Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241710EnglishN-0001November30General SciencesAMELOBLASTIC FIBRO SARCOMA OF THE MANDIBLE IN A YOUNG MALE
English0105Balasubramanian A.English N. S. KannanEnglishAim: Aim of this study is to report a rare case of Ameloblastic Fibro Sarcoma (AFS) of mandible arising as a denovo malignancy and to review the literature with reference to so far reported cases, nomenclature, classification, differential diagnosis and management.
Case report: A 14 year old male patient presented with complaints of a painless swelling of left side of the face since 1 year. Based on clinical presentation and investigation reports it was diagnosed as a case of AFS in left side of mandible arising as a denovo malignancy. He underwent left hemimandibulectomy ‘en bloc’ with part of the adjacent masseter and pterygoid muscles under general anaesthesia.
Discussion: Ameloblastic Fibro Sarcoma (AFS) is one of the rare histopathology variety of odontogenic tumours. The first case of AFS was reported in 1887 by Heath. Since then only 91 cases have so far been reported. This number includes both denovo and sarcomatous transformation from pre-existing ameloblastic fibroma, occurring in different sites. The most common site affected is mandible [78%]. The mean age of patients with tumours arising denovo is 22.9 years. Ours is a case of AFS arising as a denovo malignancy in left side of mandible.
Conclusion: We are presenting our case due to rarity and the limited information that exists regarding histopathology characteristics of AFS, lack of defined criteria for grading and biologic behaviour of these tumours, making the diagnosis eluding, treatment decision challenging and assessment of prognosis difficult.
EnglishOdontogenic tumours, Denovo malignancy, Orthopantomogram, Hemimandibulectomy ‘en bloc’INTRODUCTION
Ameloblastic Fibro Sarcoma (AFS) is one of the rare histopathology variety of odontogenic tumours. The first case of Ameloblastic Fibro Sarcoma (AFS) was reported in 1887 by Heath. Since then only 91 cases have so far been reported in literature. This number includes both denovo and sarcomatous transformation from pre existing ameloblastic fibroma, occurring in different sites. The most common site affected is mandible [78%]. The mean age of patients with tumours arising denovo is 22.9 years. Biopsy is required for preoperative diagnosis. The management of AFS should be wide surgical excision with surrounding soft tissue especially if there is cortical disruption as in our case, due to its propensity for high local recurrence. We report a rare case of Ameloblastic Fibro Sarcoma (AFS) in left side of mandible in a 14 year male, arising as a denovo malignancy and the literature is reviewed with reference to so far reported cases, nomenclature, classification, differential diagnosis and management.
CASE DETAILS
A 14 year old male patient presented in outpatient department with complaints of a painless swelling of left side of the face since 1 year (Figure 1a and 1b). Clinical examination revealed a swelling of 12 x 10cm involving the left side of the mandible with firm to hard consistency. Overlying skin appeared normal. On intraoral examination, the swelling was extending from the region of left lower canine tooth to the retro molar region and with lingual version of canine and premolars, medially displaced second premolar, loosening of first molar and missing left lower second molar tooth. There was no cervical lymphadenopathy. Orthopantomogram (Figure 2) showed expansile lytic lesion involving the left side of the mandible extending from the area beneath the root of the left lower canine, posteriorly up to the condyle with resorption of roots of both the premolars, fracture of the 1st molar tooth, missing of second molar tooth and grossly displaced unerupted third molar tooth. Contrast Enhanced Computerised Tomography (CECT) of head and neck showed circumferential cortical expansion with thinning of the cortex and areas of cortical disruption involving the horizontal ramus, coronoid process and ascending ramus up to the condyle on the left side of the mandible (Figure 3a 3b and 3c). Other routine investigations were within normal limits. Incision biopsy revealed features of Ameloblastic Fibro Sarcoma. The case was posted for surgery and under general anaesthesia, left hemimandibulectomy ‘en bloc’ with part of the adjacent masseter and pterygoid muscles was done (Figure 4a 4b and 4c). Left lower jaw reconstruction was done with titanium plate. Post operative orthopantomogram is shown in (Figure 5). Postoperative period was uneventful and specimen (Table/Fig 6) sent for histopathology (Figure 7a, 7b and 7c) was reported as Ameloblastic Fibro Sarcoma with negative resection margins. Immunohistochemistry for Vimentin marker was positive. Immediate post operative picture is shown in (Figure 8a). Picture at one month follow up was aesthetically satisfying (Figure 8b). On one year follow up, the patient was hale and healthy and no recurrence so far. He is still under continuous follow up.
DISCUSSION
The first case of Ameloblastic Fibro Sarcoma (AFS) was reported in 1887 by Heath1 . So far, only 91 cases have been reported in the literature2-4. AFS is a rare mixed malignant odontogenic tumour composed of benign epithelial component and malignant ectomesenchymal component5 .Classification of malignant odontogenic sarcomas includes other odontogenic sarcomas, specifically two closely related entities that have similar histological features as AFS, ameloblastic fibrodentinosarcoma and fibro-odontosarcoma; These sarcomas have similar morphologic features of AFS; however, in addition they either have dysplastic dentin (fibro-dentinosarcoma) and/ or enamel and dentin (fibro-odontosarcoma) a feature not seen in AFS6,7. These tumours can arise either denovo8 constituting two thirds or as sarcomatous transformation of pre-existing ameloblastic fibroma forming remaining one third9 . They commonly occur in young adults, usually in third decade with a wide age range from 4 months to 89 years reported in the literature and have male predilection4,6-9. The mean age of patients with tumours arising denovo is 22.9 years and is 33 years for those derived from ameloblastic fibroma10. The age of our patient is below the mean age i.e. 14 years. The most common sites affected include mandible [78%], followed by maxilla [20%] and rarely skull base. Moreover, tumours affecting maxilla and mandible tend to occur more in the posterior aspect11. Using the term odontome for any tumour arising from the dental formative tissues, Broca12 suggested a classification of odontogenic tumours (OTs) in 1869. Since then it has undergone many modifications until 1966, when WHO established a Collaborating Centre for the Histological Classification of Odontogenic Tumours and Allied Lesions (including jaw cysts) headed by Dr Jens Pindborg13. In 1971, the first authoritative WHO guide to the classification of OTs and cysts appeared, followed in 1992 by a second edition. In 2002, Philipsen and Reichart produced a revision of the 1992-edition and in 2003, the editors of the WHO Blue Book series: ‘WHO Classification of Tumours’ decided to produce a volume on the Head and Neck Tumours including a chapter on Odontogenic Tumours and Bone Related Lesions. In July of 2005, this volume was published by International Agency for Research on Cancer (IARC), Lyon. Mosqueda-Taylor, in his article have concluded: ‘The lack of uniform criteria employed for their proper identification, as well as the histomorphologic similitude found among some of them which behaves in different way, and the scantiness of proper methods to determine their precise origin makes necessary to recognize that at present, in spite of having more or less strict diagnostic criteria which have been internationally accepted, there is a need to continue developing research in the epidemiological, clinico-pathological, morpho-physiological and therapeutical fields in this area of the maxillofacial pathology’14. Still many new findings and controversies are on the offing regarding odontogenic tumours and their classification14. Classification of malignant odontogenic tumours as per WHO Classification of Head and Neck Tumours is reproduced here for ready reference (Table 1)6 . Differential diagnosis of Ameloblastic fibro sarcoma. (Reproduced from WHO Classification of Head and Neck Tumours) is shown in (Table 2)6 . The natural history of these tumours is characterised by only local aggressiveness contributing to high rate of local recurrence with little propensity for regional and distant metastases. So far, in the literature, only one case had been reported to have metastases to mediastinum and liver. It is because of this behaviour these tumours are categorised as low to intermediate grade malignancy. The gross appearance of these tumours is fleshy with white to yellowish cut surface. Microscopically epithelial component resembles follicular ameloblastoma where the cells have palisading arrangement. These epithelial islands are separated by ectomesenchymal stroma, which forms the bulk of the tumour. Stroma is hyper cellular with polygonal to fusiform cells revealing cellular atypia and increased mitosis8,10. The common clinical features include swelling and pain. They can also present with mucosal ulceration, loosening of teeth and paraesthesia. Radiologically these tumours present as expansile radiolucent lesion with indistinct margins. Biopsy is required for preoperative diagnosis and it is often difficult to diagnose these tumours in preexisting ameloblastic fibromas wherein focal area of malignant degeneration is often missed in biopsies. In such instances, serial sectioning of the surgical specimen is mandatory to establish appropriate diagnosis. The management of AFS should be wide surgical excision with surrounding soft tissue especially if there is cortical disruption as in our case, due to its propensity for high local recurrence rate14. In mandibular AFS, it often results in segmental or hemimandibulectomy. The reconstructive options for resulting defects include mandibular reconstruction with plates or osteocutaneous free flaps. Some authors have recommended adjuvant chemotherapy and radiotherapy but their role is uncertain due to paucity of data in the literature. Radiotherapy may be of use in margin positive resections to decrease the local recurrence rate.
CONCLUSION
To conclude AFS are rare tumours and a high index of suspicion is needed before proceeding to dental extraction since these patients often present with dental pain. So far, only 91 cases have been reported in the literature. This number includes both denovo and sarcomatous transformation from pre existing ameloblastic fibroma, occurring in different sites. AFS of mandible as denovo malignancy below mean age group so far reported, continues to be a rare entity. All patients with ameloblastic fibroma treated by local excision/conservatively should be kept under close surveillance for detecting recurrence/malignant transformation, which may turn out to be AFS. These cases require to be treated by wide surgical resection en bloc with removal of surrounding tissue if tumour has perforated cortical plates. The rarity of AFS and the limited information that exists regarding histopathology characteristics, lack of defined criteria for grading and biologic behaviour of these tumours makes not only the diagnosis challenging and the treatment decision and assessment of prognosis difficult. Presentation of our case report may add up for further research.
ACKNOWLEDGMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors/editors/publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Authors are grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript.
Source of funding: Nil
Conflict of interest: Authors declare that they do not have any conflict of interest.
Englishhttp://ijcrr.com/abstract.php?article_id=536http://ijcrr.com/article_html.php?did=5361. Heath C. Lectures on certain disease of the jaws. Br Med J. 1887;2:5–13.
2. Hu YY, Deng MH, Yuan LL, Niu YM. Ameloblastic fibrosarcoma of the mandible: A case report and mini review. Exp Ther Med. 2014;8(5): 1463–6.
3. Pontes HA, Pontes FS, Silva BS, Cury SE, Fonseca FP, Salim RA, et al. Immunoexpression of Ki67, proliferative cell nuclear antigen, and Bcl-2 proteins in a case of ameloblastic fibrosarcoma. Ann Diagn Pathol. 2010;14(6):447–52.
4. Demoor-Goldschmidt C, Minard-Colin V, Cassagneau E, Supiot S, Oberlin O, D’hautuille C, et al. Ameloblastic fibrosarcoma of the mandible: report of 2 chemosensitive pediatric cases. J Pediatr Hematol Oncol. 2012;34(2):e72–6.
5. Dallera P, Bertoni F, Marchetti C, Bacchini P, Campobassi A. Ameloblastic fibrosarcoma of the jaw: report of five cases. J Craniomaxillofac Surg. 1994;22(6):349–54.
6. Barnes, L.; Eveson, J.; Reichart, P.; Sidransky, D. WHO Classification of Head and Neck Tumors Pathology and Genetics of Head and Neck Tumours; IARC Press: Lyon, France, 2005; pp. 283-328.
7. Gilani S M, Raza A, Al-Khafaji B M. Ameloblastic fibrosarcoma: A rare malignant odontogenic tumor European Annals of Otorhinolaryngology, Head and Neck Diseases. 2014;131(1):53–56.
8. Zabolinejad N, Hiradfar M, Anvari K, Razavi AS. Ameloblastic fibrosarcoma of the maxillary sinus in an infant: a case report with long-term follow-up. J Pediatr Surg. 2008;43:e5–e8.
