:1After the age of 45 years, there is no significant gender difference in the prevalence of vascular events. In the younger (Englishhttp://ijcrr.com/abstract.php?article_id=2888http://ijcrr.com/article_html.php?did=28881. McCully KS, Ragsdale BD. Production of arteriosclerosis by homocysteinemia. The American journal of pathology. 1970 Oct; 61(1):1.
2. Wilken, D.E.L., and Wilken, B. ().Pathogenesis of coronary artery disease. A possible role for methionine metabolism. J. Clin. Invest. 1976: 57, 1079-1082.
3. Boushey CJ, Beresford SA, Omenn GS, Motulsky AG. A quantitative assessment of plasma homocysteine as a risk factor for vascular disease: probable benefits of increasing folic acid intakes. Jama. 1995 Oct 4;274(13):1049-57.
4. Welch GN, Loscalzo J. Homocysteine, and atherothrombosis. New England journal of medicine. 1998 Apr 9;338(15):1042-50.
5. Lentz SR, Malinow MR, Piegors DJ, Bhopatkar-Teredesai M, Faraci FM, Heistad DD. Consequences of hyperhomocyst (e) anemia on vascular function in atherosclerotic monkeys. Arteriosclerosis, thrombosis, and vascular biology. 1997 Nov;17(11):2930-4.
6. Verhaar MC, Wever RM, Kastelein JJ, van Loon D, Milstien S, Koomans HA, Rabelink TJ. Effects of oral folic acid supplementation on endothelial function in familial hypercholesterolemia: a randomized placebo-controlled trial. Circulation. 1999 Jul 27;100(4):335-8.
7. Mudd S.H. The natural history of homocysteinemia due to cystathionine beta-synthase deficiency. Am. J. Hum bent. 1985;37; 1-31.
8. Graham IM, Daly LE, Refsum HM, Robinson K, Brattström LE, Ueland PM, Palma-Reis RJ, Boers GH, Sheahan RG, Israelsson B, Uiterwaal CS. Plasma homocysteine as a risk factor for vascular disease: the European Concerted Action Project. Jama. 1997 Jun 11;277(22):1775-81.
9. Arnesen E, REFSUM H, BØNAA KH, UELAND PM, FØRDE OH, NORDREHAUG JE. Serum total homocysteine and coronary heart disease. International journal of epidemiology. 1995 Aug 1;24(4):704-9.
10. Boers GH, Smals AG, Trijbels FJ, Fowler B, Bakkeren JA, Schoonderwaldt HC, Kleijer WJ, Kloppenborg PW. Heterozygosity for homocystinuria in premature peripheral and cerebral occlusive arterial disease. New England Journal of Medicine. 1985 Sep 19;313(12):709-15..
11. Clarke R, Daly L, Robinson K, Naughten E, Cahalane S, Fowler B, Graham I. Hyperhomocysteinemia: an independent risk factor for vascular disease. New England journal of medicine. 1991 Apr 25;324(17):1149-55..
12. Farhadi D. Plasma homocysteine levels and mortality in patients with coronary artery disease. The New England journal of medicine. 1997 Nov;337(22):1632-author..
13. Boushey CJ, Beresford SA, Omenn GS, Motulsky AG. A quantitative assessment of plasma homocysteine as a risk factor for vascular disease: probable benefits of increasing folic acid intakes. Jama. 1995 Oct 4;274(13):1049-57.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareRole of Chromium Enriched Tobacco in the Occurrence of Oral Carcinogenesis
English2024Smrutipragnya SamalEnglish Priyanka DebataEnglish Santosh Kumar SwainEnglishCancer is a disease of major concern grasping the entire globe. It is one of the diseases characterized by high rates of incidence and mortality. Among all the cancer types, oral cancer has a high occurrence in countries like India, where people are more inclined towards the use of tobacco either for smoking or for chewing purpose. Nicotianatabacum being a hyperaccumulator plant can thus accumulate high amount of heavy metals in its parts, mostly leaves. The carcinogenicity of tobacco may be linked to the high concentrations of metals present in it. The presence of chromium in the trivalent or Cr(III) form in the leaves of the tobacco plant is ignored assuming it to be non-toxic. However, smoking or chewing tobacco can lead to the conversion of Cr(III) to the toxic Cr(VI) as hypothesized in the current review. The paper in its current form discusses the process of aggregation of chromium in the above-ground parts of the tobacco plant. The rhizospheric factors that promote the metal uptake by the plant are also discussed. The notion that Cr in tobacco is harmless has been argued upon. The paper proposes the role of Cr enriched tobacco in causing oral cancer and predicts the probable underlying mechanism. It emphasizes on the need to regulate rhizospheric factors, to prevent the accumulation of high concentration of the toxic heavy metal in the biomass of the tobacco plant.
English Cancer, Chromium, Heavy metal, Mutation, Rhizosphere, TobaccoIntroduction
Cancer is one of the leading global diseases responsible for high incidence and mortality rates. In terms of the number of deaths, it lies second only to cardiovascular disease accounting for 16% of mortality (Fig.1). As per the 2018 GLOBOCAN statistics, one out of five males and one out of six females are found to suffer from cancer, while one out of eight males and one out of eleven females die of the disease.1 Cancer of the lip and oral cavity is the second most common cancer in India as far as the incidence (10.4%) and mortality rates (9.3%) are concerned.2 Oral cancer is caused due to addiction habits and Human Papilloma Virus (HPV). However, majority of oral cancer in India is caused due to consumption of tobacco products either in form of smoking or non-smoke forms and account for 80-90% of cases.3, 4Indian Council of Medical Research (ICMR) has reported that 30% of all cancers in India are mainly caused due to tobacco. Among the tobacco linked cancers, oral cancer is the most frequent type in India and is responsible for approximately 42% of deaths in males.5
Tobacco has been reported to contain high levels of metal possibly resulting in an increased risk of exposure of these toxic components to the smokers and consumers of various products of smokeless tobacco. The toxic effect of these carcinogenic metals present in tobacco depends on the dose and the time of exposure. These toxic metals and metalloids present in tobacco are poorly studied and the mechanism behind their toxicity remains unexplained .6 Among several chemical compounds present in tobacco, 11 of these are metals or metalloids. An expert panel on tobacco regulation constituted by WHO prioritized four of the heavy metals like nickel, cadmium, arsenic, and lead in tobacco and tobacco smoke as of serious concern.7 The tobacco constituents are mostly related to several diseases especially cancer.
Chromium is a toxic heavy metal present in tobacco but its role in carcinogenesis is poorly understood and therefore ignored. The current review explains the probable role of hexavalent chromium generated from tobacco consumption and smoking in oral carcinogenesis. The authors have put forward a hypothetical model predicting the possible pathway of Cr(VI) involvement in oral carcinogenesis.
Chromium in Oral Carcinogenesis
Chromium, unlike other toxic heavy metals, is available in several oxidation states, out of which, the trivalent or Cr(III) and the hexavalent or Cr(VI) are the two highly stable forms.8Cr(VI) is considered to be a carcinogen because of its several toxic effects on the living biota including humans.9,10 Chromium remains a chief constituent of tobacco. It is mostly found in the trivalent form in tobacco products and therefore is not regarded as toxic. However, the inter-conversion of Cr in tobacco smoke and non-smoke form and its role in carcinogenesis has been poorly understood.
Sources of Cr in the environment
Cr mainly occurs from two sources – natural and anthropogenic (Fig.2). Cr occurs naturally over the earth crust in rocks, soil, water streams, and volcanic dust. It generally remains as Cr(III) bound to primary rocks and other metal oxides like iron.11 Anthropogenic sources are mostly responsible in increasing the toxic load of Cr(VI) in the environment and can be further categorized into direct and indirect sources. The direct sources include industrial operations like mining, leather tanning, chrome plating, wood preservation, and production of paints, pigments, dyes, paper, and pulp.8 Water treatment plants, Portland cement, dumping of wastes and effluents, incineration of wastes, coke ovens, and cooling towers are some of the indirect sources ofenvironmentalCr(VI).12 Dumping of Cr rich solid and liquid wastes mainly contribute towards environmental toxicity.
Cr(VI) and human carcinogenicity
The chemical structure of Cr(VI) plays a major role in facilitating its entry into human cells and thereby causing toxic effects(Fig.3). Cr(VI) mostly exist in the form of oxyanion (CrO4) which structurally resembles that of sulphate oxyanions (SO4). This structural resemblance allows Cr(VI) to use sulphate transporters present on the cell surface to enter the cells.14 Cr(VI) is mutagenic to human cells and is responsible for causing genotoxicity. It leads to the formation of DNA adducts which includes DNA-proteins crosslinks and DNA-aminoacids crosslinks15 which in turn inhibits DNA replication process.Cr(VI) also creates genomic instability by causing double-strand DNA breaks16. Cr(VI) causes epigenetic silencing, mutations, thereby leading to loss of mismatch repair mechanism16. The toxic form of the heavy metal induces chromosomal instability and abnormalities thereby causing DNA lesions17. Cr(VI) has been found to alter gene expression and actively induce the development of cancer through several mechanisms. It has also been found to actively participate in DNA methylation and gene silencing thereby leading to several types of cancer18. Cr(VI) is also believed to have a certain influence on microRNAs. The microRNAs play an active role in gene regulation and are often found to be dysregulated in Cr(VI) carcinogenesis thereby affecting important biological processes19,20.
Chromium in Tobacco: Nicotianatabacum as a metal accumulator
Plants can uptake essential elements from the soil and utilize them as nutrients. However, certain plants can aggregate high metal concentrations in their biomass and are referred to as hyperaccumulators12. Such plants are used to clean up soils contaminated with heavy metals by the process known as phytoremediation 21. Similar metal accumulation ability by Nicotianatabacum plant makes it a viable option for metal removal from contaminated soils. However, such ability of the tobacco plant becomes a threat to health. Nicotianatabacum can uptake several heavy metals from the soil which includes cadmium, aluminium, arsenic, chromium, nickel, copper, zinc, lead and mercury. These metals are uptaken by the roots and then translocated and stored in the above-ground parts of the plant, mostly leaves. Cr is mostly up taken from the soil and translocated to aerial parts of the tobacco plant in its hexavalent state. The transport of Cr(VI) from roots to shoot is an active process and occurs through sulphate or phosphate channels22. Once Cr(VI) reaches the leaves, it gets reduced to Cr(III) by binding to specific ligands and sequestered into leaf vacuoles23 of the tobacco plant where it is stored as Cr(III).
Chromium accumulation and factors governing its bioavailability for uptake
Accumulation of Cr(VI) in hyperaccumulator plants like Nicotianatabacumis highly dependent on several rhizospheric soil factors like redox potential, pH, organic content, and availability of suitable microorganisms 24.
The redox potential (Eh) of soil provides idea on the oxidation and reduction nature of the soil and plays a pivotal role in bioavailability and speciation of Cr(VI) in the soil. At high soil Eh values, generally, an oxidation reaction occurs25,26. Soils with high Eh values can cause the Cr(III) present in the soil to get oxidized to highly mobile Cr(VI), thereby increasing its availability in the soil for uptake by the plant.
Soil pH also is an important factor in metal availability to plants. Metals are highly soluble and mobile in acidic pH and are precipitated over alkaline soil conditions27. However, the same does not apply to Cr and its bioavailability under varied pH conditions depends on the form in which it is present in the soil. Cr(VI) mostly exists in the anionic form (CrO42- and HCrO4-1) in the soil. Its bioavailability and mobility increases under high pH conditions and the reverse happen at low pH. At high pH, the hydroxyl ions increase providing the soil with a net negative charge and thereby decreasing sorption of Cr(VI) 28.
Soil organic matter content also plays a vital role in the movement and availability of Cr(VI) 29. Presence of soil organic matter lowers the soil pH making it acidic and thus increasing H+ ion concentrations. This positive charge of the soil helps in retention or adsorption of Cr(VI) to soil matrix 30. Moreover, organic matter creates a reduced condition in the soil and also favours the growth of microorganisms. Therefore, Cr (VI) is reduced in two different ways catalysed in the presence of soil organic content. Firstly organic content of the soil creates reduced conditions that directly reduces Cr(VI) to Cr(III)31. Secondly, it favours microbial growth indirectly leading to reduction of Cr(VI) to Cr(III) as a result of biotic interaction between the microbes and the heavy metal 32.
The rhizosphere soil due to its high nutrient concentration forms a favourable habitat for the growth of microorganisms. The microorganisms mostly bacteria have been found to play a major role in enhancing soil fertility and sustaining plant growth by processes such as mineralization, decomposition, nutrient immobilization, and nitrogen fixation 33. As far as the biogeochemical activity of heavy metals in the plant-soil rhizosphere is concerned, microbes indeed play an influential role 34, 35. Several groups of microorganisms having the ability to reduce Cr(VI) to Cr(III) have been identified 36. These include bacteria 37, algae38, fungi39, and yeast40. Microbial reduction of Cr(VI) to Cr(III) highly relies on the microbial strain, concentration of chromium, pH, and temperature of the soil41,42.
Soil conditions like high redox potential, high pH, low organic content, and high soil temperature are the driving force for successful accumulation of Cr(VI) by tobacco plant and need to be regulated accordingly.
Cr(VI) rich tobacco in oral cancer: A hypothesized model
Chromium is a chief constituent in tobacco which may be attributed to the hyperaccumulation ability of the tobacco plant under favourable conditions. Cr is found in the trivalent form in tobacco and therefore not considered to be toxic by several researchers. The authors in the current review however have put forward contrasting views. The manuscript in its current form strongly advocates the probable involvement of Cr(VI) rich tobacco in oral cancer. A hypothetical model explaining the probable mechanism underlying oral carcinogenesis due to the presence of chromium in tobacco has been put forward.
The tobacco plant has been known to accumulate heavy metals like Cr in its aerial parts, mostly leaves. The leaves of the plant accumulate the heavy metal in its trivalent (non-toxic) form. Therefore, Cr(III) is not considered as a carcinogen in tobacco. However, there is always a chance that the non-toxic Cr(III) may get oxidized to the toxic Cr(VI) under favourable conditions thus promoting carcinogenesis. Cr(III) and Cr(VI) are the two most stable states of Cr that can interchange their oxidation states by undergoing redox reactions under conditions like metal content, presence of oxygen, high temperature, and moisture. Tobacco leaves in addition to Cr also contain manganese (Mn) which further oxidizes the less toxic Cr(III) to the highly toxic Cr(VI). During smoking of tobacco, the Cr(III) present in it may get oxidized to Cr(VI) due to the combustion of tobacco that involves oxygen and high temperature. Moreover, tobacco smoke when inhaled through mouth or nose gets mixed up with moisture thereby also leading to the formation of Cr(VI). Cr(VI) toxicity not only spreads from tobacco smoke but also smokeless forms. Tobacco, when taken in chewable form, gets in contact with oxygen and moisture thereby converting the elemental manganese present in it into MnO2, that catalyses the oxidation of Cr(III) to Cr(VI)(Fig.3).
The oral cavity being the first point of contact of both smoking and non-smoking form of tobacco products is hence more exposed to Cr(VI) and most probably its toxic impacts like the occurrence of oral cancer. Cr(VI) being highly mobile and permeable easily passes through the human cell membrane. Cr(VI) generated from cigarette smoke or chewing of tobacco can easily get absorbed into the squamous epithelial cells present in the internal surface of the oral cavity. Once Cr(VI) enters into the cells, it undergoes detoxification. Cr(VI) either gets reduced to Cr(III) directly or indirectly in a stepwise manner. In the indirect reduction process Cr(VI) gets converted to Cr(III) via several intermediates like Cr(V) and Cr(IV). During the reduction, the different species of chromium produce intracellular reactive oxygen species (ROS). Chemical compounds present in the cells like ascorbic acid and glutathione act as ROS scavengers thereby reducing Cr(VI) to Cr(III) and in the process lead to the production of free radicals (hydroxyl radicals) 43. Production of hydroxyl radicals inside the cells occurs in the presence of H2O2 through a Fenton-like reaction 44. ROS in the form of hydroxyl radicals can activate various pathways like apoptosis 45. Cr(VI) reduction inside the cells can also directly cause damage to the DNA by interacting with the proteins, amino acids, and even the DNA directly leading to single or double-strand breakage46. Cr(VI) after reduction to Cr(III) can form bulky binary and ternary DNA adducts, thereby causing severe damage due to mutations 47.
Cr(VI) induced oxidative damage mostly occurs to the DNA of p53 gene48 present in the oral squamous cells thereby affecting the gene function. Being a tumour suppressor gene, p53 works as a control centre of the cell and regulates the activity of several genes under stress conditions and also is involved in DNA repair. Damage to this gene leads to failure of repair mechanism in DNA of the oral epithelial cells, thereby resulting in mutations, uncontrolled cell division and finally cancer of the oral cavity.
Conclusion
Tobacco consumption remains a significant threat to public health around the world and smoking-related diseases are considered the world’s most preventable cause of death.
Consumption of tobacco causes a significant threat to public health. Tobacco-related diseases are linked to the world’s most prevalent cause of death. Tobacco has several carcinogens. Chromium has a strong link with the carcinogenesis of oral cancer.Cr(VI) is a toxic heavy metal that arises from several anthropogenic activities. Nicotianatabacum is a plant hyperaccumulator that can easily accumulate heavy metals like Cr(VI) in large quantities from contaminated soil and water bodies. This is the main reason behind the presence of the toxic heavy metal in tobacco and tobacco products. Being a major component of tobacco, Cr(VI) has all the possibility of causing oral cancer by bringing about DNA mutations in the p53 and other linked genes. The author(s) hereby advises preventing the accumulation of the toxic Cr(VI) in tobacco plant that is meant for commercial purposes to prevent the risk of oral carcinogenesis. This could be achieved by appropriately regulating the rhizospheric factors governing its uptake by the tobacco plant.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareA Recent Report on ‘Plants with Anti-Candida Properties’
English2534Darshan KumarEnglish AyeshaEnglish Madhulika JhaEnglish Pankaj GautamEnglish Himanshu JoshiEnglish Navin KumarEnglishFungal infections are drawing attention because of the high mortality and morbidity rate associated with them. Candida, Cryptococcus, Pneumocystis, and Aspergillus are the main members of fungal genera responsible for life-threatening fungal infections all over the world. Candida exists as commensal opportunistic pathogens in the natural flora of human beings. Members of this genus have specialized virulence attributes which include adhesion, biofilm formation, yeast to hyphal transition, cell surface hydrophobicity, and secretion of hydrolytic enzymes. C. albicans, C. parapsilosis, C. glabrata, and C. tropicalis are key species, mainly responsible for 95% of candidiasis worldwide. Azoles, amphotericin B, echinocandins and terbinafine are the main synthetic drugs against the pathogens. Rising resistance to antifungals demands the development of alternative drugs, especially of plant origin. In this review, we have included the selected plants having significant anti-Candida potential, based upon recent studies.
English Candida, Candidiasis, Biofilm, Anti-Candida, Phytoactive, Synthetic drugs, MIC, Camellia sinensis, Hypericum havvae.INTRODUCTION
Fungi are considered to be one of the potential health hazards to animals including humans. Annually, fungal diseases are responsible for over 1.5 million deaths and infecting over a billion people worldwide. Candida, Cryptococcus, Pneumocystisand Aspergillus are the main fungal genera responsible for such infections1. The occurrence of life-threatening fungal infections has increased in immune-compromised AIDS patients, blood cancer, neonates, and organ transplants2,3. Fungal infections present a possible danger to health worldwide owing to their elevated mortality and morbidity rate 4. Mortality associated with the fungal disease is similar to that of tuberculosis (more than 1.6 million) and above 3-fold more than malaria 1.
Candida is a well-known group of fungi containing around 20 pathogenic species. It is a member of the Saccharomycetes class, the Saccharomycetales order, and the Saccharomycetaceae family. Ubiquitous, opportunistic, dimorphic, and commensal fungi are representatives of this group. The natural flora of the gastrointestinal tract, the mucosal oral cavity, and the human reproductive organs comprises of various species of Candida5.
Candidiasis is a condition of Candida infection which causes shallow mucocutaneous infections, invasive tissue, and bloodstream infections6,7. C. albicans, the most common pathogenic species, is followed by C. tropicalis, C. glabrata, and C. parapsilosis8. Clinical isolates have been reported to be resistant to existing antifungals, particularly azoles, echinocandins, and polyene9. Hydrophobicity of the cell surface, hyphal transformation hydrolytic enzyme secretion and development of biofilm over abiotic and biotic surfaces are well established primary virulence features of the Candida10,11. Most important features of Candida spp. are the ability to form a biofilm, a three-dimensional multicellular structure mainly composed of proteins, carbohydrates, phosphorus, hexosamine, and, uronic acid. Biofilm facilitates adhesion and maturation on the biotic and abiotic surfaces, ranging from the mineral surface and mammalian tissues to synthetic polymers and indwelling medical gadgets, resulting in drug resistance12,13,14.
For decades plants have been known as the primary source of medicinal products among common citizens. Additionally, several countries still used plants as major remedies, particularly in Africa and Asia. Several plants had exhibited successful anti-Candida activities which are required to be tested for efficacy and safety15.
GLOBAL BURDEN OF CANDIDIASIS
Candidiasis is due to the Candida albicans and non-albicans Candida (NAC) infection, which is mostly known to cause high rates of mucosal infection to humans worldwide.1 Candida infects mucosal tissues, including mouth, oesophagus, gastrointestinal, vagina, and deep tissue infection16. Vulvovaginal candidiasis (thrush or yeast infection) continues to be a worldwide health problem for women17,18. Candida infection is common in hospitalized patients having a weak immune system or immunocompromised patients and elderly people 19. More than 30 species of Candida have been recognized as the causative agent of candidiasis and approximately 95% of the contaminations are caused by its four species: C. albicans, C. parapsilosis, C. glabrata, and C. tropicalis20, 21.
Nearly 50% of individuals have Candida yeast in the oral cavity which is responsible for the superficial infection. However, Candida infection can spread through the body and can end-up in life-threatening incidences, specifically in immunocompromised patients 22, 23.
The global burden of candidiasis is given in Table-1.
(Table 1. Global burden of candidiasis)
DRUG RESISTANCE:
Azoles and its derivatives (fluconazole, voriconazole, Itraconazole, ketoconazole) are primarily used antifungals 24-25. Isolates of Candida have been reported to develop resistance to the existing antifungals (fluconazole, anidulafungin, caspofungin, micafungin, etc). According to the Centers for Disease Control and Prevention (CDC, NIH, USA), about 7% of all Candida bloodstream isolates tested at CDC were resistant to fluconazole and about 1.5% were resistant to Echinocandin (Figure 1).
(Photo Source: CDC Report)
Increasing resistance to selected drugs encouraged the clinical practice of other drugs also e.g. amphotericin B, echinocandins, terbinafine, etc. as shown in Table-2 along with its mode of action.
(Table 2. Synthetic anti-Candida drugs)
PLANTS WITH ANTI-CANDIDA PROPERTIES:
Plants and their extracts have been used in traditional medicine since prehistoric times due to its availability and efficacy without toxicity33. Plants produce numbers of natural active compounds for defence against fungi, insects, and herbivorous mammals. And many more phytoactive compounds have biological activities34. The use of herbal medicines has been widely accepted in many developed and developing countries. Herbal remedies are widely used in Asia, mainly India and China, and are now getting popularity in the UK and Europe, as well as in North America and Australia33,35. WHO estimated that around 80% population of the developing countries (like Latin America, Asia, Africa, etc.) depends on traditional therapy based on herbal medicines for their primary health care needs. In the year 2000, the global trade of medicinal plants and their products was reported to be US$ 60 billion, with a projected forecast to touch US$ 5 trillion by 205035. India and China are the top global exporters of herbal drugs due to its systematic traditional knowledge of plant-based medicines and culture.
In the modern era, natural products are the source of bioactive substances with possible medical uses in pharmacy and dentistry. Natural ingredients include essential oils and their elements and can form part of several classes of compounds, most commonly phenylpropenes and terpenes with antioxidant, anti-inflammatory, antiseptic, and curative properties 36. Looking at the rising demand for plant-based drugs, we tried to compile the details of plants showing anti-Candida properties (Table-3).
(Table. 3: Plants having anti-Candida properties)
Table-3 is an effort to compile some recent studies in the subject matter in a tabulated form.
Biofilm is an important pathogenic implication of the Candida to survive the existing synthetic drug, which is responsible for drug resistance. Some of the plant extracts and their phytoactive compounds have exhibited remarkable anti-biofilm properties; e.g. Berberis vulgaris,42 Buchenaviatomentosa Eichler,44 Cinnamomum zeylanicum,47 Curcuma longa L.,48,49 Matricaria chamomilla,55 Peganum harmala L.58 and Sanguinaria Canadensis 61. Berberine, Sanguinarine, Harmaline, Curcumin, and many other phytoactive compounds have been reported to decrease the viability of Candida biofilm significantly42,48,49,61.
CONCLUSION
Since the prehistoric period, plants have been the source of medicine in different countries like India and China. According to a WHO report, approximately 80% of the premier health issues in developing countries depend on traditional medicine. Currently, the scientific research community and government health agencies are focusing on the studies related to the bioactive compounds. Phytoactive compounds are generally safe and easily available for commercial-scale drug production. Therefore, it’s encouraging to develop an effective and safe drug against microbial human pathogens from natural resources. Nature holds ample resources for the discovery of new and highly effective herbal drugs. It may be concluded from the table-3 that two plants Camellia sinensis and Hypericum havvae have remarkable anti-Candida properties and can be used to develop alternative anti-Candida drugs. Camellia sinensis have shown promising results against many pathogenic species of the Candida e.g. C. albicans, C. parapsilosis, C. Tropicalis, and C. Glabrata, and Hypericum havvae was effective against C. glabrata, C. kreusei, C. parapsilosis, C. guilliermondii, and C. tropicalis.
Source(s) of Funding: No funding is involved.
Conflicting Interest: The authors declare no conflicting interest.
Englishhttp://ijcrr.com/abstract.php?article_id=2890http://ijcrr.com/article_html.php?did=2890
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareAdvanced Empirical Studies on Group Governance of the Novel Corona Virus, MERS, SARS and EBOLA: A Systematic Study
English3541Debnath BhattacharyyaEnglish Nakka Marline Joys KumariEnglish Eali Stephen Neal JoshuaEnglish N. Thirupathi RaoEnglishCoronavirus condition (COVID-19) is a contagious illness brought on by a freshly discovered Coronavirus. Most individuals contaminated with the COVID-19 infection will certainly experience moderate to modest respiratory system health problems and recoup without needing unique therapy. Older people and those with underlying clinical problems like cardiovascular disease, diabetic issues, persistent respiratory conditions, and cancer are more likely to create a significant health problem. Aim and Objective: This paper gives the best way to prevent and reduce transmission is to be well educated about the COVID-19 infection, its causes, and its spread. Protect your own and others from infection by cleaning your hands or using an alcohol-based rub frequently and not touching your face. The COVID-19 infection spreads out primarily via beads of saliva or discharge from the nose when an infected person coughs or sneezes, so it is vital that you additionally exercise breathing rules (for instance, by coughing right into a flexed elbow joint). Right now, there are no detailed vaccinations or therapies for COVID-19. Nevertheless, there are several ongoing professional trials assessing capacity treatments. Method: The study aimed to develop a statistical model to predict how the cases are growing exponentially in various parts of the world. Even after starting from a low base, there is no proper statistical analysis of cases we can expect. It is an ambiguous thing that numbers of cases are exponentially increasing. We have analyzed the mortality rate, the number of deaths per country, and the number of recovery cases. Conclusion: By comparing the statistical analysis of confirmed cases vs. deaths within a short period, nCov-19 affected the most compared with Zoonotic viruses. The coronavirus disease remains to spread out throughout the globe, adhering to a trajectory that is challenging to predict. The health, altruistic, and socio-economic policies have taken on by nations will certainly figure out the rate and stamina of the healing. There has to be a global human-centred reaction that is based on solidarity.
English nCoV-19, SARS, MERS, EBOLA, Mortality, Zoonotic, Exponential Growth. Introduction
Coronaviruses are a large, diverse team of viruses and need a useful microscopic lens to see them. There are several types of coronaviruses, and also they infect a broad range of creatures and birds. Moreover, some even create moderate respiratory system illnesses in people each year. The infection that causes COVID-19, we call SARS Coronavirus 2. This virus originated in bats, indicating that bats lug this infection and are infected with this virus at all times. However, this virus developed a unique technique. It developed the ability to leap between varieties and also infect people. All of these coronaviruses likewise originated in bats currently infect individuals and can be spread from one person to another. So the initial of these viruses was called acute severe breathing disorder, or SARS Coronavirus, the initial SARS Coronavirus. More just recently, at the end of 2019, SARS Coronavirus 2 emerged in Wuhan, China. Viruses need to live in other cells, and afterwards, they duplicate in those cells and go on to infect various other cells in the body. The natural history of SARS-coronavirus-2. Indicators of the disease are objective dimensions to define an ailment or condition observed during a physical examination. So, as an example, the temperature is a sign of illness, because it can be determined by taking temperature level. Breathing faster than typical is another sign because a person can count the variety of times that we are taking a breath per min and identify whether it is faster than usual. Signs are not something that can be reasonably measured, however how the person claims they are feeling. The essential points regarding the Corona Virus Condition 2019.
Instigated by a SARS-COV-2 Coronavirus and first case identified in Wuhan, Hubei, China.
Primary reported symptoms occurred on 1 December 2019.
Introduction
Coronaviruses are a large, diverse team of viruses and need a useful microscopic lens to see them. There are several types of coronaviruses, and also they infect a broad range of creatures and birds. Moreover, some even create moderate respiratory system illnesses in people each year. The infection that causes COVID-19, we call SARS Coronavirus 2. This virus originated in bats, indicating that bats lug this infection and are infected with this virus at all times. However, this virus developed a unique technique. It developed the ability to leap between varieties and also infect people. All of these coronaviruses likewise originated in bats currently infect individuals and can be spread from one person to another. So the initial of these viruses was called acute severe breathing disorder, or SARS Coronavirus, the initial SARS Coronavirus. More just recently, at the end of 2019, SARS Coronavirus 2 emerged in Wuhan, China. Viruses need to live in other cells, and afterwards, they duplicate in those cells and go on to infect various other cells in the body. The natural history of SARS-coronavirus-2. Indicators of the disease are objective dimensions to define an ailment or condition observed during a physical examination. So, as an example, the temperature is a sign of illness, because it can be determined by taking temperature level. Breathing faster than typical is another sign because a person can count the variety of times that we are taking a breath per min and identify whether it is faster than usual. Signs are not something that can be reasonably measured, however how the person claims they are feeling. The essential points regarding the Corona Virus Condition 2019.
Instigated by a SARS-COV-2 Coronavirus and first case identified in Wuhan, Hubei, China.
Primary reported symptoms occurred on 1 December 2019.
The proportion of individuals who pass away from a defined disease amongst all individuals identified with the condition over a specific time as shown in Fig.117. In this paper, we are working towards the statistical analysis of the Zoonotic diseases and their impact on people's timeline of existence. Diseases like Ebola, SARS, and MERS created a significant loss to humankind over some time.
Symptoms
Coming to the clinical symptoms of this life-threatening viral disease, they range from having no symptoms at all (asymptomatic) to very severe respiratory problems, which may eventually lead to people losing their lives. MERS-CoV's most common symptoms reportedly are fever, cough, cold, and a shortage of breath. Pneumonia is also found in most people suffering from this disease but not certainly in every individual affected by it. Gastrointestinal problems like diarrhoea are also some of the symptoms. If the illness becomes too severe, it may lead to various respiratory severe problems. Patients need to be kept on the ventilators and have to be treated in intensive care units to bring the situation back to normal. Although figures say that around 35% of the patients have died fighting this dangerous disease, it should be considered that many of the mild cases of MERS have been excluded in the scrutiny. These rates are counted based on only the information provided by the well-recognized laboratories as shown in Fig 217, Fig317 and Fig417.
Transmission
SARS-CoV-2 is transmitted very efficiently. It is due to two main reasons that it transmits between the persons. When the virus stays in the person their respiratory tract, mouth nose and throat contains the virus and in some when the droplets come out will also have the possibility of holding the virus. When it falls on some others there is a high chance of transmitting the virus that makes very difficult to detect and stop. There may be a chance of not transmitting the virus in a few cases also.so they could also infect other people without knowing that they are infected. So, we need to test symptomatic people and identify whom they have had contact with quickly to limit the spread. This is done through contact tracing. Due to this, the transmission of the virus is likely to occur when the affected person comes closer to another. 1Prisons and jails are examples of congregate housing, as are group homes and dormitories like schools or shelters. These places are all high risk for the rapid spread of the infection because people live close together and share spaces. When we think about the risk of transmission, nursing homes represent a worst-case scenario for COVID-19.
One is a diagnostic test, and that test identifies a virus that's in the body. It is called a PCR test, which stands for a polymerase chain reaction. That is the chemical reaction that's done in the lab to look for the virus. The other one is the antibody test3. Antibodies3are made by your immune system to fight off viruses or bacteria. We can identifyantibodies that are specific to this virus in your blood.
The typical variety of people who will undoubtedly get a transmittable illness from someone keeping that illness as shown in Fig 5.17 It especially applies to a population of people who were previously without infection and have not been vaccinated.
Health-care facilities
The virus is transmitted easily in healthcare environments in several countries, especially from patient to patient and patient to the health care worker and visitors before the MERS-CoV Virus was diagnosed as shown in Table 117. It is highly challenging to diagnose the MERS-CoV Virus without testing, owing to the non-specific nature of clinical features and symptoms that do not show in the disease's early onset. It is critical to prevent the infection and implement control measures to prevent the possible spread of MERS-CoV Virus in health care environments. The facilities that cater to the patients of MERS-CoV Virus need to take adequate measures to avert the risk of transmission of the virus from infected patients to others, including doctors, visitors, and health care workers. Health care workers should be extensively educated and continuously updated about the measures and protocols to prevent and control the virus as shown in Fig 617and Fig 7.17
Exploring the nCoV-2019 dataset
The data set, ‘covid_19_data.csv’, contains the following columns:
Sno Identification Number
Observation Day Date of the monitoring in MM/DD/YYYY
Province/State Province or state of the monitoring
Country/Region Country of observation
Last Update Time in UTC at which the row updated for the offered district or area
Confirmed Cumulative variety of confirmed cases up until that day
Deaths Advancing variety of deaths till that day
Recouped Cumulative number of recovered instances up until that date
NCoV-19 was epidemiological from 22 January 2020, and the World Health Organization declared a pandemic in March. Presentall the datasets are maintained by the John Hopkins University Center for Systems Science Engineering (JHUCCSE) from the various sources like Ministry of Health Italy, the Republic of China, The Government of Spain, Hong Kong Department of Health Commission, Taiwan ministry of health sciences, Ministry of Health Singapore, European Disease prevention Centre for disease prevention maintain the updated information of every hour and minute. The Republic of China, JSU, and CCSE maintain the entire data process in the GITHUB repository. The Attributes present in the dataset Province/State, Country/Region, Update list, Confirmed, Suspected, Deaths, and Recovered. Hence this data is sufficient for finding out of occurrence or finding out about the severity of the disease. For the Statistical finding, it plays a crucial role.
The proposed framework was shown in Fig 8. for predicting the cases.
Literature Review
In a study,1have taken around 142 DNA coding sequences of Middle East respiratory syndrome from the Biotechnology information centre, and also South Korean Quarantined DNA Protein sequences and made a comparative study. They further classified the patterns into several groups. A unique technique for web scraping data from the Twitter handle for the development of a better system for supervision, and they have examined swain flu pandemic and compared the difference between the hypothesis and evidence.2,3In 2016, in an article, Al-Hazmi had made a drastic improvement to find out the symptoms caused by Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS). He implemented this with the help of various machine learning algorithms. In 2016, Chen established a mathematical induction model to analyze and predict the Ebola virus that originated in Middle Africa. With the help of a Bio Python, they analyzed the sequence of an E protein from various MERS-CoV, causing factors that severely affected humanity.4,5,6 To predict this E protein, MERS he separated the B cells from the sequence using Lase Gene software.In 2019, Kelly et al., statistically proven the accuracy of the SARS by comparing the number of forecasted samples vs. actual outbreak size, by applying the hypothesis testing and out of sample log the likelihood of the person affecting diseases can also be predicted. Machine learning algorithms work fine because of the increase in computational speed.7,8,9 In this paper, he implemented CNN, where he analyzed the result on the epoch's values using Wiener series to predict things and decision making through computational methodologies.10,11,12,13,15
Results
The first thing we can do is generate some statistics on the 'Confirmed' column as shown in Fig.97.
Let us take a look at the mean and standard deviation in confirmed cases:
Mean: 611.8238586156112
Standard Deviation: 5121.319656069395
We can also generate a histogram of confirmed cumulative cases:
We can generate similar statistics for recovered cases as shown in Fig 10.17
Mean: 167.7042709867452
Standard Deviation: 1650.055340859415
Moreover, finally, we can look at the statistics for deaths as shown in Fig 11.17
Mean: 17.756111929307806
Standard Deviation: 187.19536561001198
We can also use box plots to visualize the distribution in numeric values based on the minimum, maximum, median, first quartile, and third quartile as shown in Fig 12.14
Let us plot the distribution in confirmed cases for 'Anhui,' 'Beijing,' and 'Chongqing' as shown in Fig 13.16
And for deaths as shown in Fig 15.16
We can do the same for recovered cases as shown in Fig 14.16
The above fig 16 shows the timeline of Zoonotic viruses effect from2003 to 2019 for table2.16
By this, we can estimate the rate of cases confirmed vs. Deaths occurred because of listed viruses in Fig 17.8 and the number of countries affected in Fig 18.8 and Rate of increase of cases in Fig 19.9, which leads to an abnormal increase of effect through the viruses.
Conclusion and future work
Among the family of SARS (Severe Acute Respiratory Syndrome), nCov-19 has dominated all the other Zoonotic Viruses with exponential growth. nCov-19 effected the persons on their protein structure and DNA. By comparing the statistical analysis of confirmed cases vs. deaths within a short period, nCov-19 affected the most compared with Zoonotic viruses. The coronavirus disease remains to spread out throughout the globe, adhering to a trajectory that is challenging to predict. The health, altruistic, and socio-economic policies have taken on by nations will certainly figure out the rate and stamina of the healing. There has to be a global human-centred reaction that is based on solidarity. The unique coronavirus spread out so quickly that it has transformed the rhythm of the globe. Whether from the viewpoint of a single country or multilateral degrees, the solidity of international connections has been put under examination. One of the most noticeable effects includes the economic recession, a situation of global governance, profession protectionism, and also increasing isolationist view. People-to-people, social as well as travel exchanges, have all been restricted. However, this is just the tip of the iceberg.SARS-CoV-2 gets in human cells by binding to ACE2, a cell surface healthy protein that functions as a door to the infected cells. ACE2, an enzyme produced by the ACE2 healthy protein, naturally contributes to the upkeep of high blood pressure but is tricked by the infection into coming to be an entryway. One of the SARS-CoV-2 virus factors is extremely transmittable because it can bind to the ACE2 cell receptor with greater fondness contrasted to the previous SARS-CoV infection, which created the condition called SARG which was much less transmittable, even though it created an epidemic in 2003. All-natural human ACE2 healthy protein variant inscribed in an individual's DNA can enable the infection to bind to ACE2 either strongly or weakly and, therefore, modify their susceptibility to the illness triggered the present pandemic. Further research can be done on Gene mutations that affect the healthy Z-Form of DNA.
ACKNOWLEDGMENTS
Nil.
Conflict of Interest: Nil.
Funding Source: Nil.
Englishhttp://ijcrr.com/abstract.php?article_id=2891http://ijcrr.com/article_html.php?did=2891
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareEvaluation of Anxiogenic Effect of Pseudoephedrine in Albino mice
English4247Srinivasa Rao KonijetiEnglish Kadiri Sunil KumarEnglish Sri Leela MovvaEnglish Muralikrishna K. S.EnglishObjectives: The study was designed with the rationale to investigate the anxiety-like behaviour with pseudoephedrine treatment in albino mice. Numerous reports of case studies suggest that pseudoephedrine treatment triggers anxiety symptoms in patients. Methods: Pseudoephedrine at doses 2 mg/kg and 5 mg/kg p.o was tested for its anxiogenic effect in albino mice by using elevated plus maze (EPM) and elevated zero mazes (EZM) models. Control and test group mice were treated with distilled water and pseudoephedrine for 15 days. The anxiogenic assessment was done on 15th day one hour after pretreatment with distilled water and pseudoephedrine. Results: In EPM study, there is a significant reduction in the number of entries (1.8 ± 0.63 with 5 mg/kg and 2.8 ± 1.39 with 2 mg/kg) and time spent in open arm (5.8 ± 0.47 seconds with 5mg/kg and 8.0 ± 1.98 seconds with 2mg/kg) with pseudoephedrine treatment at both doses when compared to control-treated mice (Number of entries=3.2 ±1.78 and time spent in open arm= 12 ± 0.14 seconds). In EZM there is a significant decrease in the number of entries in open arm (1.4 ± 0.21) and time spent in open arm (4.4 ± 1.72 seconds) with pseudoephedrine 5 mg/kg treatment when compared to control mice (Number of entries= 2.6 ± 1.35 and time spent in open arm= 11.6 ± 1.26 seconds). Conclusions: The reduction in the tendency of the mice to enter into the open arm after pseudoephedrine treatment indicates anxiety. This indicates that pseudoephedrine has an anxiety-inducing property.