9. Kobayashi K, Murakami R, Fujii T, Hirano A. Malignant transformation of ameloblastic fibroma to ameloblastic fibrosarcoma: case report and review of the literature. J Craniomaxillofac Surg. 2005;33(5):352–55.
10. Bregni RC, Taylor AM, García AM. Ameloblastic fibrosarcoma of the mandible: report of two cases and review of the literature. J Oral Pathol Med. 2001;30(5):316– 20.
11. Khalili M, Shakib P A. Ameloblastic fibrosarcoma of the upper jaw: Report of a rare case with long-term follow-up. Dent Res J (Isfahan).2013;10(1):112–5.
12. Broca P. Recherches sur un nuveau grupe des tumeurs désignées sousle nom d’odontomes. Gaz Hebd Sci Med. 1868;5:70-84 (Research on a new group of tumors designated under the name odontomas by Mr. Paul Broca, ... [1867 Edition]).
13. Pindborg JJ, Kramer IRH. Histological Typing of Odontogenic Tumours, Jaw Cysts and Allied Lesions. 11th ed. Geneva: World Health Organization; 1971.
14. Mosqueda-Taylor A. New findings and controversies in odontogenic tumors. Med Oral Pathol Oral Cir Bucal. 2008;13(9):E555-8.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241710EnglishN-0001November30General SciencesSYNTHESIS AND CHARACTERIZATION OF SOME NEW AZO COORDINATION POLYMERS
English0610Mohammed Khalil YounisEnglishThe synthesis of the ligand 2,2’-(4,4’-(1-methyl-3,4-phenylene bis(diazene-2,1-diyl)) bis(4,1-phenylene)) bis(azanediyl) bis(oxomethylene) dibenzoic acid (L) and its coordinated polymers with six metals (Cu+2, Co+2, Ni+2, Pt+2, Th+4 and U+6) are characterized by elemental analysis, IR, electronic spectra and magnetic susceptibility. Thegeometries of the complexesdiver between octahedral and square plannerexcept for Th+4 and U+6 complexes which are eight coordinated number. All the complexes have a well considerable biological activity against different organisms.
EnglishCoordination polymers, Azo dye, Phthalamic acid, Biological activity1. INTRODUCTION
Coordination polymers were mentioned and developed nearly 50 years ago1 . Since that time, they witnessed much progress as their properties focus on waste water treatment in metal recovery, antifouling paints, anti-bacterial, anti-fungal properties, sensing and gas storage2-5. Azodyesareconsidered to be one of thefamous class of organic chemical family characterized with wide properties and attracted the attention of researchers since that time.The diversity of their colors turns the application towards pigments and dyes for a long time.6,7 Furthermore, their superior optical and thermal properties have been studied widely8 in optical recording medium9 , nonlinear optical elements and printing systems10. In this work,bisazo dye is synthesized with phthalamic acid group in order to investigate itscoordinated bonding with six elements. This approves that this compound acts as a good metal chelating agent. 2.
2. MATERIALS AND METHODS
3,4 toluene diamine (fluka), cobalt(II) chloride dihydrate (Carl Roth), nickel(II) chloride dihydrate (Carl Roth), Copper(II) chloride dihydrate (fluka) (Carl Roth), potassium tetrachloroplatinate(II) (fluka), thorium(IV) nitrate hydrate (fluka), uranyl(VI) acetate dihydrate (fluka), all the other chemicals were used as received without any purification and were of analytical grade.
Synthesis of 2,2’-(4,4’-(1-methyl-3,4-phenylenebis (diazene-2,1-diyl))bis(4,1-phenylene))bis(azanediyl) bis(oxo methylene)dibenzoic acid(L):
The ligand was prepared as described earlier by diazotization and coupling classical procedures11,12, as seen in scheme 1.
Scheme 1: Synthesis of 2,2’-(4,4’-(1-methyl-3,4- phenylenebis(diazene-2,1-diyl))bis(4,1-phenylene)) bis(azanediyl) bis(oxo methylene)dibenzoic acid [L] and their polymeric complexes
2.1. Synthesis ofCoordination
Polymers (0.001 mol) of metal salt is dissolved in formic acid (50 ml) and mixed with (0.001 mol) of ligand L solution in (50 ml) formic acid. The mixture is reflexed for 8hs. In order to complete the precipitation of the polymeric complex, the solution must be alkalized with dilute ammonia solution and heated for 3 hr. The complex is filtered and washed several times with water accompanied with acetone and dried at 45 °C for 24 hr.
2.2. Physical Measurements
Analysis of the ligand L and its complexes are carried out using C.H.N.S elemental analyzer model 2400 Perkin Elmer. IR spectra are measured at room temperature using Perkin-Elmer spectrum one B FTIR spectrophotometer equipped with potassium bromide (KBr). Conductivity meter JENWAY 4510 , is used to measure the conductivity of the complexes. These measurements are carried out using 10-3M of absolute ethanol. The magnetic susceptibility measurements of coordination polymers are carried out at room temperature by Faraday’s method using Bruker BM6 instrument. The electronic spectra of coordination polymers are recorded by UnicamHEλIOSβ UV-VIS 2000 spectrophotometer using 10-3absolute ethanol solution at room temperature.
2.3. Antibacterial Activity
Biological activity of the prepared complexes are screened against five isolated organisms (Klebsiella pneumonia, Escherichia coli, Enterococcus faecalis Pseudomonas aeruginosa and Staphylococcus aureus) at 10-3M concentration in DMSO on Muller-Hinton agar plates by disk diffusion method25. These agars are incubated for 24 hs at 37 °C. The inhibition zone is measured in mm as well. 3.
3. RESULTS AND DISCUSSION
3.1. Infrared of the Ligand and its Polymeric complexes
The ligand 2,2’-(4,4’-(3-methyl-1,2-phenylenebis (diazene-2,1-diyl))bis(4,1-phenylene))bis(azanediyl) bis(oxomethylene)dibenzoic acid (L), isisolated in pure form (dark brown color). The important spectral bands for this ligand and its coordination polymers in IR spectrum are recorded as KBr disks and are shown in (Table 2). The main functional bands for the prepared ligand are as follow, a broad band at 3326cm-1 and 3441 cm-1 of ?(COO-H) and ?(NH) respectively. The bands at 1708 cm-1 and 1637 cm-1 are of ?(C=O) for the carboxylic and amide groups as follow. The band around 1505 cm-1 are attributed the azo ?(N=N) group, all the other groups at their expected regions13. This confirm the successful synthesis of the ligand. As a result of comparing the spectrum of the ligand with its polymeric complexes, it is found that there are many shifts and differences which can be illustrated as follows, The broad band at 3336 cm-1 of the ligand is disappeared in the spectrum of the polymeric complexes. This confirms the bonding at (-OOH). The ?(C=O) band of amide are shifted to lower frequencies (18-24 cm-1) except the complexes of Th+4 and U+4 which shifted to higher one (4-9 cm-1). These shifts give us an idea about the type of coordination bonding occurred at (C=O and COOH) groups respectively14. Also the weak stretching bands at 1268 cm-1 and 1278 cm-1 for (C-O) in the ligand are shifted to lower frequencies in their complexes. These results indicate the formation of C-O-M stretching bond15 . The uranyl complex exhibits two bands at 937 and 874 cm- 1 , which are as-signed to the asymmetric stretching frequency and symmetric stretching frequency, respectively of the dioxouranium ion16.
3.2. Electronic Spectra and Magnetic Susceptibility
The magnetic moment (µeff) of the complexes are given in (table 1). The electronic spectrum of the Co+2 complex gives three bands at 318, 359, 484 nm(broad in nature) with transitions 4 A2 g(F)→T2 g(F), 4 T1 g(F)→4 A2 g(F), 4 T1 g(F)→4 T1 g(P).These bands with its magnetic moment value indicate the high spin octahedral geometry with orbital contribution16.Cu+2 complex also gives three bands at 311, 354 and 473 nm mainly of 2 B1g→2 A1g. A transition typically suggestsa distorted octahedral geometry enhanced by a high value of magnetic moment 2.1 (µeff)17. Ni+2 complex also gives three bands at 306, 365 and 477 nm assigned as 3 A2 g →3T2g(F), 3 A2 g→3 T1 g(F), 3 A2 g→3 T1 g(P) transitions respectively .These bands with magnetic moment 4.8 (µeff) suggest octahedral geometry with orbital contribution18.Platinum+2 complexes show strong band at 306 nm and two weak bands at 399 and 498 nm. These two bands are assigned as 1 A1 g →1 A2 g transition in square planner geometry19,20, with diamagnetic property as enhanced with magnetic moment value 0.981 (µeff).Uranyl(VI)complex gives three bands, the first two peaks at 311 and 355 nmare of charge transfer, while the last band at 475 nm can be definitely assigned as oxygen to f transition with almost eight coordinate geometry21,22. Thorium (IV) complex also givesfour bands, the first three one at 306, 360, 398 nm which assigned as charge transfer while the fourth one at 503 nm, as in uranyl complex, with almostten coordinate geometry23,24.
3.3. Biological Activity Study
The antimicrobial activity examination of the polymeric complexes is carried out by disk diffusion method25,26. The test solutionsis prepared in dimethyl sulfoxide. The zone of inhibition is measured in mm and the values are summarized in (table 3). These values indicate that all the complexes have moderate activity towards the tested organisms.Thorium and uranium complexes have the highest activity and that has beenexplained on the basis of overtone’s concept and chelating theory27,28. 4.
CONCLUSION
Bisazo dye with phthalamic acidshowsa good chelating activity towards different metals, and act as a bidentate ligand. The geometry of the complexes vary as octahedral(copper, nickel and cobalt), square planner (platinum) and 8 to 12 coordination number (thorium and uranium) respectively. All the complexes show moderate biological activity towards different bacterial types. 5.
ACKNOWLEDGEMENT
Author acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors /publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=537http://ijcrr.com/article_html.php?did=5371. Chin-Ti C. and Kenneth S. Suslick, Coordination Chemistry Reviews, 1993,128, 293.
2. MorsaliA. and MasoomiM. Y., Coord. Chem., Rev.2009, 253, 1882.
3. GaralehM.,LahciniM.,KricheldorfH.R and Weidner S. M., J PolymSci Part A: Polym Chem., 2009, 47, 170.
4. KirillovA.M., KarabachY.Y., HaukkaM., Guedes da Silva M.F.C., anchizJ.,Kopylovich M.N. andPombeiroA.J.L., Inorg. Chem., 2008,47, 162.
5. Chu Z.L., Huang W., Zhu H.B. andGou S.H., J. Mol. Struct., 2008,874, 1.
6. KohJ. and Greaves A.J, Dyes Pigments,2001,50, 117.
7. Karci F., ?ener I and, Deligöz H., Dyes and Pigments, 2003,59, 53.
8. Maho K., Shintaro T., Yutaka K., Kazuo W., Toshiyuki N. and Mosahiko T., J Appl Phys., 2003, 42, 1068.
9. Patel A.D., Patel R.S. and Patel G.R., E-Journal of Chemistry.,2010, 7(3),1023.
10. Patel K.D. and Patel H.S.,Der Pharmacia Lettre., 2011, 3(1), 356.
11. Shukla H. M. , SolankiYogesh K., Shah Ashish R., Shah PurveshJ.,Shah Amish I. and Raj Dilipsinh S., Res.J.Chem. Sci., 2013, 3(1), 48.
12. Al-JibouriM. N , Taghreed M. M. and Al-Ameen B. O., Eur. Chem. Bull., 2014, 3(5), 422-425.
13. Dana W. Mayo, Foil A. Miller and Robert W. Hannah, 2003 “course notes on the interpretation of infrared and raman spectra”,1st Edition John Wiely New York.
14. SatpathyK.C., PandeA.K., Mishra R. andPanda I., Synth. React. Inorg. Met. Org. Chem., 1991,21, 531.
15. Nakamoto K. ,1997 “Infrared of inorganic and coordination compounds”, 6th Edition, John Wiely New York.
16. Mamdouh S. Masoud, Sawsan S. Hagagg, Alaa E. Ali andNessma M. Nasr, Journal of Molecular Structure, 2012, 1014, 17–25.