EnglishPseudoephedrine, Anxiogenic, Elevated plus maze, Elevated zero maze, Open arm, Number of entries.INTRODUCTION
Anxiety disorders are a group of conditions set apart by outrageous or obsessive uneasiness or dread.1 Anxiety disorders can meddle with an individual's work, family and public activity. They will in general be constant and can be impairing. Despite their across the board commonness, anxiety issues have not gotten a similar acknowledgement as other significant conditions, for example, mood and psychotic disorders, also, the primary care doctor is typically the central assessor and treatment provider.2,3 In any case, anxiety turns into an issue when it interferes with typical capacities, is irrelevant to a genuine danger, causes physical side effects and gets excruciating to the individual.4 Pseudoephedrine is a sympathomimetic drug beneficial and widely used in nasal congestion problems during the common cold.5 The psychotropic impact of pseudoephedrine is notable since their broad use by belligerents on all sides of the Second World War, is one of stimulation with increased aggression and higher fatigue threshold.6 There are several reports which indicate that continuous treatment with pseudoephedrine can lead to cardiovascular, neurological, anxiogenic and mood-related issues.7,8,9 However there are no preclinical studies till date regarding the anxiogenic effect of pseudoephedrine treatment. Therefore the present study was planned to explore the anxiety-like behaviour induced by pseudoephedrine treatment in albino mice by using widely accepted anxiety models such as elevated plus maze and elevated zero mazes.
MATERIALS AND METHODS
For the present study, a pure sample of pseudoephedrine was purchased from Chandra Laboratories, Hyderabad. Pseudoephedrine was suspended in 0.5% w/v acacia and the suspension of pseudoephedrine was utilized for acute toxicity and in vivo anxiety study.
Experimental animals
Albino mice (20-25g) were used for the anxiogenic evaluation. They were procured from Sainath agencies, Musheerabad, Hyderabad (282/99/CPCSEA). After randomization into various groups and before initiation of the experiment, the rats were acclimatized for 10 days. Animals were housed in polypropylene cages and maintained under standard environmental conditions such as temperature (26±2°C), relative humidity (45-55%) and 12 hr. dark/light cycle. The animals were fed with mice/rodent pellet diet (Golden Mohur Lipton India Ltd) and water ad libtum. The research was carried out in the experimentation room of animal husbandry of Marri Laxman Reddy Institute of Pharmacy, Dundigal, Hyderabad. The study protocol was approved from the Institutional Animal Ethics Committee (IAEC) before the commencement of the experiment (1567/PO/Re/S/11/ CPCSEA)
Determination of Acute Toxicity (OECD Guidelines 423)10
Pseudoephedrine was studied for single-dose oral acute toxicity study at a dose of 5 mg/kg, 50 mg/kg, 300 mg/kg and 2000 mg/kg p.o in albino mice (6 mice in each group) by following the guidelines of OECD 423. All the mice were observed for toxicity signs for 24 hrs followed by 14 days. On 8th day and 14th-day body weights of mice were recorded.
Evaluation of Anxiogenic activity of Pseudoephedrine in albino mice11
Control and test mice were treated with 0.5% acacia and pseudoephedrine suspension 1 hour before the evaluation of anxiogenic effect.
Elevated Plus Maze
The EPM mechanical assembly comprises two crossing arms that frame the state of a '+'. Two contradicting shut arms are built with high dividers and are frequently named alleys. The converging open arms are a similar width and length as the closed arms, yet need sides to make a raised, thin strolling surface. Mazes can be built of the scope of materials, including wood or shaded Plexiglas, or metal. The size of the maze changes by species, research facility and producer. A common rodent maze raised roughly 70cm over the floor, with each arm estimating 10cm wide by 45cm long with the dividers of the encased arms around 30cm high. For mice, the device is downsized with arms that are around 5 cm wide by 30cm long, the side nooks 15cm high, and the whole contraption raised roughly 30cm over the floor. The walking surface might be secured with elastic or fixed with ledged on the external edges of the open arms to improve footing. All the animals were also subjected to elevated plus-maze assessment of anxiety levels. Every rodent was set separately in the focal point of the maze looking towards the open arm and coming up next were recorded a) time spent in open arm. b) Number of entries in the open arm during 5 minutes session.12
Elevated Zero Maze
All the animals were investigated for anxiety levels by employing elevated zero mazes set up. This test is the pharmacological validated assay of anxiety in animal models that is based on the natural aversion of mice to EZM. It is composed of a 6 cm wide range ring with outer diameter of 45cm containing four equal quadrants of alternating walled or installed sections. The entire ring is elevated to a height of 20 cm from the floor. Control and Pseudoephedrine treated mice were placed in the walled region at the start of 5 minutes session and the number of entries and time spent in the open arm by individual mice were recorded during these 5 minutes.13
Statistical Methods
The values are demonstrated as mean ± S.E.M and measurable noteworthiness among treated and control group was analyzed utilizing One way ANOVA, trailed by Dunnett's test where ***PEnglishhttp://ijcrr.com/abstract.php?article_id=2892http://ijcrr.com/article_html.php?did=2892Frye CA, Walf AA, Rhodes ME, Harney JP. Progesterone enhances motor, anxiolytic, analgesic, and anti-depressive behaviour of wild-type mice, but not those deficient in type 1 5α-reductase. Brain research. 2004 Apr 9;1004(1-2):116-24.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareGreen Tea Enhances Nutritional and Antioxidant Potential of Pearl Millet Based Cookies: A Healthy Approach
English4854Jigisha AnandEnglish Gargi KandwalEnglish Manya NathEnglish Vijay KumarEnglish Jaya SinhaEnglish Sanjay KumarEnglish Nishant RaiEnglishBackground: The study aimed to prepare cookies with high-quality ingredients which are a rich source of nutrition and have a good shelf life. The study proposed a healthy composition of cookies by incorporating antioxidant-rich green tea while replacing usual principal ingredients like all-purpose flour with cereals like Pearl Millet (Bajra) and oats while substituting unhealthy refined sugar with healthy powdered jaggery. The study thus evaluated the health benefits of green tea cookies based on their nutritional value and sensory analysis. Method and Materials: Cookies composed of five different compositions with varying concentrations of green tea, pearl millets, oats, jaggery, and other ingredients were prepared. Their physicochemical studies like change in width, density, thickness, volume, spread ratio, baking weight loss, fat, and ash contents were evaluated using standard protocols. Total flavonoid content, total phenolic content, and antioxidant activities of all cookies were determined. The sensory analysis was performed for all the five samples of cookies by Preference Tests-9 point hedonic rating. Results: There was a significant increase in TPC, TFC, and antioxidant activity. The sensory profile showed likeliness for these cookies. Conclusion: It can be inferred from the study that substituting pearl millet, oats, and jaggery with the normal ingredients enhanced the nutritional value and the likeliness of the cookies. Further incorporating green tea extract improved the quality of cookies and thus these cookies could be the promising source of healthy antioxidants.
English Antioxidant, Cookies, Green tea, Jaggery, Pearl millet, Sesame.INTRODUCTION
In today’s lifestyle, continuous stress, and negligence of a healthy diet have led to cause many diseases such as hypertension, diabetes, obesity etc.1. Cookies are one of the convenient and tasteful delicacies in our daily appetite. Moreover, owing to its wide utility, health prospect has become an important aspect and therefore emphasis is being made to enhance the nutritive value of the cookies2, 3.
The market of cookies is one of the rapidly growing sectors in the fast-moving consumer goods (FMCG) category, while it is expected that the compound annual growth rate of the global packaged bakery products market will be 4.6% during the period 2017-20254. It is known that many cookies contain industrial pollution or they are made from unhealthy all-purpose flour5. Health experts never support the idea of having cookies made from all-purpose flour due to its side effects. Therefore this research is based on making cookies that are baked and contain a high nutritional value which imposes beneficial health effects of rich antioxidants.
In the past several years, the concept of multigrain cookies has emerged tremendously and claimed to be rich in energy, fiber, and carbohydrates; these cookies are now widely accepted by the consumers. Nutritious cookies could be made by substituting all-purpose flour with some other products like Pearl Millet Bajra, oats which are rich in fiber and filled with nutrition6.
Green tea is now considered as the world’s healthiest drink because of the presence of the highest amounts of antioxidants of any tea. Green tea contains 20-45 percent polyphenols of which 60-80 percent are catechins such as epigallocatechin gallate (EGCG) which are credited with its rich antioxidant, anti-inflammatory, and anti-carcinogenic effects7.
The EGCG contains healthy bioactive compounds that increase metabolism and reduces the rate of diseases such as diabetes, Alzheimer’s, heart disease and maintain the blood pressure7, 8. Likewise, sesame seed provides a good source of vitamin E, boost digestion, strengthens bones, and prevent disease such as cancer9. Jaggery (gur) is a natural sweetener that is made up of concentrated sugarcane juice. Jaggery contains minerals and vitamins which are good for our health and it is also called “medicinal sugar” because of its use in Ayurveda10.
Pearl millet, commonly known as ‘Bajra’ in the Indian sub-continent, is a high energy cereal known for its rich nutritive value. It comprises of protein (12-16%), fats (4-6%), vitamin B1(0.25mg), vitamin B2 (0.20mg), Vitamin B3(0.86mg), vitamin B6 (0.50mg), carotenoids (293µg), carbohydrates (0.81g), and minerals, dietary fiber and polyphenols (0.2-0.3%)11. Besides, their rich nutritional attributes, millets confer increase antioxidant activity and helps in curing metabolic diseases, cardiovascular disorders, diabetes etc12.
Oats are known scientifically as Avena sativa and contain many components contributing to health benefits. The soluble fiber in oats is β-glucan, which helps in slow digestion, increase sufficiency, and subdue appetite. β-glucan binds with the cholesterol-rich bile acids present in the intestine and transports it through the digestive tract and at the end out of the body13. Whole oats commonly called rolled oats contain phenolic compounds and phytoestrogens having antioxidant properties that reduce the damaging effects of chronic inflammation which is associated with various diseases like cardiovascular disease and diabetes14.
Jaggery contains more nutrients than refined sugar because of its molasses content and is a sweetener now popular as a "healthy" replacement for sugar. Molasses is a nutritious by-product of the sugar-making process and, unlike refined sugar; it is rich in micronutrients, minerals, and vitamins15.
Sesame seed or “Til’, is a rich source of protein. It has a non-culinary application. The seeds contain Sesamin and Sesamolin having a cholesterol-lowering effect in humans and the prevention of high blood pressure16.
Fennel seeds or “Suaf’ indeed contain numerous flavonoids, anti-oxidant like kaempferol and quercetin. These compounds function as a powerful antioxidant agent. Fennel seeds are also a rich source of dietary fibre, resistant to digestion and re-absorption in the colon which contributes to lowering serum LDL cholesterol levels17.
The present study addresses the enhancement of green tea, pearl millet, oats, sesame seed, fennel seeds, and jaggery in green tea-based cookies (GTC) preparation. The study aims to investigate the effect of all the above ingredients on quality attributes of green tea-based cookies (GTC).
MATERIALS AND METHOD
The materials used for making cookies i.e. green tea, pearl millet flour, oats, jaggery, sesame seeds, fennel seeds, refined flour, and unsalted butter were procured from the local market Dehradun. All the chemicals used in the present study were purchased from Hi-Media, India.
Preparation of Green tea cookies (GTC)
The green tea cookies i.e. GTC-A, GTC-B, GTC-C, GTC-D, and GTC-E were prepared by mixing all the ingredients in a proper ratio and baked it at 170°C for 15-20 min5. The prepared green tea cookies were packed in food grade bags and stored at room temperature in an airtight container for further analysis (Table 1).
Physicochemical analysis of Green tea cookies (GTC)
The prepared cookies were analyzed based on the change in density, thickness, width, volume, spread factor, baking weight loss18. Density was calculated using the formula; Density= Mass/Volume. The diameter was measured using a vernier calliper. The thickness of biscuits (T) was measured in triplicate and means were recorded. Spread ratio (Sr) was calculated using the formula:
Sr= D/T
Volume (V) was calculated using the formula:
V = (D2 π T)/4
Baking weight loss (BWL) was determined by measuring the weight of the biscuit before and after baking.
It was calculated using equation:
BWL (%) = (w0-wt)/w0 × 100
where, w0 = initial weight (g) of cookie and wt = weight (g) after baking19.
Moisture content was measured by hot air oven drying method20.
Total ash and fat content were determined by AOAC method21.
Total flavonoid content:
For TFC estimation, calibration curve was plotted at 0.0156, 00312, 0.0625, 0.125, 0.25, 0.5, and 1.0 mg/ml concentration of hydrated catechins (as standard) respectively. 100 µl of the GTC sample at the concentration of 1 mg/ml was taken and mixed with 400 µl of distilled water. To the above mix, 30 µl of 7% sodium nitrate was added and was incubated for 5min. Further 30µl of 10% aluminium chloride was added and incubated for 5 min. Then, 20 µl of 4% NaOH was added. Volume makeup was done to 1 ml by adding 420 µl of distilled water. To calculate the TFC optical density was recorded at 570 nm. Triplicate measurements were carried out and total phenolic content was expressed as milligram of catechin22.
Total phenolic content:
Determination of total phenolic content was carried out using Folin–Ciocalteu reagent (FCR) assay. 20 µl of the cookies (stock solution 1mg/ml) was dissolved in 80 µl of water and 500 µl of FCR was added. The solutions were mixed followed by incubation in dark at room temperature for 5 minutes. After incubation, 400 µl of 7.5% Na2CO3 solution was added and kept for further incubation in dark for 30 minutes at room temperature. The absorbance was recorded at 765 nm using a colourimeter. Gallic acid (as standard) was used for the calibration curve that is plotted at 0.0156, 00312, 0.0625, 0.125, 0.25, 0.5, and 1.0 mg/ml of concentration respectively. The measurements were taken in triplicate and total phenolic content was expressed as milligram of gallic acid equivalents (GAE) per gram of samples22.
DPPH
DPPH is highly photosensitive; therefore all the procedures were done in dark. DPPH solution was prepared by dissolving 2.4 mg of DPPH in 50 ml of 100% methanol. Ascorbic acid served as the standard. Both samples and standards were prepared in a concentration of 1mg/ml. The standard was then diluted by using half fold dilution method. 100µl of GTC sample was taken and 1900 µl of DPPH solution was added. All the treated test samples and standard dilutions were incubated for 2 hours in dark. After incubation, the O.D was recorded at 517nm. The calibration curve of standard was plotted at 0.0156, 00312, 0.0625, 0.125, 0.25, 0.5, and 1.0 mg/ml of concentration respectively22. Measurements were taken in triplicate and the percentage scavenging effect was determined using the formula:
scavenging rate (%) = [(A0 - A1)/A0] / 100
where A0 = Absorbance of the control (without extract)
A1 =Absorbance in the presence of the extract
Sensory analysis
Sensory analysis was performed for all the five samples of cookies by Preference Tests -9 point hedonic rating. Nine different people and their responses were recorded in context to the three main attributes that are colour, taste, and flavour23.
Statistical analysis:
All the estimated data was statistically analyzed accordingly using ANONA two-way analysis (with duplicates) and t-test. All the parameter scores were expressed in terms of Mean ±SD 2The statistical significance was set at a 5% level of significance (pEnglishhttp://ijcrr.com/abstract.php?article_id=2893http://ijcrr.com/article_html.php?did=2893
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcarePrevalence of Morbidities among Peri-Menopausal and Postmenopausal Women in Selected Urban Slums of Eastern India
English5560Kamal Kishor DewanganEnglish Lipilekha PatnaikEnglish Trilochan SahuEnglishBackground: Women having menstrual Menopause is a universal physiological transitional process of the reproductive phase to the nonreproductive phase of life. During this transition, women suffer somatic, psychological and urogenital morbidities those are due to a decrease in the level of oestrogen that affects their quality of life. Objective: To find out the prevalence of morbidities among perimenopausal women using Modified Menopausal Rating Scale (MRS) and their associated factors of morbidities. Methods: It is a community-based cross-sectional study conducted on selected 9 urban slums under Urban Health Training Centre area of IMS and SUM Hospital, Bhubaneswar in September to November 2018. probability sampling method was used and the sample size calculated was 220. Perception of morbidities using Modified Menopausal Rating Scale was used. Data were entered in excel spreadsheet and analysis done by using SPSS VS.20. Results: The mean age of menopausal women in the study was 49.35 ±5.4 years and the majority were in the age group was 51-55years (35.4%). The most common perceived symptoms were joint and muscular discomfort (92.27%), anxiety (72.72%), hot flushes and physical mental exhaustion (71%), bladder problem (67.2%), sleep problem (62.27%), heart discomfort and irritability (57%), Depression (55.9%), sexual problem (56.36%) and vaginal dryness (55%). Conclusions: Depression and physical and mental exhaustion complaints were high among perimenopausal women. The severity of morbidities was higher among postmenopausal women in somatic and urogenital subscales, Illiteracy and the high proportion of low SES made the menopausal quality of life worse in slum population.
EnglishModified menopausal Rating Scale (MRS), Menopausal morbidity, Urban slums.Background:
Menopause is a specific physiological transition from reproductive to the non-reproductive phase of women’s life.1 Due to rapid globalization, urbanization, awareness and increase longevity in urban middle-aged Indian women, menopause problems are emerging as an issue in the world leading to morbidities. According to the World Health Organization menopause defined as “Permanent cessation of menstruation resulting from loss of ovarian follicular activity” and post-menopause as the 12 months after natural amenorrhea.2,3 It occurs due to a reduction in the number of ovarian follicles about to end, but natural declining of secretion of the ovarian hormone.4Perimenopausal period defines the time before; during and after menopause. Complains that start with the menopausal transition typically continue making a compensatory decrease in the Post-menopause.5According to Population Projection Survey in India 45 years and above is expected to increase in 401 million in 2026 and at the present 96 million population. These enormous numbers of women are predicted to approx. 30 years post-reproductive period of life.6 Women achieved menopause through various ways as spontaneous decreasing of reproductive hormones, hysterectomy, due to deficiency of primary ovarian and chemo and radiation therapy.7
Worldwide, the mean age of menopause ranges from 40-65 years. During the menopausal transitional phase, women experience vasomotor, psychosomatic, urogenital as well as sexual complaints. So, theses morbidities effect decreasing the quality of life and make susceptible for early mortality from following chronic diseases like Osteoporosis, Ischemic Heart Disease etc.8According to Indian Menopause Society menopause of Indian women average is 47.5 years. It was much less than westerns countries (51years), Hence menopausal health in Indian scenario should be higher priority.9
Objective: To find out the prevalence of morbidities among perimenopausal women using Modified Menopausal Rating Scale (MRS) and their associated factors.
MATERIALS and METHODS
This study was conducted in selected urban slums of Bhubaneswar catered under Urban Health Training Centre of Department of Community medicine, Bhubaneswar, Odisha. It was a cross-sectional study, of 3 months duration from September 2018 to November 2018.
Inclusion criteria:
1. Women of 40-60 years age group.
2. Who willing to take part in the study and had given informed consent
Exclusion criteria
Having any systemic illness and on hormonal replacement therapy or hysterectomy is done in past. The sampling technique used convenient sampling, the slums and menopausal women were identified from the urban field practice area of the medical college and included in the study.For sample size calculation conducting a pilot study on 30 women and prevalence of major menopausal symptoms found was 60%, Sample size formula N = 4PQ/L², P = 60%, Q = 40%, L = 10% (Absolute precision) with 95% Confidence interval, 2 design effect for sampling, 10% non-response rate, total sample size was calculated 220.
Study tool: Among participants a conducting interview using Menopausal Rating Scale (MRS), this tool already validated through various authors and broadly used for capturing the menopausal morbidities and their quality of life indexing, before the interview informed consent had been taken from participants.
MRS consists of 11 items and separated into subscale categories
a.Somatic: Hot flushes/sweat discomfort, heart discomfort/palpitation, sleeping discomfort then joint and muscle ached complains)
b. Psychological: Depressive mood complains, irritability, anxiety status, physical and mental exhaustion conditions
c. Urogenital: Sexual complains, bladder discomfort, and vaginal dryness.
The scoring each item can be graded from the point by point rises by its severity of perceived complains. It’s 11 complaining items of indexing quality of life scale, each complaining item classified from 0-4, (0 = no complain/normal), (1= mild), (2= moderate), (3= severe), (4= very severe) MRS assortment between 0 (lowest level of complain) and 44 (maximal gradation of complain)10
The gradation of lowest/highest score differ between three subscale categories according to their number of perceived problems distributed to their categorised under subscale
For somatic subscale category classified into those who received score 0 to 2 categorised under no complains/few complains, 3 to 4 have under mild complains then 5 to 8 under moderate complains last score > 8, under severe complains.
Psychological category those who received score 0 to 1 classified under lowest or few complains, 2 to 3 have under mild complains then 4 to 6 have moderate complains last >6, classified severe complaints.
Urogenital category those who got score 0, classified under lowest / few complaints, 1 to have under mild complains, 2 to 3 have moderate complains then > 3 classified under severe complain.10
Statistical analysis: data were entered in the excel spreadsheet and for SPSS version 20 was used for analysis. Chi-square test was used to analyse quantitative variables. Continuous data were expressed as mean ±SD, (95% C.I.), P-value < 0.05 was taken statistically significant.
RESULTS
Table.1 shows the distribution of the study population according to socio-demographic factors. Out of 220 women, 35.4% of women were in the age group of 51-55years.126 postmenopausal women revealed their menopausal age. Mean age of menopause in the study was found to be 49.35 ±5.4. The majority were Hindu (92.6%), followed by Muslim (7.7%), among them General category(51.4%) followed by OBC(41%) and ST/SC (7.8%). Structure of family majority was in Joint family (55.9%) type, 95% of respondents were married and most of the respondents have 3 or more children. Mostly half of the participants (48.2%) were illiterate by their educational status, Majority of participants (67.3%) working labourer by profession and 52.7% of study participants belonging to Upper lower Socioeconomic status according to modified Kuppuswamy 2018 Socioeconomic rating scale.11
Table 2. describes the prevalence of menopausal symptom, major symptoms were joint and muscles pain (92.27) in total followed by anxiety (72.72%), Hot flushes and night sweat (71.34%), Physical mental exhaustion(71.36%)) and Bladder problem (67.27%)), sleep problem (62.2%), Irritability (57.7%), heart problem (56.8%), depression (56.34%), sexual problem (55.9%), and vaginal dryness (55%). Difference between peri and postmenopausal symptoms are statically not significant.
Table.3 In somatic symptoms of severity severe were higher proportion in postmenopausal women (p 0.05).
Discussion
Ageing is a specific unavoidable process besides its related to several changes that reduce the quality of life. Menopause is one of the natural processes of women’s life. It’s a specifical estrogen deficit state and affects many organs of the body those have sensitive for estrogen, thus declining level of estrogen raising cause of numerous physical, sexual and psychological changes of women’s life. frequency of sign and symptoms differ over some time. Few complaints frequency prevalent in the perimenopausal phase and declines over a period, thus some complains raises gradually after the perimenopausal phase and more severe after postmenopausal life.12
In the present study menopausal mean age was 49.35 ±5.4 years. This was earlier than the western part of the world, which is around 51.14 ± 2.11 years worldwide.2Nevertheless, it is marginally higher than Indian population which is around 47.5 years.9Which is in good same opinion and findings of others studies of Ganapathy et al.6 in Saudi Arabia (49.59 ± 3.09 years), Khatoon F et al.13in Lucknow (50.33±5.26 years), and Singh and Pradhan14 in Delhi (46.24 ± 3.38 years). Among white women the median age ranges between 50 and 52 years and at perimenopause is 47.5 years in developed countries accompanied by slight evidence of increasing age at menopause over time. Beginning of these perimenopausal symptoms differ by race and nationality, influence by demographic and habits factors.15
There was no significant association found among respondents menopausal age, religion, caste, education status, occupation status, parity and SES. Our findings are similar to M. Deotale et al.16 and S.K Panda et al.17, who found there was no association between the various sociodemographic factors and age onset of menopause.
Most common symptoms found in our study was joint and muscular pain in postmenopausal women (95%) and perimenopausal (88%). This finding was similar to many other studies where this complaint was found to be dominant. In a study by F. Khatoon et al.13 and S.K Panda et al.17found pain is the main symptoms and Rahman et al.18also found same major symptoms. Hot flushes were most commonly reported by many Indian as well as in western countries studies, our study respondents reported mostly hot flushes 72.40% by postmenopausal and 70% by perimenopausal women. The proportion of hot flushes more in postmenopausal women as per the study of similar results Senthilvel et al.19 Nayak G et al.20 and hot flushes symptoms range between 0 % to 80% worldwide.21
Other somatic problem sleep disturbance in perimenopausal 61.3% and postmenopausal were 63% and heart discomfort almost the same 57% in peri and postmenopausal women in the study. These findings compare with the study done by Khatoon F et al.13 sleep disturbance 56%, and heart disturbance 60% and also similar in the study of Panda Set al.17
This study shows most common psychological complains physical and mental exhaustion in perimenopausal in 73% and postmenopausal were 70%, anxiety 71% in peri and 74% in postmenopausal women, depressive mood complains in peri and postmenopausal respectively 63% and 56%. Irritability complains were found in study peri and postmenopausal were 53% and 60% these results also resembles with the study of Khatoon et al.13 also found depressive mood 70%, Physical mental exhaustion 60% also similar study in Rahman et al.18
Urogenital complain in the study sexual problem in peri and postmenopausal women respectively 51% and 59%, bladder problems were reported 63% in peri and 67% in postmenopausal women and Vaginal dryness 53% in peri and 55% in postmenopausal women in the study. Urogenital severity high in postmenopausal women it's statistical significance in the study similar result found in Pal A et al.22 also found in their study bladder problem (56%) and vaginal dryness (53.3%) much prevalent and similar result also in Ganapathy T et al., Panda S et al.6,17 Menopause is a natural phase of reproductive biorhythm of woman’s life. Menopause is a biopsychological process and is a natural ageing system which signals a decreasing in body function. Due to the decreasing level of oestrogen, the body goes through various physiological alterations. This needs the combined medical and psychological support. Hence, the women can have the strength to overcome the severity of changes which affects the wellbeing of women.13
Limitation:
Firstly, recall bias was unavoidable because retrospective information was collected for menopausal symptoms in the preceding one month which was difficult for the elderly women to remember. Secondly the MRS questionnaire is in English language and the women in the slum were not well versed with the language thus it was explained by the principal investigator in Odia language in an interview and filled accordingly. Before starting the study, pilot testing was done for 30 participants.
Conclusion:
Most common symptoms perceived in the study were joint and muscular pain, followed by anxiety, hot flushes and physical mental exhaustion. The severity of morbidities was higher among postmenopausal women in somatic and urogenital subscales. The awareness regarding menopausal symptoms and its management should be enhanced by the staff of urban health and training centre.
Acknowledgement
We are thankful to all Urban Health Training Centre staff to help us conduct survey and data collection, also thankful our professors of the department to analysis and guide for article writing.
The authors gratefully acknowledge all volunteers for participation in this study. We acknowledge the immense help received from the scholars whose articles are cited and included in references to 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 and discussed.
Source of Funding: None
Conflict of Interest: None
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13. Khatoon F, Sinha P, Shahid S, Gupta U. Assessment of menopausal symptoms using a modified menopause rating scale (MRS) in women of Northern India. Int J Reprod Contracept Obstet Gynecol 2018;7:947-51. International. Int J Reprod Contraception, Obstet Gynecol. 2018;7(3):947.
14. Singh A, Pradhan SK. Menopausal symptoms of postmenopausal women in a rural community of Delhi, India?: A cross-sectional study. 2014;5(2):2–7.
15. Gold EB. The Timing of the Age at Which Natural Menopause Occurs. Obstet Gynecol Clin North Am. 2011;38(3):425–40.
16. Deotale M, Ranganathan U, Mankeshwar R, Akarte S. Study of epidemiological features of health problems in perimenopausal and postmenopausal women in an urban community. Int J Med Public Heal. 2015;5(2):147.
17. Panda SK. Assessment of Health Status in Peri- and Postmenopausal Women Residing in Urban Slums. J Med Sci Clin Res. 2018;6(5):490–6.
18. Rahman S, Zainudin S, Mun V. Assessment of menopausal symptoms using modified Menopause Rating Scale (MRS) among middle-age women in Kuching, Sarawak, Malaysia. Asia Pac Fam Med. 2010;9(1):5.
19. Sumathi Senthilvel SV, P. S. Anju, Anjana Sukumaran JS. Assessment of symptoms and quality of life among postmenopausal women in a tertiary care hospital in Kochi, South India: A hospital-based descriptive study. J Midlife Health. 2018;9:185–90.
20. Gayathry Nayak AK, Pratap Kumar AR. A study of quality of life among perimenopausal women in selected coastal areas of Karnataka, India. J Midlife Health. 2012;3(2):71.
21. Mahawar P, Sakalle S, Dixit S, Rathore D, Gangwani D. Assessment of Morbidity Pattern and Its Knowledge Assessment of Peri- and Postmenopausal Women Using Menopause Rating Scale - A Cross-sectional Study. Ann Community Heal. 2017;5(2):2–6.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareEpidemiological Study and review on Chronic Insomnia; Neurological Disease
English6172Mohammad Gayoor KhanEnglish Thangapandi M.English Sabitha Mary KurianEnglish Veena SureshEnglish D. Nagendra BabuEnglish Aarti Singh KushwahEnglish Umama YezdaniEnglishIntroduction: Chronic Insomnia is a Psychological disorder or neurological disease. It is a very common condition and estimated one-fourth the population of clinical affecting by this. In short long term sleeplessness or difficulty in sleeping. In chronic insomnia case if person per week at least not sleep 3 days and this routine continues for 3-4 months regularly or longer period then the condition is considered chronic insomniac patient. Difficulty in sleeping breaks in sleepings there is several causes. Aim: This study aims to identify particular treatment options for the treatment of insomnia. Objective: The major objective of this study is to identify the causes of insomnia. For the treatment of the disease we first need to have a proper diagnosis after that we can provide an accurate cure to it. Various treatment measures have to be taken for the treatment of this disease including pharmacological and also non-pharmacological. Conclusion: Treatment of this sleep disorder can be completely done. Treatment consists of modifying sleep habits to cut back involuntary and psychological feature factors and education regarding healthier sleep follow. Drug treatment ought to be reserved for the shorter alleviation of sleep disorder. Applicable treatment of chronic sleep disorder improves the standard of life. The hindrance of sleep disorder consists of a balance of rest, recreational exercise together with stress management and a healthy diet.
English Neurological disease, Chronicinsomnia, Stress, Sleep disorderINTRODUCTION:
Insomnia is a sleep disorder which is common causes in adult women's mostly. In chronic insomnia, the patient feels difficulty in sleeping, uninterrupted sleep.1, 2Insomnia first time discovered by Johann Heinroth in 1818. It is the first psychosomatic disorder. Most of the study it is proved research adopt an arbitrary definition of insomnia as delay lower than 30 min sleep efficiency. The chronic insomnia is defined as difficulty in sleeping at least 3-4 nights in a week that repetition goes for at least 2-3 months3 or more that condition known as chronic insomnia condition.
Types of insomnia:
According to NSF various types of insomnias are there. They are comorbid insomnia, acute insomnia, chronic insomnia, maintenance insomnia and onset insomnia.
Acute insomnia: It happens often and they cure without any treatment procedures. It is considered as acute insomnia when the person is unable to sleep for a few weeks. Acute insomnia happens due to stress because of job loss, loss of loved one, jet lag and divorce. Sometimes surrounding things like a baby crying, noise, light and temperature may also be the causes of this condition.
Chronic insomnia: Difficulty in sleeping over a long period. The person feels very hard to falling in asleep or continuing the sleep without interruption throughout the night in a week not less than 3 months and more. Chronic insomnia cause due to having diseases like low back pain, sleep apnea, arthritis, depression, cancer, hypothyroidism, restless leg syndrome.
Co-Morbid insomnia: This sort of sleep deprivation happens due to some disease condition as psychiatric symptoms – anxiety and depression, cardiovascular, airway diseases, diabetes and cerebrovascular diseases.
Onset insomnia: This condition is characterized by difficulty in falling asleep at early sleeping at night.
Maintenance insomnia: This condition is described as difficulty in sleeping throughout the night. They wake up at any point of the night and have difficulty to sleep again.
Causes: Cold/ allergies, Parkinson’s diseases, GERD, low back pain, sleep apnea, arthritis, depression, cancer, hypothyroidism, restless leg syndrome. Antipsychotic medication, caffeine, nicotine and biological factors such as heightened cortisol, reduced Estrogen, progesterone.
Symptoms: Dissatisfaction in sleep, day time sleeping, low energy, early wakeup, concentration difficulties, inability to do regular work, unsatisfied in between relationship, family, friends and fatigue.
Insomnia risk factors: Affects mostly women, adults more than men and older adults.Chronic illness, mental health issues and working in time.
EPIDEMIOLOGY:
On an average, it is estimated that around 7-11% of the adult human population suffering from chronic insomnia which is often undertreated, under-diagnosed the condition of insomnia also increases as age passes which are most common in women’s this interface with normal functioning causes anxiety, depression, disturbance increase, poor cognitive functioning mood swings and mood changes. In chronic insomnia causes slow reactions times difficulty in balance maintaining, increase risk of mortality as it results in chronic insomnia misinterpreted as mild cognitive or dementia. Every four in one person with medical condition experience insomnia disease. When compared to males women’s are 1.4 times more chance to get affected by insomnia disease.About$100 billion amount is spending every year by the people’s in united states for the treatment of insomnia. Insomnia affects concentration, productivity, disability to do regular work and increases the healthcare cost of the individual who is chronically affected by insomnia. According to the 2002 NSF poll, 63 % of women experience symptoms of insomnia for a few nights per week. 4,5 Adults (68%) are more affected when compared to adult ages (59%). Surprisingly parents not having children in their household reported insomnia more when compared to parents those are having children (66 vs 54).
NATURAL HISTORY:
One of the studies claimed and it is found that remission rate 13.1% after 4 months. Follow up in Population suffering from insomnia for 1 month or more than that.6
PATHO PHYSIOLOGY:
Chronic insomnia is a disorder distinguished by lack of sleep and the uneasiness of falling asleep, recurrent of awakening in sleep. Chronic Insomnia has impacted 6-10% of the total adult population. Due to lack of generality, the symptoms are underrated by various age groups. Women’s are mainly affected by this and it increases as age rises. This also has a rapid rate of showing up in people who suffer from diabetes. Chronic insomnia intervenes with the development of body and various systems; it convicts anxiety, emotional disorder, drowsiness, retarded psychological health. The hyperarousal creates by disturbed mind causes a higher level of cortisol and adrenocorticotropic hormone indicates towards thronging insomnia.
DIAGNOSIS OF INSOMNIA:
Evaluation of a patient with Insomnia
The assessment of insomnia can be augmented by a prototype that allows for the progression of insomnia disorder.A comprehensive history retrieved during the patient interview is the linchpin of the assessment of insomnia. Whereas the interview approach may vary in consonance with the practitioner, the core should be covered to ensure an accurate evaluation. The primary objective of the evaluation process is to identify comorbid disorders that can be directly controlled. Evaluation pursues to be based on a cautious history and examination of patients dealing with sleep and waking functions, as well as prevalent medical, psychiatric, and comorbidities linked to medication/substances.
Sleep History
Components of an Insomnia intake history
1. Principal complaints of insomnia or sleep pattern
Insomnia patients may complain of sleeping difficulties, recurrent awakenings, struggling to get back to sleep, early morning awakenings, or sleep that fails to feel calm, reviving, or remedial.
Key elements include:
Distinguish of the type of ailments
Frequency (occurrence per night)
The severity of night discomfort and daytime symptoms
Factors that fluctuate symptoms
Recognition of precipitants
Perpetuating factors
Duration (months, years, lifetime)
Treatments and responses
Course (progressive, irregular, persistent)
Pre-sleep conditions with behavioural factors
Classification of the sleeping status
The psychological state of the patient (drowsy /conscious, easy/uneasy) is useful in grasping which factors may ease or endure sleep or awakening after sleep.
Sleep-wake schedule
The sleep schedule should be reviewed to comprise sack time, sleep inactivity, frequency, and duration of night time arouse, sleep re-initiation time, wake time, bedtime, and entire sleep time.
The ability of the patient to fall asleep can be impeded by the consuming and work up times in close temporal link with bedtime. Collateral reports from relatives, teachers, or companions may evince valuable if the patient is heedless of the extent of symptoms.
Nocturnal symptoms
To point out nocturnal signs associated with:
Breathing anomalies (sleep apnea)
REM sleep behaviour disorder (kicking, punching, shouting)
Parasomnias (abnormal movements, emotions)
Neurological disorders/comorbid conditions (palpitations, epilepsy, headaches).
Other Psychological emotions associated with wakefulness (restlessness, anxiety, frustration) may impart to insomnia.
Day time activities and day time functions
Daytime activities and behaviours can give clues about possible provocation and the outcome of insomnia such as
Nod off (frequency per day, time)
work (working hours, type of work)
Lifestyle (inactive/active, shut-in, daytime exposure, exercise)
travel, daytime dysfunction (cognitive dysfunction, mood, quality of life)7
Evaluation of Comorbid conditions
· A major part of the patient interview should be aimed at the assessment of medical conditions, mental conditions, and other sleep disorders often comorbid with insomnia. 8
Current or past treatment response
Over-the-counter medication approaches, alcohol, and prescription drugs must be included in the assessment of current and past treatments.
The type, dosage, use frequency, administration time, a typical response must be evaluated
It is also important to assess the acceptance of pharmacological and non-pharmacological therapies by the patient since these perspectives are likely to impact adherence to guidance and yield treatment outcomes.8
Examination by physically and mentally
Physical examination may disclose signs compatible with sleep apnea, respiratory, thyroid, cardiac, and neurological disorders. 9,10
The mental examination may give details concerning the effect, mood, level of observant, and ability of the patient to attend.10
Objective Assessment Tools
In the evaluation of insomnia, laboratory testing, polysomnography, and actigraphy are not regularly suggested and be suitable for individuals with certain comorbid conditions/ sleep disorders.
Sleep Diaries
Subjective sleep diaries are often used to aid for insomnia assessment in clinical settings and outcome measures in insomnia treatment. It can help to track a patient's sleep-wake routines recorded over 1 to 2 weeks. Information can be collected from the diaries including sleep-wake times, the time duration in bed, and frequency in sleep-wake times.
Polysomnography
Polysomnography is not used commonly to assess insomnia; instead, it is the patient interview that is responsible for the diagnosis. It is only used to exclude the sleep existence disorderly breathing or PLMS condition.
Actigraphy
The actigraph is an actimetry worn on the wrist of the patient. They can measure gross motor activity for 2 weeks and record rest or activity conditions. Some advanced actigraphs can fetch information such as light exposure or patient self-reporting data. The patient is presumed to be asleep when there is no movement. The data collected from the device by connecting to a computer and downloads from the actigraph, performs an asleep and wake evaluation algorithm, and presents data in numerically and graphically.
Multiple sleep latency test
It is the evaluation tool for measuring excessive daytime sleepiness. It is the standard tool for diagnosis in narcolepsy or idiopathic hypersomnia.
Neurobehavioral testing
The neurobehavioral and cognitive test is used to compute insomnia-associated daytime impairment. Many have found no daytime deficits objectively measured. They have to consider sensitivity and specificity when tests conducted for the daytime insomnia.13
TREATMENT OF INSOMNIA:
The incidence of sleep disturbance and the degree to which insomnia remarkably affects daytime activities decide the requirement for assessment and treatment. For acute stress disorder patients, physicians begin treatment for insomnia at the initial visit where no further assessment may be needed. However, if insomnia is severe or chronic, a detailed examination is required to detect comorbidities and associated condition, psychiatric or neurologic disorder. Treatment should initiate with nonpharmacologic treatment followed by pharmacologic treatment, in case of no improvement. 14
Non-Pharmacological Treatment:
Sleep hygiene
It incorporates educating the patients about lifestyle modifications like wellbeing practices (substance abuse, diet, and exercise) and environmental factors (light, sound, and temperature). 15Assess sleep hygiene with the help of specific practice scales like sleep hygiene index and awareness scales. But sleep hygiene counselling alone might be unproductive in managing chronic insomnia patients and should be utilised with different aspects of cognitive behaviour therapy. 16
Stimulus control therapy
It helps to initiate a regular sleep-wake cycle and involves the restriction of maladaptive behaviour like late-night use of digital devices, reading or eating on the bed. 15Recommendations include limit the utilisation of the bedroom to sleep and lovemaking and leave the room if unable to sleep in 20 minutes.
Temporal control measures
It involves a consistent time of wakening ignoring the sleep duration and avoids sleeping during the day. 17The technique involves “early to bed and early to rise, makes a person healthy, wealthy, and wise”.
Sleep Restriction therapy
It is useful for patients who invest a significant amount of time in bed attempting to fall asleep, which initially restrains the time in bed to the total sleep time (TST). Thereby, it aims to improve sleep progression by utilising sleep limitation to build a sleep drive. 18The major limitation of this therapy is excessive daytime sleepiness.
Relaxation therapies
Relaxation therapies include various activities such as
Autogenic training: Self-directed relaxation training by encouraging body recognitions such as warmth and heaviness of the limbs.
Imagery training: Practice of generating pleasant images in mind, which helps in relaxation and stress reduction, thereby leads to good sleep.
Progressive muscle relaxation: It involves straining and loosening up of various muscle groups to reduce stress and anxiety.
Visual or auditory biofeedback training: It trains the patient to control certain physiologic factors like breathing, heart rate and brain activities using visual and auditory feedback to enhance from stress, anxiety and related insomnia. 15,17
Breathing exercise, meditation or yoga: Mindfulness-based therapy for insomnia (MBTI) is a meditation-based initiative that helps in emotion regulation and stress reduction. 19
Paradoxical intention therapy
The therapy advises the patient to stay awake to reduce the anxiety associated with the strain to sleep. 18
Cognitive behavioural therapy
Cognitive Behaviour Therapy for Insomnia (CBT-I) includes various components of intervention such as behavioural (sleep hygiene, stimulus control, relaxation, and sleep limitation) and psychological approaches (e.g., psychological rebuilding). 20It helps to alter false deceptions and mentalities about sleep, for example, unreasonable desires, confusions, enhancing outcomes of restlessness. The methods comprise of reattribution training (objective setting and arranging adapting reactions), decatastrophizing (planned for adjusting anxious programmed thoughts), assessment, and shifting attention. 14Effective CBT-I can show remarkable advancement in sleep onset latency (SOL), wakefulness after sleep onset (WASO) and total sleep time (TST). 16
Exercise
Excess activity and exercise training help in improving the quality of sleep by significantly reducing depression and anxiety. But, avoid exercise before bedtime.21
Pharmacological Management of Insomnia:
Pharmacological therapy can be beneficial for short-term relief of insomnia but may not be efficient for long-term use.