17. Khyati D. Patel and Hasmukh S. Patel, Der Pharmacia Lettre, 2011, 3(1), 356.
18. Purav T. and ChaudhariJ.A.,J. Chem. Bio. Phy. Sci. Sec. A, 2013, 3, (1), 109.
19. Monika T. andSulekh C., Open Journal of Inorganic Chemistry, 2012, 2, 41.
20. Erik W.,la Gerard van Koten, Christopher T. Knaap,la HoussainOssor, Michel Pfeffer and Anthony L. Spekld, Inorg. Chem., 1988, 27, 4409.
21. El- Ayaan U., Youssef M.M., Al-ShihryS., J. Mol. Struct., 2009, 936, 213.
22. Jahanara N., International Journal of Materials Science and Applications, 2015,4(1), 20.
23. ButtrusN.H.,and Mohammed S.I., Mutah Lil. Buhuth wad. Dirasat (Jordon), 2004, 16(1), 87.
24. Andrew C. Behrle,Charles L. Barnes, Nikolas Kaltsoyannisand Justin R.Walensky, inorg. Chem., 2013, 52, 10623
25. Franklin RC, Matthew AW, Jeff A, Michael ND, George ME, Mary JF, Dwight JH, David WH, Janet AH, Jean BP, Mair P, Jana MS, Richard BT, Maria MT, John DT, Melvin PW
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241710EnglishN-0001November30General SciencesAN AUDIT OF RED CELL CONCENTRATES USAGE FOR THALASSEMIA PATIENTS VERSUS OTHER PATIENTS IN A TERTIARY CARE HOSPITAL AT RAJKOT
English1113Ghatna KotadiaEnglish Amit AgravatEnglish Gauravi DhruvaEnglishObjective: To perform a retrospective audit of total Red Cell Concentrates (RCC) used for thalassemia patients in comparison with all other patients attended to Blood bank,P.D.U Medical College and Hospital,Rajkot.
Materials and Methods: Each and every patient who attended blood bank are considered in the study with every episodes or blood transfusion in one year.
Results: Total 4930 units of Red Cell Concentrates were issued to thalassemia patients in comparison with 9070 units of Redcell concentrates to other indoor patients.
EnglishRCC for thalassemia patientsINTRODUCTION
Thalassemias are a group of hemolytic anemia which results from an inherited abnormality of globin production. Both alpha and beta thalassemia are the most common monogenetic disorder worldwide [1]. In India ,beta thalassemia is found throughout the country and an estimated 35 million people are carriers with a higher incidence in communities like Sindhi, Punjabi, Bengali, Gujrati, Parsi and Lohana mainly[2].Regular blood transfusion remains the mainstay of therapy in absence of curative treatment, such as stem cell transplantation. While stem cell transplantation is curative, issues of donor availability, access and cost make this option available to only a small fraction of individuals. Main objective of transfusion is to suppress ineffective erythropoiesis and to prevent anemia.
MATERIALS AND METHODS
Out of total 15671 patients attended the Blood Bank, P.D.U Medical College and Hospital, Rajkot Total 365 thalassemia patients were analyzed including all the episodes of blood transfusion from January 2014 to December 2014.On an average each patients of thlassemia major were transfused with one unit of red cell concentrate at an interval of every 15 to 20 days and thalassemia intermediate at a duration of 6 months. All thalassemia patients irrespective of their age were included in the study. In patients having history of transfusion related illness leucodepleted red cell concentrates were transfused.
RESULT
Out of total 14225 units of whole blood collected in blood bank, 9070 units of red cell concentrates were issued to indoor patients in comparison with 4930 units of red cell concentrates issued to thalassemia patients in a period of 1 month. It corresponds to 64.8% of total red cell concentrates used for indoor patients and 35.2% RCC usage for thalassemia patients.
DISCUSSION
Thalassemia major is a complex disease which is common in Mediterranean regions particularly in India. Treatment for thalassemia has dramatically improved with patients living full life with carriers and children of their own. Unfortunately many patients die prematurely or develop complications. Prior to transfusion therapy it is necessary to confirm patient’s diagnosis by hemoglobin electrophoresis or by high performance liquid chromatography. Parents and siblings should be screened. Patients with thalassemia intermedia may have exaggerated anemia due to nutrition deficiency or any infection. It is important to elicit history for all these including any drugs, viral illness or environmental factors which can lower hemoglobin. Chronic transfusion prevents most of serious growth, skeletal and neurological complications of thalassemia major [3]. Irrational and long term use of transfusion in thalassemia patients without iron chelation can lead to hemosiderosis with resultant growth hormone and other endocrine deficiency leading to death [4]. Iron overload is the major cause of morbidity and mortality in thalassemia patients. The target is to keep the pre-transfusion hemoglobin level at 9 to 10 g/dl. The decision to start regular transfusion is clear when the initial hemoglobin level is well below 6g/dl. The decision to start transfusion is based on inability to compensate for low hemoglobin, or less commonly on increasing symptoms of ineffective erythropoiesis [5].The decision of chronic transfusion should not be based exclusively on presence of anemia. Febrile non-hemolytic transfusion reactions are frequent complication and can lead to additional costly medical interventions such as antipyretic and/or antibiotic usage as well as blood product wastage [6].The use of leukoreduced RBCs has been shown, in the general transfused population as well as in thalassemia patients specifically, to significantly reduce the incidence of febrile non-hemolytic transfusion reactions [7]. Annual transfusion volume exceeding 225 to 250 ml/kg per year with packed red blood cells indicate the presence of hypersplenism. Often hypersplenism develops because of low pre-transfusion hemoglobin. Increasing the pre-transfusion hemoglobin to between 9.5 to 10g/ dl may reverse hypersplenism.
CONCLUSION
Continous scrutinity regarding both the amount and duration of red cell concentrates transfusion must be done for thalassemia patients in order to prevent irrational use of red cell concentrates,iron toxicity and hypersplenism.
Englishhttp://ijcrr.com/abstract.php?article_id=538http://ijcrr.com/article_html.php?did=5381. Modell B, Darlison M.Global epidemiology of haemoglobin disorders and derived service indicators. Bull World Health Organ 2008;86:480-7.
2. Dr. Tejinder singh, Atlas and Text of HEEMATOLOGY,third edition,Hemolytic anaemia,p.g 133.
3. Piomelli S, Danoff SJ, Becker MH, et al. Prevention of bonemalformations and cardiomegaly in Cooley’s anemia byearly hypertransfusion regimen. Ann N Y Acad Sci 1969;165:427-36.
4. Schorr JB, Radel E. Transfusion therapy and its complications in patients with Cooley’s anemia. Ann N Y Acad Sci1964;119:703-8.
5. Wolman IJ. Transfusion therapy in Cooley’s anemia:growth and health as related to long-range hemoglobin levels. A progress report. Ann N Y Acad Sci 1964;119:736
6. Lane TA, Anderson KC, Goodnough LT, et al. Leukocytereduction in blood component therapy. Ann Intern Med1992;117:151-62.
7. Dzik S, Aubuchon J, Jeffries L, et al. Leukocyte reduction ofblood components: public policy and new technology. Transfus Med Rev 2000;14:34-52.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241710EnglishN-0001November30General SciencesAN EXPLORATORY ANALYSIS OF KNOWLEDGE AND PRACTICE, JOB-RELATED DIFFICULTIES AND DISSATISFACTION OF ASHAS IN RURAL INDIA
English1419Adwitiya DasEnglish Aparajita DasguptaEnglishBackground: Accredited Social Health Activist (ASHA), a voluntary worker operating under National Rural Health Mission (NRHM), was launched with the intention of improving the reproductive and child health (RCH) services in rural India.
Objectives: This study aimed to assess the knowledge and practice of ASHAs in rural Bengal, find out the predictors of poor performance, and search for causes of dissatisfaction and difficulties faced during work.
Methods: This cross-sectional study was conducted for a period of three months on 56 ASHAs, working in a particular service area. Mixed methods were employed.
Results: Out of 56 ASHAs participating in the study, working as ASHA was the only source of income in 76.79%. Majority received inadequate modular trainings (73.21%), and 39.29% lacked job satisfaction. 44.64% ASHAs had poor performance. Predictors of poor performance were age > 35 years, education less than graduate, and lack of job satisfaction. Focused Group Discussion (FGD) revealed that they were dissatisfied with inadequate remuneration and troubled by lack of essential medicine supply.
Conclusion: Urgent and effective measures should be taken for betterment of the performance of ASHAs, and to redress their grievances.
EnglishASHA, NRHM, RCH, knowledge, Practice, Job satisfactionINTRODUCTION
The Millennium Development Goals (MDGs) aim towards improvement of the physical health as well as quality of life of the people, but their achievement is limited by resource constraints, mainly dearth of health manpower.1 There is a growing concern about shortage of medical personnel and health workers worldwide as the population continues to rise.2 This shortage is far more prominent in the developing countries. Moreover, there is clustering of health workers in urban regions, along with resultant paucity of manpower in rural and remote areas.3,4,5 At this point of time, the gradually increasing role of community health workers (CHWs) is being recognized, as they are indispensable for achievement of the MDGs.6 In general, CHWs workers are healthcare providers who belong to a particular community, are selected from and trained in the same community, work for the same community and are acceptable to that community.7 CHWs is a generalized term which includes nurse-midwives, home-based care givers, salaried personnel and volunteers.6 The Accredited Social Health Activist (ASHA) is a voluntary worker, operating in the rural health system of India, introduced as the main task-force of National Rural Health Mission (NRHM). The NRHM, launched by the Government of India on April 2005 was an initiative towards achievement of the MDGs in India.8 The aim of NRHM is comprehensive healthcare, focused mainly on the rural women and children, thereby improving the reproductive and Child Health (RCH) services. ASHAs represent the cornerstone of the NRHM. The actualization of the goals of NRHM depends on the proper functioning of ASHAs. ASHAs are trained according to modules, and expected to act as a link worker between the rural popu lation and the health infrastructure.8 The present study aimed to assess the knowledge and practice of ASHAs in rural West Bengal, and find out the predictors of poor performance, along with exploratory analysis of various difficulties and causes of dissatisfaction among the ASHAs.
METHODOLOGY
This cross-sectional study was conducted in the service area of Rural Health Unit and Training Centre, Singur, Hooghly district, West Bengal, under the purview of All India Institute of Hygiene and Public Health (AIIH and PH), for a period of 3 months, starting from July 2012 to September 2012. Mixed methods, i.e. combination of a quantitative survey and qualitative technique consisting of focused group discussions (FGDs) were employed in this study. The study population comprised all ASHAs working in the said service area, and giving informed consent for inclusion in the study. For the quantitative survey, a pre-designed, pretested semi-structured questionnaire was used. The questionnaire included information regarding socio-demographic variables, a schedule for interview regarding the knowledge about the service area as well as responsibilities and practice of different services provided, job related difficulties, time allocation, and a checklist regarding training and recruitment norms. Content and face validity was ensured and translation from English to Bengali was done with care for semantic equivalence. The Crohnbach-Alpha for reliability was 0.85. The knowledge and performance were scored, with each correct response fetching ‘1’ mark, and every wrong/ unanswered response fetching ‘0’ marks respectively. The cumulative score was calculated. Median score was calculated, and ASHAs scoring less than median score were considered to have scored poorly. Finally, 56 ASHAs operating in the service area were included. For the qualitative part, 5 FGDs were conducted for 43 ASHAs, with 7-9 different participants in each, with assurance of confidentiality, anonymity and choice of dropping out at any point of time. Each FGD was about 45 minutes long, and interviews were carried on until saturation of data was achieved. The interviews were conducted in the local language, Bengali. Topics like causes of dissatisfaction about work, difficulties faced during performing their duties and attitudes of the rural people towards the ASHAs were covered. They were also asked to discuss about possible solutions to the problems they face. Written informed consent was obtained from each participant, and participation was completely voluntary. The study received clearance from the Institutional Ethics Committee of AIIH and PH. The quantitative data was entered and analyzed in IBM SPSS version 20.0. A p value less than 0.05 was considered as statistically significant. The qualitative data analysis was done after verbatim transcription and methodical and meticulous collection, collation and coding of the items into the following themes: Relevant themes were classified as individual, community, and health system. The qualitative findings were corroborated with the quantitative data appropriate to the conceptual framework of the study.
RESULTS
The background parameters of the study population is shown in Table 1. Most of the ASHAs belonged to the age group of 31-35 years (41.07%), completed graduation (33.9%), were married (94.6%), and had a low family income (55.36%). Most of them were working as ASHA for 2 years or more (82.14%). Working as ASHA was the only source of income in 76.79%. Majority received less than/equal to five modular trainings (73.21%). Nearly 39.29% reported to be not satisfied with their job as ASHA. All of them were not satisfied with their remuneration and role clarity (not shown in the table). On assessment of the knowledge regarding responsibilities and performance of ASHAs, it was observed that only 51.79% had correct knowledge about their service area and the population served. Knowledge regarding various do-s and don’t-s for maintaining optimum maternal and child health was present in 69.64% and 78.57% respectively. Regarding choice, availability and timing of contraception and family planning, only 35.71% had correct knowledge, whereas, regarding the other miscellaneous activities like community mobilization, counselling and organizing activities on nutrition and sanitation, and role as drug-depot holder was present in only 32.14% ASHA. (Table 2) Satisfactory performance in the area of maternal health, family planning, child health were present among 57.14%, 21.43% and 62.5% respectively. (Table 2) Regarding escorting the mothers and child for perinatal visits, immunizations and during minor ailments, along with staying with them when required was rather neglected (42.86%). The ASHAs facilitated institutional deliveries in only 36 (64.29%) cases (not shown in table). Other miscellaneous activities were satisfactorily performed by only 30.36% ASHAs. The median knowledge score was 6[Inter-quartile range (IQR) 5-10; Range 1-14], and median performance score was 14[IQR 12-17; Range 7-27]. When cumulative scores were calculated by summing up both the scores, median was 20 [IQR 18-26; Range 9-41]. Scores less than median were taken as poor cumulative scores. Twenty five (44.64%) ASHAs had a poor cumulative score. On multivariate analysis, covariates of poor cumulative scores were age more than 35 years, education less than graduation, and absence of job satisfaction. (Table 3)
FGDs revealed several sensitive, confidential and hidden societal aspects regarding the grievances, and commonly faced difficulties. One middle-aged ASHA said: “We are not able to carry out our duty properly most of the time, as we have to deal with inadequate and irregular medicine supply.”Another ASHA opined: “People treat us harshly, and some consider us as unwanted. I remember, one day I was not allowed to enter the premises of a house to weigh a newborn, as I belong to a backward class. In this scenario, it is impossible for us to carry out our work.” Lack of co-operation and avoidant attitude on the part of villagers was also pointed out by some ASHAs. All the ASHAs were dissatisfied with remuneration. A young ASHA commented: “I will rather pursue some clerical job in an office than continue this job. There is no fixed salary, and the remuneration is also insignificant.” Most of the ASHAs were of the opinion that the remuneration was too little for too much work: “We want to serve the villagers. But if we are paid this less, how can we continue this job? We have dependent family members.” Last year, some of the ASHAs had to leave their job because of the inadequate and inconsistent remuneration, they said. Nobody could definitely point out any possible solution, except one ASHA who asked: “Why doesn’t the government do something for us, like a fixed payment along with job-based incentives?” All the others agreed. The findings of the FGD are summarized in figure 1.
DISCUSSION
Our study revealed poor knowledge and performance in 44.64% of the ASHAs in this service area. We also found out a few predictors of poor knowledge and performance, in the form of increased age, low education and lack of job satisfaction. FGD revealed that inadequate medicine supply and harsh behaviour towards ASHAs were the main barriers to their proper functioning, and all of them were displeased regarding remuneration. The utilization of ASHA services in different scenarios and for various purposes was assessed by some authors. ASHAs have been called as a link worker, who bridges the gap between the facilities and the beneficiaries.9 However, the proper functioning of ASHAs as well as proper utilization of their services is always not possible.6 ASHA’s capacity in influencing the pregnant women to deliver in public institutions as a part of Janani Suraksha Yojana (JSY) appeared limited in a study in Ujjain district.10 On the other hand, Stalin et al have commented that ASHAs can be effectively involved in the newborn care, provided they are trained adequately.11 Studies from other parts of the country have aimed at exploring the performance of ASHAs and finding factors on which poor performance depends. Kansal et al have found that low education was a predisposing factor for poor performance, when it comes to keeping records in village health registers. He also found that performance was satisfactory in the areas of antenatal care and child care.12 Swain et al, Haider et al and Malini et al have expressed similar views.13,14,15 In our study, we observed that increasing age of ASHAs was an important predictor of poor scores in knowledge regarding responsibilities, and performance. In the present study, mean age was 33.06 years, similar to Kansal et al and Jain et al.12, 16 However, no other study has thrown any light on the effect of age on knowledge or performance. Surprisingly, in a study by Shrivastava et al, it was discovered that many of the ASHAs were below 25 years of age, which is against the rule. This, the authors explain, was due to paucity of candidates who could serve as ASHAs.17 While we found lacunae in the fields of contraception, nutrition, sanitation and imparting health education, Shrivastava et al have found deficits in the field of childhood illness recognition and referral. Jain et al have found that 70% of the institutional deliveries were facilitated by ASHA, a finding similar to our study.16 A sharp contrast is the study by Shrivastava et al. who found that ASHA facilitated institutional delivery in about 100% cases. Qualitative research in the form of focused group discussion revealed that ASHAs preferred greater hours of training and less hours of meeting.6 No other study mentions adequately about job satisfaction of ASHAs, and their grievances.
CONCLUSION
The present study, in spite of having a small sample size and cross-sectional nature, hints at probable factors which might influence proper functioning of ASHAs. However, to formulate effective measures to improve the performance of ASHAs as well as facilitate the adequate utilization of ASHA services by the beneficiaries, large-scale longitudinal and interventional studies are required. To our belief, this study might carve the path for future research regarding improper functioning of ASHAs.
ACKNOWLEDGEMENTS
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=539http://ijcrr.com/article_html.php?did=5391. Mannan H, Boostrom C, Maclachlan M, McAuliffe E, Khasnabis C, Gupta N. A systematic review of the effec-tiveness of alternative cadres in community based rehabilitation. Hum Resour Health. 2012; 10: 20.
2. Ossai E N, Ibiok N C, Chukwuogo O, Umeobieri A K, Aniwada E C, Ugwunna N C. Rural retention of human resources for heath. Niger J Med. 2012;21:138-45.
3. Lehmann U, Dieleman M, Martineau T. Staffing remote rural areas in middle- and low-income countries: a literature review of attraction and retention. BMC Health Services Research. 2008; 8: 19.
4. Dussault G, Franceschini M C. Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce. Human Resources and Health. 2006; 4: 1.
5. Schriver M, Ertner G, Aabenhus M M, Kallestrup P. [Solutions to the global shortage of health workers]. Ugeskr Laeger. 2012; 174: 1521-4.
6. Gopalan S S, Mohanty S, Das A. Assessing community health workers’ performance motivation: a mixed-methods approach on India’s Accredited Social Health Activists (ASHA) program. BMJ Open. 2012; 2.
7. Scott K, Shanker S. Tying their hands? Institutional obstacles to the success of the ASHA community health worker program in rural north India. AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV 2010; 22 Suppl 2:1606-12.
8. Government of India. National Rural Health Mission (2005- 2012) Mission Document. New Delhi: Ministry of Health and Family Welfare, 2005.
9. Singh M K, Singh JV, Ahmad N, Kumari R, Khanna A. Factors Influencing Utilization of ASHA Services under NRHM in Relation to Maternal Health in Rural Lucknow. Indian J Community Med. 2010; 35: 414–419.
10. Sidney K, Diwan V, El-Khatib Z, De Costa A. India’s JSY cash transfer program for maternal health: Who participates and who doesn’t - a report from Ujjain district. Reprod Health. 2012; 9: 2.
11. Stalin P, Krishnan A, Rai S K, Agarwal R K. ASHA’s Involvement in Newborn Care: A Feasibility Study. Indian Pediatrics. 2011; 48: 897-899.
12. Kansal S, Kumar S, Kumar A. Is educational level of ASHA matters for their effective functioning? A cross- sectional study in eastern Uttar Pradesh. Indian Journal of Community Health. 2012; 24: 41-44.
13. Swain S, Swain P, Nair K S, Dhar N, Gupta S, Nandan D. A rapid appraisal of functioning of ASHA under NRHM in Orrisa. Health and Population: Perspectives and Issues. 2008; 31: 73-79.
14. Haider S, Adhisih V, Gupta S, Dhar N, Datta U, Manon S, Nandan D. A rapid appraisal of Sahiya in Jharkhand. Health and Population: Perspectives and Issues. 2008; 31: 80-84.
15. Malini S, Tripathi R M, Khatter P, Nair K S, Tekhere Y L, Dhar N, Nandan D. A rapid appraisal of functioning of JSY in south Orrisa. Health and Population: Perspectives and Issues. 2008; 31: 126-131.
16. Jain N, Srivastava NK, Khan AM, Dhar N, Manon S, Adhish V, Nandan D. Assessment of functioning of ASHA under NRHM in Uttar Pradesh. Health and Population: Perspectives and Issues. 2008; 31: 132-140.
17. Shrivastava SR, Shrivastava PS. Evaluation of trained Accredited Social Health Activist (ASHA) workers regarding their knowledge, attitude and practices about child health. Rural and Remote Health. 2012; 12: 2099.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241710EnglishN-0001November30General SciencesCADAVERIC STUDY OF THE EXIT OF SCIATIC NERVE
English2024Shaheen RizviEnglish Sharadkumar Pralhad SawantEnglishAims: To study the exit of sciatic nerve in 100 cadavers.
Materials and Methods: In the department of Anatomy of K.J.Somaiya Medical College, Sion, Mumbai, India, the study on exit of sciatic nerve was performed on 100 (200 specimens of Inferior Extremities) embalmed donated cadavers (80 males and 20 females). The specimens were classified into six groups.
Observations: In Type I, 106 (103 males and 3 female) of the 200 (53%) specimens, the exit of the sciatic nerve below piriformis muscle. In Type II, 44 (all males) out of 200 (22%) specimens, the exit of common peroneal nerve through piriformis muscle and
the tibial nerve below piriformis muscle. In Type III, 24 (22 males and 2 female) out of 200 (12%) specimens, the exit of common peroneal nerve above piriformis muscle and the tibial nerve below piriformis muscle. In Type IV, 16 (all males) out of 200 (8%) specimens, the exit of sciatic nerve through piriformis muscle. In Type V, 6 (4 males and 2 females) out of 200 (3%) specimens, the exit of tibial nerve above piriformis muscle and common peroneal nerve through piriformis muscle. In Type VI, 4 (all males) out of 200 (2%) specimens, the exit of sciatic nerve above piriformis muscle.
Conclusion: Sciatic nerve division into the tibial and common peroneal components at a higher level can result in the involvement of only one out of the two divisions in sciatic neuropathy. It can also result in a failure of the sciatic nerve block while performing popliteal block anaesthesia. These anatomical variations may contribute to clinical conditions such as piriformis syndrome, sciatica and coccygodynia.