Drugs Acting on GABA-A Receptors
Both Benzodiazepines (BZD) and benzodiazepine receptor agonists (BzRA or non-BZD) act on the gamma-aminobutyric acid (GABA) receptor sites which exert anxiolytic, muscle relaxant, sedative, and hypnotic effects hence, for quite some time been acknowledged as one of the significant treatment options for insomnia. Nonetheless, certain limitations are related to long-term utilisation of such hypnotics which include the risk of tolerance and dependence. Therefore, it is recommended that BZDs should just be utilised for a brief time of about a month to prevent the incidence of the drawbacks related to long-term use
BzRA is approved by the Food and drug administration (FDA) for the treatment of insomnia.23 Compared to benzodiazepines, they are rapidly absorbed, relatively short-acting and have fewer side effects. These are useful in treating sleep maintenance insomnia, sleep onset insomnia or both.
Zolpidem
It binds specifically to the alpha-one subtype of GABA-A receptor. They exhibit hypnotic effects with negligible myorelaxant, anxiolytic, and anticonvulsant properties. It shows action by decreasing sleep dormancy and night-time awakenings and increases total sleep time. The side effects include falls, somnolence, headache, and antegrade amnesia.
Zaleplon
Zaleplon is almost similar to Zolpidem but has the shortest span of action with a half-life of an hour. It reduces sleep latency but does not reduce nocturnal awakenings or increase total sleep time. The adverse effects include drowsiness, headache, nausea, and worsening of depression symptoms in patients associated with comorbid depressive disorder.
Eszopiclone
Eszopiclone is an isomer of zopiclone and is approved by the FDA for longer use. It aids to increase sleep productivity, daytime working alongside a decrease in sleep onset latency and wakefulness after sleep onset. The commonly observed side effects include unpleasant taste, headache, somnolence, and dizziness.
Drugs Acting on Melatonin Receptors:
The pineal gland produces a natural hormone called melatonin. The circadian system in the hypothalamus and the suprachiasmatic nucleus (SCN) regulates the levels of this hormone throughout the day and night. Melatonin is available over the counter and is approved by FDA for treatment of insomnia, especially in older adults.
Ramelteon:
It is a melatonin receptor agonist which decreases the sleep latency by acting on the melatonin MT1 and MT2 receptors in the SCN with higher affinity than melatonin itself. It exerts minimal adverse effects, including somnolence, fatigue, and dizziness. It should be advised with caution in pregnancy and is contraindicated in severe hepatic impairment.
Englishhttp://ijcrr.com/abstract.php?article_id=2895http://ijcrr.com/article_html.php?did=2895
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareComparison of 0.5% Hyperbaric Bupivacaine Versus 1% Chloroprocaine in Spinal Anaesthesia in an Ambulatory Setting; a Randomized DoubleBlind Interventional Study
English7379Poonam KalraEnglish Priyanka JainEnglish Piyush SharmaEnglish Ravindra PoddarEnglishThe choice of ideal local anaesthetic agent for spinal anaesthesia is therefore crucial in the ambulatory setting. Lignocaine is associated with a high incidence of transient neurological symptoms, and bupivacaine produces sensory and motor blocks for a prolonged duration. Aims: This study was designed to compare preservative-free 2-chloroprocaine 40 mg with hyperbaric bupivacaine 15 mg for spinal anaesthesia in an elective ambulatory setting. Methodology: After approval from the institutional ethics committee, this prospective double-blind interventional study was conducted in 64 patients undergoing spinal anaesthesia. Informed consent was obtained and the study sample was divided into two groups. Group A-1%2-chloroprocaine(n=32), Group B-0.5% hyperbaric bupivacaine(n=32).For statistical analysis, unpaired T-test and chi-square test were used. Results: The onset characteristics of the sensory block were similar between the groups. However, the onset of motor block, regression characteristics did show a different profile between the two groups. The time for complete regression of sensory blockade to S2 in the 2-CP group was less that of the bupivacaine group (147 min vs 252 min, respectively, p valueEnglish Infra-umbilical surgeries, 2-chloroprocaine, Bupivacaine, Spinal Anaesthesia, Sensory Block, Motor BlockIntroduction:
Spinal anaesthesia is often addressed as one of the most desired modes of delivering anaesthesia due to its high reliability, straight forward technique, avoidance of undesirable complications of general anaesthesia, in addition to being more economical.
Infra-umbilical, perineal procedures are most commonly performed under spinal anaesthesia1, the short duration of the procedure and high turnover of case necessitates the choice of local anaesthetic that exhibit fast onset and quick recovery profile.
Lidocaine has an attractive pharmacokinetic profile as it shows a rapid onset and allows a fast recovery of both motor and sensory block1. However, is associated with an increased risk of transient neurological symptoms (TNS) including back and leg pain2,3,4. As an alternative, attempts have been made to adapt hyperbaric bupivacaine, a long-acting local anaesthetic, Bupivacaine may provide prolonged postoperative analgesia and has a lower incidence of TNS. However, the longer duration of action may delay the recovery of motor function, cause urinary retention, and therefore ultimately may lead to delayed discharge from the hospital5.
2-chloroprocaine is an amino-ester local anaesthetic agent with a short half-life and a potentially favourable for short outpatient procedures in spinal block6,7. 2-chloroprocaine was withdrawn from the market in the 1980s because of concern about neurotoxicity8,9,2-chloroprocaine with a new formulation without preservatives that have no longer been associated with neurotoxicity10,11 which was introduced into clinical practice since 2004. 2-chloroprocaine is characterized by both a very fast onset and a quick recovery time12,13.
This study is conducted to assess and compare the onset, level and regression of sensory and motor block, postoperative ambulation, intra-operative and post-operative analgesic effect, hemodynamic stability and side effects if any after giving 1% 2-chloroprocaine (40 mg) vs 0.5% hyperbaric bupivacaine (15 mg) in spinal anaesthesia in an ambulatory setting.
Subjects and Methods:
After obtaining approval from the institutional ethics committee (202/MC/EC/2018, Dt. 27/02/2019, SMS MC Jaipur) and acquiring a written informed consent, 64 patients were randomised into two groups(32 each) for this randomized double-blind interventional study.
Patients between ages 18 to 60 years, with an American Society of Anaesthesiologists (ASA) grade I or II, weighing between 40-80 kg, scheduled to undergo elective infra-umbilical, perineal (general, genitourinary, gynecologic) surgeries lasting for approximate 60 minutes, under subarachnoid block were included. Exclusion criteria included patients with contraindications to spinal anaesthesia, known or ascertained hypersensitivity to local anaesthetics (medications used in the trial), coagulopathies, infection at the local site of injection, history of neurological/psychiatric diseases, any spinal deformity and patient refusal. The different surgeries included were urologic surgery (transurethral resection of the prostate), general surgeries (haemorrhoidectomy, any short anorectal surgery), and gynecologic surgeries (VVF repair). The sample size was calculated as 32 subjects in each of two groups at 95% confidence & 80% power to verify the expected minimum difference of 25(±18) minutes in mean two-segment regression in both the groups15. So, for this study 32 subjects were taken for each of the two groups. This sample size was adequate to cover all other study variables also.
The study population were divided into two groups, 2-chloroprocaine Group A (n=32) and hyperbaric bupivacaine Group B (n=32) using the sealed envelope method. A day before surgery a thorough pre-anaesthetic evaluation of the patient was done including history, complete systemic examination and all routine blood investigation, coagulation profile, electrocardiogram and x-ray chest. All patients were kept nil per oral for at least 6 hours before the surgical procedure. After the arrival of the patient in the operation theatre, an intravenous cannula of size 18G was inserted and the crystalloid infusion was started. All routine monitors such as electrocardiography, non-invasive blood pressure and pulse oximetry were connected and baseline hemodynamic parameters were recorded. Pre-medication in. metoclopramide 10mg IV were given. The drug was prepared in a 5ml syringe in equal volume by an anesthesiologist not involved in the study. The syringe used was wrapped with white paper. This trial was so planned that the anesthesiologist who had prepared and introduced anaesthetic agent was different from the anesthesiologist who observed the study participants and observed data. The patients were told that some anaesthetic agent would be given, but the type of anaesthetic agent was not disclosed to them.
Under all aseptic precautions spinal anaesthesia was performed by a blinded investigator in patient with sitting position at L3-L4 subarachnoid space using spinal needle of size 25 G. After clear and free cerebrospinal fluid flow, patients received either 4 ml (40 mg) of 1 % 2-chloroprocaine or 3 ml (15 mg) of 0.5% hyperbaric bupivacaine according to their study groups. No adjuvant medication was added to both local anaesthetic. After the administration of spinal injection, patient was placed in supine position with a 15° head down tilt immediately to achieve level ofblock of T5-T6. The same blinded observer evaluated the sensory (with 25g hypodermic needle) and motor blocks (as per modified bromage score) every two minutes for 15 minutes, then every five minutes for 45 minutes, and then every ten minutes for 60 minutes, and finally every 15 minutes until the sensory block regressed to the S2 dermatome. During surgery, the patient’s blood pressure (systolic, diastolic and mean arterial pressure), electro- cardiogram, and pulse oximetry were recorded. Vitals were checked every 5 minutes for 30 minutes and after that every 10 minutes till the end of the surgery.
The sensory block was assessed by pin prick test bilaterally in mid-clavicular line by using 25G hypodermic needle. The level of sensory block was assessed every two minutes till the highest level of the block was achieved. The Highest level of sensory block achieved was noted and time taken to achieve highest level of sensory block was also noted.
Motor block was assessed using Modified bromage Scale [1: Complete block (unable to move feet or knee), 2: Almost complete block (able to move feet only), 3: Partial block (just able to move knees), 4: Detectable weakness of hip flexion while supine (full flexion of knees), 5: No detectable weakness of hip flexion while supine, 6: Able to perform partial knee bend]. Onset of motor block and duration of motor block were recorded. During surgery, the motor block evaluation was suspended till the end of the procedure. If the patient complains of pain, fentanyl 25 to 100 mcg iv was administered. If additional sedation needed, midazolam 0.025 to 0.05 mg kg-1 iv was administered. The total dose of any given medication was recorded. If the patient still felt pain, general anaesthesia was provided and the protocol was stopped.
Intraoperatively, hemodynamic parameters (BP, HR, SPO2) were charted every 5 minutes for the first 30 minutes and then even 15 minutes until the end of surgery. Side effects like hypotension (blood pressure 0.05) were comparable in both the groups and not significant statistically, but the two-segment regression of sensory blockade and time for complete regression to S2(total duration of the sensory block) were significantly shorter in chloroprocaine group. (Table 2).
Both the groups were comparable concerning age(years), sex, weight (kgs), height (cms.), ASA grade, and duration of surgery (Table 1).
The onset of sensory block (p-Value 0.800) and time to reach peak sensory block height p Value>0.05) were comparable in both the groups and not significant statistically, but the two-segment regression of sensory blockade and time for complete regression to S2(total duration of the sensory block) were significantly shorter in chloroprocaine group. (Table 2).
The time of onset of motor block was earlier and the duration of motor block and analgesia was shorter in Group A than Group B respectively (p < 0.001). The time to return of voiding functions was also earlier in Group A than Group B (p < 0.001) (Table 3).
Figure 1:Shows comparison of mean VAS between the groups at different time interval in the post-anesthesia care unit.
The time for the first ambulation after spinal anaesthesia was also shorter in chloroprocaine group in comparison with bupivacaine group(Table 4).
There was no significant variation in hemodynamic measurements between groups. Three subjects with bupivacaine group were treated with ephedrine 6 mg for slight nausea and two patient were treated with atropine for the incidence of bradycardia, similarly, in chloroprocaine group one patient experienced hypotension and one patient suffered from bradycardia and was treated with ephedrine and atropine respectively during the intra-operative period(Table 5).
There was no significant change in mean arterial pressure over time in both Groups A and B (p > 0.05) (Figure 1).
No subjects reported any adverse symptoms, including TNS or other neurologic symptoms, either immediately after administration of spinal anaesthesia, or through the 24-hours observation period.
Discussion:
The study aimed to compare intrathecal 0.5% hyperbaric bupivacaine with 1% 2-chloroprocaine in infra-umbilical surgeries in an outpatient setting. The principal finding was observed that spinal anaesthesia with 2-chloroprocaine can provide a satisfactory surgical block while permitting earlier ambulation than spinal anaesthesia with bupivacaine. This is brought about by more rapid regression of the sensory and motor block, which helped patients to ambulate faster.
The time of onset of sensory blockade in chloroprocaine and hyperbaric bupivacaine group were 143.03±10.72 seconds and 142.34±11seconds respectively. The P value< 0.800 is statistically insignificant. Thus, we observed that the difference in onset time was non-significant in both groups. This finding was also observed by Dr. Kannan Bojaraaj et al.,18 in his study of 2- Chloroprocaine 40mg and 0.5% Bupivacaine 10mg where he observed that the onset of sensory block was comparable in group A and group B 150.42 ± 7.77 seconds and 156.5 ± 10.21 seconds respectively(P value=0.77).
The time of onset of motor block was 3.87±0.75 minutes and 6.12±0.65 minutes in group A and group B respectively with the P-value of 0.05). Our result also coincides with the previous study by Marie-Andre ´e Lacasse et al.15 who observed Spinal anaesthesia with 2% preservative-free 2-chloroprocaine 40 mg or 0.75% hyperbaric bupivacaine 7.5 mg. Time to reach peak block height (minutes) were 15 (8)minutes with 2-chloroprocaine and 18 (11)minutes with bupivacaine(P value=0.15). Similar results were also observed by Dr.ManjulataTandan et al19 in her study.
The mean time for two-segment regression of sensory block was 49.22 ± 6.52 minutes versus 78.97 ± 6.17 minutes in groups A and groups B respectively with statistically significant P value< 0.001. Thus, we observed that difference in the mean time for two-segment regression was significantly shorter in group A. Our results were similar to the previous study by Jessica R. Yoos et al.16, who compared chloroprocaine 40 mg vs bupivacaine 7.5 mg; the two-segment regression was 45±20 minutes vs 74±20 minutes(P value=0.01)15,19,20.
The time for complete regression to S2 (Time for the full recovery of the sensory block) in group A was 147.81±9.15 minutes and in the group, B was 252.16±31.43 minutes. The difference was statistically significant between the group's P-valueEnglishhttp://ijcrr.com/abstract.php?article_id=2896http://ijcrr.com/article_html.php?did=2896
Liam BL, Yim CF, Chong JL. Dose-response study of lidocaine 1% for spinal anaesthesia for lower limb and perineal surgery. J Anaesth.1998;45:645-650
Zaric D, Pace NL. Transient neurologic symptoms (TNS) following spinal anaesthesia with lidocaine versus other local anaesthetics.Cochrane Database Syst Rev.2009: CD003006.
Schneider M, Ettlin T, Kaufmann M, et al. Transient neurologic toxicity after hyperbaric subarachnoid anaesthesia with 5% lidocaine. Anesth Analg.1993;76:1154-1157.
Freedman JM, Li DK, Drasner K, Jaskela MC, Larsen B, Wi S. Transient neurologic symptoms after spinal anaesthesia: an epidemiologic study of 1,863 patient. Anesthesiology.1998;89:633-634.
Nair GS, Abrishami A, Lermitte J, Chung F. systematic review of spinal anaesthesia using bupivacaine for ambulatory knee arthroscopy. Br J Anaesth. 2009;102:307-315.
Foldes FF, McNAll PG. 2-chloroprocaine: a new local anaesthetic agent. Anesthesiology 1952;13:287–64.
Kouri ME, Kopacz DJ. Spinal 2-chloroprocaine: a comparison with lidocaine in volunteers. AnesthAnalg 2004;98:75–80
Reisner LS, Hochman BN, Plumer MH. Persistent neurologic deficit and adhesive arachnoiditis following intrathecal 2-chloroprocaine injection. Anesth Analg.1980;59:452-454.
Ravindran RS, Bond VK, Tasch MD, Gupta CD, Luerssen TG. Prolonged neural blockade following regional analgesia with 2-chloroprocaine. Anesth Analg.1980;59:447-451.
Hejtmanek MR, Pollock JE. Chloroprocaine for spinal anaesthesia: A retrospective analysis. Acta Anaesthesiol Scand. 2011;55:267-272.
Drasner K. chloroprocaine spinal anaesthesia: Back to the future. AnesthAnalg. 2005;100:549-552.
Goldblum E, Atchabahian A. The use of 2-chloroprocaine for spinal anaesthesia. Acta Anaesthesiol Scand. 2013; 57:545-552.
Pollock JE. Intrathecal chloroprocaine-not yet “safe” by US FDA parameters. Int Anesthesiol Clin. 2012; 50:93-100.
Pflug AE, Aasheim GM, Foster C. Sequence of return of neurological function and criteria for safe ambulation following subarachnoid block. Can Anaesth Soc J 1978; 25:133–9.
Lacasse MA, Roy JD, Forget J, et al. Comparison of bupivacaine and 2-chloroprocaine for spinal anaesthesia for outpatient surgery. A double-blind randomized trial. Can J Anaesth. 2011; 58:384-39
Yoos JR, Kopacz DJ. Spinal 2-chloroprocaine: a comparison with small-dose bupivacaine in volunteers.AnesthAnalg. 2005; 100:566-572.
ArTeunkens, Kristien Vermeulen, Elke Van Gerven, Steffen Fieuws, Marc Van de Velde, Steffen Rex. Comparison of 2-chloroprocaine, bupivacaine, and lidocaine for spinal anaesthesia in patients undergoing knee arthroscopy in an outpatient setting, A Double-Blind Randomized Controlled Trial. Regional Anesthesia and Pain Medicine. 2016; 41:576-583.
Bojaraaj K, Lalitha M. Spinal anaesthesia for perineal surgeries: a comparison of 1% 2-chloroprocaine with 0.5% bupivacaine. Indian J Appl Res. 2017;7(11):272-3.
ManjulataT, Lakra AM, Sandeep Bhagat, Dwivedi SK, Hyperbaric bupivacaine and 2–chloroprocaine for spinal anaesthesia in outpatient procedures: A comparative study., Indian Journal of applied research . 2018;8(6):210-214.
Khare A, Thada B, Yadav D, Mathur V, Singh M. A randomized double-blind study to compare 1% 2-chloroprocaine and 0.5% hyperbaric bupivacaine in spinal anaesthesia for infra-umbilical surgeries. Anaesth. pain & intensive care 2019;23(2):162-167
Camponovo C, Wulf H, Ghisi D, Fanelli A, Riva T, Cristina D, Vassiliou T, Leschka K, Fanelli G; Intrathecal 1% 2-chloroprocaine vs. 0.5% bupivacaine in ambulatory surgery: a prospective, observer-blinded, randomised, controlled trial; Acta Anaesthesiol Scand. 2014 May;58(5):560-6.
Udonquak MM, Kalu QN, Eshiet AI. Pethidine and bupivacaine spinal anaesthesia: a comparative evaluation of postoperative complications and recovery profile. Int J Res Med Sci 2017; 5:2490-6.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareDiagnostic Accuracy of Clinical History for Detection of Acute Myocardial Infarction: A Cross-Sectional Study
English8084Gajanan V. Wasalwar1English D. S. WasnikEnglishIntroduction: Acute myocardial infarction (AMI) is an important cause of admission in the intensive care unit in hospitals. AMI ranks very high in the differential diagnosis of acute chest pain because prompt diagnosis and early treatment can save a life, preserve left ventricular function, reduce complications and can also impact the quality of life. Aim: Current study was done to evaluate the diagnostic accuracy of clinical history for detecting acute myocardial infarction compared to the reference standard. Result: Our final dataset comprises of 450 patients (279 [62%] men, 171 [38%] women) ages 20 to 90 years. The prevalence of acute myocardial infarction was 41% (187 of 460, 95% CI 37% to 46%). Of the 450 patients, 47 (10%) died during the hospital stay. Those who died were significantly older than those who survived (63.4 vs. 57.01 years). Patients with AMI were more likely to die (26%; 38 of 147) compared to those without MI (9 of 263; 3%). Conclusion: Of the 187 patients with acute AMI, 145 (78%) were assigned a discharge diagnosis of ST elevated myocardial infarction (STEMI) and 42 (22%) were assigned a diagnosis of non-ST elevated myocardial infarction. A total of 34 of 145 (23%) patients with STEMI died, compared to 4 of 42(10%) patients with non-STEMI. Even in a high prevalence setting, no sign or symptom exhibited by patients presenting with possible acute MI proved effective enough alone to rule in or out Acute Myocardial Infection (AMI).
EnglishAcute myocardial infarction, STEMI, Clinical history, Intermittent, Pain, AMI.INTRODUCTION:
Despite advances in diagnosis, physicians miss up to 10% of AMI presenting with acute chest pain1,2,3. Conversely, a large proportion of people with chest pain who are admitted, do not turn out to AMI. According to the American Heart Association criteria, patients with proven AMI must receive thrombolysis within 30 minutes of their arrival to the hospital (door to needle time). To ensure that patients with AMI receive evidence-based therapies, it is important that AMI is ruled in or ruled out, quickly and accurately. No less important is to exclude other life-threatening conditions such as pulmonary embolism, tension pneumothorax and aortic dissection.
History and physical examination are key elements used by physicians to triage patients with acute chest pain4,5. Typically physicians take a quick but focused history (quality, site, intensity, radiation and aggravation of pain), note the presence or absence of risk factors (smoking, obesity, hypertension and diabetes) and perform a physical examination (vital signs, assessment of heart size, third heart sound and crackles)6,7,8. In the initial management of patients presenting with suspected MI, the history and physical examination help physicians decide which diagnostic tests to order (ECG, biomarkers of AMI, biomarkers, chest radiogram or endoscopy)or plan therapeutic interventions (aspirin, streptokinase or primary angioplasty).
AIMS & OBJECTIVES:
To evaluate the diagnostic accuracy of clinical history for detecting acute myocardial infarction compared to the reference standard.
SUBJECTS AND METHODS:
We conducted this study in an intensive care unit (ICU) of the Department of Medicine. The Medicine department has an ICU (10 beds) and a step-down unit (18 beds). The ICU is equipped with ventilators, monitoring systems and electronic hospital information system. The hospital offers basic cardiac diagnostic and therapeutic facility but lacks set up for cardiac catheterization or cardio?vascular thoracic surgery and therefore cannot offer primary angioplasty to patients reporting within 90 minutes of AMI. This is a prospective cross-sectional study in which consecutive patients with acute chest pain and possible ACS presenting to the intensive care unit were enrolled. Before we began the study, we formulated the research question, wrote research protocol, and obtained approval from the institutional research committee and a waiver for obtaining informed consent from the study participants.
We conducted this study according to the principles of the Declaration of Helsinki and after the study protocol was approved by the institutional ethics committee. The diagnosis of acute myocardial infarction was based on the criteria proposed by the World Health Organization (WHO). We summarized data with the mean and median as measures of central tendency and standard deviations and interquartile ranges as measures of spread for continuous variables.
RESULTS:
We used STARD (Standards for Reporting Diagnostic Accuracy Study) guidelines to report this study. We screened patients, 30 years of age and older suspected to have acute myocardial infarction and admitted to the intensive care unit. The total number of patients presenting with acute chest pain and admitted to the intensive care unit were 481. Out of which 31 were excluded due to death or incomplete data. So final study subjects were 450. Out of which 187 had AMI & 263 had chest pain other than AMI. Out of total 187 cases of AMI, 145 had ST-elevated myocardial infarction & 42 had Non-ST- elevated myocardial infarction.
Thus, our final dataset comprises of 450 patients (279 [62%] men, 171 [38%] women) ages 20 to 90 years. The prevalence of acute myocardial infarction was 41% (187 of 460, 95% CI 37% to 46%). Of the 450 patients, 47 (10%) died during the hospital stay. Those who died were significantly older than those who survived (63.4 vs. 57.01 years). Patients with AMI were more likely to die (26%; 38 of 147) compared to those without MI (9 of 263; 3%). Of the 187 patients with acute AMI, 145 (78%) were assigned a discharge diagnosis of ST elevated myocardial infarction (STEMI) and 42 (22%) were assigned a diagnosis of non-ST elevated myocardial infarction. A total of 34 of 145 (23%) patients with STEMI died, compared to 4 of 42(10%) patients with non-STEMI.
After analysis of the character of pain during acute myocardial infarction, we found out that squeezing or gastric type of pain are good predictors of acute myocardial infarction. While sharp/ stabbing/ burning pain is poor predictors. In maximum cases of acute myocardial infarction, the location of the pain is substernal.
In most cases, the pain radiated to right arm or both arms or individual shoulder or both shoulders. While in a maximum of the cases, that pain is of intermittent type. While regarding frequency, there was no specific relation. In all the cases it was either first episode or had some history of the episode.
In most of the cases, the episode was aggravated by exertion & coughing, while it was relieved by nitroglycerine or rest or by taking an analgesic. There was no significant effect of taking antacids.
Along with chest pain, most of the patients experienced sweating & few experienced dyspnea. Rest of the factors like associated nausea, vomiting, palpitation, giddiness etc are not of much having predictive value.
When we consider history, hypertension and angina are the most important findings which can’t be missed. While findings like diabetes, Hyperlipidaemia or smoking are of not much predictive value. While the family history of coronary heart disease or diabetes also having not much predictive value.
After analysis, following features of history emerged as independent predictors of AMI: crushing chest pain, pain radiating to the right arm, heavy chest, burning character of chest pain, male sex, sweating, apprehension, pain relieved with nitroglycerine, and pain radiating to both shoulders.
DISCUSSION:
The main finding of our study which is explicitly demonstrated in the table (1,2,3,4,5), clearly demonstrate that in patients presenting with-and admitted because of- acute chest pain, the presence of any of the following characteristics of pain increased the likelihood of AMI: male sex, patients perceiving a sense of impending doom, chest pain radiating to either right arm, or both shoulders, squeezing chest pain, burning pain and so on. Fourteen studies 4,9,12-17 have assessed the accuracy of the medical history, physical examination, and ECG in the diagnosis of acute MI9, 13,14,15,16. In this study, we compare and contrast our results with those from the studies that enrolled patients with suspected AMI in the ICU setting.18,19.
The diagnosis of AMI in the setting of acute chest pain is a challenging task. Although doctors and patients believe that classic ischemic chest pain chooses the substernal or left chest area, few studies have assessed whether specific chest pain locations predict AMI or ACS. The word chest pain radiation typically refers to pain that originates in the chest but spreads to places other than the chest, such as the neck, back or arm. Ischemic chest pain is classically characterized as radiating from the chest through one arm or both, a lesson supported by several studies.9,12,17 Physicians teach that Chest pain that is pleuritic, positional, or reproducible with chest wall palpation is unlikely to be due to acute MI. This teaching is supported by a systematic review5 that showed that clinical features that decrease the probability of MI in patients presenting with acute chest pain are pleuritic chest pain.
There is a well-known correlation between exercise and angina. However, there is a less direct link between exercise and AMI. Mittleman et al.11 reported that AMI patients were more likely to report heavy exertion in the hour preceding their event, confirming an association between exercise and AMI. Several studies9,12,14,15 have examined the ability of associated symptoms such as nausea, vomiting and diaphoresis to predict AMI. Two meta-analyses show that nausea or vomiting and diaphoresis aid in the diagnosis of AMI. However, in the study by Goodacre et al.10 vomiting and diaphoresis failed to retain their place in the final multivariate logistic regression model.
CONCLUSION:
Based on our study result shoed in table no 6, out of the 187 patients with acute AMI, 145 (78%) were assigned a discharge diagnosis of ST elevated myocardial infarction (STEMI) and 42 (22%) were assigned a diagnosis of non-ST elevated myocardial infarction. A total of 34 of 145 (23%) patients with STEMI died, compared to 4 of 42(10%) patients with non-STEMI. Even in a high prevalence setting, no sign or symptom exhibited by patients presenting with possible acute MI proved effective enough alone to rule in or out AMI.
Conflict of Interest: Nil
Source of Funding: Nil
Englishhttp://ijcrr.com/abstract.php?article_id=2897http://ijcrr.com/article_html.php?did=2897
Lee T et al. Acute chest pain in the emergency room. Identification and examination of low-risk patients. Arch Intern Med. 1985;145(1):65-9.
Tierney W et al. Predictors of myocardial infarction in emergency room patients. Crit Care Med. 1985;13(7):526-31.
Rouan G et al. Clinical characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms (a report from the Multicenter Chest Pain Study). Am J Cardiol. 1989;64(18):1087-92.
Chiwhane, A., and Pradeep. “Study of Rhythm Disturbances in Acute Myocardial Infarction.” J. Association of Phys. India 66, no. January 2018: 54–58
Charan, N., M. Choudhari, M. Sonkusale, and R. Deshpande. “Anesthetic Management of Chronic Thromboembolic Pulmonary Hypertension for Pulmonary Endarterectomy.” Journal of Datta Meghe Institute of Medical Sciences University 12, no. 4 (2017): 289–91.
Cladius, S., U. Jadhav, B. Ghewade, S. Ali, and T. Dhamgaye. “Study of Diabetes Mellitus in Association with Tuberculosis.” Journal of Datta Meghe Institute of Medical Sciences University 12, no. 2 (2017): 143–47.
Bhinder, H.H.P.S., and T.K. Kamble. “The Study of Carotid Intima-Media Thickness in Prediabetes and Its Correlation with Cardiovascular Risk Factors.” Journal of Datta Meghe Institute of Medical Sciences University 13, no. 2 (2018): 79–82.
Rathi, N., B. Taksande, and S. Kumar. “Nerve Conduction Studies of Peripheral Motor and Sensory Nerves in the Subjects with Prediabetes.” Journal of Endocrinology and Metabolism 9, no. 5 (2019): 147–50. https://doi.org/10.14740/jem602
Berger J et al. Right arm involvement and pain extension can help to differentiate coronary diseases from chest pain of other origin: a prospective emergency ward study of 278 consecutive patients admitted for chest pain. J Intern Med. 1990;227(3):165-72.
Goodacre S et al. How useful are clinical features in the diagnosis of acute, undifferentiated chest pain? Acad Emerg Med. 2002;9(3):203-8.
Mittleman M et al. Triggering of acute myocardial infarction onset by episodes of anger. Determinants of Myocardial Infarction Onset Study Investigators. Circulation. 1995;92(7):1720-5.
Tierney W et al. Physicians' estimates of the probability of myocardial infarction in emergency room patients with chest pain. Med Decis Making. 1986;6(1):12-17.
Klaeboe G et al.. Predictive value of prodromal symptoms in myocardial infarction. Acta Med Scand. 1987;222(1):27-30.
Herlihy T et al. Nausea and vomiting during acute myocardial infarction and its relation to infarct size and location. Am J Cardiol. 1987;60(1):20-22.
Jonsbu J et al. Rapid and correct diagnosis of myocardial infarction: standardized case history and clinical examination provide important information for correct referral to monitored beds. J Intern Med. 1991;229(2):143-9.
Karlson B et al. Early prediction of acute myocardial infarction from clinical history, examination and electrocardiogram in the emergency room. Am J Cardiol. 1991;68(2):171-5.
Pozen M et al. A predictive instrument to improve coronary-care-unit admission practices in acute ischemic heart disease. A prospective multicenter clinical trial. N Engl J Med. 1984;310(20):1273-8.
Rude R et al. Electrocardiographic and clinical criteria for recognition of acute myocardial infarction based on analysis of 3,697 patients. Am J Cardiol. 1983;52(8):936-42.
Yusuf S et al. The entry ECG in the early diagnosis and prognostic stratification of patients with suspected acute myocardial infarction. Eur Heart J. 1984;5(9):690-6.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareCOVID-19: Survey on Awareness Level and Psychological Status During the Outbreak
English8594Vaishnavi P.English S. RamkumarEnglishBackground: Research information is required to create evidence-driven methodologies to decrease unfavourable mental impacts and psychiatric side effects amid the pandemic situation. Objective: This survey aimed to discover awareness level, behaviour, attitudes and also to analyze the psychological status related to coronavirus outbreak. Methods: The online survey was conducted by snowball examining methods. Results: This study included 520 respondents from different cities of Tamilnadu. 71% of the members are aware of the preventive measures. 48% of the members are with high fear and uneasiness since of this widespread circumstance in Tamilnadu. 52% of the members feel boredom, frustrated since of lost their open-air exercises. 72% of the participants feel a change of mood and behaviour. There is a positive correlation between change in sleep and eating pattern and time saved. Conclusion: During the various stage of COVID-19 episode in Tamilnadu the results are compared to the existing COVID-19 widespread outbreak; they gain access to awareness level, fear, emotional distress, as the affected persons are viewed as moderate. It is very important to take care of the mental welfare of the population and proactive steps to play down its inconvenient impacts amid the COVID-19 pandemic.
EnglishCOVID-19, Coronavirus, Awareness Level, Psychological Impact, Stress, Depression.INTRODUCTION
Corona Virus is a tremendous family of infections that are known to cause sickness extending from the common cold to more serious infections such as Serious Intense Respiratory Disorder (SARS). A novel corona infection (COVID-19) was recognized in 2019 in Wuhan, China. This can be a new infection that has not been once in the past recognized in people. In January 2020 the World Health Organization (WHO) announced the flare-up of a new coronavirus disease, COVID-19, to be a public health crisis of worldwide concern. WHO expressed that there's a high hazard of COVID-19 spreading to other nations around the world. In Walk 2020, WHO evaluated that COVID-19 can be characterized as widespread.4 An outbreak of a worldwide epidemic causes panic and anxiety among numerous and allegedly impacts the psychological well-being of each person. The lives of contaminated people, family and companions, and the society are at hazard due to the propagated conceivable impacts of the 2019 novel coronavirus (COVID-19). The infection shows up to spread using human to human transmission in a comparable design to flu and a few infections causing upper respiratory diseases, i.e., through contact with discharges from infected individuals.1
The infection overwhelmingly replicates within the respiratory system amid the prodromal period, which advance contributes to the transmission of the infection as patients may still be having the disease within the absence of symptoms. After the introductory reports of contamination, in the following weeks. Universally, there are 3,021,049 disease cases detailed as of April 27, 2020, with 27,787 new diseases whereas cases detailed of COVID-2019. The current death rate is at 208,527globally of as of April 27, 2020. This is shown in figure 1.14
This virus is additionally known to be transmitted by gently sick or pre-symptomatic tainted people, which posture a challenge to control compared to the Center East respiratory disorder (MERS) and SARS pandemics. Whereas the scientific community and the WHO is still working on numerous unanswered viewpoints of this outbreak, clinicians and the common public are reacting to this dubious circumstance based on the limited affirmed data.3
WHO announced that the most common symptoms of COVID-19 are fever, dry cough, and fatigue. Other symptoms that are less common and may affect some patients include aches and pains, nasal congestion, headache, loss of taste or smell or a rash on the skin. These symptoms are usually mild and begin gradually. Some people become infected but only have very mild symptoms. The infection overwhelmingly replicates within the respiratory system amid the prodromal period, which advance contributes to the transmission of the infection as patients may still be having the disease within the absence of symptoms.15
Mostly 80% of individuals affected in India don’t show any symptoms. This uncertain circumstance has as of now made a huge extent of unsettling impacts within the lives of people over the world, which calls for the study to think about its proposal on the psychological wellbeing based on the studies of the past outbreak. The COVID-19 outbreak influences all sections of the population and is especially negative to individuals of those social groups within the most helpless circumstances; proceed to influence populations, including individuals living in poverty circumstances, older people, and people with inabilities, youth, and indigenous people groups. Early evidence shows that the wellbeing and financial impacts of the virus are being borne excessively by destitute individuals.4 Individuals without access to water, refugees, transients, or displaced people also stand to endure excessively both from the widespread and its consequence - whether due to limited development, fewer business openings, expanded xenophobia etc. In case not appropriately addressed through an arrangement, the social emergency made by the COVID-19 widespread may too increment inequality, exclusion, separation and worldwide unemployment in the medium and long term. Comprehensive, widespread social security frameworks, when in place, play a much strong part in protecting labourers and in reducing the prevalence of poverty, since they act as programmed stabilizers. That's, they give essential income security at all times, in this manner upgrading people’s capacity to manage and overcome shocks. Innate peoples are especially vulnerable at this time due to significantly higher rates of communicable and non-communicable illnesses, need of access to basic services, absence of socially appropriate healthcare, and in case any, under-equipped and under-staffed nearby medical offices. Since its onset, the COVID-19 widespread has spread to nearly all nations of the world. Social and physical distancing measures, lockdowns of businesses, schools and overall social life, which have become commonplace to reduce the spread of the infection; have also disturbed numerous normal aspects of life, including sport and physical activity. 6
The raging pandemic unleashed by profoundly infectious COVID-19 virus—has activated uncommon confinements not only on the way of life of individuals but moreover on an extension of financial activities, and the declaration of national crises in most nations around the world. Developing demand for critical healthcare and rising death rates are straining national healthcare frameworks. The widespread is disturbing worldwide supply chains and international trade. With about 100 nations closing national borders during the past month, the development of individuals and tourism flows have come to a shrieking halt. Millions of labourers in these nations are confronting the distressing prospect of losing their jobs.7 Governments are considering and rolling out expansive stimulus packages to turn away a sharp downturn of their economies which may dive the worldwide economy into a profound retreat. Fears of the exponential spread of the virus - and developing instabilities around the adequacy of different control measures have rocked.
The current COVID-19 widespread is causing far-reaching concern, depression and anxiety among individuals all over the world. As per the World Health Organisation, it has initiated a significant degree of fear, stress and concern within the population. In public psychological wellbeing terms, the most mental effect such as rates of stress or anxiety has been raised. With the presentation of new impacts – particularly quarantine, numerous people’s normal activities, schedules or employments confronting terrible impact.2 Millions of lives have been intensely influenced by a few psychological changes such as expanded levels of loneliness, depression, sedate use, and self-harm or self-destructive behaviour and demanding stress-coping-adjustment process is ongoing. Furthermore, myths and deception almost this plague, journey bans and official orders to isolate travellers might influence the public’s mental wellbeing. This may impact people’s quality of life and psychological wellbeing.5
COVID 19 in India
The first case of the 2019-20 corona infection widespread in India was detailed on 30 January 2020, starting from China. As of 27 April 2020, the Ministry of Health and Family Welfare has affirmed an add up of 28,380 cases, 144 recuperations (counting 1 migration) and 894 passing within the country.14 Specialists propose the number of contaminations can be a considerable underestimate, as India's testing rates are among the least within the world. The contamination rate of COVID-19 in India is detailed to be 1.7, essentially lower than within the most exceedingly bad affected nations. The COVID-19 infection rate in India remains low relative to population size. The COVID-19 fatality rate in India is 2.87 per cent, the lowest among countries badly hit by the pandemic.
Government of India is taking all essential steps to guarantee that we are arranged well to confront the challenge and danger postured by the developing widespread of COVID 19 – the Crown Infection. With the dynamic support of the individuals of India, we have been able to contain the increase of the virus in our nation. The foremost imperative calculates in avoiding the spread of the virus locally is to empower the citizens with the correct data and taking safety measures as per the advisories being issued by the Ministry of Health and Family Welfare. In India, the coronavirus cases have raised, with health service affirming 28, 380 positive cases so far. 894 individuals have died due to the coronavirus, as per the government. India has detailed 6,523 cured cases in novel coronavirus.15
The nation saw its single greatest bounce from April 2, with Delhi's Markaz Nizamuddin devout gathering contributing most of the cases. India is forcing one of the world's biggest lockdown, inquiring individuals to remain domestic and support social distancing. The point of the lockdown is to cut the conceivable human to human transmission and diminish the number of cases. These are as well early days to judge the effect of the lockdown but might still play out by making a difference in diminishing number of cases.14 The Bacillus Calmette-Guerin (BCG) antibody is presently examined as a conceivable reason for moo COVID-19 cases in India. The antibody is all around managed in India to secure against tuberculosis. Researchers in the US, Europe and Australia have begun examining whether BCG antibody is of any offer assistance to secure individuals against COVID-19.
Awareness Level and Preventive Measures
Awareness of an individual's awareness and being able to anticipate his or her behaviour is vital when assessing clinical awareness for pandemics with a highly pathogenic infection. The key to diminishing misfortune of life, personal wounds, and harm from the pandemic condition is widespread public awareness and instruction. Similarly imperative, public authorities and the media TV, radio, and daily papers must be completely arranged to respond viably, dependably, and quickly to large-scale crises. They got to be mindful, in advance, of methods to take after in a crisis that debilitates to paralyze the complete community they serve, and they ought to know how to communicate exact data to the public amid crises.8 To stimulate public awareness, brochures, blurbs, recreations, calendars, historical centre shows, open benefit declarations (for print, radio, and TV), and indeed excitement programming ought to be utilized.
One pivotal challenge is how to form a sense of extraordinary measures such as separation, isolate and lock-down. To drive out the myths and give an essential logical understanding of the public wellbeing degree behind the pandemic. A whole-of-society approach to pandemic flu readiness emphasizes the noteworthy parts played not only by the wellbeing division, but moreover by all other divisions, people, families, and communities, in relieving the impacts of a widespread.11 Amid a pandemic, health frameworks will have to give health-care services while attending to the convergence of patients with flu disease. Health-care offices will have to keep up satisfactory triage and contamination control measures to secure health-care specialists, patients, and guests. The Government of India is setting out on a mammoth task to anticipate COVID-19 spread among communities.
Psychological Impact of Pandemic Conditions
Pandemics are far away from being fair beneficial marvels. They disturb individual and proficient lives seriously and influence individuals and societies on numerous levels. The key methodologies advanced for control of an outbreak of this environment are detention and physical separating – both can have critical impacts on life and connections.10
Previous works have given away a deep and wide variety of psychosocial possessions on people at the person, area, and in global levels for the period of outbreaks of disease. On a personal level, people are likely to possess dread of falling sickness, feelings of vulnerability, and disgrace. Around 11% -30 % of the common public were rather worried about the possibility of contracting the virus during an influenza outbreak. With the closure of schools and industry, negative emotions experienced by individuals are compounded.7
During the SARS epidemic, many studies investigate the psychological impact on the non-infected society, providing the important psychiatric morbidities which were found to be associated with younger age and amplified self-blame. The key module learnt from the SARS and MERS epidemics was the impose for early sensitisation of community health experts to the psychological impacts of a pandemic and to provide the psychological health needs of those under medical supervision.2
The COVID-19 pandemic causes panic and mental health problems for the public, as experienced beforehand with the Middle-East respiratory syndrome coronavirus (MERS-CoV). The intervention method that is employed by a variety of health establishment and government bodies in fighting the infection may help in eliminating the threat during the time of uncertainty; however, the multivariate studies done on the previous outbreaks show that they have long-term mental health effects on the population.9
Research Problem
To control the spread of the illness, the world researcher society came together. In any case, the incompetence of the countries, indeed with the progressed therapeutic sciences and assets, has fizzled to deal with the mental wellbeing perspective among the public, as all endeavours are centred on understanding the study of disease communication, clinical highlights, transmission designs, and administration of COVID-19 pneumonia.
During an irresistible difficult outbreak, it is basic to learn as much as conceivable almost the concerns, information, demeanours, and behaviour of the public. Such data can be significant to the enhancement of communication endeavours by public wellbeing authorities and clinicians. Based on our understanding, most of the investigation related to this episode centres on distinguishing the study of disease transmission and clinical characteristics of infected patients, the genomic characterization of the infection, and challenges for worldwide wellbeing administration. In any case, no investigating articles are looking at the awareness level and mental status of individuals on COVID-19 on the common population in India. This study also involves the causes for the psychological effect of people during this outbreak and also explains the current psychological status of the people which is not discussed in many studies. This may help government offices and healthcare experts in defending the mental prosperity of the community within the confront of COVID-19 episode development in India and diverse regions of the world.
The objective of the Study
1. To analyse the level of awareness of the individuals about COVID-19
2. To investigate the current psychological status of individuals during the outbreak.
3. To suggest the measures and coping techniques to improve the psychological health of the individual during the pandemic situation.
Research Methodology
The present survey study is based on the essential information collected from 510 of the people over different parts of Tamilnadu in India. Snowball sampling survey technique is used for collecting the data. A cross-sectional overview plan to evaluate the public’s awareness and quick psychological status response amid the afflict of COVID-19 by utilizing an online survey. The online overview was, to begin with, spread to the companions and understudies and they were empowered to pass it on to others.
Procedure
As the Government prescribed the public to minimize the live interaction and confine at domestic, probable respondents were electronically welcomed by existing consider respondents. They completed the surveys through a web overview stage. Data around this study was posted. All respondents gave educated assent. Information collection took put over 20 days (30th March–25th April 2020) after the WHO announced the COVID-19 episode as a public wellbeing crisis of worldwide concern.
Survey Development
The overview comprised socio statistic factors, information and concerns almost COVID-19; prudent measures against COVID-19; the mental affect of the COVID-19 flare-up; and mental wellbeing status.
The socio statistic portion comprises of the age, sex, conjugal status, capability, range of area and occupation. The awareness level of the survey included information around COVID-19 factors included the level of certainty, in conclusion, level of fulfilment of wellbeing data approximately COVID-19, the drift of unused cases and passing, and potential treatment for COVID-19 contamination. Respondents were inquired to show their source of data. Concern around COVID-19 factors included self and other family individuals contracting COVID-19 and the chance of surviving on the off chance that infected. A self-administered survey that has been approved within the Tamilnadu population for deciding the degree of mental effect after the presentation to a public wellbeing emergency inside one week of beginning. Mental wellbeing status was measured utilizing the discouragement, uneasiness, stress and boredom of people at home.
Research Limitations
The essential confinement of this study is the self-report by the people. So there are chances for biases within the reports. The study was conducted as it were by the online mode through which as it were people utilizing social media can be analyzed. As a result, might not conduct an imminent think about that would give a concrete finding to support they require for a centred public health activity. There was an oversampling of a specific arrange of peers, driving to choice predisposition. Another impediment is that self-reported levels of mental effect, uneasiness, misery and stretch may not continuously be adjusted with an appraisal by mental health experts. So also, respondents might have given socially desirable reactions in terms of the fulfilment with the wellbeing information received and precautionary measures.
Data Analysis and Interpretation
Awareness level of individuals and Sources which keep most informed about COVID-19 and its preventive measures
Interpretation
From the data collected from 510 respondents, Table I shows the clear data, about 100 % of the individuals are aware of the pandemic situation of COVID-19, about 70 percentage of the people have strongly agreed that they follow the precautious measures to prevent COVID-19, 95 percentage of the participants possess a clear idea about the various symptoms of COVID-19.82 percentage of the people are aware of the contact numbers and the persons to be contacted during the emergency of COVID-19.100 percentage of the people agreed that they and their family strictly follow stay at home and stay safe policy. Figure 2 also shows the awareness level. From Table II it's clear that TV holds the first rank which people says that it keeps them updated and informed about the preventive measures of COVID-19, next Newspaper holds the second rank in informing the people, Friends and social media holds the third place and Government Ads holds the fifth place in keeping the people informed about the information about COVID-19.
Current Psychological Status of People
Interpretation
From Table III it’s clear that about 49 % of the individual possesses a high level of fear and anxiety about COVID-19 situation. Figure 3 shows the level of fear and anxiety. 54 percentage of the persons conveyed that they are not stressed about the pandemic situation. 37 percentages of participants do exercise as their personal care activity at this time. About 52 percentages of people feel boredom by missing their outdoor activities. 71 % of the people feel adapted to the changes in the normal patterns of living after the breakdown. About 68 percentages of the individuals have changed in their eating and sleeping pattern after the breakdown. 72 % of participants agreed that they experience a change in moods and behaviours after the outbreak.
Interpretation: Since the value of PEnglishhttp://ijcrr.com/abstract.php?article_id=2898http://ijcrr.com/article_html.php?did=2898
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareIntramedullary Interlocked Nail with Poller Screw Guidance for management of Extra-articular Proximal Tibial Fractures: A Prospective Study
English9599Avinash KumarEnglish Kishore K. PandaEnglish Anurag SinghEnglish Anand Kumar SinghEnglishIntroduction: proximal one-third of tibial fractures are fairly commonly seen nowadays. Their geometry makes them prone to angular deformities. The use of a Poller or Blocking screw along with an intramedullary nail helps in avoiding these angular deformities and malunion. In this study, we aim to evaluate the functional and radiological outcomes of proximal one-third fractures of tibia managed with an intramedullary nail and a Poller screw. Material and Method: This study was conducted between 2017-2019 and a total of 14 patients were operated and followed up. Their demographic, pre and postoperative data were recorded and assessed. For functional outcomes, the knee range of motion and Rasmussen functional scoring system was used. Result: The mean union time was 9.8 weeks and 3 cases had English Poller Screw, Blocking Screw, Proximal Tibia Fractures, Tibia metaphyseal Fractures, Intramedullary Nailing.Introduction
The intramedullary nail is designed to treat diaphyseal fracture of the tibia and is the standard treatment modality for tibia mid diaphyseal fractures.1,2 The intramedullary fixation of mid diaphyseal fractures differs from the proximal one-third fractures which have a small proximal fragment. This can cause an increase in alignment deformity, which is most commonly seen in the coronal plane. These deformities are due to many factors like discrepancy in diameter of the nail and wide tibial metaphysis, inaccurate entry point, displacing muscular forces, and residual instability. Poller screw acts as a blocking screw which reduces the width of the metaphysis and physically blocks the nail by creating an “artificial cortex”. This helps in increasing the mechanical stiffness of the implant-bone construct and, thus, minimizes the translation of nail as well as deformity.3,4 These can be used in proximal one-third fractures of the tibia. The term ‘Poller’ denotes a short metal post placed on a ship or road to control or guide traffic.5 We aim to evaluate the alignment, deformity correction, and functional outcome of proximal one-third fractures of tibial shaft managed by a nail and a poller screw. In this study, we present a prospective follow-up of the patients with fractures of proximal 1/3rd tibia managed with an intramedullary nail and blocking screw.
Material and methods
The study was conducted in the Institute of Medical Science and SUM Hospital, Bhubaneswar, India from August 2017 to August 2019 for 2 years. A total of 14 skeletally mature patients (10 males and 4 females) with extra-articular proximal one third tibia fracture were operated and evaluated prospectively for functional and radiological outcomes. Prior Institutional ethical clearance was obtained and all the patients were explained about the procedure and informed written consent was also obtained. The patients were selected based on our inclusion criteria; i.e. a) Skeletally mature patients, both sex, b) Displaced extra-articular metaphyseal fracture, c) compound fracture (Gustilo-Anderson Grade 1 and 2) and d) Patients who gave written consent for surgery. The exclusion criteria were, a) Skeletally immature patient and severe osteoporosis, b) Comminuted fractures, c) Metaphyseal fracture with intra-articular extension and, d) surgically unfit patients. All patients were operated within one week of trauma.
The principle of surgical management is to maintain axial alignment, proper length, and early mobilization, and restore function. On the standard operating table, supine position with knee kept in a semi-flexed position, a mid patellar tendon splitting incision was made. An accurate entry-point was made and a guidewire was inserted under fluoroscopic guidance. The medullary canal was reamed using a flexible reamer of the smallest diameter (8 mm). Now the deformity was assessed by removing the reamer and guide wire and checking under a fluoroscope. Poller screw was placed in the proximal fragment of the tibia on the side where the deformity is concave to prevent valgus or in mediolateral direction to prevent procurvatum and was confirmed in both Antero-Posterior (AP) and lateral (Lat) views under image intensifier. The blocking screw should be placed at least 1 cm proximal to fracture to minimize complications. Now, a guidewire is re-introduced further medially to the poller screw and reaming is done with flexible reamers of progressively increasing diameters. The intramedullary interlocking nail is then inserted and fixed with proximal and distal locking screws (Figure 1). None of the patients was given any form of immobilization. Intraoperative data like operative time, reduction difficulties, and residual deformities were collected.
Postoperatively, knee bending and quadriceps strengthening exercises were started on day one. Partial weight-bearing with the help of a walker was started on post-op day 7 and continued for 6-8 weeks (depending on fracture pattern). Complete weight-bearing was allowed after 6-8 weeks. Patients were followed at regular intervals of 6 weeks, 12 weeks, 3 months, 6 months, and 9 months and were evaluated radiologically and functionally using Knee range of motion and Rasmussen’s Functional Scoring System.
Statistical Analysis
The data were tabulated in Microsoft Excel and statistical analysis was performed using SPSS 20 (SPSS, Inc., IL).
Results
In our study, most of the patients (9) were in the age group of 30-40 years followed by 3 patients in the age group of 20-30 and one patient each in the age group of 40-50 years and 50-60 years with a male preponderance (M:F::5:1). Eight patients had a closed fracture while six patients had compound fracture which was classified according to Gustilo and Anderson Classification. All the six compound fractures were either Grade 1 or 2.Majority of the patients in our study (11 patients) had road traffic injury as the mode of injury while 3 patients had a fall from height. The basic demographic data are given in Table 1-4. All patients were operated at a mean interval of 3 days from injury (Range- 1 to 6 days). The mean operative/surgical time was 68.1 minutes. We did not encounter any intraoperative complications and reduction difficulties. Postoperatively, 3 cases had Englishhttp://ijcrr.com/abstract.php?article_id=2899http://ijcrr.com/article_html.php?did=2899
Schmidt AH, Finkemeier CG, Tornetta P. Treatment of closed tibial
fractures. Instr Course Lect 2003; 52:607–622.
Zelle BA, Bhandari M, Espiritu M, Koval KJ, Zlowodzki M. Evidence-Based Orthopedic Trauma Working Group. Treatment of distal tibia fractures without articular involvement: a systematic review of 1125 fractures.J Orthop Trauma 2006; 20:76–79.
Freedman EL, Johnson EE. Radiographic analysis of tibial fracture malalignment following intramedullary nailing. Clin Orthop Relat Res 1995;315:25–3
Krettek C, Stephan C, Schandelmaier P, et al. The use of Poller screws as blocking screws in stabilising tibial fractures treated with small diameter intramedullary nails. J Bone Joint Surg Br. 1999 Nov; 81(6):963-8.
Krettek C, Miclau T, Schandelmaier P, Stephan C, Möhlmann U, Tscherne H. The mechanical effect of blocking screws (‘Poller screws’) in stabilizing tibia fractures with short proximal or distal fragments after insertion of small-diameter intramedullary nails. J Orthop Trauma 1999; 8:550–553.
Ricci WM, O’Boyle M, Borrelli J, et al. Fractures of the proximal third of the tibial shaft treated with intramedullary nails and blocking screws. J Orthop Trauma 2001;15:264–70
Nork SE, Barei DP, Schildhauer TA, Agel J, Holt SK, et al. (2006) Intramedullary nailing of proximal quarter tibial fractures. J Orthop Trauma 20(8): 523-528
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Kulkarni SG, Varshneya A, Kulkarni S, Kulkarni GS, Kulkarni MG, et al. (2012) Intramedullary nailing supplemented with Poller screws for proximal tibial fractures. J Orthop Surg (Hong Kong) 20(3): 307-311
Tornetta P, Collins E. Semiextended position of intramedullary nailing of the proximal tibia. Clin Orthop. 1996; 328:185-189
Shahulhameed A, Roberts CS, Ojike NI. The technique for precise placement of poller screws with intramedullary nailing of metaphyseal fractures of the femur and the tibia. Injury. 2011;42(2):136?139.
Dodd L, Jackson M, Varma R. Poller Blocking Screws and Intramedullary Nailing in TibialMalunion. Ann R CollSurg Engl. 2007;89(8):816?818.
Tennyson M, Krkovic M, Fortune M, Abdulkarim A. Systematic review on the outcomes of poller screw augmentation in intramedullary nailing of long bone fracture. EFORT Open Reviews. 2020 Mar 1;5(3):189–203.
MoongilpattiSengodan M, Vaidyanathan S, Karunanandaganapathy S, Subbiah Subramanian S, Rajamani SG. Distal tibial metaphyseal fractures: does blocking screw extend the indication of intramedullary nailing? ISRN Orthop 2014;17:542623
MoongilpattiSengodan M, Vaidyanathan S, Karunanandaganapathy S, Subbiah Subramanian S, Rajamani SG. Distal tibial metaphyseal fractures: does blocking screw extend the indication of intramedullary nailing? ISRN Orthop 2014;17:542623
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareRole of Diffusion-Weighted MRI Imaging in Diagnosing Malignancy in Patients with Thick wall Gallbladder
English100106Manas AgarwalEnglish Anu BehariEnglish Ashok KumarEnglish V. K. KapoorEnglish Rajnikant YadawEnglishObjectives: Thick wall gallbladder (TWGB) is difficult to characterize on conventional imaging. Here we study the role of diffusion-weighted MRI in distinguishing between benign and malignant causes of TWGB. Methods: In this prospective study, we evaluated 25 patients with TWGB (>3mm wall thickness) on ultrasound. Diffusion-weighted MRI was done with the calculation of apparent diffusion coefficient (ADC) values. Patients were subjected to an appropriate surgical procedure. MRI findings were compared with histopathological reports. Results: Mean age was 48.52±9.6yrs (30-68yrs) with F: M ratio of 2.1:1. MRI showed diffusion restriction in 16 (64% patients), the breach in mucosal continuity in 13 (52%), and GB wall thickening in 20 (80%). MRI reported carcinoma in 12 (48%), cholecystitis in 11 (44%), and xanthogranulomatous cholecystitis (XC) in 2 (8%). Histopathology reports (available for 24 patients who were operated) revealed adenocarcinoma in 6, XC in 7, and cholecystitis in 11 patients. Diffusion restriction and absence of GB calculi were seen to be significantly related to malignancy. The sensitivity was 100% and specificity 88.9% for differentiating between carcinoma and cholecystitis. Overall, DWI-MRI had the sensitivity and negative predictive value of 100% each, the specificity of 66.67%, the positive predictive value of only 50%, and an accuracy of 75%. Conclusion: Diffusion-weighted MRI is a useful imaging modality for the characterization of thick wall GB when used with quantitative assessment of ADC values. It could help to diagnose the presence of malignancy in doubtful cases.
EnglishThick Wall Gall Bladder, Diffusion-Weighted MRI, Carcinoma Gall Bladder.Introduction: Gallbladder cancer (GBC) is the most common cancer of the biliary tract. In north India, it is the commonest gastrointestinal cancer in females and 3rd most common cause of cancer deaths in women.1 Most patients with GBC have advanced disease at presentation and thus 5yr survival rate is 3mm, TWGB) on ultrasound were included in the study. Patients with upper abdominal symptoms, who, on further workup were found to have TWGB were also included. Patients with a definite mass forming lesion on ultrasound were excluded. And other patients who were found inoperable were due to sever comorbidities and incompatibilities for MRI were excluded. After obtaining routine blood tests along with renal function test, they were subjected to contrast enhanced diffusion restricted MRI, and findings were recorded.
All MRI examinations were performed with a 3.0 T Signa HDxt MRI scanner (GE Healthcare, Milwaukee, WI, USA) with an 8 channel body coil. The scanning sequences were as follows:
Axial respiratory-triggered T2-weighted fast spin-echo (TR/TE/NEX; 3000-5647.1/78.2-81.1/1, 3 mm section thickness, 0 mm intersection gap, 288X256 matrix, 380 mm field of view),
Axial respiratory triggered DWI (diffusion weightings: b=0s/ mm2 and 1000s/mm2, TR/TE/NEX: 7058-13333/68.1/8, 3 mm section thickness, 0 mm intersection gap, 128x128 matrix, 380 mm field of view)
Pre and post contrast axial single breath hold 3D spoiled gradient echo sequence with two-point Dixon water-fat separation (LAVA FLEX) (TR/TE/NEX; 4.3/2/1, 3 mm section thickness, 0 mm intersection gap, 320x192 matrix, 380 mm field of view). Gadodiamide (Omniscan; GE Healthcare Medical Diagnostics, Little Chalfont, Buckinghamshire, UK) at a dose of 0.1mmol/kg {0.2 ml/kg} of body weight was used as contrast material.
All DWI images were transferred to an Advantage Workstation 4.4 (GE Healthcare, Milwaukee, WI, USA), at which ADC maps were evaluated. ADC value of the lesion was quantified by manually drawing on the lesion a circular region of interest (ROI) on the ADC map of (b=1000) DWI. Mean ADC was calculated from ROI’s at two different locations in the lesion. An expert radiologist with experience in interpreting abdominal imaging was blinded to information of patient’s characteristics, symptoms, sonography and CECT findings and histopathological reports.
Surgical procedure: After pre-anaesthetic checkup all 24 patients underwent for surgery. Patients with suspicion of carcinoma were for staging laparoscopy and extended cholecystectomy, cases with low suspicion were taken for anticipatory extended cholecystectomy (cholecystectomy with 2cm liver wedge excision, frozen analysis followed by lymphadenectomy only if frozen found to have positive report).8 Postoperative management was as per institution’s protocol. Patients were discharged after they resumed a normal diet and drains removal. They were followed up with histopathology report in OPD, after 10 days of discharge and findings recorded. The HPE report was correlated with MRI findings.
Statistical Analysis: SPSS version 22 was used for statistical analysis. Fisher’s exact test was used to test the association between variables. One way ANOVA test was used to compare between two groups. Receiver operating characteristic (ROC) curves were plotted to discriminate between two groups an area under the curve (AUC) was calculated. The P-value less than 0.05 was considered as significant.
Results: A total of 25 patients were included in the study. The mean age was 48.52±9.6yrs (30-68yrs). 17 (68%) were female and 8 (32% were males). Out of 25 patients, 4 (16.0%) did not have any symptoms suspicious of gallbladder disease and were incidentally detected to have TWGB on sonography. 21 patients, (84.0%) presented with one or more symptoms. 12 (48.0%) patients had presented with single or recurrent episodes of biliary colic, 4 (16.0%) had dull aching continuous right upper quadrant (RUQ) pain, 1 patient had a history of abdominal lump, 1 patient who presented with jaundice was found to have associated choledocholithiasis, and 3 patients gave the history of anorexia and significant loss of weight.
Examination findings revealed 1 patient having a palpable gallbladder, another one having a palpable gallbladder lump. None of our patients had evidence of advanced malignancy. 1 patient had icterus. All the patients were subjected to abdominal sonography. All but 3 (12.0%) patients had gall stones, with the majority having multiple stones (17, 68%). All 25 patients had thickened gallbladder walls, with 8 (32%) patients having focal thickening, and 17 (68.0%) having diffusely thickened walls. Thickening was further categorized between patients with wall thickness 3-7mm (19 patients, 76%) and patients with wall thickness >7mm (6 patients, 24%).
Out of 24 operated patients, USG suggested GB carcinoma in 11 patients out of which only 4 were found to have malignancy. USG had the sensitivity of 66.67%, the specificity of 61.11%, the positive predictive value of 36.36% and negative predictive value of 84.62%.
16 of our patients had undergone a contrast-enhanced CT scan. Out of 16, CECT revealed GB mass in 6 (24%) patients. 3 (12.0%) patients had focal wall thickening and 6(24%) patients had diffuse wall thickening. 1 patient did not have any wall thickening. None had evidence of distant metastasis in the form of liver nodules, peritoneal dissemination, para-aortic or other distant lymph nodes, and ascites. Out of a total 16 patients, malignancy was reported in 7 (43.75%) while others were reported to have benign aetiology (9, 56.25%). In our study, CECT had high sensitivity and negative predictive value (83.33% and 88.89% respectively), although specificity was 80.00% and the positive predictive value was 71.43%.
All 25 of our patients underwent diffusion restricted MRI as per our study protocol. Diffusion restriction was found in 16 (64.0%) patients while in 9 (36.0%), no restriction was present. Gall bladder calculi were present in 22 (88%) patients, and 3 (12%) patients did not have calculi in GB. Out of 22, 9 (40.91%) had solitary GB calculus impacted at the neck and 13 (59.10%) had multiple GB calculi. 13 (52%) patients had a breach in the continuity of the GB wall. MRI showed wall thickening in 20 (80%) patients, whereas USG showed TWGB in all 25 patients. (Table 1) One of these patients had a history of past cholecystectomy and was having residual GB, which was found to have thickened wall on USG, but on MRI, wall thickness was normal. Two patients had a history of spontaneous passage of stones in the common bile duct. One patient showed focal wall thickening in fundus on USG but MRI, there was no thickening, multiple small polypoidal lesions were seen, which were sent for frozen section after laparoscopic cholecystectomy, and histopathology was benign. One patient had mild wall thickening on USG (4.6mm), which was not found on MRI. Fat saturated images revealed 3 patients having fat in the wall.
ADC values were calculated for the entire group and the mean ADC value was 2.276*10-3. Finally, MRI diagnosed 12 (48%) patients having a suspicion of malignancy, 11 (44%) patients having cholecystitis, and 2 (8.0%) patients with xanthogranulomatous pathology. (Figure 1, 2, 3) Out of 12 patients reported as GBC, only 6 (50%) were found to have GBC on HPE, (Figure 4) although none of the patients (n=11) reported having benign pathology were found to have GBC, suggesting 100% negative predictive value of MRI while diagnosing GBC. MRI was seen to have a sensitivity of 100%, the specificity of 66.67%, the positive predictive value of only 50%, and an accuracy of 75%. Looking at specific findings of MRI, the breach in mucosal continuity was found in 13 (52%), in whom 4 (30.77%) patients were found to have malignancy while 5 were found to have xanthogranulomatous cholecystitis. ADC values were calculated for 24 patients who were operated, and in whom histopathology reports were available. Mean ADC value was 2.276 X 10-3. The mean ADC value for GB malignancy was lower than that of benign diseases. Mean ADC value of 6 patients with GBC was 1.57 X 10-3, and the remaining 18 patients were 2.54 X 10-3. Amongst benign causes (n=18), xanthogranulomatous cholecystitis (n=7) had lower ADC values as compared to that of chronic cholecystitis (n=11). Mean ADC value for 7 patients with xanthogranulomatous cholecystitis was 1.77 X 10-3, while that of 11 patients with chronic cholecystitis was 3.02X 10-3 (2.42 X 10-3after removing outliers). Mean ADC values were compared using “One way ANOVA test with multiple comparisons”. The comparison reached statistical significance between malignancy and cholecystitis (p=0.002), and also between xanthogranulomatous vs chronic cholecystitis (p=0.023). (Table 2)
To define the cutoff values for diagnosing malignancy and xanthogranulomatous cholecystitis, and distinguish each from chronic cholecystitis, ROC curves were plotted after excluding the outliers. For malignancy vs chronic cholecystitis, with the cutoff of 1.94X 10-3, the test reached a sensitivity of 100% and specificity of 88.9% (AUC=98.1%). (Figure 5) For xanthogranulomatous cholecystitis from chronic cholecystitis, with a cutoff of 2.22X 10-3, (Figure 6) the test reached a sensitivity of 100%, and specificity of 56%, however with the cutoff of 2.07X 10-3, sensitivity was 85.7% and specificity was 66.7%. Surgery was offered to all patients and 24 patients underwent surgery while 1 patient refused surgery due to personal reasons. Thirteen patients were taken up for laparoscopic cholecystectomy, out of which 8 underwent laparoscopic cholecystectomy, GB was sent for the frozen section for 4 patients, in whom malignancy was suspected on the cut section of GB specimen. 3 of these were found to have benign disease whereas 1 out of 4 was found to be adenocarcinoma and laparotomy was done. On laparotomy, inter-aortocaval lymph nodes were found enlarged, which were sampled and sent for frozen and reported positive for metastatic deposits. The further procedure was abandoned and the abdomen was closed. One patient underwent laparoscopic subtotal cholecystectomy, leaving part of GB wall on the liver surface (LSC type 1), 4 were converted to open procedure due to unclear calot’s triangle anatomy.9 Out of these four, 3 patients underwent complete cholecystectomy after conversion to open. One underwent subtotal cholecystectomy (she was found to have impacted calculus at the neck with dense adhesions to the hepatoduodenal ligament, and part of neck of GB was left in situ, while the remaining GB was removed). One patient underwent open cholecystectomy. She had a history of open cholecystectomy and was found to have a residual gallbladder, which was small and contracted. Hence, the open procedure was done and laparoscopy was not attempted.
Nine of our patients were taken up for staging laparoscopy and extended cholecystectomy. 3 underwent extended cholecystectomy with adequate lymphadenectomy. One patient required extended cholecystectomy with extrahepatic biliary tract excision with hepaticojejunostomy (Enlarged lymph nodes in hepatoduodenal ligament densely adherent to CBD). One patient had diffuse peritoneal dissemination and radical surgery was abandoned. One patient underwent cholecystectomy due to low suspicion of malignancy and frozen biopsy was sent, which was reported as benign. Three patients underwent anticipatory extended cholecystectomy, (2 laparoscopic and 1 open). None of them was found to have malignancy on frozen of GB. Hence, lymphadenectomy was not done. Histopathology reports of our study group (24 operated patients) were chronic cholecystitis (11, 45.83%), xanthogranulomatous cholecystitis 7 (29.17%), and adenocarcinoma (6, 25%).
We have correlated each of the symptoms, USG features, and CT and MRI findings with the pathology reports of our patients. While recording MRI findings, it was seen that absence of calculi in 3 patients were related to malignant pathology. None other features could reach statistical significance. (Table 3)
Discussion: Gall bladder pathologies are more 2-3 times more commonly found in females that is also reflected from our study (female to male ratio=2:1).10 As reported, a large majority of gall stones are asymptomatic (70-95%).11 Right upper quadrant pain has been observed to be the most common symptom of gallstone disease, amounting to 95% of patients.12
Abdominal sonography is the gold standard diagnostic imaging modality for gallstones and to diagnosing cholecystitis its sensitivity (80-100%), specificity (60-100%) and positive predictive value is >90%.13 In our study group, ultrasound was able to detect the presence of gallstones in all except one case where MRI revealed the presence of stones while ultrasound showed only wall thickening with no stones. USG revealed focal thickening in 8 patients, which is considered as a marker for malignancy, Out of these 8 patients, 4 were confirmed to have GBC on histopathology of the operated specimen.
CECT scan has been the reference standard for diagnosing and managing suspected GBC patients. It can visualize GB mass, focal or diffuse thickening of GB wall, the extension to surrounding organ, regional or distant lymph nodes and metastasis. Thus, although CECT has a high sensitivity rate for GBC specificity is not high and lots of patients end up having a more radical surgical procedure than required.14 In our study, negative predictive value was 188.89% and the positive predictive value was only 71.43%, which is close to literature data of 89% and 96% respectively. The accuracy in our study was 81.25% while a cross-sectional study in 2016, reported figures of 93.5%. We did diffusion restriction MRI to better identify patient’s disease before surgery. We found that sensitivity and specificity of MRI was respectively 100% and 66.67%, which is similar to the published data. 15,16,17 Mean ADC values for GBC was 1.5 X 10-3. Several authors have observed the ADC values and cutoff to differentiate between benign and malignant GB lesions. There is yet no accepted cutoff value. In a retrospective study by Yoshioka, et al. the cutoff value of 1.64 X 10-3for GBC vs inflammation was found to have high sensitivity and specificity (86.4% and 81.8%, respectively.18,19
Kim, et al. determined the diagnostic value of diffusion-weighted MRI for thick-walled gallbladders. They noted that mean ADC value for GBC was 1.46 X 10-3, that of benign GB lesions were 2.16 X 10-3. Optimal ADC cutoff value of 1.449 X 10-3 yields sensitivity for GBC up to 70%, and specificity 97%. Mean ADC values were similar to that of our study 3.
In another Korean retrospective study of 33 patients by Kang, et al. the cutoff for differentiating xanthogranulomatous and malignant pathology of the gallbladder was taken as 1.52 X 10-3 which showed an accuracy of 79%, with specificity and positive predictive value of 100%, but the sensitivity of just 50% 7. The mean ADC value of xanthogranulomatous lesion was 1.64 X 10-3, which is very close to our study (1.77 X 10-3). (Table 4)
This study also reported continuity of enhancing mucosal line to be seen more frequently in xanthogranulomatous disease and found it to be statistically significant although in our study, out of 7 patients of xanthogranulomatous pathology, only 2 had mucosal continuity while 5 had a breach in continuity. The fat component in the GB wall was seen in 3 of our patients, and one of them was found to have xanthogranulomatous pathology. In Kang’s study also, only 1 patient had a fat component, out of a total of 14 patients. This suggests fat in the wall is a relatively non-specific finding to diagnose this pathology. Ours is the first prospective study which looks at MRI findings and correlates it with the biopsy report of the surgical specimen.
Conclusion: Gallbladder cancer (GBC) is the most common biliary tract malignancy. Mostly present in advance stage and thus has a poor outcome. Its presentation as thick wall gall bladder is a diagnostic dilemma to differentiated, benign from malignancy. In this scenario, diffusion-weighted MRI could be a useful imaging modality for characterization of thick wall gallbladder, especially when used with quantitative assessment of ADC values. Thus, we would like to conclude that quantitative evaluation of ADC maps is a useful parameter and might improve the specificity of MRI in differentiating benign from malignant gallbladder pathology. However, more prospective studies with larger sample size are required to further implement it into routine practice.
Acknowledgement: We wish to acknowledge the immense help received from the scholars whose articles are cited and included in references to 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 and discussed.
Source of Funding: There is no source of funding.
Conflict of interest: I am declaring that we have no conflict of interests
Informed consent: we have obtained consent from patients or close kin for the images and other clinical information to be reported in the journal. They understand that the names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Dutta U, Nagi B, Garg PK, Sinha SK, Singh K, Tandon RK. Patients with gallstones develop gallbladder cancer at an earlier age. Eur J Cancer Prev 2005; 14:381-385. Pub Med PMID: 16030429.
Furlan A, Ferris JV, Hosseinzadeh K, Borhani AA. Gallbladder carcinoma update: multimodality imaging evaluation, staging, and treatment options. AJR Am J Roentgenol 2008; 191:1440-1447. PubMed PMID: 18941083.
Kim SJ, Lee JM, Kim H, Yoon JH, Han JK, Choi BI. Role of diffusion-weighted magnetic resonance imaging in the diagnosis of gallbladder cancer. J Magn Reson Imaging 2013; 38:127-137. PubMed PMID: 23281048.
Barbosa, Aldo Benjamim Rodrigues, Souza, Luis Ronan Marquez Ferreira de, Pereira, Rogério Silva. Gallbladder wall thickening at ultrasonography: how to interpret it? Radiol Bras 2011; 44:381-387.
Tseng JH, Wan YL, Hung CF, Ng KK, Pan KT, Chou AS, et al.. Diagnosis and staging of gallbladder carcinoma. Evaluation with dynamic MR imaging. Clin Imaging 2002; 26:177-182. PubMed PMID: 1983470.
Ghafoor N, Abedin N, Mohiuddin AS. Role of ultrasound and computed tomography in the evaluation of gallbladder malignancy. AKMMC J 2017; 8:105-111.
Kang TW, Kim SH, Park HJ, Lim S, Jang KM, Choi D, et al.. Differentiating xanthogranulomatous cholecystitis from the wall-thickening type of gallbladder cancer: added value of diffusion-weighted MRI. Clin Radiol 2013; 68:992-1001. PubMed PMID: 3622795.
Kapoor VK, Singh R, Behari A, Sharma S, Kumar A, Prakash A, et al.. Anticipatory extended cholecystectomy: the 'Lucknow' approach for thick-walled gall bladder with low suspicion of cancer. Chin Clin Oncol 2016; 5: PubMed PMID: 26932432.
Dilip Gode, C Palanivelu, Zahiruddin Quazi Syed. New variants of laparoscopic subtotal cholecystectomy in management of acute cholecystitis. International Journal of Medical Science and Public Health 2014; 3:397-400.
Sharma A, Sharma KL, Gupta A, Yadav A, Kumar A. Gallbladder cancer epidemiology, pathogenesis and molecular genetics: Recent update. World J Gastroenterol. 2017 Jun 14; 23:3978-3998. PubMed PMID: 28652652.
Behari A, Kapoor VK. Asymptomatic gallstones (AsGS) - To treat or not to?. Indian J Surg. 2012; 74:4-12. Pubmed PMID: 23372301.
Vahed LK, Khedmat L. Frequency of symptoms associated with gallstone disease: a hospital-based cross-sectional study. Eur J Transl Mylo 2018; 28:7412. Pubmed PMID: 29991988.
Gluskin. Ultrasound of the liver, biliary tract, and pancreas. In: Janargin W, Aleen PJ, Chapman W editors. Blumgart’s Surgery of the liver, biliary tract, and pancreas. 6th ed. Philadelphia (PA): Elsevier; 2017. p. 264.
Katz SS. Computed tomography of the liver, biliary tract, and pancreas. In: Janargin W, Aleen PJ, Chapman W editors. Blumgart’s Surgery of the liver, biliary tract, and pancreas. 6th ed. Philadelphia (PA): Elsevier; 2017. p. 339.
Tan CH, Lim KS. MRI of gallbladder cancer. Diagn Interv Radiol 2013;19:312-9. PubMed PMID: 23603123.
Baliyan V, Das CJ, Sharma R, Gupta AK. Diffusion-weighted imaging: technique and applications. World J Radiol 2016:8:785-798. Pubmed PMID: 27721941.
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Yoshioka M, Watanabe G, Uchinami H, Miyazawa H, Abe Y, Ishiyama K, et al.. Diffusion-weighted MRI for differential diagnosis in gallbladder lesions with special reference to ADC cut-off values. Hepatogastroenterology 2013; 60:692-8. PubMed PMID: 24046830.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareTo Evaluate the Efficacy of Vitamin-D as an Addon Therapy in Patients with Allergic Rhinitis
English107111Resu Neha ReddyEnglish Vadlakonda SruthiEnglish Sharath Chandra Goud C.English Sowmini KEnglishIntroduction: Allergic rhinitis (AR) is a Type 1 IgE mediated hypersensitivity disorder, characterized by sneezing, rhinorrhea, nasal congestion, itching, and postnasal drip. Recently, many studies reported that vitamin D plays a critical role in Allergic rhinitis however, this association yet remains unclear. Aim & Methodology: The study aims to evaluate total nasal symptom scores (TNSS), serum IgE, serum absolute eosinophil count (AEC) in patients of AR, pre and post-treatment with and without supplementation of vitamin D. The randomized, open-labelled, parallel-group study, including 100 patients randomized in 1:1 allocation. Group A received fluticasone nasal spray alone, group B received vitamin D (1000 IU once daily) plus fluticasone nasal spray for 3 weeks. The results of TNSS, serum IgE, serum AEC in patients with AR, pre and post-treatment with and without supplementation of vitamin D were compared and evaluated. Results: The mean difference pre and post-treatment in TNSS (group A= 6.553, group B= 7.551), serum IgE (A= 81.05, B= 109.92), serum AEC (A= 79.29, B= 97) showed no statistical significant difference between two groups (P-value ≥ 0.05). Conclusion: In this study, supplementation of vitamin D did not alter the natural course of Allergic rhinitis. Though changes in the symptoms and lab values were noted in between the groups, it was statistically not significant which would prove beneficial for the patients.
English Allergic rhinitis, Serum Absolute Eosinophil Count levels, Serum IgE levels, Serum vitamin D levels, Total nasal symptom score, Vitamin D supplementation.INTRODUCTION
Allergic rhinitis (AR) also known as Pollenosis or Hay fever, is Type 1 IgE mediated hypersensitivity disorder. Allergic rhinitis is characterized by sneezing, rhinorrhea, nasal congestion, itching, and postnasal drip.1 Allergic rhinitis results in sleep disturbances, weakness, depressed mind-set, deplete subjective capacity of cognition, understanding that impedes the quality of life, efficiency, and productivity.2 Allergic rhinitis is the most common allergic disease worldwide, affecting around 10 to 25% of the population.3 Around 20 to 30% of Indian population experience and suffer no less than one allergic disorder.4 Reported prevalence of AR in India ranges between 20% and 30%.1 It affects a large percentage of pediatric patients and causes a notable number of school days missed every year. The impedance of work in adults also exists, influencing the finances of patients indirectly through lost workdays and directly through medicinal services cost spent on the disease.5 Triggering factors of AR are domestic allergens such as mites, insects, domestic animals or of plant origin; occupation-related triggers such as latex; common outdoor allergens such as pollens; automobile fumes; tobacco smoke; aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs). The severity of the AR symptoms can be measured subjectively by total nasal symptom score (TNSS) and objectively by investigating the serum IgE and absolute eosinophil count (AEC) levels. The current guidelines suggest Intranasal corticosteroids (INSs) as first-line treatment for patients with moderate to serious AR, especially when nasal congestion is the prominent manifestation.6 INSs inhibit the inflammatory response and reduce the number of inflammatory cells, nasal mucosa permeability and the release of mediators. The current characterization of Allergic rhinitis as proposed by ARIA (Allergic Rhinitis and its Impact on Asthma) guidelines based on 1) Severity and quality of life as "mild" or "moderate-severe", 2) Duration as "intermittent" or "persistent" disease.7 Patients with Intermittent AR have sneezing, watery secretions, and eye symptoms; while patients with persistent AR have mucous secretions, nasal obstruction, postnasal drip, smell disturbances and may be associated with chronic sinusitis and asthma. In persistent AR patients, the above inflammatory responses occur in the respiratory tract.
A 2019 PAN-India study observed 70 to 90% of Indians are deficient of vitamin D. 8, 9, 10 In recent studies, vitamin D is associated with an immune-modulator effect on naïve and activated helper T-cells, which could be beneficial in Allergic rhinitis. Most of these studies utilized serum 25 (OH) D level of 30 – 80 ng/ml as normal level, 20 - 30 ng/ml as vitamin D insufficiency, and < 20ng/ml as vitamin D deficiency. Vitamin D mechanism of action regulated the performance of macrophages, toll-like receptors (TLR), and natural killer cells (NK), as well as most of the Th2 cell-mediated components. The reaction of type 1 hypersensitivity of Allergic rhinitis was characterized by releasing various mast cell mediators.11 Inhibition process of Allergic rhinitis pathophysiology by vitamin D may reduce the clinical nasal symptoms.9,12,13 Recently, many studies reported that vitamin D plays a critical role in Allergic rhinitis, however, this association yet remains unclear. The study aimed to evaluate total nasal symptom scores (TNSS), serum IgE, serum absolute eosinophil count (AEC) in patients of AR, pre and post-treatment with and without supplementation of vitamin D.
METHODOLOGY
A Randomized, open-labelled, prospective, parallel-group study, conducted in Allergic clinic of Government E.N.T. Hospital, Koti, Hyderabad for a duration of 6 months from May 2019 to Oct 2019. Patients showing signs and symptoms of Allergic rhinitis were selected for this study. Institutional Ethics Committee Approval was taken. The study was registered under Reg.No. ECR/300/Inst/AP/2013/RR-16. Written informed consent was obtained from all study participants of age more than 18 years in a prescribed format in regional language after explaining about study procedures. For the patients less than the age of 18 years, their parents were explained about the procedures, and written informed consent was obtained from them. If the participant was illiterate, the left thumb impression was taken.
Screening: After getting informed consent, 109 patients were screened. Out of 109 patients with Allergic rhinitis, 100 patients who satisfy the inclusion and exclusion criteria were enrolled in the study during 1st visit are randomized in 1:1 allocation.
Inclusion criteria:
Age: 18 - 60 years.
Both male and female patients.
Serum Vitamin D level < 30 ng/ml.
Clinical symptoms for at least 1 month or more.
TNSS: 7 – 15.
Patients willing to come for follow-ups as advised.
Exclusion criteria:
Age < 18 and > 60 years.
Co-morbid diseases that affect serum vitamin D levels.
Patients on oral or inhaled corticosteroids and medications including vitamin supplements.
Any nasal pathology.
Debilitating medical illness.
Pregnant or nursing women.
Non-consenting individuals.
Randomization: The enrolled patients were randomized by simple randomization (odd/even number) method into group A and group B.