EnglishSciatic nerve, Gluteal region, Piriformis, Sciatic nerve block, Piriformis syndrome, SciaticaINTRODUCTION
The sciatic nerve also known as the ischiadic nerve and the ischiatic nerve is 2 cm wide at its origin and is the thickest nerve in the body. It leaves the pelvis via the greater sciatic foramen below piriformis and descends between the greater trochanter and ischial tuberosity, along the back of the thigh, dividing into the tibial and common peroneal nerves at a varying level proximal to the knee. Superiorly it lies deep to the gluteus maximus, resting first on the posterior ischial surface with the nerve to quadratus femoris between them. It then crosses posterior to obturator internus, the gemelli and quadratus femoris, separated by the latter from obturator externus and the hip joint. It is accompanied medially by the posterior femoral cutaneous nerve and the inferior gluteal artery. More distally it lies behind the adductor magnus and is crossed posteriorly by the long head of the biceps femoris. It corresponds to a line drawn from just medial to the midpoint between the ischial tuberosity and greater trochanter to the apex of the popliteal fossa. Articular branches arise proximally to supply the hip joint through its posterior capsule, these are sometimes derived directly from the sacral plexus. Muscular branches are distributed to biceps femoris, semitendinosus, semimembranosus and the ischial part of adductor magnus. The point of division of the sciatic nerve into its major components (tibial and common peroneal) is very variable. The common site is at the junction of the middle and lower thirds of the thigh, near the apex of the popliteal fossa. The division may occur at any level above this, though rarely below it. It is not uncommon for the major components to leave the sacral plexus separately, in which case the common peroneal component usually passes through piriformis at the greater sciatic notch while the tibial component passes below the muscle (1). The sciatic nerve supplies the knee flexors and all the muscles below the knee, so that a complete palsy of the sciatic nerve results in a flail foot and severe difficulty in walking. This is rare and usually related to trauma. The nerve is vulnerable in the posterior dislocation of the hip. As it leaves the pelvis it passes either behind piriformis or sometimes through the muscle and at that point it may become entrapped (the piriformis syndrome; this is a common anatomical variant but an extremely rare entrapment neuropathy). External compression over the buttock (e.g. in patients who lie immobile on a hard surface for a considerable length of time) can injure the nerve. The commonest cause of serious sciatic nerve injury is iatrogenic. It may be damaged in misplaced therapeutic injections into gluteus maximus. The safe zone for deep intramuscular injections here is the upper outer quadrant of the buttock. Perhaps safer still is to inject into the quadriceps, though this can produce problems of its own, e.g. haemorrhage, leading to contracture of the muscle, which limits knee movement. Sciatic nerve palsy occurs after total hip replacements or similar sureries in 1% of cases. This can be due to sharp injury, burning from bone cement, traction from instruments, manipulation of the hip, inadvertent lengthening of the femur, or haematoma surrounding the nerve or within its soft tissue coverings. Haematoma is characterised by the development of severe pain in the immediate post operative period. Early surgical exploration and evacuation of haematoma can reverse the nerve lesion. Unfortunately the other causes may not be reversed. The majority are temporary. Complete sciatic nerve palsy is very rare. For some reason, possibly anatomical, the common peroneal part is more usually affected. The patient has a foot drop and a high stepping gait (1). The sciatic nerve bifurcates into two major divisions (tibial and common peroneal), most commonly at the lower part of the posterior compartment of the thigh (1, 2, 3, 4, 5). Several authors have reported variations in its division into the tibial and common peroneal nerve from the sacral plexus to the lower part of the popliteal space (3, 4, 5, 6, 7, 8, 9). These anatomical variations may contribute to piriformis syndrome, sciatica, coccygodynia and muscle atrophy (10). This should be taken into account by clinicians who are planning interventions around the sciatic nerve and its division in the lower extremity (11).
MATERIALS AND METHODS
This study on division of sciatic nerve was performed on 100 (200 specimens of Inferior Extremities) embalmed donated cadavers (80 males and 20 females) in the department of Anatomy of K. J. Somaiya Medical College, Sion, Mumbai, India. To study the exit of the sciatic nerve 200 specimens were classified into six groups. Group A, the exit of the sciatic nerve below piriformis muscle. Group B, the exit of common peroneal nerve through piriformis muscle and the tibial nerve below piriformis muscle. Group C, the exit of common peroneal nerve above piriformis muscle and the tibial nerve below piriformis muscle. Group D, the exit of sciatic nerve through piriformis muscle. Group E, the exit of tibial nerve above piriformis muscle and common peroneal nerve through piriformis muscle and in Group F, the exit of sciatic nerve above piriformis muscle. The photographs were taken for proper documentation.
Observations:
In Type I, 106 (103 males and 3 female) of the 200 (53%) specimens, the exit of the sciatic nerve below piriformis muscle.
In Type II, 44 (all males) out of 200 (22%) specimens, the exit of common peroneal nerve through piriformis muscle and the tibial nerve below piriformis muscle
. In Type III, 24 (22 males and 2 female) out of 200 (12%) specimens, the exit of common peroneal nerve above piriformis muscle and the tibial nerve below piriformis muscle.
In Type IV, 16 (all males) out of 200 (8%) specimens, the exit of sciatic nerve through piriformis muscle.
In Type V, 6 (4 males and 2 females) out of 200 (3%) specimens, the exit of tibial nerve above piriformis muscle and common peroneal nerve through piriformis muscle.
In Type VI, 4 (all males) out of 200 (2%) specimens, the exit of sciatic nerve above piriformis muscle.
DISCUSSION
During embryological development at the base of the limb bud, the nerves contributing to the lower limb forms two plexuses lumbar and sacral (12). Later, as the elements from each of these plexuses grow out into the limb, they are subdivided into the dorsal and ventral components, for the dorsal and ventral musculatures (13). The sciatic nerve is formed when the large dorsal component of the sacral plexus, common fibular nerve and the ventral component, tibial nerve move downward close together (13). Hence, based on their previously mentioned developmental formation, it is possible that the common fibular and the tibial divisions of the sciatic nerve separate from each other at different levels from their origins; in the gluteal region, the posterior compartment of the thigh or the popliteal fossa, as observed in this study. Various studies have reported on the level of sciatic nerve division into tibial and common peroneal nerves (Table 2). The incidence of sciatic nerve division before its exit in the gluteal region in our study was 42%, which was higher than that found in a study conducted by Pokorny et al (20.9%), Ugrenovic et al (4.0%) and Gabrielli et al (13.7%) (14, 15, 16). Guvençer et al (17) examined 50 gluteal regions in 25 cadavers and observed that in 52% of the cases, the sciatic nerve exited the pelvis as a whole nerve without any division, whereas in 48% of the cases, a high division of sciatic nerve was recorded (Table 2).
Saleh et al studied the level of division of the sciatic nerve into the tibial nerve and common peroneal nerve above the knee in 30 cadavers, and reported that the sciatic nerve divided at a distance of 50–180 mm above the popliteal fossa crease (13). Suresh et al recorded the measurements from the magnetic resonance images of 59 patients and proposed a formula for determining the point of bifurcation of the sciatic nerve in the posterior thigh using a linear regression model (18). Acute sciatic neuropathies commonly result from hip arthroplasty, hip fracture or dislocation. On the other hand, causes such as coma, which result in prolonged compression, are relatively rare (2).
The extent of involvement and neurological deficits vary depending on the level of division of the sciatic nerve. A high division of the sciatic nerve into the tibial and common peroneal nerves can result in the escape of either the tibial or the common peroneal nerve from one of the aforementioned causes, which would finally result in a decrease in neurological deficits as compared to the low division of the sciatic nerve. One important consequence of the high division of the sciatic nerve that has been reported by various authors is that it may lead to failure of popliteal block anaesthesia (19, 20).
Clinical significance
A high division of the sciatic nerve into the tibial and common peroneal nerves can result in the escape of either the tibial or the common peroneal nerve, which would finally result in a decrease in neurological deficits as compared to the low division of the sciatic nerve. One important consequence of the high division of the Sciatic Nerve is that it may lead to the failure of popliteal block anaesthesia.
CONCLUSION
The awareness of the variant exit of the sciatic nerve is clinically important for surgeons dealing with entrapment or compressive neuropathies, orthopaedicians operating on the fractures of femur, anaesthetist performing pain management therapies on the lower limb and physiotherapist doing electromyography for evaluating and recording the electrical activity produced by skeletal muscles. A lack of knowledge of such type of variations might complicate surgical repair.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
SR drafted the manuscript, performed the literature review and SPS assisted with writing the paper.
ACKNOWLEDGEMENT
Authors are thankful to Dean Dr. Geeta Niyogi Madam for her support and encouragement. Authors are also thankful to Mr. M. Murugan for his help. Authors also acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=540http://ijcrr.com/article_html.php?did=5401. Standring S. Gray’s Anatomy: the Anatomical Basis of Clinical Practice. 39th ed. London: Churchill Livingstone, 2005, pp 1364-1458.
2. Yuen E.C., So Y.T., Sciatic neuropathy, Neurological Clinic 1999, Vol. 17, pp 617-631.
3. Paval J., Nayak S., A case of bilateral high division of sciatic nerve with a variant inferior gluteal nerve, Neuroanatomy, 2006, Vol. 5, pp 33-4.
4. Rosse C., Gaddum-Rosse P., Hollinshead W. H., Hollinshead’s Textbook of Anatomy, 5th ed. Philadelphia: Lippincott-Raven Publishers, 1997, pp 324-651.
5. Moore K. L., Dalley A. F., Clinically Oriented Anatomy, 4th ed. Philadelphia: Lippincott Williams and Wilkins, 1999, pp 347-560.
6. Ndiaye A., Sakho Y., Fall F., Dia A., Sow M.L., Sciatic nerve in gluteal portion: application of sciatic nerve post injection lesion, Morphologie 2004, Vol. 88, pp 135-138.
7. Arifoglu Y., Surucu H.S., Sargon M.F., Tanyeli E., Yazar F., Double superior gemellus together with double piriformis and high division of the sciatic nerve, Surgical Radiological Anatomy, 1997, Vol. 19, pp 407-8.
8. Valade N., Ripart J., Nouvellon E. et al., Does sciatic parasacral injection spread to the obturator nerve? An anatomic study. Anesth. Analg. 2008, Vol. 106, pp 664-7.
9. Benzon H. T., Katz J. A., Benzon H. A., Iqbal M. S., Piriformis syndrome: anatomic considerations, a new injection technique, and a review of the literature, Anaesthesiology 2003, Vol. 98, pp 1442-8.
10. Schwemmer U., Markus C.K., Greim C.A. et al., Sonographic imaging of the sciatic nerve and its division in the popliteal fossa in children. Paediatric Anaesthesiology 2004, Vol. 14, pp 1005-1008.
11. Babinski M. A, Machado F. A., Costa W. S., A rare variation in the high division of the sciatic nerve surrounding the superior gemellus muscle. Europian Journal of Morphology 2003, Vol. 41, pp 41-2.
12. Demiryurek D., Bayramoglu A., Erbil M., Aldur M. M., Mustafa E. S., Bilateral divided piriformis muscle together with the high division of the sciatic nerve. Gazi Medical Journal 2002, Vol. 13, pp 41-4.
13. Saleh H. A., El-fark M. M., Abdel-Hamid G. A., Anatomical variation of sciatic nerve division in the popliteal fossa and its implication in popliteal nerve block, Folia Morphol (Warsz) 2009, Vol. 68, pp 256-259.
14. Pokorny D., Jahoda D., Veigl D., Pinskerova V., Sosna A., Topographic variations of the relationship of the sciatic nerve and the piriformis muscle and its relevance to palsy after total hip arthroplasty, Surgical Radiological Anatomy 2006, Vol. 28, pp 88-91.
15. Ugrenovic S., Jovanovic I., Krstic V. et al., The level of the sciatic nerve division and its relations to the piriform muscle. Vojnosanit Pregl 2005, Vol. 62, pp 45-49.
16. Gabrielli C., Olave E., Mandiola E. et al., Inferior gluteal nerve course associated to the high division of the sciatic nerve. Rev. Chil. Anat. 1997, Vol. 15, pp 79-83.
17. Güvençer M., Iyem C., Akyer P., Tetik S., Naderi S., Variations in the high division of the sciatic nerve and relationship between the sciatic nerve and the piriformis, Turk Neurosurgery 2009, Vol. 19, pp 139-44.
18. Suresh S., Simion C., Wyers M. et al. Anatomical location of the bifurcation of the sciatic nerve in the posterior thigh in infants and children: a formula derived from MRI imaging for nerve localization, Reg. Anesth. Pain Med 2007, Vol. 32, pp 351-353.
19. Vloka J. D., Hadzic A., April E., Thys D. M., The division of the sciatic nerve in the popliteal fossa: anatomical implications for popliteal nerve blockade. Anesth Analg 2001, Vol. 92, pp 215-7.