Treatment Plan: Group A - Fluticasone nasal spray (2 puffs/ 50 mcg in each nostril twice daily) for 3 weeks. Group B - Vitamin D (1000 IU once daily) plus Fluticasone nasal spray (2 puffs/50 mcg in each nostril twice daily) for 3 weeks.
Assessment of Patients: Pre and post-treatment TNSS, serum vitamin D, Ig E, AEC levels were done. The total nasal symptom score (TNSS) questionnaire was assessed based on signs like nasal congestion, runny nose, nasal itching, sneezing, and postnasal drip.14 The nasal symptoms like nasal congestion, runny nose, nasal itching, sneezing, and postnasal drip were assessed by interviewing the patients and graded according to severity.
Grade 0: None – No symptoms;
Grade 1:Mild - Symptom clearly present but easily tolerated;
Grade 2:Moderate- Symptom bothersome but tolerable;
Grade 3: Severe- Symptom difficult to tolerate, interferes with activity.
By adding each point of nasal symptoms, the total score of TNSS is obtained. The ARis graded depending upon the severity and total score as
Mild ≤ 6;
Moderate 7 to 10;
Severe 11 to 15.
Statistical analysis: The observations and results were tabulated accordingly and data was analyzed using the Software Package for the Social Sciences (SPSS). Statistical significance between two drugs was evaluated using student's t-test. P-value of ≤ 0.05 was considered significant.
RESULTS
Among 100 patients included in the study, 51 patients were male and 49 patients were female. During the study, 4 patients were excluded, out of which 3 patients were not willing to participate, consent was withdrawn and 1 patient end of the study visit not possible. Thus, Group A included 47 patients and group B included 49 patients after dropouts. The age distribution of all the patients included in the study is shown in figure 1. Serum vitamin D was considered insufficient with the levels between 21 - 30 ng/ml and deficient if the levels were ≤ 20 ng/ml. The serum vitamin D levels of the participants are shown in figure 2. The mean difference in total nasal symptom score (TNSS) between the two groups is shown in table 1. The mean difference in serum IgE levels between the two groups is shown in table 2. The mean difference in serum absolute eosinophil count levels (AEC) between the two groups is shown in table 3. There was no statistically significant difference in TNSS, serum IgE and serum AEC levels between the two groups.
DISCUSSION
Hyppönen et al. used a sample of subjects born in Finland in 1966 to examine the associations between infant vitamin D supplementation and adulthood allergic conditions. They found that the incidence of Allergic rhinitis (they identified Allergic rhinitis when participants experienced allergic cold — related to animal or pollen contact, e.g. hay fever - during the past 12 months) was higher in participants who had received vitamin D supplementation regularly during their first year of life compared to those who had not received supplementation at the age of 31 years.15 In another subsequent study, Wjst and Hyppönen analyzed the relationship between serum 25(OH) D3 values and AR prevalence in adults using the Third National Health and Nutrition Examination Survey (NHANES III) survey in Germany and found that the prevalence of Allergic rhinitis increased by 25(OH)D3 levels in all sub-groups and subsequent adjustments for gender, time and region of evaluation.16 Findings from these two studies indicated that in infancy or high levels of 25(OH)D3 supplementation of vitamin D was positively correlated to adult prevalence of Allergic rhinitis. Dogru and Suleyman compared serum 25(OH)D3 levels in children with Allergic rhinitis, according to the Allergic Rhinitis and its Impact on Asthma [ARIA] 2008 guidelines or non-allergic rhinitis (NAR) with the control group and found that mean serum 25 (OH) D3 levels of both Allergic rhinitis and Non-allergic rhinitis children were lower than the control group.17 But there was no association between the levels of 25 (OH) D3 and the frequency, severity, and extent of allergic rhinitis. In another study in Iran, Arshi et al. assessed 25(OH)D values in Allergic rhinitis patients and compared the results with the general population (no control group) and found that the prevalence of severe 25 (OH) D deficiency in Allergic rhinitis patients was significantly higher than the normal population.18 From the above studies, we can see that only two studies described Allergic rhinitis according to ARIA, and both reported a negative association between levels of vitamin D and Allergic rhinitis.17,18 There are conflicting conclusions about the relationship between levels of vitamin D and the risk of Allergic rhinitis. For example, after supplementation, one study reported significantly reduced IgE values in atopic patients.19 However, Back et al. reported that children supplemented with vitamin D (>13 mg /day) showed an increased risk of either AR or allergic asthma.20 In particular, the intake of vitamin D led to an increased risk of AR at the age of 6 when there was already a positive family history for AR. Similarly, Hypponen et al. showed that during infancy dietary intake of vitamin D promoted allergic diseases at the age of 31.16 In addition to supporting a deleterious role in supplementing vitamin D, Milner et al. found that early supplementation of the vitamin in children was associated with increased risk of asthma and food allergies.21 Few studies reported that vitamin D suppresses the development of T helper 1 cells (Th1 cells) but augments T helper 2 cells (Th2 cells) differentiation which increases IL-4, IL-5, IL-10 and Ig E production. The results of our study are in contrast with other previous published literature. This may be due to change in the study population, seasonal variation, sample size and duration of the study.
CONCLUSION
In this study, supplementation of vitamin D did not alter the natural course of Allergic rhinitis. Though changes in the symptoms and lab values were noted in between the groups, it was statistically not significant which would prove beneficial for the patients. Further studies are required in large sample sizes and different study designs to evaluate the efficacy of vitamin D supplementation in patients with Allergic rhinitis.
ACKNOWLEDGEMENT
Authors thank Dr. T. Chakradhar, Professor and Head, Department of Pharmacology for expert advice. We also thank Dr. Souris Kondaveti for valuable opinions. Authors acknowledge the immense help received from the scholars whose articles are cited and included in references to 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 and discussed.
CONFLICT OF INTEREST
None declared.
FINANCIAL SUPPORT
Nil
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Milner JD, Stein DM, McCarter R, Moon RY. Early infant multivitamin supplementation is associated with increased risk for food allergy and asthma. Pediatrics. 2004 ;114(1):27-32.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareNon-Stress Test in High-Risk Pregnancy
English112117R. P. PatangeEnglish S. S. PatilEnglish Prashant D. ShahEnglish Digvijiay KadamEnglish Vrishali ChavanEnglishIntroduction: The journey of the foetus through the maternal pelvis is considered most difficult. The art of obstetrics is based on balancing the risks encountered during this journey. Aims and Objectives: To evaluate the relation between the result of the non-stress test and mode of delivery. To evaluate the relation between the result of the non stress test and perinatal outcome. This prospective study was carried out in the Department of Obstetrics and Gynecology at Krishna Institute of Medical Sciences, Karad. All high-risk patients admitted for induction of labour or in the latent phase of One hundred and fifty patients with highrisk pregnancies like pregnancy-induced hypertension, intrauterine growth retardation, overdue pregnancy, oligohydramnios, gestational diabetes and heart disease. Results- Patients with the gestational age of more than 34 weeks were subjected to the non-stress test. Out of 150 patients, 85 patients (56.67%) had normal, 44 patients (29.33%) had suspicious and 21 patients (14%) had abnormal non-stress test results. 80% of patients with normal non-stress test deliver vaginally as against 50% in suspicious group and 28.57% in abnormal group. Caesarean section rate in the normal group was 20% while that in the suspicious group was 50% and 71.43% in abnormal group. In the abnormal group, caesarean section was done in 73.33% for cause related to the result of a non stress test. Conclusion: Non-stress test is a simple, non-invasive, inexpensive test for antepartum foetal surveillance. It is easy to perform and causes no inconvenience or complications to the patient. The non-stress test should be performed for diagnostic purpose in the light of clinical circumstances.
EnglishNon-Stress Test, High Risk, PregnancyINTRODUCTION
With the emphasis on “Small Family Norm”, it is all the more necessary that every wanted conception should end in the birth of a viable healthy baby. For this, close monitoring for assessment of foetal wellbeing is required especially for high-risk pregnancies.1 The ability to predict foetal survival for a finite interval has a major implication for both mother and foetus. The journey of the foetus through the maternal pelvis is considered most difficult. The art of obstetrics is based on balancing the risks encountered during this journey. For high-risk pregnancies, this balance is usually between conservative management with the risks of stillbirth and intervention with risks of prematurity complications and increased probability of operative delivery. The management of high-risk patient has always been a difficult and challenging problem. Good antenatal services backed up by vigilant intrapartum monitoring for the progress of labour and foetal conditions are the mainstay in the management of high-risk pregnancies.
A non-stress test is one of the biophysical technique for assessing the foetal condition and is one of the mainstays in the management of most high-risk pregnancies. It can identify the foetus in jeopardy, in the compromised intrauterine environment and also the foetus that may not be able to tolerate the stress of labour.2 This enables an appropriate and timely intervention to achieve the most favourable neonatal outcome.
AIMS AND OBJECTIVES
To evaluate the relation between the result of the non-stress test and mode of delivery.
To evaluate the relation between the result of the non stress test and perinatal outcome.
MATERIALS AND METHODS
This prospective study was carried out in the Department of Obstetrics and Gynecology at Krishna Institute of Medical Sciences, Karad.
All high-risk patients admitted for induction of labour or in the latent phase of labour were selected.
Inclusion criteria:
Patient with gestational age at>34 weeks
Cephalic presentation
Intact membranes
One or more antenatal high risk factor4,5
High-risk factors include:
Pregnancy-induced hypertension
Intrauterine growth retardation
Overdue pregnancy
Oligohydramnios
Gestational Diabetes
Heart disease 6,7
OBSERVATIONS AND RESULTS
In the present study, 150 study subjects with high-risk pregnancy were studied using the electronic foetal monitor. The non-stress test was used primarily as an indicator for antepartum foetal surveillance. Results were analysed in terms of mode of delivery and perinatal outcome.
64.67% of the patients belong to the age group of 20-24 years as shown in this table.
52.67% of the patients included in this study were primigravida.
60.67% of the patients were of more than 40 weeks of gestational age( Table 1,2).
In this study, 83.33% of the patients were booked while 16.67% of the patients were unbooked (Table 3).
Commonest high-risk factor encountered in the present study was overdue pregnancy (60.67%, while overdue pregnancy alone as a high risk factor was present in 46.67% of the patients.
As seen in Table 6, the percentage of the abnormal non-stress test increases with an increase in the number of high-risk factors, while the percentage of the normal non-stress test is highest with only one high-risk factor.
This table shows the results of the non-stress test in each high-risk group. Out of 150 patients, 85 (56.67%) non-stress test was normal, 44 (29.33%) were suspicious and 21 (14%) had an abnormal non-stress test.
80% of patients with normal non-stress test delivered vaginally while only 50% and 28.57% with suspicious and abnormal non-stress test delivered vaginally, respectively. 71.43% of patients with abnormal non-stress test underwent a lower segment caesarean section. None of the patients had instrumental delivery (Table 4).
17 (20%) patients out of 85 patients with normal non-stress test required caesarean section while 22 (50%) patients out of 44 and 16 (76.19%) patients out of 21 patients with abnormal non-stress test required caesarean section.
Stillbirth was 9.52% and neonatal death was 9.52% in the abnormal non-stress test group. There were no stillbirth and 4.55% neonatal deaths in the suspicious non-stress test group. No stillbirth and neonatal death were observed in the normal non-stress test group (Table 5).
DISCUSSION
Obstetricians have long searched for methods of antepartum evaluation of foetus that would be noninvasive, accurate and yield immediately available results.
Over the past fifteen years, great strides have been made in antepartum foetal surveillance. The tests for foetal surveillance are being gradually improvised and modified to make them more sensitive and specific to permit the identification of those foetus requiring intervention, to prevent death or damage and allowing us not to interfere with those pregnancies doing well, letting healthy fetuses go to term. 8,9
The ideal test should be easy to perform, less expensive, repeatable without causing inconvenience to the patient. It should be specific and sensitive. It should not have any side effects and should not cause any harm to the mother or the baby. Nonstress test is one such test which fulfils most of these criteria and thus, it is now generally accepted as a clinically useful method for detecting uteroplacental insufficiency and foetus at risk during the antepartum period. 10
In this study, 150 patients with high-risk pregnancies were evaluated. Many similar studies were carried out over years in various countries.
In the present study, overdue pregnancy was the commonest risk factor (46.67%). Overdue pregnancy was also found to be commonest risk factors in studies of Iman Bano et al (30%). Uchil et al (45.34%), Keegan and Paul (51.7%) and Patil et al (19.7%). In studies by Jain et al (61.8%) and Habeebullah et al (27%), bad obstetric history was the commonest risk factor. 11,12
Iman Bano et al included pregnancy with jaundice and foetal tachycardia in their study while Habeebullah et al included cardiac diseases during pregnancy and premature rupture of membranes in their study. Uchil included infertility, previous caesarean section, placenta praevia in their series. Factors like infertility, previous caesarean section, threatened preterm labour were not included in this study because they were less likely to affect uteroplacental circulation. 13
The non-stress test was done in these patients after 34 weeks of pregnancy. Maximum and minimum gestational age in studies of various authors is shown in this table.
In the present study, patients below 34 weeks of gestational age were not included because of the following reasons. 14
A] Before 34 weeks, the incidence of the non reactive non-stress test is more due to immature control of the cardiovascular system. Characteristics of the premature non-stress test are
Less variability.
More number of foetal movements which are less powerful and of short duration.
Short episodes of activity and quiescence in the foetus (about 10 min. each).
Before 30 weeks, decelerations are more common than accelerations in response to foetal movements. These decelerations are of short duration (15-30 sec) with an amplitude of 15-30 bpm.
Foetal tachycardia.15,16
Due to these factors, interpretation of the non-stress test is very difficult.
B] Foetal survival could not be guaranteed because of less developed neonatal care units in our setup.
In the present study, the normal non-stress test was observed in 56.67% non-stress tests. 29.33% of the non stress test was suspicious and 14% of the non-stress test was abnormal. The result of the non stress test in the study by Rochard et al was similar to the present study.
Mode of delivery concerning non-stress test results
In the present study 68 patients (80%) delivered vaginally while 17 patients (20%) underwent LSCS. The indications of LSCS were the failure of induction in 6 patients (35.29%), non-progress of labour in 5 patients (29.41%), foetal distress in 3 patients (17.65%) and thick meconium-stained liquor, DTA and cervical dystocia in 1 patient (5.88%) each.
Percentage of vaginal delivery in the present study with normal non-stress test result was similar to that of study by Imam Bano et al.17
Mode of delivery about the abnormal non-stress test:
In the present study, only 6 patients (28.57%) with abnormal non-stress test results delivered vaginally, while 15 patients (71.43%) underwent LSCS. The indications of LSCS were foetal distress in 9 patients (60%), failure of induction in 4 patients (26.67%) and thick meconium-stained liquor in 2 patients (13.33%).
Percentage of vaginal delivery and LSCS in the present study with abnormal non-stress test result was similar to that of study by Imam Bano et al.
Suspicious non-stress test:
In the present study, 22 patients (50%) had a vaginal delivery and 22 patients (50%) underwent LSCS out of a total of 44 patients with the suspicious non-stress test.
Perinatal outcome about non-stress test results
No perinatal mortality was observed in patients with the normal non-stress test. Rochard et al, Imam Bano et al, Bahebullah et al, and Patil et al also had no perinatal mortality in their studies in patients with the normal non-stress test.
Though Keegan et al observed 7% perinatal mortality in his study.
Perinatal outcome about the abnormal non-stress test:
Percentage of perinatal mortality in patients with the abnormal non-stress test was 19.04% in the present study while it was as high as 39.6% in the study by Rochard et al and lowest being 1.6% in the study by Patil et al.
In the present study, there were 2 neonatal deaths and 2 stillbirths in patients with an abnormal non-stress test.
Stillbirth:
One patient was having severe Pregnancy-induced hypertension with intrauterine growth retard at 38 weeks of gestation and LSCS was not considered due to very low expected birth weight. Patient delivered a stillborn child of 1020 grams.
Another patient having severe PIH with heart disease with IUGR at 35 weeks of gestation and keeping in mind the very low expected birth weight and risk of complications due to heart disease (severe mitral stenosis), the option of LSCS was not considered. Patient delivered a stillborn child of 1000 grams.
Neonatal death:
There were 2 neonatal deaths in patients with the abnormal non-stress test. Both the patients underwent LSCS, one for foetal distress whose baby expired due to birth asphyxia while the other for thick meconium-stained liquor whose baby expired due to meconium aspiration syndrome.
Percentage of perinatal mortality with an abnormal non-stress test of the present study was 19.05%. Imam Bano et al observed perinatal mortality of 50% and Rochard et al observed perinatal mortality of 39.6% with the abnormal non-stress test.
Suspicious non-stress test
In the present study, there was 2 neonatal death in patients with a suspicious non-stress test. One of the patients who had mild PIH with IUGR underwent LSCS for thick meconium-stained liquor and baby expired due to birth asphyxia and meconium aspiration syndrome. Another patient who had oligohydramnios had vaginal delivery and baby expired due to birth asphyxia and meconium aspiration syndrome.
CONCLUSION- non-stress test is a simple, non-invasive, inexpensive test for antepartum foetal surveillance. It is easy to perform and causes no inconvenience or complications to the patient. The non-stress test should be performed for diagnostic purpose in the light of clinical circumstances.
Conflict of interest- nothing to report.
Source of funding- Kimsdu Karad
Acknowledgement- Authors acknowledge the immense help received from the scholars whose articles are cited and included in references to 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 and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=2902http://ijcrr.com/article_html.php?did=2902
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareExploring Quality of Life and Perceived Experiences Among Couples Undergoing Fertility Treatment in Western India: A Mixed Methodology
English118123Sonali BanerjeeEnglish Mary Mathews N.EnglishBackground: Diagnosis and related advanced fertility treatments are multifaceted and protracted with unstipulated outcomes. There remains a risk of bodily burden, psychological distress, furthermore may impact the quality of life among infertile couples. Objectives: Study was aimed to 1. assess the quality of life among infertile couples undergoing fertility treatment and compare it between respective partners. 2. explore in-depth their perceived experiences. Methods: Explanatory mixed method design with sequential data collection, nested sampling technique was adopted. Participants included 300 women & 300 men attending a fertility clinic at a tertiary hospital. 300 couples were administered FertiQoL questionnaire for quantitative data collection while qualitative data were collected by in-depth interview of eleven couples, and thematic analysis was done. Ethical compliance was maintained throughout the study. Analysis: Socio-demographic data revealed that the mean age of the wives and husbands were 31.17± 5.4 and 35.4± 5.6 years respectively. BMI was higher in 39.7 % of wives and 58.7 % of husbands. The mean of total FertiQoL score of 300 couples in Western India was 29.3 ± 9.2. Wives had significantly lesser scores than their husbands in emotional (p=0.007*), social (p= 0.001*) and environmental (p=0.013*) subscales. The total FertiQoL mean scores were significantly lower among wives (p=0.001*). Themes emerged from qualitative data as a societal burden, physical pain and distress, monetary crisis and interpersonal problems. Conclusion: Infertile couples in western India reported poor QoL. Wives have poorer FertiQoL scores as compared to their partners. Couples undergoing fertility treatment face various challenges jeopardising their quality of life.
English Infertility, Quality of life, FertiQoL, Experiences of infertile couples.Introduction
Reproduction and enduring the lineage are amid the most innate and important instincts of all living beings. Indian Statistics (2017) showed a decline in total fertility rate (TFR), 2.4 in rural areas and 1.7 in urban. Western state Maharashtra reported TFR 1.7.1 Furthermore, global statistics conjecture that approximately 15% of the reproductive age population is affected by infertility. Indian scenario, as per WHO records shows a wide-ranging figure i.e. 3.9 to 16.8% as per different states.2 Both the datasets implied a decline in TFR on other hand an incline in infertility prevalence.
In the past few decades, fertility treatment has been advanced immensely, concurrently awareness and treatment-seeking behaviour also displays a steady upsurge among the infertile couples. The labelling of the infertility diagnosis itself triggers consequences like changes in emotions, thoughts, and beliefs of the couples. They not only face a medical condition but also pertinent challenges. As per the description given by the World Health Organization (WHO), Quality of life is individuals’ perceptions of their position in life in the context of culture and the value systems where they live .3 Thus, it may be considered that fertility QoL encompasses a replication of Indian infertile couples’ life status during their infertile period. Inability to conceive eventually trails to stigma, eviction and social anguish in milieu to Indian societal framework as parentage is considered with utmost repute, significance and urgency. Both partners endure tremendous family and social pressure for commencing a family. Infertility is an intricate and situational predicament predisposing to psychologically threatening, emotionally traumatic, monetary challenging, and physically painful due to the diagnostic-curative procedures.
Furthermore, enormous marital life unhappiness and repetitive pregnancy trials play a vital role in worsening the experiences and the couple, especially women are predisposed to marital distress.4 As spouses become more discreet toward one another, their marriage life may also be adversely altered affecting their Quality of life.
With extensive literature review, it was observed that QoL was explored typically among infertile women, very few studies were conducted considering both the partners. However, an in-depth study about the impact on the quality of life of such couples is less into documentation with Indian population context. The present study was conceptualized to explore exhaustively the quality of life among couples undergoing fertility treatment, and compare it between respective partners and also to explore in-depth the related experiences of infertile couples.
Materials and methods
Explanatory mixed method design with sequential data collection (QUAL -› Quan) 5 was aptly adopted. The qualitative data was collected to support the quantitative findings. The study was merged at the time of interpretation of findings. The current study was conducted as a part of the larger project, from October 2018 to June 2020 in various phases. Settings of the study were at a tertiary hospital and research centre, at Navi Mumbai, with a super specialised fertility clinic.
Couples who were willing to participate, women aged above 18 years and below 50 years, men aged above 21 years and below 55 years and who can read, write, speak and understand English/Hindi/ Marathi were included in the study. As per exclusion criteria couples with secondary infertility, previous history of In Vitro fertilization treatment, were not enrolled in the study. For creating better participation and interaction, the couple- based dyadic approach was incorporated. All participants were interviewed in one or two sessions lasting approximately 30 to 60 minutes. This study was part of research approved by the Ethics Committee for Research on Human Subjects (ECRHS) at MGM Institute of Health Sciences, Kamothe, Navi Mumbai, approval letter: MGMIHS/RES/02/2017-18 dated 20.03.2018. Before the commencement of the project, all written permissions were procured from authorities. Before the interviews, participant couples were acquainted with the research aims and informed consent was obtained from both the partners. Confidentiality was the utmost priority of the study and they could withdraw from the project as desired.
Data collection was done with the sequential approach, 346 couples were screened for the study, 300 couples (300 women, 300 men) were finally selected through purposive sampling technique with maximum variations for quantitative strand. Qualitative data was collected by in-depth interview of eleven couples, using nested sampling until data saturation. All couple of interviews were recorded and transcribed. Conventional thematic analysis was done. The trustworthiness of the data was ensured by maximal variation, peer debriefing and 3rd party review of transcripts.
The tools for data collection: a. Socio-demographic sheet, b. Standardised FertiQoL questionnaire to elicit QOL among the infertile couples. FertiQoL is a worldwide validated tool to quantify the quality of life of couples undergoing fertility issues and was used with author permission.6 FertiQoL consists of 36 questions, two general questions, Core FertiQoL with 24 questions, four domains ( emotional, mind-body, relational and social ), and optional Treatment module with 10 questions and two subscales ( environment and tolerability) It is available in English and Hindi, translated to Marathi (Cronbach’s alpha internal consistency r = 0.89). Scaled scores range from 0 to 100, lower QoL was inferred with lower scores.
Statistical analysis was performed using SPSS 21.0 software. Categorical variables were expressed as frequency and percentage, continuous variables as mean and standard deviations. Comparisons were done using the Mann-Whitney z test and two-sample z test. Statistical significance was inferred with a p-value less than 0.05.
Results
Quantitative Data Analysis
Data were analysed for 300 couples with 100% participation. The mean age of the wives and husbands 31.17± 5.4 and 35.4± 5.6 years respectively. Both the groups were homogenous in terms of religion and education as shown in Table 1 below.
Significant Difference in terms of age & occupation.
Around 27.4 % of the wives quit their jobs to conform with the frequent schedules for hospital appointments and treatment. Revised Kuppuswami scale 7was incorporated to determine the socio-economic status of the couples, it was seen that the majority (67 %) couples belonged to Upper middle class. The majority (58%) of the couples stayed as a nuclear family, around 19.9% has separated from joint families due to family pressure. Body mass index revealed that 119 (39.7%) wives and 176(58.7%) were overweight. As per personal habits, women were non-smokers and non-alcoholics. Among men 27.8 % were smokers and 48.3 % reported occasional alcohol indulgence.
Reproductive health per se, the average age at marriage of women was 24.9 ± 4.7 years, men were 29.2 ± 5.0 years. Majority 36% were married for 3 to 6 years and 56.3% reported duration of infertility less than 3 years. Around 74% of couples reported the frequency of physical relation was less than 2 times/week, and around 56.7% had ovulation unmatched relationship. Majority i.e. 70 % of the couples were staying together, 14 % of them stayed separately due to different location of the job of spouse and remaining 16 % stayed separately due to personal issues with the duration of 1 to 3 years.
As per psychological aspects, majority i.e. 88.0 % wives were stressed while in a physical relationship with the partner, whereas 70.7 % of husbands reported as stressed. Towards the treatment expenses, the majority (54.7%) of the couples expressed that they would meet the financial expenses by taking loans.
Infertility causes identified female index case: 39.3 %, male index case: 22%, mixed: 21, idiopathic: 17.7 %. Majority of the women i.e. 27.3 % had the polycystic ovarian syndrome, whereas, among men, 27.3 % were diagnosed with oligospermia.
Quality of life was measured among the infertile couples using the FertiQoL tool. The mean FertiQoL score of infertile couples was 29.3 ± 9.2. depicted in Fig1 as below.
The comparison was done between the partner scores. Wives had significantly lower scores than respective partners about emotional and social, treatment environment domains (p0.05). Total FertiQoL scores were significantly lower among wives (pEnglishhttp://ijcrr.com/abstract.php?article_id=2903http://ijcrr.com/article_html.php?did=29031. Estimates of fertility indicators. Encyclopedia Brittanica. 2019;29–66. Available from: https://www.censusindia.gov.in/vital_statistics/SRS_Report_2017/10. Chap_3-Estimates of Fertility_Indicators-2017
2. Prevalence of Infertility in India. National Health Portal https://www.nhp.gov.in/disease/reproductive-system/infertility. 2016.
3. WHO. Health statistics and information systems. Metrics: Disability-Adjusted Life Year (DALY) [Internet]. 2012;0:2–3. Available from: http://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/
4. Barani Ganth D, Thiyagarajan S, Ganth BD, Thiyagarajan S, Nigesh K. Role of infertility, emotional intelligence and resilience on marital satisfaction among Indian couples. International Journal of Applied Psychology. 2013;3(3):31–7.
5. Creswell JW. The Selection of a Research Approach. Research Design [Internet]. 2014;3–23. Available from: http://www.sagepub.com/upm-data/55588_Chapter_1_Sample_Creswell_Research_Design_4e.pdf
6. Boivin J, Takefman J, Braverman A. The fertility quality of life (FertiQoL) tool: Development and general psychometric properties. Human Reproduction. 2011;26(8):2084–91.
7. Sharma R. Revised Kuppuswamy’s socioeconomic status scale: Explained and updated. Indian Pediatrics. 2017;54(10):867–70.
8. Moura-Ramos M, Gameiro S, Canavarro MC, Soares I, Almeida-Santos T. Does infertility history affect the emotional adjustment of couples undergoing assisted reproduction? the mediating role of the importance of parenthood. British Journal of Health Psychology. 2016;21(2):302–17.
9. Karabulut A, Özkan S, O?uz N. Predictors of fertility quality of life (FertiQoL) in infertile women: Analysis of confounding factors. European Journal of Obstetrics and Gynecology and Reproductive Biology. 2013;170(1):193–7.
10. Jahromi BN, Mansouri M, Forouhari S, Poordast T, Salehi A. Quality of life and its influencing factors of couples referred to an infertility centre in Shiraz, Iran. International Journal of Fertility and Sterility. 2018;11(4):293–7.
11. Valsangkar S, Bodhare T, Bele S SS. An evaluation of the effect of infertility on marital, sexual satisfaction indices and health-related quality of life in women. J Hum Reprod Sci. 4(2)(2):80-5.
12. Desai HJ, Gundabattula SR. Quality of life in Indian women with fertility problems as assessed by the FertiQoL questionnaire: a single-centre cross-sectional study. Journal of Psychosomatic Obstetrics and Gynecology. 2019 Jan 2;40(1):82–7.
13. Rashidi B, Ramezanzadeh F, Montazeri A, Shariat M, Abedinia N, Ashrafi M. Health-related quality of life in infertile couples receiving IVF or ICSI treatment. BMC Health Services Research. 2008;8:1–6.
14. Gao M, Ji X, Zhou L ZZ. The fertility quality of life (FertiQol) in Chinese infertile women. Transl Androl Urol. 2016;Apr;5(Supp(DOI: 10.21037/tau.2016.s084. PMCID):56–7.
15. Aarts JWM, Huppelschoten AG, van Empel IWH, Boivin J, Verhaak CM, Kremer JAM, et al. How patient-centred care relates to patients quality of life and distress: A study in 427 women experiencing infertility. Human Reproduction. 2012;27(2):488–95.
16. Santoro N, Eisenberg E, Trussell JC, Craig LB, Gracia C, Huang H, et al. Fertility-related quality of life from two RCT cohorts with infertility: Unexplained infertility and polycystic ovary syndrome. Human Reproduction. 2016;31(10):2268–79.
17. Neumann K, Kayser J, Depenbusch M, Schultze-Mosgau A, Griesinger G. Can a quality-of-life assessment assist in identifying women at risk of prematurely discontinuing IVF treatment? A prospective cohort study utilizing the FertiQoL questionnaire. Archives of Gynecology and Obstetrics [Internet]. 2018;298(1):223–9. Available from: https://doi.org/10.1007/s00404-018-4797-2
18. Taha EA, Sabry M, Abdelrahman IFS, Elktatny H, Hosny A. Impact of irregular marital cohabitation on quality of life and sexual dysfunction in infertile men from upper Egypt. Clinical and Experimental Reproductive Medicine. 2020;47(1):77–82.
19. Hsu PY, Lin MW, Hwang JL, Lee MS, Wu MH. The fertility quality of life (FertiQoL) questionnaire in Taiwanese infertile couples. Taiwanese Journal of Obstetrics and Gynecology. 2013;52(2):204–9.
20. Huppelschoten AG, van Dongen AJCM, Verhaak CM, Smeenk JMJ, Kremer JAM, Nelen WLDM. Differences in quality of life and emotional status between infertile women and their partners. Human Reproduction. 2013;28(8):2168–76.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareHealth Insurance Service Utilization and Willingness to Adopt Health Insurance Schemes Among Admitted Patients in a Tertiary Hospital of India
English124130Ria GangulyEnglish Lipilekha PatnaikEnglish Trilochan SahuEnglishBackground: With technological advances, new procedures and more effective medicines, the costs of healthcare have driven up. So, taking health insurance is more affordable. Aims: To know health insurance service utilization and willingness to adopt a health insurance scheme among patients admitted in a tertiary hospital. Materials and Methods: The study was conducted during September - November 2019 among 126 patients admitted in a tertiary care hospital using a predesigned and pretested schedule. The study design was cross-sectional. Non-probability sampling method was used. Data were entered to an excel sheet and SPSS software version 20 was used for analysis. Results: Among the persons interviewed, about 20% were admitted under the health insurance scheme, 71% were aware of health insurance. Around 60% of the respondents gained knowledge about health insurance from radio and television followed by agents and friends (31.1%) and print media (8.9%). Among those insured 72% had ESIS, 24% had CGHS and 4% had taken private insurance. Among participants, 55% were not willing to join any health insurance scheme but if given a chance,61% preferred Government health insurance. 84 % of participants who were admitted under insurance belonged to upper socioeconomic status. This association was statistically significant (p=0.002). Government health insurance was preferred by 80% of participants. Conclusion: Health insurance coverage will further increase by increasing awareness about different schemes and the initiative taken by health care personnel will be more effective.
English Health insurance, Awareness, Out of pocket expenditure, Inpatients, Willingness to pay, Social security
Introduction:
The prevalence of lifestyle diseases is rising due to changing lifestyles which in turn is increasing the demand for healthcare. With technological advances, new procedures and more effective medicines the costs of healthcare have driven up. While these high treatment expenses may be beyond reach, taking health insurance is much more affordable.1 Health insurance has been acknowledged as a valuable tool in health financing. The design of health systems and insurance schemes in countries like USA, Australia, Indonesia and India is based on the potential impact of how health systems are financed on the wellbeing of households, particularly poor households.1,2
The insurance system works on the basic principle of pooling of risks of unexpected costs of persons falling ill and needing hospitalization by charging premium from a wider population base of the same community.3 despite its significance, the subscription is very less. People who can afford or aware of health insurance are also found to be ignorant towards it. According to the 71st round of surveys, the National Sample Survey Office (NSSO) published the report “Key Indicators of Social Consumption in India: Health” in 2016. In the report, it was observed that more than 80% of people were not covered under any health insurance plan. The majority were covered by government-funded health insurance. Just 18% of the urban and 14% of the rural population were covered by some type of health insurance policy.4
A report from World Bank in 2002 showed that, an enormous proportion of individuals borrow money or sell assets for hospitalization. Out of pocket health care expenses account for more than 80% of total healthcare expenditure in India.5 People of lower socio-economic groups usually spend a higher proportion of their annual income on health than high socio-economic groups.6 Once admitted to the hospital, the poor usually undergo a severe financial crisis.
The health insurance schemes for the poor were introduced to relieve their financial burden. Keeping in mind the healthcare needs of different strata of the population, insurance companies design innovative products with optimal pricing and comprehensive coverage. Plans funded by central government are Employee State Insurance scheme, Central Government Insurance Scheme, Rashtriya Swasthya Bima Yojana. In 2018, the Government of India has introduced Ayushman Bharat Yojana (Pradhan Mantri Jan Arogya Yojana), which aims to help economically vulnerable citizens for their health care need. Presently many private insurance companies like Star Health, ICICI Lombard, Reliance, Apollo Munich, Max etc. have come forward to offer health insurance. People have to pay premiums as per conditions of the policy, which vary according to medical care benefits. With so many features in different policies, the demand for health insurance has grown at a rate of 25 % per year, driven by rapidly increasing awareness, and is going to rise even more rapidly in the future.7
In Odisha, service delivery is mostly dominated by the public sector. The state still struggles with high levels of out of pocket expenditures and poor accessibility and quality of healthcare services in hard to reach areas. There is a tremendous opportunity for private sector investment to boost healthcare in this state, but private sector investment should go hand in hand with strong private sector regulation.8 People are not purchasing health insurance because of low awareness, lack of finance and high premium charges in India.9 In some studies in Maharashtra, India, lower levels of awareness (11–30%) and utilization of health insurance were reported,10 whereas higher levels of awareness (64%) were reported from a South Indian population.11 The most important reason for low coverage might be vast geographic and economic variation. Therefore, it was necessary to understand the awareness, utilization and willingness in buying health insurance among people in hospital inpatients of Odisha. So this study was conducted to assess the awareness of health insurance service among admitted patients in a tertiary hospital and to assess utilization and willingness to adopt a health insurance scheme among them.
Materials and Methods:
This study was cross-sectional and was conducted from September to November 2019 among 126 admitted patients in a tertiary hospital of eastern India. The sample size was calculated taking prevalence of awareness of health insurance in the urban area as 64% concerning a study by B. Reshmi et al.11 with 10% allowable error and 20% non-response rate. The sample size was estimated to be 110. Bed numbers were chosen by simple random sampling method and the interview was done in 126 admitted patients by a pre-designed and pre-structured schedule. The schedule consisted of questions on sociodemographic characteristics and awareness, utilization and willingness to join insurance scheme. Before the start of the interview, informed written consent was taken from the participants. Privacy and confidentiality of the interviewer were maintained. Those who did not give consent for the interview were excluded.
Statistical analysis: Data were entered in the excel sheet and analysed using SPSS software version 20 licenced to the institute. The level of awareness about health insurance in the study population was calculated in percentage. The association between various factors with awareness and enrolment were evaluated by Chi-square test. P-value ≤ 0.05 was considered a significant association.
Results:
Among 126 respondents, the mean age was 46± 13.3 years. Majority of respondents (48.4%) were in the age group 41-60 years. Among them, 63.5% were male and 36.5% were female. Majority of the respondents were Hindu (96.03%). Overall 50.8% population had education till High school and below. Most of the respondents (82.5 %) were married and69% belonged to the nuclear family. Majority of participants belong to the upper class (57.14%) and upper-middle class (38.88%) according to B. G. Prasad classification 2019. (Table 1)
Out of 126 participants, 25 (19.8%) were enrolled in any of the health insurance schemes. Awareness about health insurance was 71.4% (n=90) and among those who were aware, only 28% were enrolled. In comparison, males (69%) were more aware of Health insurance than females (54%) but the difference was not significant. (Figure 1)
Among insured patients, 72% were enrolled under the ESIC scheme, 24% CGHS and 4% private insurance policy. Insurance scheme was adopted to meet unforeseen expenses by 68% of the enrolled and 40% of those enrolled were satisfied with the benefits. 16.7 % of the insured find it easy to access the network hospitals and 10.3% find it easy to file a claim.
The main barriers for the subscription of health insurance were not commensurate benefit (38%), lack of awareness (36%) followed by financial constraint (12%). (Figure 2)
The main factors that motivated for the subscription of health insurance found were – cashless benefit (12%), lack of finance (20%), to meet medical emergencies (68%).
It was observed that, awareness insurance scheme was significantly associated with the education of participants, and enrolment was significantly associated with education, occupation and socio-economic status (pEnglishhttp://ijcrr.com/abstract.php?article_id=2904http://ijcrr.com/article_html.php?did=2904
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareSerum Magnesium in Diabetes Mellitus
English131135Rahul S. PatilEnglish R. J. KapaleEnglish Dany P. JhonEnglish Gosavi RohitEnglish Pramod KulkarniEnglishIntroduction: Diabetes mellitus is the most common endocrine disorder, encountered in practice. The incidence of diabetes is increasing at a rapid pace and is evolving into an epidemic. Methodology: In the present study, serum magnesium levels of 100 diabetic patients are compared with 30 nondiabetic patients with age and sex-matched controls. Serum magnesium levels are significantly low amongst diabetics as against nondiabetic controls giving the incidence of hypomagnesemia in diabetics to be 66%. Results: Amongst diabetics serum magnesium levels are adversely influenced by factors like male gender, longer duration of diabetes, poor glycemic control, higher serum cholesterol levels, hypertension as well as micro and macrovascular complications showing significant prevalence. Values of serum magnesium are significantly low in patients with microvascular complications as against those with macrovascular complications. Diabetic ketoacidosis is significantly associated with lower serum magnesium levels. However, age group, type of diabetes, presence of infection do not influence serum magnesium levels in the present study group. Conclusion: consider magnesium deficiency as a prognostic factor influencing the progression of diabetic complications and justify the therapeutic role of magnesium supplementation in achieving the reduction in insulin resistance, better glycemic control and slowing down of progressive diabetic complications.
English Serum, Magnesium, Diabetes MellitusINTRODUCTION
Diabetes mellitus is the most common endocrine disorder, encountered in practice. The incidence of diabetes is increasing at a rapid pace and is evolving into an epidemic. The worldwide prevalence of diabetes mellitus has risen dramatically over the past two decades, from an estimated 30 million cases in 1985 to 177 million cases in 2000. Based on current trends more than 360 million individuals will have diabetes by year 2030.1
The restricted diets which most diabetics must follow do not allow them to meet the recommended daily allowances of micronutrients like zinc, copper, chromium, manganese, and magnesium regarding diabetes mellitus remains controversial with many questions unanswered.
Magnesium, one of the abundant intracellular cation has many wider metabolic implications as it relates to diabetes mellitus.
Hypomagnesemia has long been known to be associated with diabetes mellitus. Magnesium is an essential cofactor in both glucose transporting mechanisms of cell membranes and more than 300 enzymes in carbohydrate metabolism. Thus the association of diabetes and hypomagnesaemia is significant for its wide-ranging impact on diabetic control, glycosuria, atherosclerosis, dyslipidemia, metabolic, microvascular and macrovascular complications. Magnesium supplementation is safe and effective for the improvement of diabetic complications. However no supplements can replace insulin for patients with type -1 diabetes, even in type 2 diabetes these supplements may only reduce rather than eliminate medication needs.1
We know that diabetes is a progressive disorder and complications are inevitable. People with severe hyperglycemia can remain largely asymptomatic for a long period. Consequently, at the time of diagnosis of diabetes, many of them have some end-organ damage. Thus the enormous impact of diabetes on morbidity and early mortality in western as well as developing countries underscores the importance of closely examining all possible factors in pathogenesis.2,3
Hence only hope to lessen the burden of diabetes is the universal screening of diabetes so that early detection and intervention is possible. So we are studying here serum magnesium levels in diabetes mellitus.
MATERIALS AND METHODS
Hundred diabetic patients attending diabetics clinic and admitted in medicine wards throughout one and half year are included in this study.
Inclusion criteria
Diabetic patients randomly selected irrespective of age, sex, type of diabetes, duration, glycemic control, with or without diabetic complications. Thirty age and sex-matched non-diabetic controls.
Exclusion Criteria
Patients with malabsorption, nephrolithiasis, hyperthyroidism, hyperparathyroidism, malignancy, chronic renal failure: i.e., the conditions mainly influencing serum magnesium levels.
Patients who have gone through gastrointestinal tasks and nephrectomy. Patients on hormones other than insulin just as on diuretics, anticonvulsants, chemotherapy and immunosuppressants.
OBSERVATIONS AND RESULTS
There is a highly significant difference in mean values of serum magnesium levels as observed in diabetic and nondiabetic individuals. This provided us with a normal range of serum magnesium as 1.892 - 2.008 mg/dl. In the present study, the values below 1.8 mg/dl are considered as low.
In this, there are 66 diabetic patients and 8 non-diabetic patients (controls) whose serum magnesium level is £ 1.892 and 34 diabetic patients and 22 non-diabetic patients (controls) whose serum magnesium level is >1.892.
Comment: Statistically significant low Serum magnesium levels are found in diabetics as compared to age and sex-matched non-diabetic controls. (P0.05)
Correlation of serum magnesium with the type of diabetes mellitus-
Type of diabetes is not found to have any influence on serum magnesium levels. (P>0.05)
Correlation of serum magnesium with the duration of diabetes mellitus
Longer duration of diabetes has a statistically significant influence on low levels of serum magnesium in diabetic subjects under study. (PEnglishhttp://ijcrr.com/abstract.php?article_id=2905http://ijcrr.com/article_html.php?did=29051.Yajnik CS, Smith RF, Hockaday TD, Ward Nl, Fasting plasma magnesium concentrations and glucose disposal in diabetes. BMJ 1984:288: 1032-1034
2.Brown IR, McBain AM, Chalmers J. Campbell IW, the Sex difference in the relationship of calcium and magnesium excretion to glycemic control in type I diabetes mellitus.
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5.V.K.Srivastava, A.K.Chauhan, V.LLahiri, The significance of serum magnesium in diabetes mellitus. Indian Journal of Medical Sciences, May 1993 47(5): Page 119-122
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareVertigo in Pediatric Age: Often Challenge to Clinicians
English136141Santosh Kumar SwainEnglish Satyabrata AcharyEnglish Saurjya Ranjan DasEnglishVertigo or dizziness is perceived to be a common handicapping clinical entity in all the age group of the human being. Vertigo is an uncommon symptom in pediatric age group and rarity of this clinical entity may be due to unrecognized in children. It is often associated with a range of otological, neurological and psychiatric diseases. In younger children, benign paroxysmal vertigo is often seen whereas vestibular migraine is common in adolescent girls. The aetiology of the pediatric vertigo is usually multifactorial, so each pediatric patient with vertigo should be approached in an open mind. Thorough history taking is important for getting a diagnosis of pediatric vertigo. Establishing the diagnosis of vertigo or dizziness is often challenging, especially in the pediatric age group. This article is a narrative review discussion on prevalence, etiopathology, clinical manifestations and management of pediatric vertigo. This review article will make a baseline from where further prospective trials can be designed and help as a spur for further research in this clinical entity as there are not many studies of pediatric vertigo.
English Pediatric age, Vertigo, Vestibular migraine, Benign paroxysmal vertigo, Meniere’s disease, Vestibular neuritisINTRODUCTION
Vertigo is common complaint posed to a clinician in routine clinical practice. Vertigo is considered as the most common causes for referral to neuro physician and Otorhinolaryngologists in office-based settings and emergency clinics1. Vertigo is described as as a subjective sensation of movement, typically spinning or turning, in absence of actual movement of the body2. Vertigo is not an uncommon clinical symptom in pediatric age group, though it may often unrecognized. Disorders that cause vertigo in pediatric age vary concerning one another in many ways. Vertigo or dizziness may be a nonspecific squeal of the several impairments including problems in proprioception, vision, vestibular function, musculoskeletal and autonomic systems2. Proper history taking is often difficult to obtain because of the pediatric age and unable to tell their clinical symptoms precisely. There is an added challenge faced by the clinician in evaluating and managing pediatric vertigo owing to a lack of the proper history, practical difficulties during clinical examination and a lack of standard objective evaluation methods. Here, this review article discusses the aetiology, prevalence, clinical presentations, diagnosis and treatment of pediatric vertigo. This review article aims to give awareness among the readers with the difficult clinical entity such as vertigo, particularly in the pediatric age group.
METHODOLOGY
We conducted an electronic search of the SCOPUS, Medline and PubMed databases for searching the published articles. The search terms in the database included vertigo, pediatric age, dizziness and impairment of balance in children. The abstracts of the published articles are identified by this search method and other articles were identified manually from these citations. This review article reviews vertigo in the pediatric age group including the etiopathology, prevalence, presentations, diagnosis and current treatment. This review article presents a baseline from where further prospective trials can be designed and help as a spur for further research in this clinical entity where not many studies are done.
PREVALENCE
Dizziness and balance disorders are thought to be uncommon in the pediatric age group. This may be due to poor understanding of the epidemiology of vertigo or balance problems in children 3. The literature for pediatric vertigo is scant. Prevalence of vertigo in the pediatric age group ranges from 8% to 15% 4. In otolaryngology clinic, the prevalence of the pediatric vertigo patients constitutes around 0.7% 5. A study in Scotland with 2165 pediatric patients with an age range from 5 to 15 years found the one-year prevalence of one episode of rotary vertigo to be 18% along with the prevalence of reducing to 5% for minimum three episodes [6]. One study sampled 1050 children with an age range from 1 to 15 years in Finland and found the lifetime prevalence of vertigo to be 8% and that for poor body balance to be 2% 4. Episodic vertigo and dizziness are usually uncommon in pediatric age group than in the adult population. Valid estimation of the prevalence of vertigo among pediatric age group must be determined when someone considers that such clinical symptoms could have some adverse psychosocial associations like anxiety and avoidance behaviour, which leads to child’s educational impairment and poor quality of life 7. It is also vital that physicians should keep it in mind and aware of those characteristic features of vertigo or dizziness in pediatric patients, so that appropriate intervention can be provided.
ETIOLOGY AND TYPES OF VERTIGO IN PEDIATRIC AGE
The aetiology of vertigo in children is multi-factorial, so the management depends on accurate diagnosis. Vertigo in the children is broadly classified into Acute nonrecurring spontaneous vertigo, recurrent vertigo and non-vertiginous dizziness, disequilibrium and ataxia. Vestibular migraine and benign paroxysmal vertigo are commonly found cause for vertigo in pediatric age. The common differential diagnosis of vertigo in the pediatric age group is discussed below.Table.1 showing the differential diagnosis in higher than two thousand pediatric patients with vertigo and dizziness obtained by a group of clinicians 8.
Vestibular migraine
Majority of the pediatric vertigo is due to vestibular migraine. The patient typically presents with headache, cyclical vomiting, abdominal pain, vertigo, recurrent episodes of pyrexia or head banging, attacks of pallor and somnolence. The diagnosis of the vestibular migraine in children needs awareness where a meticulous history for headache and careful family history towards migraine is an important part of the diagnosis. However, vestibular migraine remains a diagnosis of exclusion. Neuhauser and Lempert (2009) used the term vestibular migraine as it stresses the vestibular manifestations of migraine 9. It is often seen in adolescent girls and is usually associated with menstrual periods. The vertigo is associated with a headache which lasts for hours with nausea and vomiting as well as photophobia and phonophobia. Sensory stimuli like intense smell, bright lights and loud noise may precipitate the attack. A history of motion sickness is often associated with a family history of migraine. The otologic, neuro-otologic, general physical and vestibular examinations are often normal in between the episodes of the vestibular migraine 10.
Benign paroxysmal vertigo (BPV)
The characteristic features of the BPV in pediatric age are recurrent brief attacks of vertigo without any warning and resolving spontaneously in otherwise normal child 11. BPV is a common cause of vertigo in pediatric patients, showing with a prevalence of 2.6% 12. It is often reported classically at less than four years of age and uncommon after 8 years of the age 13. The etiopathology of this clinical entity is still not known. It appears to occur due to vascular changes which produce transient hypoxia at the vestibular nuclei and the vestibular pathways. This type of pathophysiology of BPV is similar to the pathophysiology of the migraine; so the majority of pediatric patients with BPV will develop migraine in later part of the life 13. There are no presentations of altered consciousness, neurological abnormalities and audiovestibular changes during the attack. The vestibular evoked myogenic potential l (VEMP) and caloric test results support the diagnosis. In the majority of BPV patients, thermal caloric tests show asymmetry 14. The prognosis of BPV is usually favourable and tends to disappear spontaneously before adolescence age.
Post-traumatic vertigo
Children having post-traumatic vertigo without any deafness in the pediatric age could be due to labyrinthine concussion whiplash syndrome, vertiginous seizures, basilar artery migraine or non-specific dizziness 15. In the case of temporal bone fracture, inner ear disruption may happen which results in vestibular dysfunction and leakage of the cerebrospinal fluid. Temporal bone trauma may lead to perilymphatic fistula which can occur even without evidence of the fracture line in temporal bone and often associated with the fluctuating type of deafness16. Surgical closure of the labyrinthine fistula can reduce the vertiginous symptoms completely but the deafness may not be recovered 17. After trauma to the labyrinth, pediatric patients may exhibit abnormal results of the vestibular tests in approximately half of the cases, even children are asymptomatic 18. After trivial trauma in case of children with congenital inner ear anomalies such as Mondini’s dysplasia, enlarged vestibular aqueduct and genetic disease like CHARGE syndrome are predispose to vertigo along with hearing loss 19. The prognosis of the post-traumatic cases with vestibular dysfunction is variable and unpredictable.
Vestibular neuritis
The aetiology of the vestibular neuritis is somewhat controversial; many authors have suggested that is due to viral infections although bacterial and other variety of infections have also been suggested 20. One study found around 47% of the upper respiratory tract infection before the onset of the vestibular neuritis 21. The exact aetiology of vestibular neuritis is controversial, although an association with herpes simplex virus has been found. Pediatric patients suffering from vestibular neuritis often present with similar symptoms as their adult counterparts. Vestibular neuritis is rarely found in children less than 10 years of the age 21. It presents with sudden onset of severe vertigo, nystagmus, nausea and vomiting. This vertigo is worsened by head movements and children or patients usually prefer to lie down, often with the affected ear up. They do not present with hearing loss and tinnitus. Vestibular laboratory investigation shows the unilateral reduced vestibular response to the thermal caloric test. The clinical symptoms of the child will resolve within a few days. The management of this patient includes supportive and symptomatic treatment with early ambulation. A short treatment with vestibular suppressants such as meclizine (≥12 years) or dimenhydrinate (≥2 years) may be prescribed but should be limited as it often delays central compensation 22.
Vestibular paroxysmia (VP)
This is an interesting type of the vestibular entity because of the involvement or compression of the vestibular or eighth cranial nerve also termed as disabling positional vertigo 23. In 1994, Brandt and Dieterich coined the term vestibular paroxysmal 24. Although it is rare in clinical practice, the VP can cause vertigo in the pediatric patient as well. It usually presents frequent episodes of vertigo, multiple times in a day, lasting for seconds to minutes with or without the presence of postural variation. The attacks of vertigo can be up to thirty times or more in a day. Magnetic resonance imaging (MRI) and/or angiography helps demonstrate the neurovascular compression of the vestibulocochlear nerve and also to rule out cerebellopontine angle tumours 25. In the majority of the cases, vascular lop by anterior inferior cerebellar artery is seen to compress the nerve, however posterior inferior cerebellar artery and vertebral artery or vein are rarely involved. Low dose sodium channel blocker such as carbamazepine is shown to help control vertigo in pediatric age of VP. Micro-vascular decompression is an absolute option for relieving the vestibular symptoms but indicated only in certain cases such as a failed pharmacotherapy, fear of surgical morbidity and difficulty in deciding the size of the lesions.
Meniere’s disease (MD)
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16.Kim SH, Kazahaya K, Handler SD. Traumatic perilymphatic fistulas in children: aetiology, diagnosis and management. International journal of pediatric otorhinolaryngology2001;60(2):147-53.
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19. Chiarella G, Viola P. The challenge of pediatric vertigo. J Ear Nose Throat Disord 2017;2(3):1027.
20.Strupp M, Brandt T. Vestibular neuritis. Semin Neurol2009; 29 (5): 509-19.
21. Taborelli G, Melagrana A, D'Agostino R, Tarantino V, Calevo MG. Vestibular neuronitis in children: study of medium and long term follow-up. International journal of pediatric otorhinolaryngology 2000;54(2-3):117-21.
22. Li CM, Hoffman HJ, Ward BK, Cohen HS, Rine RM. Epidemiology of dizziness and balance problems in children in the United States: a population-based study. The Journal of paediatrics 2016;171:240-7.
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31. Suzuki M, Kitano H, Yazawa Y, Kitajima K. Involvement of round and oval windows in the vestibular response to pressure changes in the middle ear of guinea pigs. Acta oto-laryngologica1998;118(5):712-6.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareBasti Chikitsa for Healthy Life in Present Scenario: A Review
English142148Shilpa M. GabhaneEnglish Geeta V. SathavaneEnglish Dheeraj ZadeEnglish Arun WankhedeEnglish Swarupa ChakoleEnglishIntroduction: In the present scenario, it is very difficult to maintain our health and lifestyle balance. Ayurveda is an ancient medical science and has a solution for this situation in the form of Panchakarma. As stress and busy life schedule cause the vitiation of Vata, among Panchakarmas -especially Basti is very effective in maintaining our healthy life because Basti maintains the proper functions of Vata. When Vata has maintained properly then the normal physiological body function runs properly and decrease the chances of disease. As Vata regulates all functions of our body, we should maintain the equilibrium of Vata in our body to keep it healthy. Basti is also very useful to maintain the disorder of Vata such as hemiplegia, muscular dystrophy, sciatica, Parkinsonism, cerebral palsy. Along with digestion and metabolism, Basti maintains our inner beauty as well as our outer beauty. Conclusion: Basti is very useful in infertility. It is also useful in mental disorders. That’s why Acharyas say,” Basti is half treatment for any diseases”. Basti is not only useful for a diseased person but also in healthy persons. In diseased person it cures disease and in normal person it maintains health.
EnglishAyurveda, Panchkarma, Vata, Basti, Healthy lifeIntroduction
In a present era, the human being is prone for numerous degenerative issues, because of modern lifestyle, professional stress, food habits etc. 1,2 Lifestyle related disorders like hypertension and diabetes, reported especially in young adults are a prior concern. 3-7 Association between different diseases like cardiac dysfunction and chronic liver diseases have also been reported. 6,8 In such disorders Ayurveda management is very useful and satisfactory because of its long-lasting effects and multisystemic regenerative actions without any harm. 6 Panchakarma is a comprehensive system of knowledge and practice to purify the body from the degenerative influence of toxins and restore it to balance with natural laws.
In Ayurveda, there are two types of Karmas Shaman Karma and Shodhana Karma. In Shodhana Karma there are five types of Karma such as Vaman, Virechana, Basti, Nasya and Raktamoshana. Among the Shodhana Karma, Bastikarma is considered as prime as it can provide relief in Koshtagata, Dhatugata, Marmagata andSarvashareergatavikara. 9 Basti is one of the major treatment modality that comes under Yuktivyapashraya Chikitsa. As Vata is responsible for disjunction and conjunction of faeces, urine, bile etc. with their receptacles, there is no remedy other than Basti for the pacification of Vata when it is aggravated severely. Hence Basti is said as half medicine or even whole medicine by Acharyas. The rectal absorption can prove the good alternative route of drug administration as it provides partial avoidance of first portal pass metabolism. It has been demonstrated that the rectal route is more efficient than even the intravenous route. 6,10
Ayurveda aims mainly at maintaining the health of healthy persons and recovering the deceased persons. 6 As per this view, Basti is used not only for the diseased person but it used in a healthy person. It seems to be very effective concerning immunity. Basti provides equilibrium of Dosha, Dhatu, Malas, provided person should follow Dinacharya and Ritucharya. Shodhana in the form of Basti possesses benefits like disease preventive, curative and health promotive. Thus, this is the relevance of Basti in healthy person for its immunity. Keeping this in view, this article has highlighted the relevance of Basti Karma in diseased person as well as healthy persons to cures the disease and maintains health respectively.
Aims and Objective
To discuss, evaluate and elaboration of Bastichikitsa in a healthy person.
To discuss, evaluate and elaboration of Bastichikitsa in diseased persons.
Material and methods- Ayurvedic classical text such as Charak Samhita, Sushrut Samhita, Ashtanghrudaya etc. and other literature were reviewed critically and scientifically to compile the concept of Basti. Modern scientific literature describing the mechanism of absorption was reviewed critically. Further, data available data on web-based sources and article published on the internet were compiled.
Literary review of Basti
Basti karma means enema which is medicated. In this process, medicated decoctions and oils are administered via anus in the body with the aid of instruments specially designed for the process of Basti. Basti karma's place of action is Pakwashaya which is Vata Dosha's main site. 11 Hence it is the major treatment modality for Vata Dosha. It is the major treatment modality for Vata Dosha. V?ta is considered as the cause of all type of movements of the body and is the main etiological factor in the pathogenesis of various diseases. 12 Apan Vayu is responsible for the elimination and retention of faeces, urine and other excreta. 13 Vata is mainly located in the large intestine.
Basti sustains the age, improves strength, digestive fire, intellect, voice, and complexion and provides a happy life. The body performs all its functions smoothly. 14 It is very beneficial for all age groups. The bioavailability of the drug i.e. the part of the drug increases when given as Basti. According to Acharya Sushrut, Basti works as plant watered at its root and then root circulate it in all branches. 15 It has also been described as Ardha Chikitsa i.e. half treatment for the management of diseases. 16 The age of administration of Basti starts from one year.
Classification of Basti
According to the consistency of the drugs, Basti is broadly divided into two types
Niruha Basti (Aasthaapana) and Anuvasan Basti
Niruha Basti/ Aasthaapana Basti,- Decoction of medicinal plants is the major content of this Basti, other ingredients like honey, Saindhava, Sneha, Kalka, Prakshepa Dravya are also included to form a suspension. Niruha means to eliminate. This Basti eliminates morbid Doshas from the body. It is also known as Asthapan which means to establish life span and sustains age. 17 12 Prasuta i.e. approximately 1200ml is the quantity of Niruha Basti for administration. The quantity of Sneha to be added depends upon the dominance of Dosha. 18
Vata dominance- 6 Pala i.e. 1/4th of Niruha Bastidravya
Pitta dominance- 4 Pala i.e. 1/6th of Niruha Bastidravya
Kapha dominance- 3 Pala i.e. 1/8th of Niruha Bastidravya
Sneha Basti/Anuvasan – In this type medicated Sneha in the form of Oil/ Ghee, lipids are administered. Anuvasan means to stay, the administrated medicines stay inside for a longer period, without causing any harm. It can be given daily.
Sneha Basti again subdivided according to the quantity of Sneha(oil) into two types. 19
Anuvasana Basti- 1/4th of the quantity of Niruhabasti
Matra Basti- 1/2th of the quantity of Anuvasanabasti
The number of Basti to be given according to the need of the patient, Basti is divided into 20
Karma -30 Basti
Kala -16 Basti
Yog -8 Basti
Anuvasana and Niruha Basti are given alternately. Rasayana and Burhan Basti can be given to the geriatric person. Dosha shaman Basti is preferred for the young person as metabolic activities are at its peak level. Varnya Basti is preferred for the people who are more beauty conscious. Lekhan Basti can be given to the obese person or who want to be loose their extra fats. Vrushya Basti can be given in infertility. Burhan Basti can be given to the children for their normal growth and development. The person who is habituated with heavy work or heavy exercise can undergo Matra Basti. Matra Basti has an advantage as the person does not need to follow any special Pathya.
Bastikala (Time factor for Basti)-According to various authors, Basti in a healthy person can be given in Varsharitu. Varsharutu is the best time for Basti because in this season Vataprakopa is present in the body as well as in the environment. 21 Usually, NiruhaBasti is given in the morning because evening time is the period of Vataprakopaka and Niruha Basti causes Vataprakopa. This is the reason why snehadravya is added to NiruhaBasti. AnuvasanaBasti can be given in the evening. Basti can also be given according to age, Rutu, Kala, etc.
Indications22 - Vatajvikara(hemiplegia, muscular dystrophy, sciatica, parkinsonism, cerebral palsy), diseases related to muscles and bone, Rheumatic diseases, Vibandha(constipation), abdominal distension, delayed mild stone in children, Ashmari(kidney stone, bladder stone), Jeerna Jwara(chronic fever), Niramaatisar(chronic diarrhoea).
Contraindication- Krusha(very emaciated), Amatisara(Acute diarrhea), Chhardi(vomiting), Kasa(cough), Shwas(asthma), Madhumeha(Diabetes), Shoonapayu(inflamed anus), Kritahara(immediately after taking food) Table 1.
Bastikarmukata (Stepwise Mode of Action of Basti)–
Before starting Basti Chikitsa some Purvakarmas(pre-treatment) are to be carried out to achieve better results.
Amapachana- It clears the obstruction in Srotas caused by Ama. Amapachana is done with the Deepana, Pachana Dravyas such as Trikatu Churna or Panchkola Churna. When Amapachana is achieved, the Srotomukh becomes clear and Srotas become ready to carry vitiated Doshas from Shakha back to Koshtha.
Snehana(oleation of the body)- Sneha enters the body through tiny pores of the skin by its Anupravana Prabhava. After entering the Srotas, it causes Vishyandana and softness in the body and destroys obstruction in srotas. 27 It also pacifies Vata as Sneha is Vatashamaka.
Swedana- After proper Snehana, Swedana is done to liquefy the Doshas which obstruct the minute channels. 28
Thus with the help of these three procedures, Amapachana, Snehana and Swedana Dosha move from Shakha towards Koshtha.
Basti- Any substance present in the body which is not conducive to health is considered as mala. 29 Vagbhata said that if one ignores to evacuate this Mala properly, it may lead to various diseases such as Prameha, Arsha, Grahani, Medoroga etc.In healthy and empty rectum the absorption is more and in diseased condition and the presence of stool delays absorption. 30 Hence proper excretion of Mala is very essential which is done by Basti.
Bastidravya given through rectal route reaches Pakwashaya which is considered as the main site Vata. As Vata is pacified the disease itself get cured because it is a major causative factor in the disease. Other two Doshas do not have existed without Vata.
VataSthana and so it can alleviate the Vataat.
According to Ayurveda, water given at the root of the plant gives nutrition to the whole plant similarly the Basti functions. 31 Guda (rectum) is considered as the Moola of Sharira. It has rich blood and lymph supply. The Bastidravya cross the rectal mucosa and absorption of unionized and lipid-soluble substances from the rectum takes place through the rectal venous plexus. The absorption of the drug from the rectum is according to the laws of transfer of molecules across the biological membrane. It is known as diffusion. Diffusion is the transport of molecules from a region of higher concentration to a region of lower concentration. The concentration of Bastidravya is more in the lumen of the rectum and lower in the cells adjacent to the rectum. Thus the molecules of Basti move from the rectum to surrounding cells. Many factors such as physical status of Bastidravya, ingredients of Basti and their solubility, temperature, size of molecules, pH of gastrointestinal fluid, ionization, the surface area of absorption, vascularity influence the rate of diffusion and absorption.
The constituents of Basti reach up to the small intestine and get absorbed through the gut wall, dispersed in the body and thus exert systemic effects. 32 The intestine is enclosed by 4 layers viz. Muscular, Submucosal, Serosa land mucosal layer. When Basti is administered, initially Bastidravya comes in contact with the mucosal layer which is most superficial. The layers of the intestine and the villi get the nutrition thereby improving the absorption of micronutrients. These micronutrients enter the circulation and finally reach up to the target organ. These all things would be possible only when the intestine gets purified regularly. The mucous membrane of the intestine can easily absorb the lipid-soluble content and finally thrusts into circulation. Thus drug may deliver to the target tissues and Basti proves effective in curing many diseases.
Furthermore, in Niruhabasti the contents of Basti are Makshika, Saindhava, Sneha, Kalka. Saindhava by its Sukshma. Teekshna and Vyavayiguna spread in the minute channel of the body. 33 The other Dravyas used to prepare Basti different properties, some are water-soluble and some are fat-soluble and get absorbed accordingly. Sushrut explained how the Basti eliminate the Doshas from the body, Virya of Bastidravya extracts the morbid Doshas from all parts of the body to the Pakwashaya just like the sun which resides in the sky and evaporates the water from the earth surface. Similarly, by its Ushna, Tikshnaguna, Basti not only eliminate the Mala and Apana Vayu but also vitiated Doshas present inside the body along with Bastidravya. 34
Discussion
V?ta is considered to be the cause of all type of movements of the body and plays a major role in the pathogenesis of many diseases. It aggravates due to Dh?tuksaya (diminution of Dhatu) or by Margavarana(occlusion of its channel by other tissues).35 Most of the neurodegenerative disorders occurring in present scenario show Vata dominant symptoms where Vata primarily gets aggravated due to Margavarana (occlusion), which in turn leads to Dh?tuksaya (diminution of Dhatu) leading to the increased provocation of V?ta. Due to this critical mechanism, neurodegenerative diseases become almost incurable, if they are treated late.
Basti administered in the Pakvashaya affects the whole body by its Virya. According to modern science, its action of active principles of drug act on receptors in the gastrointestinal tract which is similar to the enteric nervous system. ENS (Enteric Nervous System) is a considerable group of neurons, it is accomplished with Autonomous reflex without the influence of the central nervous system. More than 500 million neurons are present in the ENS (Enteric Nervous System). Hence it’s also called “the second brain”. 36 There are several similarities between CNS -ENS concerning cellular structure, neuropeptide secretion and specific functions and recent studies have shown that there is a great impact of CNS and ENS on each other. 37 Basti may act on the receptors of the ENS to stimulate the CNS causing secretion of obligatory hormones or other chemicals. It is recognized that the enteric nervous system has a unique capability to arbitrate reflex activity independently of input from the brain or spinal cord. 38 This suggests that the ENS comprises sensory receptors, primary afferent neurons, interneurons and neurons of the motor. The events regulated, at least in part, by the ENS are numerous, involving motor activity, secretion, absorption, blood flow and interaction with other organs, such as the gall bladder or pancreas. 39 ENS produces several hormones and around 40 neurotransmitters of the same classes as found in the brain. Moreover, neurons in the gut are supposed to generate as much dopamine as those in the head. Serotonin produced in the gut comes into the blood, it is involved in mending damaged cells in the liver and lungs there. 40
Basti administered through Guda (rectal route) normalizes Apana Vayu leading to Vatanulomana and improves physiological functioning of Vata. Moreover, Bastidravya spreads all over the body, pacifies the aggravated Dosha along with Vyana Vayu leads to Samyaka Rasa Raktadi Dhatu Nirmana. Samyak Rasa Dhatu leads to the formation of Samyak Rakta, Mamsa and Uttarottar Dhatu. It strengthens the muscle power of the body and promotes tissue regeneration. It improves the function of the bladder, uterus, fallopian tube, and ovary.
Basti is effective on Asthivaha and Majjavaha Srotas also. Purishadhara Kala, the colon membrane, is considered as Asthidhara Kala, the membrane of the bone tissue. 41 Asthi is important sites of Vata Dosha. Hence, medications are given rectally affect all the tissues up to bone tissue. A significant increase in serum calcium was seen after the course of Basti. Though serum calcium decreased after 90 days, it was still higher than the baseline level. Basti Chikitsa exerts a modifying influence on immune responses by regulating pro-inflammatory cytokines, immunoglobulins and functional properties of T-cells. 42
In Rickets, there is decreased absorption of calcium and phosphorus from the intestine, leading to bending and softening of the long bones. The large intestine contains a large number of Ca-Na ion channels, which take up calcium from the extracellular fluid. 43
Basti in pregnancy- Nowadays the ratio of normal labour is decreasing rapidly because of lifestyle changes. Administration of Matrabasti during the ending of 8th month and in 9th month of pregnancy helps in the induction of normal labour.
In children- Basti is like nectar in child patient. It is very effective in the development of the baby as it develops para-neuron which stimulates the nervous system. Significant improvement occurs in the case of cerebral palsy.
Agnimandya, Dhatudurbalata and Strotovaigunya are the main pathological conditions for manifestations of any disease. Thus, Basti acts on these factors and improves health. Different types of Basti like Snehabasti, Chakshushyabasti, Madhutailikbasti, Yuktharathbasti, Siddhabasti, Bruhanbasti, Utkleshanbasti, Doshaharbasti, Yapanabasti, Vrishyabasti, Rasayanabasti, can be considered as health promotive. Most of the Dravyas used in these types of Basti like Tail, Ksheer, Madhu, Saindhav, Triphala, Mamsa Rasa etc are significant sources of protein, vitamins and minerals. Different clinical studies have shown that there is a considerable increase in serum proteins, essential fatty acids, vitamin- k, and vitamin B-complex levels after the course of Basti treatment.
When the channels of the body are cleaned by Niruha Basti it provides complexion and strength. Anuvasana Basti destroys roughness, lightness and coldness of Vata. Basti provides clarity of mind, energy, and strength to the body. 44
All the Dhatus gets nourished by Basti enhancing the body’s Dhatwagni to maintain Dhatusamya (homeostasis) and increase the immunity of the body towards the invasion of the disease.
Conclusion
Basti is one of the most important and useful treatments for a diseased and healthy person. There are so many types of Basti according to diseases, Rutu, Bala, Kala. So we can consider these factors while adopting the Basti in any person. Basti is not only curative but also disease preventive and health promotive. Basti helps to maintain the equilibrium of Vata dosha in our body. It increases Shukra(potency), Oja (vital energy) and Agni (digestive fire). In this modern era, as per our daily routine, health management is very difficult. So, by the use of Basti Karma, we can manage our hectic lifestyle and make it a healthy life.
Englishhttp://ijcrr.com/abstract.php?article_id=2907http://ijcrr.com/article_html.php?did=2907
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareFungal Infection in the Oral Cavity: A Review
English149153Smarita LenkaEnglish Santosh Kumar SwainEnglish Ruchi BhuyanEnglish Mahesh Chandra SahuEnglishFungal infection in the oral cavity is a completely microbes-oriented disease most probably caused due to biofilm formation on the floor of the mouth and its surrounding. Most of the studies revealed that Candida and Asparigellus spp. are frequently isolated fungus. Smoking, alcohol consumption, high intake of carbohydrate diet, loss of salivary function and immunosuppression are colonizing factors and predisposing factors for fungal infection in the oral cavity and may lead to the chronic stage at its severity. Oral candidiasis is an opportunistic infection of the oral cavity and the incidence depends on the age of the patient and certain predisposing factors. There are three varieties of oral candidiasis such as acute candidiasis, chronic candidiasis and angular cheilitis.CD4 T lymphocyte and CD8 T lymphocyte provides primary as well as secondary immunity towards oral fungal infection. Denture wearers, HIV patients, children and elders are mostly infected by an oral fungal infection. This systematic review tends to focus on etiological factor, salivary action, and immunity behind fungal infection in the oral cavity with management and treatment of oral fungal infection.
English Oral cavity, Fungal infection, Fungal biofilm, Candida spp, Antifungal agentIntroduction
Fungal infection in oral cavity emerges due to both chemical as well as biological reasons and stands before us as a worldwide problem varies according to age groups but seems to be very common among old ages particularly in those who do not take care of their mouth. Fungal infection arises in the oral cavity due to the colonizing character of microbes, especially by food debris. The biofilm formation through pathogenic organisms alternately converted into white fungal patches. Initially, the biofilm formed in the oral cavity promotes contamination and attracts fungal infection. Systemic oral fungal infection is seen approximately 50% to 60% of cases that depend upon dentures in old age2,3. Persons having diabetes mellitus, high carbohydrate on their diet and smoking like habits could disturb the normal microflora of the oral cavity and that can initiate fungal infection4,5. Patients suffering from fungal infection in oral cavity increases eventually due to many reasons and arise the number of difficulties particularly for immunocompromised patients such as those receiving chemotherapy during cancer treatment and fighting with human immunodeficiency virus (HIV)2. Those having poor immunologic response this fungal contamination remains a significant problem throughout their life6. Fungal infection frequently occurs those have an immunosuppressive illness or going through organ transplant surgery7. The oral fungal infection seems to be very opportunistic in HIV patients that are more than 90% people showing developmental oral fungal infection8
Methods for Literature search
For searching the published articles, we conducted an electronic search of the Google Scholar, Scopus, Medline, Scopus and PubMed databases. The search term in the database included oral cavity, fungal infections, Candida infection and oral thrush. The abstracts of the published articles are identified by this search method and other articles identified manually from the citations. This review article reviews the oral cavity fungal infection. This review article sets out a framework on which more prospective trials can be formulated and support as a spur for further research in this commonly observed clinical entity where not many studies are done.
Etiological factors
Factors that are responsible for oral fungal infection mainly arise due to our unconsciousness about oral health care. Acid formation in the oral cavity occurs due to both smoking and alcohol consumption and high intake of sugar and carbohydrate in the food. The high rate of drinking alcohol can disrupt the oral microflora and can persist acetaldehyde formation that leads to adherence of oral fungal colonisation 9,10. Some of the other challenging predisposing factors that induce oral fungal infection are hormonal disorders, epithelial changes, physiological disorders, poor oral hygiene, endocrine disorders, immunologic disorders, poorly fitting dentures and empirical drug therapy11. The most common colonising isolated fungi from the oral cavity is Candida albicans(Fig.1) 5,12,13, derived from Latin word candid means white.
It is a spore-forming fungus that remains harmless until there are no disturbances occurred in host microflora balance of oral cavity 14. With the addition to candida spp, Aspergillus spp, Fusarium spp., and Acremonium spp. are some of the isolated contaminated factors causing fungal infection in the oral cavity. Somehow infections also caused by non-Candida and non-Cryptococcus isolates and infections caused by Trichosporon spp., Malassezia spp., and Rhodotorula spp. are mainly notable but in many cases, it is observed that Candida and Cryptococcus are factors that initiate fungal colonisation specifically candida spp. When the oral cavity comes in contact with several microbes especially spore containing fungal pathogens forms a biofilm on the upper part of epithelial cell and create the environment for the survival of them15. Except for C. albicans, C. glabrata, C. lusitaniae and C. guilliermondii. C. albicans, C. glabrata, C. parapsilosis, C. krusei, are some non-albicans found in oral cavity causing colonisation but less life threatening than C.albicans6,8.
Etiology of fungus
According to mycological study fungi are found in both form; unicelluar and multicellular depending on their stage of life style. They cannot make their own food as they are heterotrophs hence they obtain their nutrients from other source using their pseudohyphae, along with network formation of hyphae called mycelium. When nutritional, environmental as well as immunological variation occurs, a saprophytic fungus associated with oral cavity reproduces and giving rise to more compact colonies of new fungus forming a row of elongated cells found in white patches and lesions.
Role of saliva in fungal infection
The oral cavity is a wide field for the variety of microorganisms and acts as a host to survive on it. It needs a natural microflora for normal development and physiology16. The oral cavity is lined by mucosal epithelial cells and continuously filled with saliva secreted by various salivary glands and activate the mechanism of many beneficial microbes. Any disturbances occur in the secretion or function of saliva, epithelial cell damage can lead to making physiological differences in the oral cavity. Some certain microbes can affect or change the normal microflora. C. Albicans is a mutualistic fungus which can form fungal colonisation in the oral cavity causing oropharyngeal candidacies. In other words, we can say that saliva has a defence mechanism which stands as a barrier against the fungal attack17,10. Because of the flushing action of saliva, microbial infection in the oral cavity can be diluted and appears to show minimum emergence but fungi have that capacity to multiply under these types of adverse circumstances and reflects infection18. It brings nutrients, peptides, and partially dissolved carbohydrates and delivers to oral biofilm. Addition to this it helps in lubrication for digestion, temperature regulation, including host defence by saliva flow19. Immunoglobulin action of saliva can identify protective function against fungal pathogen concerning innate immunity and contribute to first-line oral defence20.
The immune system of the oral cavity
The innate immunity of our body always tends to ready for fighting any adverse condition during necessity but in case of oral fungal infection mouth act as an entry point of the outer harmful components. In the oral cavity whenever there becomes an interaction between host immunity and the foreign pathogen that leads to either mutualism and confirms salivary defend mechanism against that pathogen or break the epithelial barrier 10. In the epithelial cells, there is a polysaccharide receptor named Toll-like receptor (TLR4) expresses the immune recognition against pathogenic microbes and by the action of macrophages and dendritic cell it prevents the colonisation of fungal flora like C.albicans21,22. The cell-mediated immune system and humoral immunity play a crucial role in protecting oral mucosa from fungal colonisation8. Also with the epithelial barrier, primary immunity is provided by type 1 CD4 T lymphocyte that is activated by the help of interleukin (IL)-4, IL-6, and IL-12, secondary immunity provided by CD8T lymphocyte through several immunological mechanisms6 using T cell receptor (TCR) on their cell surface where MHC I or MHC II helps to display fungal pathogen 23. Activated T-cells produces lymphokines that regulate the functions of macrophages and other leukocytes like interferon-gamma (IFN-γ), which is the only lymphokine that helps to enhance the microbicidal action of macrophages. T lymphocyte also activates TNF (tumour necrosis factor) synthesis by them. In the presence of suboptimal levels of IFN-γ, fungus killing by neutrophils is developed by tumor necrosis factor-α (TNF-α)24,25. Whenever the CD4 T lymphocyte count fallen down (approximately 200 cells/mm3) recurrence rate of the disease could be possible26. Reduction of antibodies such as IgA, IgM and IgG defects in lymphocyte transformation and stimulate most severe types of oral fungal infection27. There is a confusing relationship between inflammation and immunity that what comes first, whether the change in the integrity of the biofilm or the host immune response19.
Clinical presentation of oral fungal infection
The primary stage of oral fungal infection is initiated by the primary colonisers found in the surface of the oral cavity; later on, that is proliferated into superficial colonisation with a large number of migratory fungal colonisers forming a multi-layered biofilm. According to the differential environmental mechanism of the oral cavity such as temperature, atmospheric conditions, pH, salinity, redox potential, and liquid activity from saliva can alter the microbial composition and trigger the shelter to fungal biofilm19. Artificial equipment like dentures can restrict the arrival of oxygen and flow of saliva to the appropriate tissue area; that’s why low PH and scarcity of oxygen level promote the storage of dense fungal film on the floor of the oral cavity. The microbial film deposited on the surface of the oral cavity nothing but infected scales of epithelial cells with fungal hyphae looks like curd deposits with superficial patches8. Oral fungal infection often remains asymptomatic mostly at the initial stage, but periodically symptoms have seen like irritation in the mouth, burning during eating, difficult to talk and alteration in sense of tasting. Candida albicans remain all-time common isolated microorganism in oral fungal infection. Oral candidiasis classified into primary and secondary oral candidiasis. Primary candidiasis affects oral and perioral tissue only but during secondary candidiasis, superficial candida association may lead to keratinised lesions 28,29. Deep fungal infection in the oral cavity with high efficiency may alter to the ulcerative lesion(Fig.2)30.
Diagnostic method
Oral fungal infection can be clinically diagnosed by biopsy and there is another way that is microbiological diagnosis through oral sample culture on laboratory8,31. Like another disease, a fungal infection in the oral cavity can also be diagnosed clinically and pathologically. About 90% region of the oral cavity can get infected including the tongue, lip surface and complete floor of mouth with curd-like white patches. Mostly in older adults when excessive deposition of plaque occurred on the oral cavity then mixed white and red lesions are seen with heavily keratinised surface32. The clinical diagnosis followed by biopsy can reveal hyphae or pseudohyphae of identified fungi. The cytological study can reveal microscopic evaluation and another way that is sample culture reveals the actual and exact process of diagnosis of fungal era28. Diagnosis of oral fungal infection can be carried out by morphologically, biochemically, immunologically and genetically. Identification, as well as isolation of fungal infection in oral cavity, have several approaches of diagnostic method like direct microscopy of smear, staining and microbiological culture. New advanced optical devices allow the direct microscopic examination to clinicians. Cytological identification is made possible through direct microscopy by simply transformation of the sample in a glass slide collected from the infected site. Potassium hydroxide, gram stain and periodic acid–Schiff (PAS) are three diagnostic agents help to clear background, making fungi clearly visible and easily identified 29,33, 34. In the case of the failing procedure to cytological smear identification, Sabouraud’s dextrose agar (SDA) is recommended as media for fungal culture. After an incubation period of 24-28 hours at approximately 370C, fungal colonies appeared on the plate containing SDA5. There is another staining diagnostic process named Gridley’s or Grocott’s methenamine silver (GMS) stains are ideal for confirming fungal elements in tissues, deeply dying from those stains. In further techniques, with the availability of chronic or periodic acid, the hydroxyl groups of complex polysaccharides of the yeast cell wall are oxidized to aldehydes35. The genetical diagnostic method involves enzyme-linked immunosorbent assay(ELISA) and polymerase chain reaction PCR in which the strain persistence has been investigated by DNA fingerprinting during chronic or repeated infection and clear all hesitation to follow antifungal therapy, microevolution in infecting populations, and the cause of oral fungal infection31,36.
Management and treatment
Disease and host immunity are interlinked with some agents that help to keep balance on the physiology of the human body that are vitamins and nutritional supplement. Therefore, deficiency states of iron, folic acid, vitamins B12, vitamin C and vitamin A; able to weaken our immune system. As saliva has defended mechanism, salivary gland function and salivary hydration testing should be performed. Dentures should be avoided, if not, should clean those things properly soaking with white vinegar. Nutritional factors should be implemented on the treatment of fungal infection with the prohibition of carbohydrate-rich diet5. Smoking, alcohol and tobacco consumption should be avoided as C.albicans come in the very active form with cigarette smoke getting it as a nutritional factor and cigarette smoke contain aromatic hydrocarbon that can convert the enzyme system of candida species to carcinogen37. Some study reveals that fluconazole and amphotericin B remain sensitive toward most of the fungal isolates in antifungal susceptibility test and very few were resistant to them6.
An oral fungal infection could be managed by following the required guidelines like:
Diagnosis by accurate medical and dental records, clinical demonstration verified with morphological, biochemical, immunological and genetical laboratory tests.
Predisposing factors that are responsible for the initiation of oral fungal infection should be rectified wherever required.
Maintaining good oral cavity hygiene and oral prostheses like dentures.
Adoption of antifungal therapy based on the intensity of the infection and susceptibility of the fungal species.
For proper maintenance of oral cavity natural remedies like grapefruit seed extract; garlic; tea tree oil, clove oil can be used as pre-treatment for better oral health.