20. Nayak S., An unusual case of trifurcation of the sciatic nerve, Neuroanatomy 2008, Vol. 5, pp 6-7.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241710EnglishN-0001November30General SciencesRETROSPECTIVE ANALYSIS OF REASONS FOR PRE DONATION DEFERRAL - A SUCCESSFUL KEY TO MODIFY BLOOD DONOR RECRUITMENT STRATEGIES
English2534Sonam KumariEnglishBackground: To make blood collection, processing and transfusion safe for the patients as well as the donors and blood bank staff, many safety measures are undertaken, and the most important of which is the selection of suitable blood donors. Moreover, the knowledge of rate and causes of donor deferral can guide the recruitment strategy for whole blood donation.
Objectives: To analyse the incidence and reasons for deferrals and to apply relevant findings to modify recruitment strategy for blood donors.
Materials and Methods: Data for whole blood donorspresenting for donation in our blood centre and outdoor blood donation camps over three years were analyzed retrospectively. National guidelines were used for selection and deferral of whole blood donors.
Results: 895 (5.61%) donors were deferred. Among them 790 (4.95%) were voluntary donors and 105 (0.65%) were replacement donors. Majority 534 (59.7%) of the donors deferred were between 18 – 30 years. Temporary deferrals were 791(88.37%) and permanent deferrals were 104 (11.6%). Among temporary deferrals, themost common causes were medical (400 i.e 44.7%) causes followed by anemia (163 i.e. 18.2%). Among permanentdeferrals, the most common cause was Jaundice (34 i.e. 3.8%).
Conclusion: Donor counselling to improve the return rate of temporary deferrals and strict donor selection criteria should be implemented with more proactive measures to make blood donation a safe and pleasurable experience.
EnglishDonor deferral, Temporary, Permanent, Anemia, Underweight, High risk donorsINTRODUCTION
A huge number of blood donors are not able todonate blood successfully for several reasons, either temporarily or permanently. The donors are deferred/ rejected for several reasons related to the safety of the donor and the potential threat to the recipient and the blood bank staff. Donor (Blood Donor) is a person who, after complete medical examination by the doctor, is declared fit for donation of blood. Individualsdisqualified from donating blood are known as ‘deferred’ donors.[1] Deferring prospective donors often leaves them with negative feelings about themselves as well as the blood donation process. Additionally these donors are less likely to return for blood donation in future. Criteria for these deferrals and their implementation strongly influence the quality of blood supply. Thus, every blood transfusion centre has to balance the fulcrum between acceptable quality and desired quantity.[2] A few studies from India in the past have provided different common reasons for deferralof whole blood donation highlighting differing demographic profile in different parts of thecountry.[3]Most of the efforts at government, community (various organizations like religious, political or societies) and individual levels are focused at recruiting more and more new donors while ignoring the retention and re-entry of those recruited but deferred due to various temporary causes. Retention and re-entry of these temporarily deferred donors can be achieved by analyzing the reasons of their deferrals and ameliorating the causes wherever possible.
AIM
The present study was undertaken to analyze the deferral incidence and pattern among blood donors and to apply relevant findings to modify recruitment strategy for blood donors.
MATERIALS AND METHODS
The study was conducted at Department of Transfusion Medicine, Gian Sagar Medical College and Hospital, Patiala, India during the period from January 2012 to December 2014.The study involved donors who had donated blood at outdoor voluntary blood donation camps and at the blood bank. Donors were selected by Medical officer. Information regarding the donor deferral was recorded. Each donor was examined by MedicalOfficer based on detailed medical history and brief physical examination as per the criteria laiddown by the Drugs and Cosmetic Act 1940 (and rules there under) supplemented by the Technical Manual (Directorate General of Health Services, Ministry of Health and Family Welfare, Govt. of India) and the Departmental Standard Operating Procedures. [4]Detailed informationof the deferred donors including the age, sex, cause of deferral whether temporary or permanentwere recorded. The quantity of blood collected was 350ml from donors who weighed> 45 kg and450 ml from donors who weighed >60 kg. All the donors were screened clinically for anemia and those found anemic or borderline anemic were tested for haemoglobin estimation (Hb%) by DIASPECT Hemoglobinometer and the cut-off value was 12.5g/dl. Pulse rate between 60 – 100/ minute with adequate volume and without any irregularity was accepted. Donors with systolic blood pressure (BP) between 100 and 160 mm of Hg and diastolic BP between 60-100 mm of Hg were accepted for blood donation.An average of three measurements were taken for those not falling within this range of systolic or diastolic BP. Detailed information on the donor deferral including the cause of deferral were recorded in the donor questionnaire cum consent form and the donor record register. Temporarily deferred donors during that period were counselled regarding the importance of blood donation, and they were informed that they could be recruited for blood donation after removal of the cause. Deferral reasons were analysed amongst replacementvoluntary, male-female, occupation and various age group categories. Donors were categorized into five conventional age group categories for analysis.
STATISTICAL ANALYSIS
Computer Software SPSS programme was used to analyse the data. All the datawere compiled, tabulated and analysed
RESULTS
During the study period total 15,951 donors were screened out of which 15056 (94.38%)were accepted both in the outdoor voluntary blood donation camps and at the blood bank. Of the total donors who were willing for blood donation, 895 (5.61%) donors were deferred.Total Male donors screened were15307 (95.9%) and female were 644 (4.03%) out of which 728(4.75%) males and 167(25.93%) females were deferred [Table 1]. Among the total 895(5.61%) deferred donors, 728(81.3%) were male and 167(18.7%) were female while gender wise 4.75% males25.93% females were deferred [Table 2]. Out of total 11,555 voluntary donors (VD), 790 (6.83%) were deferred and out of 4396 replacement donors (RD), 105 (2.38%) were deferred. Out of 5.61% deferred donors, 4.95% were voluntary and 0.65% were replacement donors[Table 3]. Age category was divided into 5 groups i.e. 65 years. Majorityi.e. 534 (59.7%) of the donors deferred were between 18 – 30 years of age followed by 182 (20.3%) in 30 – 40 years age group. 27 donors were not eligible for blood donation i.e. 25 of them were underage 65 years of age [Table 4]. Donor Population were divided into 8 groups on the basis of occupation as shown in [Table 5] and the most common group of deferred donors was of students 274 (30.6%) followed by those doing private job 187 (20.9%). One of these 8 groups was of drivers (local and long route drivers) 30(3.4%). Most common cause of deferral among drivers was medical (17) including hypertension (8) followed by Chronic alcoholic or some drug abuse (like opium addiction) (10). Precise detail of causes of deferrals among blood donors was shown in [Table 6] with total number and percentage of each while for convenience and statistical analysis, these causes were divided into 14 groups shown in [Table 7]. Most common causes of deferral were Medical 410 (45.8%) causes followed by anemia 163 (18.2%), donors who left without donation 92 (10.3%) and High risk donors 50 (5.8%). Medical causes of deferral included hypertension, Jaundice, fever, cough, typhoid, malaria, antibiotics or medication intake, dental treatment, diarrhoea, ,chickenpox, surgery, open wound, kidney disease, lung disease, hypotension, dengue, thyroid disorder and allergy. High risk group included those donors with high risk of donation related adverse events and it consists of cardiac disease, epilepsy, diabetic on insulin, antidepressant or antipsychiatry treatment and bleeding disorders. ‘Others’ category of deferral included chronic alcoholic, chronic smoker, ear piercing or tattooing, menstruating or lactating woman, lack of sleep, antirabies vaccination and transfusion within a year. Medical causes were the most common causes of deferral among 18 – 30, 31 – 40, 41 -65 years age group i.e. 244(47.6%), 84(46.2%) and 82(53.9%) respectively followed by anemia i.e. 104(19. 3%), 32(17.6%) and 27(17.8%) respectively. Donors left without blood donation were more among the younger population of 18 – 30 years age group i.e. 66 (12.4%). [Table 7]. Medical causes are the most common causes of deferral among both voluntaryand replacement donors. All the reasons of deferral are more common among voluntary donors except for anxiety which is more common among replacement donors i.e. 4 out of 5[Table 7]. Donor deferrals were tabulated into temporary and permanent as shown in [Table8].Causes of Permanent deferral included high risk group, drug addicts, jaundice, thyroid disorder, long route driver and high risk behaviour. Temporary deferrals were 791(88.37%) and permanent deferrals were 104 (11.6%). Among males, the mostcommon causes of temporary deferral were medical causes i.e. 388 (53.8%) followed by donors who left without donation 92(12.6%)and anemia 45(6.2%). In females, anemia118 (70.2%) was the most common cause fortemporary deferral followed by medical causes 22(16.2%)[Table 7]. Among Medical causes, the most common causes for deferral were hypertension 87 (9.7%), on antibiotic treatment 65(7.3%), throat infection 64 (7.2%) and typhoid within 1 year 57 (6.4%). The most common cause of permanent deferral among males wasJaundice 34 (3.8%). All the donors falling in High risk group 50(7.8%) were also deferred permanently. In females, thyroid disorder (4 out of 5 donors) was the common cause for permanent deferral.