Cleaning of mouth with water or mouthwash after every meal and use of an inhaler that contains corticosteroids.38
Conclusion
Oral fungal infection reveals many microbes including Candida and Aspergillus spp. mostly. Misbalance in host immunity and saliva function plays a crucial role in the induction of fungal suspension on the oral cavity. Immunogenic misbalance of host allows microbes to be settled. Long term deposition of fungal biofilm may lead to chronic ulceration and could be life-threatening. Self-awareness about oral hygiene and regular cleansing can control the deposition of food debris and restrict the risk of oral fungal infection. Avoiding smoking, alcohol, tobacco and by adding healthy nutritional factor in the diet could enhance the innate immunity for a better host response towards an oral fungal infection. Now treatment with empirical therapy is at high risk because many antifungals become resistant to isolated microbes. Medication should be proper following antifungal susceptibility test. Clinicians have to treat timely using proper diagnostic techniques and medication.
Englishhttp://ijcrr.com/abstract.php?article_id=2908http://ijcrr.com/article_html.php?did=2908
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareCase of Corneal Melting with Phthisis Bulbi with Uveal Tissue Prolapse in Left Eye
English154157Sonal MuleyEnglish Chetan SaojiEnglish Sachin DaigavaneEnglish Tejas SadavarteEnglishIntroduction: This is a case of a 26-year-old female who presented to the medicine OPD with fever, chills, periorbital swelling of the left eye associated with discharge. The patient had a history of blood transfusion and severe anaemia (Hb-2.8gm%). Visual acuity in the right eye was 6/6 with a normal examination. The visual acuity in the left eye was no PL with no retinal glow. Result: There was the presence of bloody discharge, lid oedema, ecchymosis, chemosis, subconjunctival haemorrhage, hyphema in the anterior chamber, corneal melting and uveal tissue prolapse. MRI Brain and orbit was suggestive of Phthisis Bulbs of the left globe with tuberculoma with ventriculitis with ependymitis. Treatment given was blood and platelet transfusion, iv antibiotics, injection dexamethasone and anti-tubercular drugs. Evisceration of the left eye was done. Conclusion: Manifestations of tuberculosis in the eye are varied. No part of the eyeball is immune to tuberculosis except the lens. Timely intervention and treatment may help retain the eye. With the advent of keratoprosthesis surgery, early treatment may help save the eye.
English Ocular Tuberculosis, Epididymitis, Keratoprosthesis, Ecchymosis and hypotony
INTRODUCTION
Phthisis Bulbs :
It is the degenerative change of globe involving all the tissues. It is due to diminished production of aqueous humour causing reduced intraocular pressure (hypotony) and shrinkage of the globe.
There is typical disorganization of intraocular contents, opaque media, corneal scars, exudate in anterior and posterior chambers, advanced cataracts, destruction of vitreous, scleral thickening cyclitic membrane extends from one ciliary body behind the lens to the other ciliary body, complete detachment of retina; also ossification of bone.1,2
Tuberculosis:
M. Tuberculosis, an obligate aerobe, slow-growing, non-motile bacterium, causes tuberculosis. It is transmitted primarily as an airborne aerosol that gains access to susceptible hosts via the lungs and contributes to latent or dormant infection in hosts with normal immune systems. The onset of symptoms may occur after an age-related deterioration of the patient’s immune system, illness, or immunosuppressive therapy for other conditions.3,4 The organism may invade any tissue or organ within the body in immunocompromised persons, rapid progression of the disease can occur. It sometimes invades the local lymph nodes and spreads to extrapulmonary locations, mostly through hematogenic routes. Usually, infected end-organs have high oxygen stress (apices of the lungs, kidneys, bones, meninges, eye and choroid).
Ocular involvement occurs in patients with tuberculosis in around 1% to 2% per cent. This appears to masquerades as other infections and disease processes. The hallmark of extra-pulmonary TB is caseating granuloma and necrosis. Extrapulmonary tuberculosis develops in combination with or in isolation from clinically evident pulmonary TB, with no laboratory evidence of pulmonary infection.5,6
Clinical Presentation:
Systemic tuberculosis patients experience fatigue, weight loss, fever, nausea, night sweats and cough. The disease is typically chronic and insidery. In the eye, it may affect any structure. It may be unilateral or bilateral resulting from the hematogenic spread, direct local extension from the skin, mucous membranes and sinuses or as a reaction to distant infection with hypersensitivity. Posterior uveitis, followed by anterior uveitis, panuveitis, intermediate uveitis tend to be the most common ocular clinical presentations. The sclera is also involved in panophthalmitis, which leads to globe perforation. Other ocular findings are interstitial keratitis, retinitis, scleritis, orbital abscess, optic neuropathy and palsies of cranial nerves, tuberculous retinal vasculitis or Eales disease.6
Diagnosis and Treatment
Diagnosis of ocular tuberculosis is exceedingly difficult because ocular tuberculosis tends to have no findings on chest x-ray or negative tuberculin skin test. To diagnose ocular tuberculosis clinically, subconjunctival tuberculin test or therapeutic isoniazid (INH) test can also be performed. Polymerase chain reaction (PCR) technique has been used to detect mycobacterium in intraocular samples such as aqueous or vitreous humour to confirm the diagnosis of ocular tuberculosis. Retinal vasculitis and tuberculoma are usually responsive to corticosteroid treatment. The mainstay of treatment is antituberculosis agents. 7
MATERIALS AND METHODS:
A case of 26 years old female was reported in the medicine OPD with chief complaints of fever with chills and periorbital swelling of the left eye which was associated with redness and discharge of blood. Thus the patient was referred to the ophthalmology department.
• History of headache and rash all over the body.
• History of 5 units of blood transfusion in a private hospital given 2.8gm% of haemoglobin according to reports.
No history of redness
ulcers
trauma to eye
• General examination was within normal limits. On neurological examination, she was fully alert and oriented and had fluent speech. There were no signs of meningeal irritation. All cranial nerve examination was normal
Ophthalmologic Examination
Visual acuity and anterior segment evaluation in the right eye was within normal limits
• Visual acuity left eye- NO PL.
• Presence of discharge of blood, lid oedema, ecchymosis, chemosis, subconjunctival haemorrhage, hyphema in the anterior chamber, corneal melting and uveal tissue prolapsed(Fig. 1,2 and 3).
• Fundus examination-
• RE- within normal limits • LE- glow not seen
MRI Brain and orbit was suggestive of Phthisis Bulbi of the left globe with tuberculoma with ventriculitis with ependymitis
• Treatment :
- 2 units of blood transfusion with 13 units of platelet transfusion.
- iv antibiotics were given.
- Injection Dexamethasone 4 mg iv QID x 7 days.
- The patient was started on anti-tubercular drugs. -The evisceration of the left eye was done.
DISCUSSION
Manifestations of tuberculosis in the eyeball are varied. No part of the eyeball is immune to tuberculosis except the lens.
• The usual parts affected are however conjunctiva, choroid, iris, rarely the optic nerve and the orbital tissue.
• The eye may be affected in three different forms.
• Miliary form-small yellow grey transparent nodules
• Ulcerative form
• Diffuse form. 8
Tuberculosis can have a varied appearance and timely intervention can go a long way in salvaging the vision and the eye. In a case report by Ashutosh, a 28-year-old woman presented with diminution of vision in both eyes with choroidal tubercles in the RE and a chorioretinal patch in the macula in the left eye. Systemic therapy with steroids and ATT helped gain vision in the RE with the resolution of the choroidal tubercles but n0 improvement was noted in the left eye. 9
Ocular tuberculosis can also present as panophthalmitis with rapid progression and phthisis bulbs. In a case report by Savita Agrawal et al, a 26-year-old male with a painful red eye with vision loss in the left eye for the last 1 month. He has also complained about and off about low-grade fever for the last 2 months.
The patient was a known pulmonary TB case and had been on antitubercular medication for the last 2 months. At the time of presentation, the left eye exam revealed no perception of light, circumcorneal congestion with ciliary staphyloma, fixed and dilated pupil, and marked limitation of eye movements. It increased intraocular tension to 29.4 mmHg. Other than complicated cataracts, the anterior chamber had exudates, cells 2 +, and flare 2 +. The vision was 6/6 unassisted in the left eye, intraocular stress was within the normal range (14.6 mmHg), and pupillary consensus reaction was absent. 10
Definitive diagnosis requires that nucleic acid amplification procedures show either AFB in tissue sections or bacterial genome.11 A newer test based on anti-cord factor antibody detection by enzyme-linked immunosorbent assay is also used.12 Balne et al. Studied multiple factors affecting polymerase chain reaction outcomes in patients with clinically suspected ocular TB.13
There are less new TB detection techniques available, such as interferon-gamma release assay, which is focused on the synthesis of gamma interferon by T-cells sensitized to specific MTB antigens and therefore not affected by Calmette – Guérin bacilli and most non-TB bacteria. Such measures include the In-Tube QuantiFERON-TB Gold and ELISpot PLUS.14
Techniques for detecting MTB in aqueous and vitreous samples from patients with suspected uveitis TB are also used in the polymerase chain reaction. The most antigenic and abundant cell wall feature of MTB, the detection of antibodies against purified cord factor, may provide clear evidence of the infection. Nonetheless, the sensitivity was reported to be small, as many ocular manifestations may reflect a delayed hypersensitivity reaction rather than a direct mycobacterial infection, resulting in less sensitive analysis of a fluid sample from the eye.14
It is recommended that a regular eye test is a must in all susceptible individuals (immunocompromised / identified TB cases). Early antitubercular therapy should be begun on the clinical diagnosis of ocular TB to prevent progression to panophthalmitis and loss of vision.
CONCLUSION:
A significant difference in the clinical appearance and non-specific ocular TB expression delays the proper diagnosis and thus requires strong clinical suspicion for timely diagnosis. It is recommended that a regular eye test is a must in all susceptible individuals (immunocompromised / identified TB cases). Early antitubercular therapy should be begun on the clinical diagnosis of ocular TB to prevent progression to panophthalmitis and loss of vision.
Englishhttp://ijcrr.com/abstract.php?article_id=2909http://ijcrr.com/article_html.php?did=2909
Pernick N. Phthisis bulbi. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/eyeglobephthisisbulbi.html. Accessed July 27th, 2020.
Pandey S, Satyawali V, Joshi D, Titiyal G. Central Corneal Thickness and Diabetes Mellitus - A Study of Correlation in Terms of Duration and Glycemic Control in North Indian Hilly Population International Journal of Current Research and Review. 2009; 11(14): 01-05.
Cladius, S., U. Jadhav, B. Ghewade, S. Ali, and T. Dhamgaye. “Study of Diabetes Mellitus in Association with Tuberculosis.” Journal of Datta Meghe Institute of Medical Sciences University 2017;12(2): 143–47
Gupta, V., and Bhake A.. “Clinical and Cytological Features in Diagnosis of Peripheral Tubercular Lymphadenitis – A Hospital-Based Study from Central India.” Indian Journal of Tuberculosis.2017; 64(4): 309–13.
Bagdia M, Bijwe S, Hirani N, Joshi A, Chowdhary A, Agrawal M, Bagdia A. Lab Diagnosis of Extra Pulmonary Tuberculosis: Comparison of Histopathology, Cytology, ZeihlNeelsen stain and Light Emission Diode Microscopy with Culture and Nucleic Acid Amplification Tests International Journal of Current Research and Review. 2017; 10(08): 15-19.
Sharma A., Lavaju P. Thapa B. Nepalese journal of ophthalmology: a biannual peer-reviewed academic journal of the Nepal Ophthalmic Society : NEPJOPH .2011;3(5):52-67 ·
Ishihara M, Ohno S. Nihon Rinsho. 1998;56(12):3157-3161.
Shrivastav J.B, Sharma K.D. Tuberculosis of the eyeball, with a case report of tuberculoma of the orbit. Indian J Ophthalmol 1954;2:15-8.
Ashutosh. A Rare Presentation of Ocular Tuberculosis: A Case Report. 2017; 5(1): 5556-5563.
Agarwal S, Gupta P, Pandey P, Ralli M.Tubercular Panophthalmitis: A case report of a rare entity. Med J DY Patil Univ 2017;10:390-392.
Rajpal I, Bhartiya S, Bhargav S. Ocular tuberculosis: Current paradigms in diagnosis and management. DJO 2008;14:23-26.
Sharma A, Thapa B, Lavaju P. Ocular tuberculosis: An update. Nepal J Ophthalmol 2011;3:52-67.
Balne PK, Modi RR, Choudhury N, Mohan N, Barik MR, Padhi TR, et al. Factors influencing polymerase chain reaction outcomes in patients with clinically suspected ocular tuberculosis. J Ophthalmic Inflamm Infect 2014;4:10.
Shakarchi FI. Ocular tuberculosis: Current perspectives. Clin Ophthalmol 2015;9:2223-2227.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareSignificance of Tumour Markers (CEA and CA15-3) in Carcinoma Breast
English158163Sujata R. KanetkarEnglish Ramesh M. OswalEnglish Mahendra A. PatilEnglish S. J. PawarEnglish A. V. ManeEnglishIntroduction: Breast malignancy is a significant general medical issue for women all through the world. In the United States, breast malignant growth remains the most incessant disease in ladies and the second most frequent cause of cancer death. Methods: Fifty cases of carcinoma of the breast in which tumour markers were studied All the cases were admitted in this institution, investigated and treated accordingly but tumour marker was sent to the outside standard laboratory, Mumbai. The cases were followed up, for a minimum period of 24 months. Results: In 13/24 cases with abnormal CA15-3 value in postoperative follow up period, there are 54% of patients with metastatic disease. In 4/24 cases with preoperative abnormal CA15-3, metastasis occurred in 75% and locoregional recurrence occurred in 50%. In 8/50 cases with preoperative abnormal CA15-3, 75% of patients are presented with locally advanced disease. In 9/24 cases with abnormal CEA value in the postoperative follow-up period, there are 67% of patients with metastatic disease. In 15/24 cases with preoperative abnormal CEA, metastasis occurred in 40% and In 16/24 cases with preoperative abnormal CEA, locoregional recurrence occurred in 25%. In 32/50 cases with preoperative abnormal CEA, 63% of patients are presented with locally advanced disease. Conclusions: There is the significance of Tumour markers in carcinoma of the breast. The use of CA15-3 for early detection of metastasis seems to be promising. It appears that CA15-3 is a valuable prognostic indicator in following up of breast cancer patients as it had a significant association with both metastases and loco-regional disease.
EnglishTumour Markers, (CEA and CA15-3) Carcinoma, BreastINTRODUCTION
Breast malignancy is a significant general medical issue for women all through the world. In the United States, breast malignant growth remains the most incessant disease in ladies and the second most frequent cause of cancer death. In 2007 it is that breast cancer will account for 26% of cancer cases and 15% of cancer deaths, which translates to 176,296 new cases and 40,515 deaths.1 Breast cancer was also the most common form of cancer seen in Europe in 2006, 429,900 new cases, representing 13.5% of all new cancers.2 Since 1990, the death rate from breast cancer has decreased in the United States by 24% and similar reductions have been observed in other countries.3,4 Mathematical models suggest that both the adoption of screening mammography and the availability of adjuvant chemotherapy and tamoxifen have contributed approximately equally to this improvement.5
Although breast cancer has traditionally been less common in non-industrialized nations, its incidence in these areas is increasing. location of breast malignant growth repeat. CA15-3 levels are likewise expanded in colon, lung and hepatic tumours Roughly 50% of these recently analyzed patients are hub negative, anyway 30% of these cases progress to metastatic illness. Several tumor markers can assist clinicians with distinguishing and analyze which breast malignant growth patients will have forceful malady and which will have a lethargic course. These markers incorporate estrogen and progesterone receptors, DNA ploidy and percent-S stage profile, epidermal development factor receptor, HER-2/neu oncogene, p53 tumour silencer quality, cathepsin D, expansion markers and CA15-3. CA15-3 is generally valuable for checking patients post-operatively for the repeat, especially metastatic maladies. 96% of patients with the neighborhood and fundamental repeat have raised CA15-3, which can be utilized to foresee repeat sooner than radiological and clinical rules. A 25% expansion in the serum CA15-3 is related to the movement of carcinoma. A half diminishing in serum CA15-3 is related to the reaction to treatment. CA15-3 is more delicate than CEA in right on time.
Carcinoembryonic Antigen and Cancer Antigen 15-3are the most thoroughly investigated tumour markers in breast cancer. Circulating levels of CEA and CA15-3 have become established diagnostic tools as fast, noninvasive, reproducible, quantitative parameters in follow up care and monitoring therapy of breast cancer patients. CEA is a member of immunoglobulin superfamily. The human CEA quality family is grouped on chromosome 19q and includes 29 qualities. Of these, 18 are communicated, with 7 having a place with the CEA subgroup and 11 to the pregnancy-specific glycoprotein subgroup6. When isolated from liver metastasis, CEA is a glycoprotein consisting of ~ 60% carbohydrate and a molecular mass of ~180–200 kDa. Most of the carbohydrate is composed of mannose, galactose, N-acetylglucosamine, fucose, and sialicacid7. CA 15-3 assay measures the protein product of the MUC-1gene located on chromosome 1q. MUC1 protein is a large transmembrane glycoprotein containing a large extracellular domain, a membrane-spanning sequence and a cytoplasmic domain.8,9
The CA15-3 is a glycoprotein, helps in cell adhesion, immunity and metastasis.6 The antigen is defined by reacting with two monoclonal antibodies DF3 and 115D8. The DF3 antibody was raised against a membrane-enriched fraction of human breast carcinoma. The 115D8 antibody was prepared against human milk fat globulin membrane and may be directed to a carbohydrate epitope.10 Serum CEA and CA15-3 are established prognostic markers in breast cancer patients. This study is aimed to correlate the serum marker levels with the clinical stage of the disease, size of the tumour, nodal status and for detecting metastasis, loco-regional recurrence in female breast cancer patients. If a correlation is found, it could provide clinicians with an indication of prognosis, thus enabling appropriate adjuvant therapy.
MATERIALS and METHODS
This study was conducted in KRISHNA HOSPITAL and MEDICAL RESEARCH CENTRE, KARAD during the period from May 2006 to May 2008. The study comprises of a total of 50 cases that were admitted in this hospital. On admission case, history was noted and the patients were examined clinically. In this study, the TNM staging system was followed and blood samples were collected in plain bulbs. The study was approved by the Institutional Ethical Committee. Informed consent was obtained from each patient before sample collection.
Tumour markers (CEA and CA15-3) were analysed by the sandwich ELISA method using C.L.I. Technology. (Fully automated Bidirectionally interfaced Chemiluminescent Immunoassay)
CEA: 50 microlitres of the patient’s samples and 100 microlitre anti-HRP (Horseradish Peroxidase) conjugate were added to the microwells coated with a monoclonal antibody (Mab). The antibody-enzyme conjugate solution contained goat anti CEA antibody conjugated to HRP. CEA is the patient’s serum bound to anti-CEA MAb on the well and the anti-CEA-HRP second antibody then bound to CEA. Unbound protein and HRP conjugate were washed off by wash buffer (phosphate buffer saline). Upon the addition of the TMB (3 3' 5 5' tetramethylbenzidine) substrate, the intensity of the colour is proportional to the concentration of CEA in the samples. The colour development was stopped with the addition of stop solution(1N HCl).
OBSERVATIONS AND RESULTS
In 13/24 cases with abnormal CA15-3 value in the postoperative follow-up period, there are 54% of patients with metastatic disease. In 4/24 cases with preoperative abnormal CA15-3, metastasis occurred in 75% and locoregional recurrence occurred in 50%.In 8/50 cases with preoperative abnormal CA15-3, 75% of patients are presented with locally advanced disease. In 9/24 cases with abnormal CEA value in the postoperative follow-up period, there are 67% of patients with metastatic disease. In 15/24 cases with preoperative abnormal CEA, metastasis occurred in 40% and In 16/24 cases with preoperative abnormal CEA, locoregional recurrence occurred in 25%.In 32/50 cases with preoperative abnormal CEA, 63% of patients are presented with locally advanced disease.
Distribution of study subjects according to age
In the present study, 84%patients were in the age group 36-65 years
The youngest patient in this study aged 29 years. Eldest patient aged 80 years(Table 1).
Clinical stage of the disease
In the present study, 4% of patients had stage I, 40% had stage II, 52% had stage III and 4% of patients had stage IV(Table 2).
Relation of preoperative abnormal CEA with clinical stage
In the present study correlation of clinical-stage in patients with preoperative abnormal CEA value. 2%patients had stage I disease.
22% of patients had stage II disease, 36% of patients had stage III disease
4% of patients had stage IV disease(Table 3).
Relation of preoperative abnormal CEA with tumour size in 50 patients
If c2 < 3.84 then p>0.05 i.e. CEA is not significantly associated with tumour size(Table 4).
Relation of preoperative abnormal CEA with axillary lymph node in 50 patients
If c2 < 3.84 then p>0.05 i.e. CEA is not significantly associated with axillary lymph node(Table 5).
Relation of preoperative abnormal CA15-3 with clinical stage
In the present study correlation of clinical-stage in patients with preoperative abnormal CA15-3 value. 2%patients had stage I disease. 2% of patients had stage II disease. 8% of patients had stage III disease. 4% patients had stage IV disease(Table 6).
Relation of preoperative abnormal CA15-3 with tumour size in 50 patients
If c2 > 3.84 then p0.05 i.e. CA15-3 is not significantly associated with axillary lymph node(Table 8).
Relation of preoperative abnormal CEA with locally advanced disease in 50 patients.
If c2 < 3.84 then p>0.05 i.e. CEA is not significantly associated with locally advanced disease(Table 9).
Relation of preoperative abnormal CA15-3 with locally advanced disease in 50 patients.
If c2 < 3.84 then p>0.05 i.e. CA15-3 is not significantly associated with locally advanced disease(Table 10).
Relation of preoperative abnormal CEA with locoregional recurrence in postoperative follow up 24 patients.
If c2 < 3.84 then p >0.05 i.e. CEA is not significantly associated with locoregional recurrence in postoperative follow-up breast cancer patients(Table 11).
Relation of preoperative abnormal CA15-3 with locoregional recurrence in postoperative follow up 24 patients.
If c2 > 3.84 then p0.05 i.e. CEA is not significantly associated with metastatic disease in postoperative follow-up breast cancer patients(Table 13).
Relation of preoperative abnormal CA15-3 with Metastatic disease in follow up to 24 patients.
If c2 > 3.84 then p 3.84 then p 3.84 then pEnglishhttp://ijcrr.com/abstract.php?article_id=2910http://ijcrr.com/article_html.php?did=29101. American Cancer Society. Breast cancer facts and figures 2005–2006.
2. Ferlay J, Autier P, Boniol M, Heanue M, Colombet M, Boyle P. Estimates of the cancer incidence and mortality in Europe in 2006. Annals of oncology. 2007 Mar 1;18(3):581-92.
3. Parkin DM, Bray FI, Devesa SS. Cancer burden in the year 2000. The global picture. European journal of cancer. 2001 Sep 1;37:4-66.
4. Ries LA, Eisner MP, Kosary CL, Hankey BF, Miller BA, Clegg L, Mariotto A, Feuer EJ, Edwards BK. SEER Cancer Statistics Review, 1975–2001. Bethesda, MD: National Cancer Institute; 2004. Available on http://seer. cancer. gov/csr. 2005.
5. Berry DA, Cronin KA, Plevritis SK, Fryback DG, Clarke L, Zelen M, Mandelblatt JS, Yakovlev AY, Habbema JD, Feuer EJ. Effect of screening and adjuvant therapy on mortality from breast cancer. New England Journal of Medicine. 2005 Oct 27;353(17):1784-92.
6. Thompson JA, Grunert F, Zimmermann W. Carcinoembryonic antigen gene family: molecular biology and clinical perspectives. Journal of clinical laboratory analysis. 1991;5(5):344-66.
7. Thomas P, Toth CA, Saini KS, Jessup JM, Steele Jr G. The structure, metabolism and function of the carcinoembryonic antigen gene family. Biochimica et Biophysica Acta (BBA)-Reviews on Cancer. 1990 Dec 11;1032(2-3):177-89.
8. Duffy MJ. CA 15-3 and related mucins as circulating markers in breast cancer. Annals of clinical biochemistry. 1999 Sep;36(5):579-86.
9. Keyomarsi K, O'Leary N, Molnar G, Lees E, Fingert HJ, Pardee AB. Cyclin E, a potential prognostic marker for breast cancer. Cancer research. 1994 Jan 15;54(2):380-5.
10. Price MR, Rye PD, Petrakou E, Murray A, Brady K, Imai S, Haga S, Kiyozuka Y, Schol D, Meulenbroek MF, Snijdewint FG. Summary report on the ISOBM TD-4 Workshop: analysis of 56 monoclonal antibodies against the MUC1 mucin. Tumour Biology. 1998;19(Suppl. 1):1-20.
11. Kleer CG, Giordano TJ, Braun T, Oberman HA. Pathologic, immunohistochemical, and molecular features of benign and malignant phyllodes tumours of the breast. Modern Pathology. 2001 Mar;14(3):185-90.
12. Shooshtary MH, Talaizadeh AH, Assar S, Arnineh BK, Nateghi J, Rahdar M. Evaluation of carcinoembryonic antigen CEA and CA15. 3 tumour markers in patients operated for breast cancer. Pak J Med Sci January-March. 2007 Jan 1;23(1):115-8.
13.K. Thriven!, Lakshmi Krishnamoorthy and Girija Ramaswamy Correlation Study Of Carcino Embryonic Antigen & Cancer Antigen 15.3 In Pretreated Female Breast Cancer Patients Indian Journal of Clinical Biochemistry, 2007:2 (1) 57-60.
14.Busetto M, Vianello L, Franceschi R, Bolzan M. CA 15-3 value and neoplastic disease predictivity in the follow-up for breast cancer. Tumour biology. 1995;16(4):243-53.
15.Coveney EC, Geraghty JG, Sherry F, McDermott EW, Fennelly JJ, O’Higgins NJ. The clinical value of CEA and CA 15-3 in breast cancer management. Int J Biol Markers1995; 10: 35-41.
16.James TWU. Diagnosis and management of cancer using serologic tumour markers. In: Henry JB, ed. Clinical Diagnosis and Management by Laboratory Methods.20th ed. New York: WB Saunders; 2001; 1028. 1042.
17.Hou MF, Huang TI, Hsieh JS, Huang YS, Huang CJ, Chan HM, et al. Comparison of serum CA15-3 and CEA in breast cancer. 1995;11(4): 231-234.
18.Arsalan N, Serdar M, Deveci S, Ozturk B, Narin Y, ligan S. Use of CAI5-3, CEA and prolactin for the primary diagnosis of breast cancer and correlation with the prognostic factors at the time of initial diagnosis. Ann Nucl Med 2000;14(5):395-9.
19.Safi F, Kohler I, Rottinger E, Beger HE. The value of the tumour marker CA15.3 in diagnosing and monitoring breast cancer.Cancer1991; 68: 574-82.
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21.Duffy MJ, Duggan C, Keane R, Arnold DK, Hill, McDermott E. et al. High preoperative CA15-3 concentrations predict adverse outcome in node-negative and node-positive breast cancer: Study of 600 patients with histologically confirmed breast cancer. Clinical Chemistry 2004; 50:559-63.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareRadiological Findings of Spinal Neurocysticercosis
English164166Vasant GawandeEnglish Kunal SaojiEnglish Ajith NairEnglish Kiran SaojiEnglishIntroduction: Neurocysticercosis is one of the most common parasitic diseases of the CNS in which the central nervous system is involved by taenia solium. However, it is uncommon that neurocysticercosis involves the spine. Result: Here, we reported a 35-year-old man with intramedullary cysticercosis in the thoracic spinal cord. MRI of the spine revealed a small (0.5x0.7cm) intramedullary lesion in the cord at the level of D8 vertebral body. Conclusion: Since the patient had progressive neurological deficits, surgery was recommended to decompress the spinal cord. Here, we also conversed the diagnosis and management of intramedullary cysticercosis in the combination of the literature review.
English Intramedullary, Cysticercosis, Spinal cordINTRODUCTION
Cysticercosis is the commonest parasitic disease to affect the central nervous system (CNS). According to the review of published literature, more than 2.5 million people worldwide are infected. 1
1Encysted larval form of Taenia solium (Cysticerus cellulose) commonly called porcine tapeworm causes neurocysticercosis. The parenchyma of brain, intracranial subarachnoid space and ventricular system is involved when it affects the central nervous system.
Intraspinal cord involvement is reported in only 1 to 5% of patients, of which leptomeningeal involvement is more common than intramedullary involvement.
Neurocysticercosis is one of the most common parasitic diseases of the CNS in which the central nervous system is involved by taenia solium. However, it is uncommon that neurocysticercosis involves the spine accounting for 1.2 % to 5.8 % of all cases of neurocysticercosis.
Based on the location of cysticercus in the spine, Cysticercosis has been classified anatomically as extraspinal (vertebral) or intraspinal (epidural, subdural, arachnoid, or intramedullary), among which intramedullary type is very rare.
CASE
A 35-year-old man presented with 3 episodes of seizures over 1 month. It was followed by trouble in walking associated with falls which were followed by severe weakness in both lower limbs since 15 days making him confined to bed. His bladder and bowel habits were normal. He also complained of abnormal sensations like pins and needles in both lower limbs
On examination, his spine was normal. The patient had spasticity and power of grade 2/5 in the lower limbs, wasting of lower limb muscles with hypoesthesia below T7 level, and exaggerated deep tendon reflexes in his lower limbs. Both Planters were extensors.
With these features, the patient was referred to the radiology department.
Imaging
MRI of the spine revealed a small (0.5x0.7 cm) intramedullary lesion in the cord at the level of D8 vertebral body.
On T1weighted image, it was isointense to CSF and on T2 it was slightly hypointense to CSF. Hyperintensity was noted in FLAIR. There was e/o a hypointensity around the lesion on T2 images suggestive of minimal oedema. Post-contrast MRI showed enhancement in the area ( Fig 1 and 2)
With this presentation, possibility of an infective aetiology such as Tuberculoma or Neurocysticercosis was considered. The MRI of the brain was performed, which revealed multiple small ring enhancing lesions with hole with dot appearance in few, thus confirming diagnosis of Neurocysticercosis ( Fig 3).
Discussion
Spinal neurocysticercosis is commonly encountered in the CSF spaces surrounding the cord. This site is common in spinal neurocysticercosis because of dissemination of lesions from brain via CSF. 2
Intramedullary NCC is an extremely rare condition. The probable etiology is hematogenous dissemination from a primary source other than CNS (Fig no 1). Thoracic spine is the preferred site for intramedullary NCC due to higher blood volume in this area as compared to other spinal segments3. In present case also thoracic involvement in noted.
MR imaging of intact intramedullary cysts typically shows cystic areas within the spinal cord along with intensity of cyst fluid that is analogous to CSF on both TI- and T2- (Fig no 2) weighted images. Sometimes the scolex can be recognized as a mural nodule within the cavity of cyst on TI-weighted images.
However it was not seen in the cord in our case but it was seen in the sections of brain. As in the brain, degenerating cysticercotic cysts within the spinal cord may show a subtle hypointense rim surrounding the intramedullary cyst on T2-weighted images and evidence of irregular peripheral enhancement after IV gadolinium administration.3 Similar finding were found in present case also.
The differential diagnosis of a small ring enhancing area in the cord will be tuberculoma, metastasis and abscess. The closest differential diagnosis is tuberculoma, however tuberculoma will usually have a size of 2-8mm and appear hypo- or isointensity or central hyperintensity with a hypointense rim on T2W images and isointensity and/or hypointensity on T1W images (Fig no 3).4
The other differential diagnosis includes cerebral metastasis and abscess. However cerebral metastasis appear isointense to hypointense on T1W images and typically hyperintense on T2W images. The enhancement pattern in it can be uniform, punctate, or ring-enhancing, but it is usually intense.5
Abscess appears hypointense on T1W images and hyperintense on T2, but there is surrounding vasogenic edema, on T2W images it appears as surrounding hyperintensity. With iv contrast abscess shows typical rim like enhancing pattern. 6
The CSF examination frequently shows raised proteins, a low or normal glucose level, moderate level of lymphocytic pleocytosis and eosinophilia. ELISA or serum enzyme-linked immunoelectric transfer bolt assay helps in finding cysticercal antibodies in CSF and have good sensitivity and specificity in cysticercosis diagnosis. 7
Timely diagnosis and management can increase the result. Sharma reported that 60% patients acquired improvement after surgery, 25% did not improve, and 15% died3. In recent years studies, there is significant increase in results by surgical management; there is no death and most of patients may possibly live devoid of special support. When in doubt surgical management is the management of choice or else medical therapy has its benefits. 8,9
Albendazole is a drug which is effective since 1996 in patients with intramedullary cysticercosis. It is thought that preoperative adjunctive treatment with albendazole helps to stabilize the lesion and thus causes a strong dissection plane during surgery. Albendazole is generally used postsurgery as a routine therapy (15mg/kg/day) for 4 to 6 weeks, according to the idea that cysticercosis is a generalized disease with focal manifestation. Moreover, Albendazole is often combined with corticosteroids, for the reason that its level in the blood can increase by the latter. 9,10
Conclusion
To conclude we suggest that neurocysticercosis should be considered in the differential diagnosis of ring lesions involving the cord, particularly in endemic areas.
Englishhttp://ijcrr.com/abstract.php?article_id=2911http://ijcrr.com/article_html.php?did=29111.Bin Qi, Pengfei Ge, Hongfa Yang, Chunhua Bi, and Yiping Li, Spinal Intramedullary Cysticercosis: A Case Report and Literature Review, Int Journal of Medical Science. 2011; 8(5): 420–423.
2. Eric T. Kimura-Hayama, MD, Jesús A. Higuera, MD, Roberto Corona-Cedillo, MD, et al Neurocysticercosis: Radiologic-Pathologic Correlation, radiographocs; 2010; 30(6);1705-1707
3. Claudia C. Leite1 J. Randy Jinkins1 Beatriz E. Escobar1 Alvaro C. Magalhaes2 et al ,MR Imaging of Intramedullary and Intradural-Extramedullary Spinal Cysticercosis, AJR:169, December 1997; 1713-1717
4. Sheth TN, Pillon L, Keystone J et-al. Persistent MR contrast enhancement of calcified neurocysticercosis lesions. AJNR Am J Neuroradiol. 1998;19 (1): 79-82
5. Eichler AF, Loeffler JS. Multidisciplinary management of brain metastases. Oncologist. 2007;12 (7): 884-98.
6. Haimes AB, Zimmerman RD, Morgello S. et al. MR imaging of brain abscesses. AJR Am J Roentgenol. 1989;152 (5): 1073-85
7. Tsang VC, Brand JA, Boyer AE. An enzyme-linked immunoelectro transfer blot assay and glycoprotein antigens for diagnosing human cysticercosis. J Infect Dis. 1989;159(1):50–9.
8. Kasliwal MK, Gupta DK, Suri V. et al. Isolated spinal neurocysticercosis with clinical pleomorphism. Turkish Neurosurgery. 2008;18(3):294–7.
9. Garg RK, Nag D. Intramedullary spinal cysticercosis: response to albendazole: case reports and review of the literature. Spinal Cord. 1998;36(1):67–70.
10. Corral I, Quereda C, Moreno A. et al. Intramedullary cysticercosis cured with drug treatment. A case report. Spine. 1996;21(19):2284–7.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareChildren Coping with Stress During Lockdown
English167172Vijay KumarEnglish Nishu ChawlaEnglish Shipra GuptaEnglish Jigisha AanadEnglishBackground: The coronavirus disease 2019 (COVID-19) pandemic is having an intense effect on all aspects of society, including mental health and physical health. A major adverse consequence of the COVID-19 pandemic is likely to be increased social isolation and loneliness which are strongly associated with anxiety and depression. Tracking loneliness and intervening early are important priorities. Crucially, reducing sustained feelings of loneliness, and promoting belongingness are candidate mechanisms to protect against self-harm and emotional problems. Social and physical distancing has abruptly interrupted many social opportunities important to physical and psychological health. Method: In this study, 2140 children of different categories (gender, age, education, region, and location) have participated. The questionnaires depend upon the argument tendency, depressive order, adverse mental problem symptoms, behavioural health symptoms, and anxiety disorder. Results: It is observed that children face anxiety, depressive disorder, argument tendency and show adverse mental problem symptoms, behavioural health symptoms, and COVID-19 related trauma and stressor-related disorder. Conclusion: The present paper also deals with how the parents can help the children coping with stress during this COVID-19.
English Coronavirus COVID-19, Children Coping, Depressive disorder, Anxiety disorder, Argument tendencyINTRODUCTION
Stress is a natural emotion or a feeling of not being able to cope with demands and circumstances. It is a destructive and weakening force. It is very important to manage stress or else it can be fatal. In an inadequate and inconstant world, such as ours, it is impossible to avoid stress. However, being vigilant to the effects of stress may help the children manage more effectively. Elements in our life that cause stress are known as ‘stressors’. Stress influences one’s mental well being. Mentally healthy children are better able to meet life’s challenges. They are also better learners and have stronger relationships1,2. Some stress can even lead to serious consequences, because of long-running trouble. One should indeed learn how to deal with the difficult times and progress, as adversities and sufferings are a part of life. Nevertheless, while that process of acquiring knowledge through our thoughts, experiences, and senses is in progress, children depend on sympathetic and empathetic relationships from adults throughout. Therefore notable and trusted adults, parents, close relatives, teachers play a vital role in helping the children out in understanding their needs, desires and minimizing their anxiety and fear3,4.
Literature Review:
Children are more likely to be experiencing the same symptoms of fright, worry, impatience as experienced by adults during this pandemic time of COVID 19. Even the researchers agree that sticking to a regular schedule is key, even when you are at home all day. Parents need to tell their children what importance of keeping some structure holds. For example, getting up, good nutrition, proper rest, going to bed around the same time every day is very important. These things can help children to cope with stress. Spending quality time with children is equally essential and will serve the purpose of understanding the children and building good and harmonious relations with them, especially if they have had a stressful day. Talking with their children, knowing their issues and requirements will let their children come closer to them. The coronavirus disease has deeply affected life around the globe. Solitary confinement, contact restrictions, and economic shutdown impose a complete change to the psychosocial environment in affected countries5,6. These steps have the possibilities to intimidate the emotional instability of kids and youngsters notability. Nonetheless, the health crisis can lead to good time or chances for self-development and emotional bonding that family members have towards one another, drawbacks may outrank these advantages. Apprehension, absence of social interaction and minimize options for stress regulation are the main concerns. “Spare time activities have been restricted. In most countries, children have not been permitted to use regular playgrounds”. Collective activities are restricted and sports clubs are closed.
Children at this time need extra love and affection7,8. So the responsibility of parents has become more and they need to respond to their child’s reactions in a supportive way, listening to their concerns and trying and keeping children close to them and Family and avoid departing children and their caretakers to the extent possible. If disconnection takes place (e.g. medication) make sure regular contact (through phone). Provide information about what has happened, disclose what is going on, and give a clear picture to them as to what has happened, and how to reduce the extent of being infected by the disease. Children are given extra care and attention during the challenging periods.
Children are spending their maximum time of theirs online. School, assignments, chats and many more- even music lessons, and other extracurricular activities are being conducted online- everything has shifted online. “Staying connected with children helps them to lessen the impact of this COVID-19 which is spread worldwide and encourage them to keep going in their lives. At the same time, it is a big challenge for parents. How can you have the best that the entire internet has to offer while minimizing harm? It is not easy to have an equilibrium when undergoing a health emergency like COVID-199,10.
There are various ways parents can help to keep their children safe online.
Children hope to enter into an honest dialogue that looks at the problems. It is the moral duty of parents to be supportive and kind in knowing their children’s problems and to try to solve them by interacting with them. Parents always need to be very cautious if their child seems to be distressed and reticent with electronic activities or if they are undergoing any kind of harassment by sending or posting mean messages, usually anonymously11.
Parents should make use of the latest multimedia to safeguard them. Make it sure that your youngster is using the updated application and the privacy settings are on. For little children, appliances likewise content filter, as well as secure search, can assist digital experience constructive12.
Generate chances for your youth to possess a positive and safe digital association.
Helping kids deal with stress during lockdown is very important. However isolation, physical, and social distancing are the new normal, it has led to enormous physical and psychological pressure on the kids. Closures of schools have restricted the movement of children and they are enforced to stay at home with their adults and caretakers who are already exhausted and fatigued. Children who are in confinement or segregated or maybe away from adult administration may also intensify protection risks. “Children with disorders may suffer from stronger consequences of the in-progress widespread disease. They might have severe discomfort, anguish, or worry as they have less control over themselves than other people. The same case is with children with physical, psychological, or mental limitations. They may need extra attention, more clarifications about the prevailing circumstances, and more sympathy and other productive reinforcement of messages. Devote time with them, care about their needs. So that they show their active participation in all activities13,14. Youth bearing anxiety and pain is quite natural during in progress pandemic like COVID-19. Being frightened about their health and the health and the health of their dearest ones can be massive and cause strong emotions. In today’s era of the information age, children also acquire different kind of information and news from various online platforms and digital media, of which some may be genuine and some may be unreal as well as causing stress and fright and this may increase when they are not able to go out and spend their leisure time with friends or attend the school where they can interact freely. Parents and caretakers should act sensibly when it comes to rumours and unreliable information. Parents should be extra attentive in dealing with such things so that their children do not face the consequences of it15, 16.
It is very important for parents to be happy for only happy parents can create a happy generation. Parents who remain stress-free can teach their children to lead a stress-free life. Children don’t like talking to parents who are always under stress. Some the reasons for parents being stressed out are that some parents always carry the burden of their past incidents and make their present suffer because of which the children are not able to communicate freely with their parents as they (parents) devote much of their time recalling their past and not able to communicate well with their children and the result is seen in the formed gap between them, speaking authoritatively with their children and not understanding their point, constantly finding mistakes in their children and shouting and demeaning them and not accepting their mistakes in front of the children, having high expectations from their children without realizing that their children to have some expectations. So parents need to introspect themselves and know where they are lacking and what can be done for self-improvement for building a better relationship with their children17,18,19.