DISCUSSION
Deferring unfit donors is the preliminary step towards safety of the blood donor and the recipient. There are definitive advantages of eliminating donors with possible risk of transfusion transmissible disease because, despite the availability of sensitive screening tests to detect these infections, blood donors can be infected, but tests are negative if they donated in the window period.[5] The rate and reasons of deferral differs from region to region and from one centre to other. Donor deferral rates in regional blood centres vary from 5 to 24 per cent and a less restrictive criteria can be used for donor selection without compromising donor safety.[6,7] Knowledge of deferral incidence and causes in a particular region helps in deciding the magnitude and direction of blood donor recruitment efforts. This knowledge also helps in calculating the eligible and potential blood donor pool. The eligible donor pool may drastically vary from the potential donor pool which is usually calculated on the basis of age alone. This fact was highlighted by William Riley and colleagues in their study where they showed that the conventional method of determining eligible donors, using age alone as the criteria, overestimated eligible donor prevalence by approximately 59 percent![8] In our study, we segregated donor deferrals on the basis of medical interview and general physical examination. Most of the donors were males 15307 (95.9%) and women accounted for only 644 (4.03%) of the donors. In studies from other countries,following deferral rates were reported 12.8% by Zou et al(2008), 14.4% by Lim et al (1993) and 13.6% by Custer et al (2004).[7,9,10] From Indian Literature, deferral rate were observed as Sundar et al. (6%), Chaudhary etal. (16.4%), Bahaduret al. (9%) and Sharma et al. (5.1%).[3,11,12,13] Deferral incidence varies among donor population, which reflects the regional diversity and variation in whole blood donor eligibility criteria internationally. In present study donor deferral rate was5.61% which was similar to that of Sundar et al and Sharma et al. The donor deferral rate can be reduced by educating the donors and providing information about the selection criteria which will result in better acceptability and there by less negative feeling about rejection and it will further enhance the future donor return rate. The most common cause of temporary deferrals in females wasanemia118 (70.2%). Among males, the most common cause of deferral was medical cause i.e. 388 (53.8%). A number of other studies showed anemia as the most common cause like Agnihothri N, 56%, Arslan et al 20.7%, Halperin et al 46%[2,14,15]. Similarly, in present study anemia was the most common cause of deferral 163 (18.2%) when all the causes of deferral were considered independently followed by medical causes like hypertension 87 (9.7%), antibiotic treatment 65(7.3%) and typhoid within 1 year 57 (6.4%). In anotherIndian study by Chaudhary et al. low weight (32.3%) and low haemoglobin (18.6%) were the twomost common reasons for deferral.[11]The relationship between haematocrit deferral rates and temperature is strongest in areas of the country with greater temperature variability, with the lowest values occurring in the summer. The effect of seasonality on Hematocrit deferrals should be taken into account for donor counselling, recruitment, and retention efforts.[20]In a study from Trinidad and Tobago, a history of high-risk sexual activity was the most common cause of deferral [16]while in present study history of high risk behaviour could be elicited only in 4 donors (0.4%) which could be due to the tendency of people to hide such information (as high risk sexual activity is considered a social taboo in Indian society). Analysis of the deferrals showed that the top ten defined causes were Anemia 163(18.2%), Donors who left with-out donation 92 (10.3%), Hypertension 87 (9.7%), Antibiotic treatment within 72 hours 65 (7.3%), Throat infection 64 (7.2%), Typhoid 57 (6.4%), Donation within last 3 months 44 (4.9%), History of Jaundice 34 (3.8%), Underweight 30 (3.4%) and Surgery within 6 months 22 (2.5%) which accounts for 73.7% of the total deferrals. A large number of deferrals due to pulse irregularities or histories suggestive of potential cardiovascular problems were reported by Blumberg et al, [19] whereas in our study 10 (1.1%) donors had known cardiac disease or symptoms suggestive of cardiovascular problems and were deferred permanently. Incidence of donors with poor veins with minimal possibility of successful phlebotomy was 11 (1.2%). These donors were deferred as trials of phlebotomy in such donors results in incomplete collections, multiple punctures, painful and unpleasant experience resulting in negative impact on such donors as well as the colleague donors.Rate of unsuccessful phlebotomy due to poor vein, double puncture, collecting less quantity were reported as 0.5% by Farrales and 0.006% by Sunder. [17,3 ] Loss of blood units due to miscollection (underweight or overweight) or poor phlebotomy are common. Such losses can be avoided by implicating trained and vigilant blood bank staff and this would further supplement the blood supply. In addition to deferral, age, sex, race, and education were associated with return of deferred donors.[21]Silvergleid et al donor attitude survey indicated 90% donor approval of direct questioning, and analysis of donor deferral patterns indicated almost a five-fold increase in the number of donors deferred for participation in high-risk activities indicating that such questioning could have a positive impact on blood safety.[22,16]Given that Human Immuno deficiency Virus (HIV) antibody screening cannot detect HIV-seronegative (but infectious) “windowperiod” donations, the deferral of at-risk donors may offer some additional protection to the blood supply.[23]In present study, 30(3.4%) of deferred donors were drivers (local and long route drivers). Since drivers were considered to be comparatively more indulged in high risk activities, causes of deferral among drivers were analysed and most common of them were medical (17) including hypertension (8) followed by chronic alcoholic or some drug abuse (like opium addiction) (10). It strengthens the fact that occupation should also be considered while analysing donor deferral patterns.The most common group of deferred donors was of students 274 (30.6%) which forms the major chunk of the eligible and potential donors. It further supports the need for donor retention and counselling as they are the most receptive part of the society and can be easily retained. Of these deferred students, 25 (2.8%) were underage; they can be made aware of their eligibility period so that they can return for donation. In our study 104 (11.6%) of donors were deferred for permanent reasons which was similar to Custer et al (2004) and Arslan (2007) who reported a permanent deferral rate of 10.6% and 10% respectively. [10,14] Two Indian studies from Chandigarh and Lucknow reported that history of jaundice was the most common cause of deferral[18,11] whereas in present study jaundice was the most common cause of permanent deferral. In females, thyroid disorder (4 out of 5 donors) was the common cause for permanent deferral. Permanently deferred donors were segregated into High risk group (50) and others (54). This high risk group consisted of donors with (high risk of donation related adverse events) cardiac disease, epilepsy, diabetic on insulin, antidepressant or antipsychiatry treatment and bleeding disorders. In the study done by Charles et al, in Trinidad and Tobago, the difference in rate of deferral amongst voluntary and replacement donors was not significant[16]while in present study, out of 5.61% deferred donors, 4.95% were voluntary and 0.65% were replacement donors which was quite significant. It is due to the fact that we had recruited more and more voluntary donors in our blood donation programmes. The incidence of all kind of deferrals was more common among voluntary donors except for deferral due to anxiety (4 out of 5) which might be due to the fact that replacement donors were forced for donation, they were not mentally prepared for donation. Donors who had donated blood within last three months comprised of 44 (4.9%) of the total deferrals. These were the donors who need not to be motivated; they should be properly guided for their eligible period so that they can return for donation regularly. According toRios JA et al, deferral of donors with low Estimated blood volume who are less than 23 years old may offer a rational approach to protecting donors at greater risk of reactions without jeopardizing the adequacy of the blood supply while Halperin D et al study showed that selective deferral of donors with low blood volume have a very negative impact on blood donor return rates and subsequent blood donations. [24,15]So, it is very important to counsel the donors who are selectively deferred for reasons like low estimated blood volume. Pindick et al concluded that it is both clinically feasible and efficient to recruit healthy prior donors older than the age of 65 years for blood donation.[25] 2 donors in present study were deferred due to age >65 years who were willing to donate and otherwise normal clinically but were not accepted. It indicates the need for formulation of a strategy to recruit such donors to improve the donor pool. The objective during donor selection should be blood collection as well as donor safety. Safety of donors is important as it helps in gaining confidence and winning the trust of future donors as well.[26]Information Education and Communication (IEC) material providing information and education on causes and duration of deferral may “prime” prospective donors about possibility of deferral. Any such sensitization beforehand results in better acceptability of “rejection” and thereby less “negative” feeling about blood donation and more chances of future return. In addition, medical examination (Hemoglobin, blood pressure, pulse rate) serves as an incentive for future repeat donations. The category of temporary deferral influences the likelihood of future return, but the demographic and donation factors associated with return are largely consistent.[27] Sawanpanyalert et al proposed adonor deferral system providing a more flexible, sensitive, and predictive tool for averting donation by those who, though HIV antibody-negative, are at a higher risk of being infected with HIV.[5] Donor self-deferral is valid for reducing the risk of HIV transmission through blood transfusions, and its implementation should be encouraged, when recruiting blood donors. [28,29] In present study, a special category of deferral was of donors who got enrolled themselves but left the donation area without donating blood which constituted 92 (10.3%) of the total deferrals. The probable reasons of such self- deferral might be the peer - pressure, long waiting periods, fear or anxiety or lack of confidence or indulgence in high risk behavioural activity. This kind of selfdeferralfurther needs to be investigated to improve the donor pool. Wherever varying staff in the deferral process - doctors, nurses and clerks - were involved, analysis and audits should be undertaken for medical donor deferrals.[30,19] Education, motivation, and treatment of these deferred donors due to anemia or other temporary deferrals are important aspects in blood banking and hence that these donors can be recruited again.[31] The entire blood bank staff, especially medical officers, should share the responsibility of winning the confidence of donors and making blood donation a safe and pleasurable experience which will eventually increase voluntary blood donation, giving a permanent remedy to the shortage of blood in the country.[26]
CONCLUSION
Analysis of rejection patterns may help medical personnel to be more focused in donor screening. Temporary donor deferrals need to be actively and aggressively managed especially medical causes (fever, throat infections, and typhoid), anemia, underage, underweight and donors who enrol themselves but don’t donate blood. This will not only help in maintaining a healthy donor pool but will also help in improving donor and recipient safety in the long run, provided the potential donors are appropriately counselled.[12]By developing strategies to identify and rationalize donor selection criteria, the blood transfusion services would be able to decrease the unnecessary deferrals.[11]
ACKNOWLEDGEMENT
The author acknowledges the immense help received from the scholars whose articles are cited and included in the references of this manuscript. The author is also grateful to the 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 No funding from any source received for this work.
Conflict of Interest No conflict of interest involved in this study.
Englishhttp://ijcrr.com/abstract.php?article_id=541http://ijcrr.com/article_html.php?did=5411. Kulkarni N. Analysis of donor deferral in blood donors. Journal of Evolution of Medical and Dental Sciences 2012; 1: 1076-1082.
2. Agnihotri N. Whole blood donor deferral analysis at a center in Western India. Asian J Transfus Sci.2010; 4(2):116- 122.
3. Sundar P, Sangeetha SK, Seema DM, Marimuthu P, Shivanna N. Pre-donation deferral of blood donors in South Indian set-up: An analysis. Asian J Transfus Sci.2010; 4(2):112- 115.
4. Department of AIDS Control Ministry of Health and Family Welfare Government of India.Annualreport:2008-2009. Availablefrom: http://nacoonline.org/upload/Publication/ Annual Report NACO 2008-09.PDF.
5. Sawanpanyalert P, Uthaivoravit W, Yanai H, Limpakarnjanarat K, Mastro TD and Nelson KE. Donation deferral criteria for human immunodeficiency virus positivity among blood donors in northern Thailand. Transfusion 1996; 36: 242-249.
6. Tomasulo PA, Anderson AJ, Paluso MB, Gutschenritter MA andAster RH. A study of criteria for blood donor deferral. Transfusion 1980; 20(5):511-8.
7. Zou S, Musavi F,Notari EP, Rios JA, Trend JT and Fang CT.Donor deferral and resulting donor loss at the American Red Cross Blood Services, 2001 through 2006. Transfusion 2008; 48: 2531-2539.
8. Riley W, Schwei M. and McCullough J. The United States’ potential blood donor pool: estimating the prevalence of donor-exclusion factors on the pool of potential donors. Transfusion 2007; 47: 1180-1188.
9. Lim JC, Tien SL, and Ong YW. Main causes of pre-donation deferral of prospective blood donors in the Singapore Blood Transfusion Service. Annals of the Academy of Medicine, Singapore 1993; 22(3):326-331
10. Custer B., Johnson E S, Sullivan SD, Hazlet T K, Ramsey SD, Hirschler NV, Murphy EL and Busch MP. Quantifyinglosses to the donated blood supply due to donor deferral and miscollection. Transfusion 2004; 44: 1417–1426.
11. Chaudhary RK, Gupta D and Gupta RK. Analysis of donordeferral pattern in a voluntary blood donor population. Transfus Med. 1995; 5: 209-12.
12. Bahadur S, JainS, Goel RK, Pahuja S and Jain M. Analysis of blood donor deferral characteristics in Delhi, India. Southeast Asian J Trop Med Public Health2009; 40(5).
13. Sharma T, Singh B, and BhattGC. Profile of deferral of blood donors in regional blood transfusion enter in North India. Asian J Transfus Sci. 2013; 7(2): 163-164.
14. Arslan O. Whole blood donor deferral rate and characteristics of the Turkish population. Transfus Med 2007; 17:379- 83.
15. Halperin D, Baetens J, Newman B. The effect of short term temporary deferral on future blood donation. Transfusion. 1998; 38:181-183.
16. Charles KS, Hughes P, Gadd R, Bodkyn C J and Rodriguez M. Evaluation of blood donor deferral causes in the Trinidad and Tobago National Blood Transfusion Service. Transfusion Medicine 2010; 20: 11-14.
17. Farrales FB, Stevenson AR and Bayer WL. Causes of disqualification in a volunteer blood donor population. Transfusion. 1997; 17:598-601.
18. Kaur R,Basu S, Marwaha N. A Reappraisal of underlying causes in donor deferral. Ann Natl Acad Med Sci. 2002;38:93-9.
19. Blumberg N, Shah I, Hoagland J, Shirer L and Katz AJ. Evaluation of Individuals Deferred from Blood Donation for Medical Reasons. VoxSanguinis 1982; 42(1): 1-7.
20. Sebok MA, Notari EP, Chambers LA, Benjamin RJ and Eder AF. Seasonal temperature variation and the rate of donor deferral for low hematocrit in the American Red Cross. Transfusion 2007; 47: 890-894.
21. Custer B, Chinn A, Hirschler NV, Busch MP and Murphy EL. The consequences of temporary deferral on future whole blood donation. Transfusion 2007; 47: 1514-1523.
22. Silvergleid AJ, Leparc GF and Schmidt PJ. Impact of explicit questions about high-risk activities on donor attitudes and donor deferral patterns. Results in two community blood centers. Transfusion 1989; 29: 362-364.
23. Johnson ES, Doll LS, Satten GA, Lenes B, Shafer AW, Kamel H, Casanova RJ and Petersen LR. Direct oral questions to blood donors: the impact on screening for human immunodeficiency virus. Transfusion 1994; 34: 769-774.
24. Rios JA, Fang J, Tu Y, Wright D J, Spencer B, Hillyer C D, Hillyer KL, Eder A. F. and Benjamin, R. J. The potential impact of selective donor deferrals based on estimated blood volume on vasovagal reactions and donor deferral rates. Transfusion 2010; 50: 1265-1275.