Methods
COVID-19, coronavirus pandemic has been associated with the mental health of the children. Due to the pandemic, the children were at home. They could not go out for sports, for attending coaching classes, for attending classes in school. It becomes a reason for adverse mental or behavioural health conditions, anxiety disorder, and trauma-related disorder. In this manuscript, 2140 children are selected for this study. The selection has been done in such a way that the students of all categories are included in this study. In this study, students of various age groups, different schools, various classes, and children from hostels are selected. The children are also selected which belong to a poor family and rich family. This study has been done for the lockdown period i.e., from 1 to 30 April 2020. The children are also taken from different states of India for this study. The argument tendency, depressive disorder, COVID-19-related Trauma, and Stressor-related disorder, adverse mental problem symptoms, behavioural health symptoms, anxiety disorder have been discussed with the children. The classification of children is done concerning gender, age groups, school boards, education, region (state or national), rural and urban.
Statistical Analysis
OBSERVATIONS
DISCUSSION
Out of 2140 children, 47.3% boys, 33.9% of girls have given responses. In this lockdown period, people and children are not able to move out of the house. Due to this, the behaviour of children was changed. The behaviour and health were observed during this lockdown period. Table 1 represents that 42.5% and 33% argument tendency have been increased in boys and girls while no effect was observed in 24.48% children in this period. The depressive disorder has been shown by 45.7% in boys, 28.6% in girls while 25.65% shown no such type of effect. 34.06% boys, 27.3% of girls were observed COVID-19 related trauma and stressor-related disorder and no effect was observed in 38.59% children. During the lockdown, children were facing a mental pressure of this pandemic. Adverse mental problem was shown by 27.17% boys, 22.89% girls, and no effect was shown by 49.48% of children. Behavioural health symptoms were found in 38.8% boys, 21.72% girls and no symptoms were found in 39.39% children. 32.2% boys and 18.08% of girls were observed by an anxiety disorder and 49.67% were observed no effect.
Different types of symptoms are observed during this period. Behavioural health symptoms were shown by 17.57% children and COVID-19 related TSRD shown by only 2.75 % children (6 to 10 years). When a survey was done on students aged between 10 to 15 years, it was found that 7.94% children were suffering a problem of anxiety disorder and 17.47% of children were increased the tendency of argument. In 15 to 20 years children, adverse mental problem symptoms were found in 11.58% and anxiety disorder was found in 22.99% of children. 19.29% and 24.76% of children (20 to 25 years age group) were suffering the problem of adverse mental symptoms and behavioural health problems, respectively. Children were also divided into another category i.e., education system. In this system, one category was taken in which students were selected from the State (Uttarakhand, Uttar Pradesh, M. P., Punjab, Haryana) Board, etc. and the second category was selected from the national board (CBSE, ISC, etc.). It was observed that in state-level students, 17.6% were facing and 23.2% were facing Behavioral health symptoms. In National board students, 24.2% were facing Behavioral health symptoms and 37.1% were facing the problem of depressive disorder. As per the analysis done on the students of various classes, the students from 1st to 10th class standard were suffering the same problem. The anxiety disorder problem was suffered by the maximum students and the dispersive disorder problem was faced by some percentage of students.
The children from the north-east, mid-east, south, and west were also selected for this study. The children of all sides were also facing the above-mentioned problem. It was observed that 13.73% of children were found adverse mental health symptoms and 25.56% of children were facing the problem of argument tendency from the north-east side. 12.6% and 22.1% of children of the mid-east side were facing Behavioral health symptoms and COVID-19 related TSRD problems, respectively. In the south side, 9.67% of children have started argument tendency and in 23.45% of children were found anxiety disorder. In 8.87% of children were found suffering from adverse mental problem symptoms and in 34.48% of children, the argument tendencies were increased in the south side. Table 2 shows that (17.9%-25.6%) children accepted that they knew COVID-19 was responsible to increase argument tendency, depressive disorder, TSRD, adverse mental problem symptoms, behavioural health symptoms, and anxiety disorder. (19.9%-27.3%) children did not accept that COVID-19 was responsible for the above-given problems. (26.3%-31.1%) children knew that prehistory heart patients may become severe during this pandemic. (19.5%-33.2%) children were not aware of that. The pandemic may create trouble for prehistory lung patients. (29.3%-37.2%) children were accepted for that and (28.9%-38.4%) were not known about this. (32.5%-41.2%) children agreed that coronavirus may become harmful for diabetic patients and (37.4%-48.31%) children did not agree with this assumption. (16.3%-42.3%) children accepted that the pandemic period may be harmful to high blood pressure patient while (29.5%-38.2%) children did not agree for that. (20.7%-29.4%) children have given their consent that kidney patients may be in danger while (14.4%-38.5%) did not agree with this assumption. The people who were affected by the diseases of the abdomen may be in trouble in the pandemic. (14.1%-31.8%) children were accepted for that while (25.2%-49.3%) were not agreed on that. (15.2%-29.4%) children were assumed that pandemic will produce mental pressure to the people while (26.3%-38.5%) were not satisfied with this assumption.
CONCLUSION
In this study of 2140 children, we found that pandemic had produced many severe problems in the whole world. The lockdown period due to the pandemic produced many types of different problems. The children, who moved here and there, have become prisoners in their homes. It produced many types of biological and mental problems in children. In this manuscript, it is observed that in children’s argument tendency was increased. The other problems which the parents were feeling are anxiety disorder, depressive disorder, adverse mental problem symptoms, behavioural health symptoms, and COVID-19 related Trauma and Stressor related disorder. The COVID-19 pandemic is potentially catastrophic for many children around the world. Its impact risks unravelling global progress across several of the Sustainable Development Goals for children, putting already ambitious targets out of sight. Put simply, we cannot afford to let this happen. It is suggested to the people that in this type of scenario, the children feel mental pressure so the parents should be interactive with their kids.
Acknowledgement- Authors of this manuscript are grateful to the management of Graphic Era Hill University Dehradun who provides us with all necessary facility for this study and also grateful to all the children and their parents who are seriously involved in this study. Authors are grateful to the researchers whose article are cited and references in this manuscript. The authors are also grateful to the editors of this journal for providing necessary guidelines for publication of this study.
Conflict of interest- None
Financial Support-None
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareAn Observance of Household Food Remains Comportment
English173179Vinod WaikerEnglish Ranjit AmbadEnglish Abhishek JoshiEnglish Vijay KhandalEnglishIntroduction: Food waste is a universal problem and attempts to curb is a big challenge worldwide as hunger rate is again rising since 2015[FAO,2017] after many years of restraint.1 As per the United Nation’s Sustainable Development Goal Target 12.3.1 and 12.3.2 the food loss and waste respectively must be halved of the per capita global food targeted by 2030. The paper aims to analyse the malpractices persist in society related to food management that leads to abundant food wastage. The percentage of food waste at the consumption stage varies from 5% in Sub-Saharan Africa to almost 58% in North America and Oceania regions defined by FAO. Even after a continuous effort from so many years, the hunger rate is biggest challenge thought the world. Food waste broadly covers retail and consumer level food and its related losses, and thus individual plays decisive role the food waste. It is pertinent to analyse the behaviour of various factors to encourage better use of food and its products. The objective of the study is to analyse the distinctive behaviour of food waste and its upshot on society and the environment that subsequently examine the possible incentives for food waste reduction. The study also focuses on the food which turned into garbage could have been utilized by the underprivileged people and their possible distribution mechanism adopted by various agencies and NGO’S worldwide. Aim: This study surveyed understanding the consumption, usage and wastage pattern of the household of Nagpur region. The food waste at any stage must be discouraged at its life cycle to minimize the lost effort and wastage of all applicable resources. The study reveals that the urban citizens, educated people and women’s are more prone to food waste as their counterparts. There should be a rehabilitation centre created by the municipal corporation to collect, distribute and manage the food waste at the city level. This will bridge the gap of food donor and food receiver in a better way. Material and Methods: The survey of some hundred households conducted to understand the behaviour of the food waste of the Nagpur region. As the food wasted more at the user level, thus the study behavioural factors contributing to waste practices. Result: This suggests that Not having the proper diet plan is influencing the food waste by multiple of 0.340, similarly overeating is also a type of food waste and influencing in multiple of 0.109. The factor which does not know how much to eat beforehand also leads to the food waste in the multiple of 0.280. All these factors give clues that are more concern about the diet and plan someone can reduce the food waste up to a larger extent. Conclusion: In India awareness and campaign about the food waste and its repercussion at all the platform will help to positively reduce the food waste as we did for the “Swacchta Abhiyan”. Though education has negative correlation and not has only factors that we can avoid the food waste
EnglishFood Waste, ZERO Hunger, Waste Behaviour, Hunger Rate, Waste ManagementINTRODUCTION
Food waste is crucial issues at international as well as national level. The specific target determined by the SDG 12.3 refers to the food waste at the stages of retail and consumer and food loss in stages of production, transport and storage. The global food waste indicator is the accumulation of country-wise representation of waste data and not available due to the variances in the data collection, methodology and presentation. Only 4.4% of the data are available as per FAO 12.3.1and the rest of the data are from various other indirect sources. 1 United Nation Environment helped in preparing the methodology to measure food loss and waste to identify this on the common platform worldwide. Food loss and waste also have an impact on climate change, greenhouse gas reduction, sustainable water management, terrestrial ecosystem, forestry and biodiversity. 2 As per the UN goals on Sustainable development all 17 goals for 2030 are interconnected and first two are extremely important i.e. No Poverty and Zero Hunger, whereas the second and third goal (Good Health and Well-being) is directly related to the lives of the human being. 2 It emphasis more on the “Avoid throwing away food” which makes the responsibility of everyone living on the earth is to take only the amount which is required to consume. Don’t store more than the required at a particular duration. Others are having a shortage of food and waiting continuously which you held up. We have limited resources to produce a finite amount of yield as per our consumption pattern.
As per the United Nations report on food and nutrition, 820 million people are not getting enough food worldwide for their healthy survival [FAO,2019] and 98% of them are from developing countries. 2 Insufficient nutrition causes 3.1 million children died every year and 66 million primary school children are hungry while attending the classes. As per food aid foundation, one-third of the food is wastage and only utilizing the 66.67 % of the food. As per the data of the world food program, China as the most populous country is low in the Hunger Index with a score of 6.5 whereas India being a 2nd most populous country in the world, despite having self-sufficiency in food grain around 21.25 % lives are not getting enough food to lead a healthy life and scored 30.3 on Global hunger Index of 2019. India had reduced this score from 38.8 in 2000 and 38.9 in 2005, still at a serious level. 2 India ranked number 102 out of 117 qualifying countries on the Global Hunger Index. The trend indicator for Indian in the category of undernourished people is 15%, child mortality is 4-5%, the prevalence of wasting among children up to five years old is 21% and the prevalence of stunting in children under five years is approximately 38%.
As the world population is increasing every hour [David Pimentel,1996], the pressure is magnified due to the rate of depletion of all non-renewable resources like Land, Water and Biological resources.3 As per the World Bank, around 1.5 to 2 billion people are malnourished under the category of moderate or severe food insure which is the highest number ever recorded. Almost 99% of the food comes from the land and only one or less than one % of the ocean and aquatic habitats. Even the agriculture growth [CPI, 2020] has increased by almost 25% since 1961 whereas the population has increased by almost 35 %.4 The gap is huge and bridging the gap is posing more challenges for all of us. After the prolonged decline of the hunger since 2015 taken the reverse direction and unfortunately it is in increasing now.1 As per the indicator defined by FAO’s i.e. Prevalence of undernourishment measures how many people lack enough dietary energy to live the normal active and healthy life. The Numbers have reached to 821.6 million people or 10.8% are undernourished which is the approximate previous level of 2010. The other indicator Prevalence of moderate and severe food security based on food insecurity experience scale, about the 9.2% or more than 700 million people are having the severe level of food insecurity whereas 17.2% or 1.3 billion people are having a moderate level of food insecurity that becomes approximately 2 billion people affected
To understand the amount of food waste disposed of is not able to measure correctly, but to estimate with various measurement methodologies. Average household waste approximately 2.40kg/week, which is comprised of around 35% of the total waste collected for a particular metropolitan city.5 Indirect method estimate quantities of food by its categories and possible waste due to economic activities and statistical measurement of total production and consumptions and far away from the real picture whereas the direct measurement gives the data just before the conversion of waste or become waste and therefore costly affair. The food waste needs to vary with household, restaurant, transportation, supply chain, packaging and with another parameter. Approximately 13% of food waste occurs during transportation and distribution. The food waste can also vary with the seasons like winter, summer and rainy seasons. The summer and rainy seasons are more prone to deteriorate the food. The food wastage may also depend upon the size of the household or the number of people living together and their eating habits. The household size and regional differences correlated with food waste over time.6 The study also reveals that income groups also correlated with the food waste generation like high-income group families generate more waste than low-income group families. The other demographic factors like age group, education, gender, occupation and family background may also play a critical role in contributing to food waste.
India is the country where usually people do not think much about food loss and waste except very few. Barilla Centre for Food and Nutrition Foundation releases food sustainability index consider the weighted average of three category scores, namely Food loss and waste, Sustainable agriculture and Nutritional Challenges.7 Food, sustainability is about various tool and techniques encourage to educate, maintain the culture, equity and respect to all for the planet we lived on. The high score on food sustainability score means a better understanding of sustainable food and nutrition. India waste as much food as some of the other country can consume [BCFN Foundation: Food and Nutrition Sustainability Index, 2019] and about 40% of the food is wasted after production in different phases from field to feed.7 According to the agriculture ministry worth Rs.50, 000 Crores food produced is wasted per year. In another context, we see that the country’s 45% of the land is degraded due to some or other reason and not available for agricultural productivity. Due to non-forests and excessive groundwater extraction, the land is unable to cultivate. The hunger statistics of various states of the country are very poor with the highest hunger index is from Madhya Pradesh falls in the extremely alarming category along with four other states, namely Punjab, Assam, Andhra Pradesh and Kerala fall in the serious category while twelve states are in the alarming category. Other states who are comparatively at a high level of the economic index have poor performance in curbing the hunger rate. Despite moderate economic conditions of the state around 200 million people, i.e. 15.38% of the total population are not food secure. 40% of production waste could have been used to feed 15.38% of the people in various states in a country. Around 836 million people 23 survive on less than Rs.20 a day that maybe the primary reason for the number of people (7000 Indians) die every day and 25 lakhs every year. Thus hunger is the number one cause of death in the world.
The component food loss and waste are a weighted average of the indicator in the policies to respond to food loss. India is 33rd in the overall score of a sustainability index recorded in 67 countries with 66.40 scores, whereas France is coming first with the highest score of 76.10. In food loss and waste category India is 7th country 81.80 and France is having the highest score with 85.80. The separate score in the list of factors, namely food loss is 92.20, the policy response to food loss is 100.0 and causes of distribution loss is 25.00. The second component of sustainable agriculture is a weighted average of the indicator in the water, land, emission and land-use category. In Sustainable Agriculture category, Austria is the country with the highest score of 79.90 and India is 47th with 65.50 scores. The individual score in Environmental impact of agriculture on the water is 0.00, the sustainability of water withdrawal is 98.40, water scarcity is 26.70, and sustainability of fisheries is 84.40 and 100.00 for water management and trade impact. The score for the environmental impact of agriculture on land, land users and the environmental impact of agriculture in the atmosphere is below 33 and are a very serious cause of concern as far as India is concerned. The other parameter agriculture subsidies, diversification of the agricultural system, agro-economic indicator, productivity, financial access and protection for land users are scored moderately from 33 to 67. Other indicators land use, the impact of the land of animal feed and biofuel, land ownership, animal welfare policies, environment, biodiversity, climate change mitigations and opportunities for investing in sustainable agriculture has fairly scored more than 67. The issues related to Sustainable agriculture are having low scores in trade impact (11.10), the sustainability of fisheries (5.80), agricultural subsidies (0.0) and land productivity (22.80). India’s performance is very poor in food waste and loss and food waste at the end user level is below the expected level, i.e. 31.90. This says that the end-user is wasting much of the food in the overall supply chain from farm to feed. This needs more focus on the end-user to educate for more efficient management of food and diet along with the impact of food wastage on people, society and environment. The average literacy rate of India is 69.1 %. The literacy rate of male and female in rural and urban India is 72.3, 56.8 and 83.7, 74.8 respectively. This shows that there is much to be done on rural India as far as education about the food waste and loss is concerned, but data shows the vice versa is also true because more food is wasted by the urban population.
Third component Nutritional challenges are a weighted average of indicator of the health and nutritional category. The case is worse for India in the Nutritional Challenge category and ranked 61th with 52.50 scores, whereas the highest score is 76.50 for Japan. Prevalence of malnourishment, Micronutrient deficiency and Number of people per fast food restaurant scores very poorly in 0.00 to 33.00. Life of quality Enabling factors, Healthy life expectancy, Physical Activity and Diet composition are moderately scored in between 33-67. Prevalence of over-nourished, impact on health, Economic determinant of dietary patterns and Policy response to dietary patterns fairly score of more than 67.
The other issues related to sustainable trade the Union Government has strengthened the regulatory framework like environment governing land issues, reform market regulations, allow the private sector, watershed management schemes, along with climate change adoption and mitigations. The sustainability of fisheries doesn't have a very positive approach due to overfishing and damaging aquatic life to a larger extent. India has a long way to follow standard and sustainable practice for fisheries. In India, agriculture subsidies are given in many forms, though the government is trying to reduce the subsidies in one way or another for efficient fertilizer supplier and sustainable farming methods. To improve the sustainable agriculture productivity up to fair level, some of the parameters need to be focused on priority like yield increase, water use efficiency, diversity of food grains, farm-based approaches, organic agriculture. Budget 2018-19 has taken many initiatives by the union government to reduce the amount of chemical fertilizer, water and improving the productivity at the farm level. The only sustainable and continuous effort will lead to double the income of farmer by 2022. The other factor number of people per fast food restaurant is scored low and consumption of unhealthy energy and protein sources is much higher in urban India and contributing to the emerging problem of obesity. Many such foods are adulterated with chemicals, colours, preservatives that exceeds permissible limits sometimes.
Material and Methods
The survey of some hundred households conducted to understand the behaviour of the food waste of the Nagpur region. As the food wasted more at the user level, thus the study behavioural factors contributing to waste practices. There is the individual and societal perspective to study the behaviour of food waste.8 The habit also plays a significant role in such behaviour. The habits also not modified due to lack of awareness about the facts of hunger around us. The survey, conducted in the city of Nagpur on the behavioural pattern of the food habits is household only. The scope of data collection is limited to the questionnaire filled from the user/consumer. The study did not consider the data from the food provider like restaurant, food joints and hotels. Though the food provider can calculate the total amount of food waste as per their daily wastage and based on consumption and dispatch, the habits or the pattern of food waste can only be understood at the individual level. The social places like marriage ceremonies, birthday party, rituals, lawn and Bhandara sort of place are also contributing much of the waste and not able to measure until there is any systematic way of disposing of the food waste. The study has included all representation proportionately of the society who are dominantly participating in the consumption of food and its waste. The survey is targeting to answer food consumption pattern and how it leads to waste which are difficult to measure in the quantitative term. The survey has been conducted both offline and online in case of not being accessible to the individual due to time and place constraints. Face to face interview is not considered due to the effect of the influence of the collector of the data. Stratified random sampling is used to outline various categories for the target respondent. Food provider is introduced as one more category in business occupation to reflect their effect on food waste. The analysis involves the demographic of the respondent and their respective pattern of food consumption and waste.
The sample distribution is representing the true population by considering the gender, age group, education, marital status, occupation, income and living place like urban or rural. The stratified random sampling is used to select the respondent from each category for proportionate representation in the dataset. The questionnaire is prepared based on the literature review of various articles published on food loss and the factors considered for the questionnaire are socio-demographic, household, psychological and health consciousness. The demographic diversity includes age group, education, gender, marital status, occupation, income and living place. Five points Likert Scale is used for the recording of responses (1- Never, 2- less than 2 times in a week, 3-3-6 times in a week, 4-7-8 times in a week and 5- More than 10 times in a week or always). As per the FAO, the definition of food loss involves any reason prevented to consume the food is considered as food loss and therefore the collection of responses to the behaviour that leads to waste food. The factors for food consumption like food taste, overcooked/undercooked and thrown away.9 Food purchase behaviour includes variable like to prepare a food list, food storage, use best before date food disposal to pet/animals donate the food, and leftover.10-12 The other variables are educated family member, thinking yourself about the food waste, health concern like diet plan, how much to eat, overeat etc.
Results and Discussion
As per the literature survey, the study conducted for selected samples 85% of them are filled form and only considered for analysis. The Cronbach’s alpha is 74.3 indicates the adequate level of internal consistency of our scale. The model summary suggests the variable food waste can be explained with the 74.4% of variations by the independent variables mentioned as below table 1.
a. Predictors: (Constant), Educate Family for Waste, Rotter Before Cook, List To Buy Food, Know-How much teat Beforehand, Over Eat, Donate Food, Feed Animal Leftover, Go Restaurant, Diet Plan, Use Best Before Date, Over Under Cooked, Eat Fast Food, Thinking of Waste, Proper Taste
This substantiates the previous study by food waste are depends largely on the variable like food taste, overcooked or undercooked, proper taste, diet plan, thinking of waste, etc. The other variable like not use the list for buying the grocery, improper storage also leads to food waste. Food disposal, donate food, call animals or pet to consume also one or another way to food waste. As per the coefficient table below, it is clear that some of the variations are not equally significant and therefore stepwise regression is done to predict the significant variables and its effect on the food waste. The other variables are having less significant result in this study that can be updated with more in-depth study or the number of samples increases showed in below table no 2
a. Predictors: (Constant), Proper Taste, b. Predictors: (Constant), Proper Taste, Over Under Cooked, c. Predictors: (Constant), Proper Taste, Over Under Cooked, Diet Plan, d. Predictors: (Constant), Proper Taste, Over Under Cooked, Diet Plan, Know-How much tea Beforehand, e. Predictors: (Constant), Proper Taste, Over Under Cooked, Diet Plan, Know-How much eat Beforehand, List To Buy Food, f. Predictors: (Constant), Proper Taste, Over Under Cooked, Diet Plan, Know-How much eat Beforehand, List To Buy Food, Donate Food, g. Predictors: (Constant), Proper Taste, Over Under Cooked, Diet Plan, Know-how much eat Beforehand, List To Buy Food, Donate Food, Feed Animal Leftover
Predictors are the major factors contributing to food waste. The health-related factors are judged separately by only considering three factors in the model to understand the regression of Diet Plan, Overeat and Know how much to eat beforehand on food waste and found that these variables explain 45.6% of the variations of the food waste and all the variable are significant shows in below table no 3
This suggests that not having the proper diet plan is influencing the food waste by multiple of 0.340, similarly, overeating is also a type of food waste and influencing in multiple of 0.109. The factor which does not know how much to eat beforehand also leads to the food waste in the multiple of 0.280. All these factors give clues that are more concern about the diet and plan someone can reduce the food waste up to a larger extent shows in table no 4.
Discussion
All the factors as discussed above are continuing the major causes of food waste irrespective of the caste, country, region or society. The remedies are more or less common for all but the implementation differs by caste, country, region and society by its culture and individual’s consciousness. This need to think in a different perspective above the self, with references to society, country, the world to the saviour of our resources and reduce the wastage. As per feedingindia.org India is the 2nd largest producer of food and 195 million people are malnourished, one-fourth of the world undernourished people are the people who live in India i.e. The three times the population of France. In India, food wastage is considered to be a part of the normal process. There is an absence of awareness among the household about the amount of food waste they are doing per day/per month or in a year is wastage of environmental resources. The people have a notion about the prepared food should always be there more than 2-3 people anytime at home and if not consumed, it leads to merely wastage. This wastage later manages by donating it to the maiden, beggar, undernourished people or pet animals. If missed then convert into waste and emitting greenhouse gases to the environment. Some of the self-help groups along with corporate, organizing the campaign against the food waste and they collect the excess food from the venue like restaurant, hotels, lawns and individual house. The vans picking up the food are checking the quality of food and keep it in customized safe and refrigerator container. This food can then be distributed to the needy people, school children and roadside people. This is the unstructured way of collecting and distributing food waste at the local level. This model should be plugged with the city civic body or Nagar Palika or Nagar Parishd. The rehabilitation centre can be created for the people who are needy, without work, without shelter and clothes. The specialized vehicle should be deployed to collect excess food and re-distribute it in such rehabilitation centres. The awareness about the program should reach to the last man to contribute as per their convenience. Such Centres are important places for food donation and consumption at particular times of the day. The people who are searching for a job for their bread and butter should channelize through the centre to get easy access to labour as affordable rates. This can organize the food, waste collection and distribution along with hunger. Municipal Corporation should add one more types of minor tax for waste management i.e. 10 or 20 Rs. and get almost 1.5-2 crore per annum if consider the population of the city is nearly 25lakhs which helps them to manage rehabilitation centre, specialized vehicle and resources required to manage along with the donation.
Food wastage in any form must be stopped and this can only be done when the individual is thinking that food as divine substance and essential for the living being. This may be the last priority for the people who have easy access to the food and never thought about saving the food for the people in need. As per Indian Vedas and Upanishad, we should also think about the type of food and its quality for better fuelling the divine vehicle i.e. our body. We spiritualize our eating from what to eat, how much to eat, when (times) to eat, how to eat (posture), to purify one’s existence, receive the strength of body, mind and soul, happiness and satisfaction.13 We should always eat balanced food in a pleasant atmosphere at fixed times and never take meals in between. We should also share food with others, always give it to the other people first and then take ourselves. Do not overeat food. Put the food on the plate as much as you can eat and save any leftover for the next meal. Don’t waste food in any form, don’t buy too much, you buy them as much food which can be prepared and consume without rotten so that this prevents it from wastage. Think from a broader perspective, every time about the food waste and its effect on the environment.
Conclusion
In this study, we discussed only the controllable factor related to individual and psychological. All factors where a human has direct interface can be avoided by improving awareness and follow some of the rules. In India, awareness and campaign about the food waste and its repercussion at all the platform will help to positively reduce the food waste as we did for the “Swacchta Abhiyan”. Though education has negative correlation and not has only factors that we can avoid food waste. The urban people, highly educated people or women tend to waste more food than their counterpart.14,15 The current study also substantiates along with the people who are concerned about a diet plan, overeat and know how much to eat are also contributing to food waste. This study also discussed the rehabilitation centres should start by Municipal Corporation of the city to bridge the gap of food donor and food receiver. There must be regular public events for awareness about the food habits and food wastage that helps to mitigate the food waste up to some extent.
Conflict of Interest: Nil
Source of Funding: Nil
Englishhttp://ijcrr.com/abstract.php?article_id=2913http://ijcrr.com/article_html.php?did=2913
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411218EnglishN2020September22HealthcareBehavioral Intervention with Fine Motor Training for Dysgraphia in School Going Children
English180187YanjanaEnglish Promila SinghEnglish Mahendra KumarEnglishAim: The main objective of this study was to examine the effectiveness of Behavioral Intervention with fine motor training on behavioral problems and learning disabilities in children with writing difficulties (dysgraphia). Materials and Methods: Those school going children who were average IQ, low academic performance and scored less than 50 on diagnostic test of learning disability (DTLD) and less than 5 on Eye-hand Coordination (EHC) subtest of DTLD were identified as subjects with writing difficulties. Subjects were also rated by teachers on behavioural problem checklist in pre-post condition. Seventy children with dysgraphia taken for intervention from the age group of 8-11 years (out of these 14 were dropouts). The quasi-experimental design was used. Hence, 28 subjects were part of the experimental group and the rest of the subjects were included in the placebo group. Three-month intervention (behavioural intervention with fine motor training) with 2 sessions per week was given to the experimental group through group and individual sessions. Placebo group were only involved in daily routine activities. After the intervention, all measurements were again administered. SPSS 16 V. was used for statistical analysis. Results: The results in eye-hand coordination (Wilcoxon W=28.000;Z=-4.059;p=.000) and diagnostic test of learning disability total score (F=4.656, p=.035) show a significant increase on post-intervention for the experimental group. The results in behavioural problems show a significant decrease in post-intervention for the experimental group (F=40.179; p=.000). Conclusions: Behavioral intervention with activity-based fine motor training to be useful in the classroom. The research empirically proves that activity had a positive effect in enhancing the EHC and overall psychological health with reducing behavioural problems in Children with writing difficulties.
EnglishLearning disability, Intelligence, Behavioral Problem, Behavioral Intervention, Fine Motor TrainingIntroduction:
Writing difficulties or dysgraphia is a type of learning disability that frequently interferes with the student's ability to form letters and words when writing. Dysgraphia can affect writing ability and fine motor skills, it can produce illegible writing, misspell words, inaccurately copy words and letters, and write in incoherent sentences. In a survey, more than 1,83,000 children below 14 cannot read and write. Total 37 % children studying in government schools in the age group of 7 to 10 years cannot read simple words and 52 % cannot even recognize numbers1. Students with learning disabilities may suffer from emotional problems and behavioural problem2,3 and associated with psychological co morbidities4. Most of the students withdraw from social interaction and involved in drugs or alcohol abused for relief from feelings of low self-worth and approximately 35% of students with learning disorders, drop out from High School5. Dyslexic students are highly thinking about to attempt suicide compared to other young people6. Youth suffer from poor reading ability were more possibility to suicide attempts or experience suicidal thought and high risk on and more probability to drop out of school than youth with typical reading7.
The researcher observed in children who were developmentally delayed, a common thread-their cognitive development as well as their fine motor development. Students struggling have poorly developed fine motor skills like poor handwriting, poor cutting and colouring skills, problem copying from the board, low skills in visual-perception, complexity with puzzles and mazes, trouble identifying letters and numerals, as well as poor ability in reading and writing. A student with dysgraphia might have fine motor difficulties such as trouble holding the pencil correctly, inability to use scissors well, or colouring inside the lines8. Fine motor skills are necessary for both reading and writing. Students need fine motor Placebo for eye muscles to focus and distinguish letters, crossing midline, and tracking all essential skills for reading and writing. They need eye-hand placebo to develop good handwriting skills so that they can express themselves in written form.
The cognitive-based remediation program has the potential for substantially improving comprehension and its underlying cognitive process among English-as-a-second-language children 9,10. This method also reported continued improvement in their reading skills, notably in comprehension11. In another study, significant improvement was observed in word identification and word attack pre-post test12. Positive effects of specific writing treatments were observed for struggling writers and students of LD in several studies13-16. Impact of experimental studies on the writing of students with LD in Grades 1 to 9 has examined and they reported instructional components were essential for effective writing instruction for students with LD17.
The study reported knowledge about behavioural disorders is poor among primary school teachers in India18. Early identification of such students can help in the early institution of intervention and suitable modifications in teaching techniques19. In India, limited studies are focused on the prevention of mental health problem and limited attention is given to child mental health promotion in LD students. Research has shown Behavioral intervention to be effective in the prevention of mental health problems in children but there are very few studies focused on behavioural intervention for LD with mental health promotion among LD students. There is an also need to examine our lack of focus on fine motor development. For this purpose this study was undertaken to examine the effectiveness of behavioural intervention with fine motor training on behavioural problems, learning disability and intelligence among children with writing difficulties.
Materials and Methods:
Participants
Seventy children of writing disabled were selected from the government school of Chhattisgarh (age range 8 -11 years). The purposive sampling technique was used. All the students are from the same pattern of education i.e. Chhattisgarh Board of Secondary Education.
Inclusion criteria:
The sample comprised of school-going children.
Age range 08 - 11
Student of rural & urban school both
Children identified by teachers as having difficulties in learning and poor academic performance.
Children study in schools would be Hindi is the medium of instruction.
Children going to school with at least 62 to75% attendance.
Willingness to participate in the study.
Exclusion criteria:
Children with mental retardation.
Children with gross and uncorrected visual or auditory sensory handicaps which could influence school performance.
Children with medical conditions such as epilepsy and a head injury which could impair the ability to learn.
Breathing-related sleep disorder;
Occurrences of progressive medical sickness i.e. (cancer, dementia); (d) mental disorder
Direct physiological effects of drugs (e.g., a drug of abuse, a medication) or a general medical condition.
Seventy participants were selected based on a priori power analysis by G∗Power computer program. Using parameters of 0.80 power, 0.80 large sizes, and 0.05 alpha, the sample size for F-test needed per group was 21 participants.
Randomization: after the enrollment of the participants, following the random sequence generation technique these 70 participates were divided into two groups as the experimental group and placebo group, each constitutes 35 participants. 56 participants were completed (28 in the experimental group and 28 in the placebo group). Figure 1 represents the CONSORT diagram showing the flow of participants through each stage of the trial.
Tools
1. Coloured Progressive matrices
Intelligence was measured by Raven’s coloured progressive matrices. In the present test, split-half reliability was found at 0.90. Coloured Progressive matrices is a suitable IQ test for the children in the age range of 6 years to 11 years20.
2. Diagnostic Test of Learning Disability (DTLD).
It is to be individually administered as well as a group on the age group 8-11 years old. A deficit in any of the area or areas or a combination of any would lead to a learning problem. It consists of 10 sub-tests: Eye-hand Co-ordination(ECH), Figure-Ground Perception (FG), Figure Constancy(FC), Position-in-Space(PS), Spatial Relations(SR), Auditory Perception(AP), Cognitive Abilities(CA), Memory(M), Receptive Language(RL), Expressive Language(EL). Eye-hand co-ordination subtest measures the ability to coordinate vision with the movement of the hands for effective use. A subject having handwriting problems because of dysgraphia will score low on this subtest21.
3. Behavioural problems checklist (BP)
To measures, the behavioural problem of the children, child behaviour checklist was used (Anuradha & Parimu, 2005). Behavioural problems were rated by the class teacher and parents based on Behavioral problems checklist. In this checklist, 30 items were included. Scores were obtained by (e.g., Yes = 1 & No = 0) and then summing all 30 items. High score reported a high level of Behavioral problems22.
Information related to their demographic (age, sex, birth order, family status, mother occupation, father occupation) variations were obtained by taking their bio-data record.
Procedure
First of all the authorities of the different school were requested to permit collecting data from the students. After getting permission, the informed consent form was taken from parents. Firstly 1200 students were assessed on intelligence test from 3rd, 4th and 5th class school going students. Students who have difficulties in learning with low academic performance were identified by the teacher. Further 570 students of average and above-average IQ with low academic performance were selected for the identification of writing disabilities. Behaviour problem checklists with a demographic and diagnostic test of learning disabilities (DTLD) were administered on 570 students. Before administering the above measure printed instructions were made clear to them when they understood the instructions completely, the measures were administered to them and response sheets were collected.
The 70 participants (n=70) who were positive in the area of difficulty in the writing and low score less than 50 on DTLD and less than 5 on Eye-hand Coordination (EHC) subtest of diagnostic tests of Learning Disability were identified as subjects with writing difficulties (dysgraphia). The participants (n=70) who were writing difficulties (dysgraphia) were considered for Intervention. The parents of the identified participants were approached for the consent, to be the part of the research. Figure-1 show 56 children were completed this intervention study in two groups (experimental group and placebo group). Three-month intervention with 2 sessions per week (1-2 hour per session) was done in a school with the experimental group through group sessions and individual (see annexure 1 and 2). Each task of the intervention was administered twice on all the 28 participants to refine their skills. The placebo group subjects only involved in daily routine activities they were not receiving any type of intervention during the period. After completing all the intervention sessions, all measurements (Raven’s coloured progressive matrices, behavioural problem checklist and DTLD) were again administered on both the groups for the postcondition data. The responses were coded by the scoring pattern given in the manual. Three months after the end of intervention sessions, a post-test assessment was done by questionnaire for both groups.
Statistical Analysis
The data were analyzed by ANOVA, Wilcoxon signed-rank test statistics on the pre-post scores of learning disability test, intelligence scale and behavioural problem for Indian children with the help of SPSS 16 V. The level of statistical significance was set at a p-value less than 0.05.
Results
The participants in this study, who were residents of Chhattisgarh, included 56 students with writing disabilities between the ages of 8 and 11 years (male, n=31; female, n=25) who were attending schools education in Chhattisgarh. Details of the participant with regards to demographics are shown in Table 1 (see table-1).
The Kolmogorov-Smirnov test and Levene's test were used to determine the normal distribution and Homogeneity of Variances of data. Due to the normality of data distribution of the Placebo group, parametric tests were used to analyze the data.
The Significant value of Levene's test of homogeneity of variance indicates that the finding would alert us to the fact that the sampling distribution might be not normal in overall EHC score of the experimental group. Further normality test of normal distribution in EHC subtest also reveals that the data is not normally distributed this permission to use the non-parametric test. For this purpose the nonparametric test of difference viz. Wilcoxon Signed Ranks Test was worked out to find the significance of the difference between pre and post condition in EHC subtest of the experimental group.
Figure-2 and table-2 show the results of the mean value of intelligence, behavioural problems, learning disability and its dimensions. Table-2 shows a small non-significant change in mean value on post-intervention for the placebo group.
The results in behavioural problems show a significant decrease in post-intervention for the experimental group (see table-2). The mean of post-intervention behavioural problems score was lower than the mean of pre-intervention behavioural problems scores (see figure-2). The results in the total LD score show a significant increase in post-intervention for the experimental group (see table-2). The mean of post-intervention total LD scores was slightly higher than the mean of pre-intervention total LD scores (see figure-3). But, the results in figure-ground perception, figure constancy, position-in-space, spatial relations, auditory perception, cognitive abilities, memory, receptive language, expressive language and intelligence showed a small non-significant change on post-intervention for the experimental group (see figure-2 and table-2).
The results in eye-hand coordination show a significant increase in post-intervention for the experimental group (see table-3). The mean rank of post-intervention eye-hand coordination scores was higher than the mean rank of pre-intervention eye-hand coordination scores (see figure-2).
Discussion
The main objective of the present study was to examine the effectiveness of Behavioral Intervention with fine motor training on learning disability test, behavioural problem and intelligence among children with Dysgraphia. These results demonstrate that increased eye-hand coordination (EHC) with fine motor development help to reduce behavioural problems. Regular physical activity and exercise help to increase adaptation and emotional stability by relieving psychological tension, anxiety, and fatigue23,24. The basic reason for the results is relaxation training because the study reported four weeks of relaxation training affects HPA- Hypothalamic-pituitary-adrenal Axis by decreasing the level of Salivary Cortisol. Cortisol is a reliable physiological marker of stress. Cortisol play important role in the development and expression of a sequence of behavioural changes25.
The experimental group reported an increase in their scores in EHC sub-tests. This study has consisted of the findings of previous studies who reported that the EHC can be enhanced through exercises or EHC training26,27. The significant difference was reported between Pre-Test and Post-Test scores of children concerning the four components of fine motor skills after Activity-based program28. Reasons for this result which could be attributed by the fine motor training and to the growing age. Some children immediate increase from their pre-class to next grade class or they pass from first-class to another class so that their brain, cognition and motivational beliefs (MB) develop and it may prevent the difficulties in writing. Influential effect on the improvement of their individual and educational behaviour can be produced by awareness of the quality of MB creation in the children29. Research related to the brain has shown that as learners to be able to connect to our world through our senses and continually make more sense of it through strengthening and building upon neural pathways. The study reported coordination of small muscle movement which occurs in fingers in coordination with the movement of eyes can be defined as fine motor skills30. The utility of writing, grasping small objects and fastening clothing skills involved in the small muscles of the body31,32. The fine motor skills involve strength, fine motor control, and dexterity. In this study, Fine Motor training includes; the ability of the eyes to follow and focus on an object in the field of vision as required for Ocular Motor Placebo and activities with the hands guided by the eyes requiring accuracy in placement direction and spatial awareness to execute hand-eye coordination. Accurately manipulate the hands and fingers for neat handwriting, drawing, typing skills ability can improve manual dexterity. The intervention group did not found any significant change in IQ. Because the review of the literature does not found in the improvement in the Intelligence yet the tasks included are aimed at delivering the cognitive stimulation which may affect the intelligence scores of the subject. The studies in which the fine motor training is used as an intervention module are also tested on the IQ but that is on the cognitive assessment system, which does not provide the traditional IQ scores. Therefore, it cannot be generalized that this behavioural intervention with the fine motor can enhance the IQ scores. Limitations of this study include the administration of assessment tools that have been not been specifically validated in a Hindi medium Indian context. Another limitation was the underrepresentation of ages (8-11) in the sample which could limit the generalisability across ages. The lesser number of participants may have affected the statistical result.
Conclusions
Findings of the research empirically prove that activity had a positive effect in enhancing the EHC and reducing the behavioral problem in children with Dysgraphia. Overall this study’s findings point behavioural intervention with activity-based fine motor training as a possible useful technique, with good acceptance by children, which can be used by campus health services to create a response to reduce students’ behavioural problems.
Abbreviations:
Diagnostic test of learning disabilities (DTLD); Eye-hand Co-ordination(ECH); Figure Ground Perception(FG); Figure Constancy(FC); Position-in-Space(PS); Spatial Relations(SR); Auditory Perception(AP); Cognitive Abilities(CA); Memory(M); Receptive Language(RL); Expressive Language(EL); Behavioral Problems(BP); Intelligence(IQ) .
Acknowledgement:
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references to 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 and discussed.
Contribution of authors:
All the authors equally contributed in planning, data collection, data processing and writing the manuscript.
Conflict of interest
There were no conflicts of interest to declare.
Sources of financial support- None
Compliance with Ethical Standards
Informed consent: All participants gave written informed consent.
Ethical consideration: The study was approved by the Institutional Ethics Committee, (Pt. Ravishankar Shukla University Raipur, India No.6917/Acad.Ph.D./2018).
What is already known?
• Students of learning disabilities may suffer from emotional problems and behavioural problem and associated with psychological comorbidities
Novelty
• Behavioral intervention with activity-based fine motor training to be useful in the classroom.
• The research empirically proves that activity had a positive effect in enhancing the EHC and overall psychological health with reducing behavioural problems.
What are the future clinical and research implications of the study findings?
Overall this study’s findings point behavioural intervention with activity-based fine motor training as a possible useful technique, with good acceptance by children, which can be used by campus health services to create a response to reduce students’ behavioural problems.
Englishhttp://ijcrr.com/abstract.php?article_id=2914http://ijcrr.com/article_html.php?did=2914
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