25. Pindyck J, Avorn J, Kuriyan M, May Reed, Iqbal MJ, Levine SJ. Blood Donation by the Elderly Clinical and Policy Considerations. JAMA. 1987;257(9):1186-1188.
26. Sareen R, Gupta GN, Dutt A.Donor awareness: key to successful voluntary blood donation. F1000Research 2012, 1:29.
27. Custer B, Schlumpf KS, Wright D, Simon TL, Wilkinson S and Ness. Donor return after temporary deferral. Transfusion 2011; 51: 1188-1196.
28. Urwijitaroon Y, Barusrux S, Romphruk A, Puapairoj C and Pakote L. Reducing the risk of HIV transmission through blood transfusion by donor self-deferral. Southeast Asian J Trop Med Public Health 1996;27:452-6.
29. Anderson SA, Yang H, Gallagher LM, O’Callaghan S, Forshee RA, Busch MP, McKenna MT, Williams I, Williams A, Kuehnert MJ, Stramer S, Kleinman S, Epstein J. and Dayton AI. Quantitative estimate of the risks and benefits of possible alternative blood donor deferral strategies for men who have had sex with men. Transfusion 2009; 49: 1102- 1114.
30. Galea G, GillonJ and Urbaniak SJ.Study on medical donor deferrals at sessions Transfusion Medicine 1996; 6: 37–43.
31. Alok K, Satyendra P, Sharma SM, Ingole NS and Gangane N. Impact of counselling on temporarily deferred donor in a tertiary care hospital, central India: A prospective study. Int J Med Public Health 2014;4:400-403.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241710EnglishN-0001November30General SciencesGENERAL DENTIST'S AWARENESS OF LASER APPLICATION IN DENTISTRY
English3538Bagheri A.English Purkhamene S.EnglishObjective: The aim of this study was to assess the knowledge of Ardabil general dentists about Laser applications in dentistry.
Methods and Materials: This is a cross sectional descriptive study that has been done on 87 general dentistis in Ardabil city. Data collected by a questinaire and then analyzed by statistical methods in SPSS.19.
Results: Of all dentists, 82(94.3%) pointed that only have heard something about Laser. 21 (24.1%) stated that have studies about Laser. Only 2 persons (2.3%) have practical and clinical usage of this method. 60 people (69%) had willing to participate
in training courses. The relationship between gender with dentists safity awareness wasn’t significant.There are significant diffrencesin general and specializedknowledge between two gender (p=0.024, p=0.002).
Conclusion: Results showed that Ardabil general dentistis have lower awareness about laser, so raising awareness and informing about application of laser is essential.
EnglishAwareness, General dentists, Laser, DentistryINTRODUCTION
We have encountered,in history of science, with a phenomenon such as laser invention which has attracted all people attention and reach of human dreams into reality. Laser is the most advanced light source and has been composed of the initials of words LightAmplification by Stimulated Emissionof Radiation.1 Inlaser therapy has been used in dentistry as an adjunct or alternative to conventional approaches.In recent years, several studies have been conducted on the clinical applications of laser in dentistry.2 A range of lasers is now available for use in dentistry. Once regarded as a complex technology with limited uses in clinical dentistry, there is a growing awareness of the usefulness of lasers in the armamentarium of the modern dental practice, where they can be used as an adjunct or alternative to traditional approaches.3 Currently laser is one of the most useful tools need in life. The use of laser in dentistry has been developed over the last three decades. Initially it was introduced as an alternative to traditional halogen curing light but now it has become the instrument of choice in many dental applications.4 The scope of this technology has been extended to all aspects of modern life including industry, hospitals, shopping centers, military bases, and communication.Of laser applications in medicine and dentistry, we can pointed to eye surgery, wound healing, hair removal, diagnosis, removal and treatment of oral lesions, root canal therapy, dental restoration, Bleaching (whitening), dental canal sterilization and dental caries diagnosis.5-7 Laser has some unique properties compared to conventional light and for reason widespread of this science application in medicine and dentistry, stilldose not exist true and complete understanding and knowledge of this technology.In addition to the familiarity with the use of this technology, protection against laser radiation is also very important. 1 Due to the excessive use of lasers in dentistry and necessary knowledge about it, the aim of this study was to assess the knowledge rate of general dentistis about laser and its application in dentistry.
METHODOLOGY
This is a cross sectional descriptive study that has been done on 87 general dentistis in Ardabil city. Necessary data colledted by a research based quesitionare include 29 questions which completed by interreview. Data analyzed in SPSS.19 using descriptive and analytical statistical methods.
RESULTS
Of all dentists, 62(71.3%) were male and rest of them were female. 39(44.8%) of them graduatedafter 2006 and rest of them before 2006. The mean of graduation time in dentists was 12.1 71 (81.6%) of all dentists, had accurate knowledge about the nature of the laser. 82(94.3%) of them have knowledge about use of laser in dentistry. Dentist’s information resources about the use of laser in first rank were book with 18.4% and then other resources. Of all dentists, 60 (69%) have willingness to participate in training courses and 2.3% of them used laser currently. 70(80.5%) of them was felt that having a laser device, all dental work had been done. (Table 1) 79(90.8%) of them believed that the use of laser requires special safety. (Table 2) Only 4.6% of all dentists have true response about the most widely used type of laser in dentistry. (Table 3)
The mean of obtaindknowledge scores about immunity in the use of laser in dentistry was 3.2 0.8. The rate of general knowledge in the use of lasers in dentistry between dentists with 61% was in the moderate level. The rate of knowledge about immunity in the use of lasers in dentistry between dentists with 48.3% was in the good level. The rate of specializedknowledge in the use of lasers in dentistry between dentists with 93.2% was in the week level. (Figure 1) The mean of obtaind scores about total awareness in the use of laser in dentistry was 7.66± 1.85. Most of dentists have total knowledge rate in moderate level (84.7%). (Figure 2) There wasnt any significant differences between time of graduation of dentists with all levels of knowledge about laser. There were significant differences between male and female dentists with specialty and total knowledge about laser. (p=0.002, p=0.024)
DISCUSSION
The rate of total knowledge about laser application in dentistry was about 96.4% which was similar to Bagheri and et al study in Rasht. (5)The reasons for lower rate of dentist’s awareness can be non attended training courses, non-credit courses offered in the university, being a new technology and the need for high-cost and proper devices for use in the office.There wasn’t any significant differences between detists sex and time graduation with knowledge rate about immunity in laser, therefore male and female dentists with each time graduation have similar knowledge.There was significant difference between dentist’s sex and their specialized and total knowledge about laser application in dentistry. (P=0.002, P=0.024) , but there wasn’t any significant diferencebetween dentist’s time graduation and their specialized and total knowledgeabout laser application in dentistry. The special awareness about laser diferencebetween female and male dentists can be due to their sensitivity in learning subject and on the other hand time graduation hasn’t effective on their specialized knowledge about laser. Result of this study showed that of all general dentists 71(81.6%) pointed out true about the nature of the laser which indicates a good level of knowledge in this field. Safe use of lasers is also one of the importantconcerns in the use of laser therapy. With the availability, utilization and future development ofdifferent laser wavelengths and methods of pulsing, much interest is developing in this growing field. (9). 66(75.9%) of dentist stated that not have any studies about new laser uses methods and compare with Bagheri and et al study more encourage for study about laser is necessary.60(69%) of all dentists has tended to participate in training courses which similar to bagheri study this rate is low and to promote the use of lasers in dentistry we must done more work among general dentists in the Ardabil city.In this study, rate of total knowledge about laser was 33.3% and so increasing the background knowledge of general dentists about laser byholding educational and expert workshops, training courses by experts, seminars and providing relevant advertising brochures is essential. In Tosun and et al study in turkey most of patients have low knowledge about laser treatments and patients with higher levels of education tend to have more information about the usage of lasers in dentistry. (10) In the otherhand, according to benefits of laser use in dentistry services, more referral patients to dentists and dentists need for laser, holding seminars and workshops to provide a theoretical and practical content is important.6.7% of dentists have true response about specialized knowledge about laser application in dentistry which indicating the weakness of dntistsspecialized knowledge of the use of lasers in dentistry, Lack of dental community effort to provide training in this field and non wanting to practice in the field of health in Iran and we must doing fundamental actions for recovery this condition, because this method of treatment Can meet the health needs of the community with the most convenient methods and least amount of pain, cost and time. In recent years many efforts have been done in our country and other countries by holding seminars, educational and practical workshops about laser application in dentistry to promote the knowledge of dentists.
CONCLUSION
Results showed that Ardabil general dentists have moderate awareness about laser application in dentistry, so planning to raise awareness of dentists about laser by various methods is essential.
ACKNOWLEDGEMENT
This study financialy supported by faculty of dentistry in Ardabil university of medical science and we tanks all physians which response to our questionaires
. Conflict of Interest: none declared
Englishhttp://ijcrr.com/abstract.php?article_id=542http://ijcrr.com/article_html.php?did=5421. Cernavin I, Pugatschew A, Martin J.T. Laser applications in dentistry, A review of the literature. Aust Dent Journal. 1994 Feb; 39(1): 28-32.
2. Assunção CM, Pereira JT, Oliveira RS, Almeida R. laser versus conventional therapies. IDEA 2013;4(4):44-47.
3. Walsh LJ. The current status of laser applications in dentistry.Aust Dent J 2003 Sep; 48(3):146-55. PMID: 14640367
4. Kumar P,GuptaV,DixitA,Marwah S. Imperative role of Lasers in perspective future dental research and advancements: An Insight story. Journal of Advanced Medical and Dental Sciences Research 2014; 7(3):114-17.
5.Husein A. Applications of Lasers in Dentistry: A Review Archives of orofacial sciences 2006 Mar;1(1):1-14.
6. Walsh LJ. The current status of laser applications in dentistry.Aust Dent J. 2003 Sep;48(3):146-55; quiz 98.
7. Todea CDM. Laser applications in conservative dentistry. TMJ 2004;54(4):392-405.
8. Bagheri A, Aghajani R. Awareness rate of Rasht general dentistis about laser applications in dentistry. The 1 st laser seminar in dentistry 2010; 2:28-9.
9. Singh S, Gambhir RS, Kaur A, Singh G, Sharma S, Kakar H. Dental Lasers: A Review of Safety Essentials. J Lasers Med Sci 2012; 3(3):91-6.
10. Tosun E, Aktas A, Bayram H, YeniayO,Altay MA. AWARENESS AND ACCEPTANCE OF LASERS IN DENTISTRY IN TURKISH POPULATION. CLINICAL DENTISTRY AND RESEARCH 2013; 37(1): 30-34.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241710EnglishN-0001November30General SciencesVISUAL OUTCOME AND COMPLICATIONS OF NEODYNIUM : YTTRIUM ALUMINIUM GARNET LASER POSTERIOR CAPSULOTOMY IN PSEUDOPHAKIC PATIENTS USING SPIRAL METHOD OF CAPSULOTOMY
English3942Garima AgrawalEnglishAim: To determine the visual outcome and complications of Neodynium : Yttrium Aluminium Garnet laser posterior capsulotomy in pseudophakic patients with visually significant posterior capsular opacification using the spiral method of capsulotomy.
Material and Methods: Neodynium : Yttrium Aluminium Garnet laser posterior capsulotomy was done in a spiral fashion in 50 eyes of 50 patients with visually significant posterior capsular opacification. The visual outcome and complications were documented 1week, 4 weeks and 12 weeks after the procedure.
Observations: 94% patients had good visual recovery (best corrected visual acuity >/=6/12) 12 weeks post laser. The complicationsobserved were intraocular lens pitting in 6 eyes but was not significant to reduce vision. Intraocular pressure spike greater than 5 mm Hg was seen in 3 eyes 1 hour post laser but was controlled with anti -glaucoma medication. Cystoid macular edema
was seen in 2 eyes, 8 and 10 weeks after laser.
Conclusion Neodynium : Yttrium Aluminium Garnet laser posterior capsulotomy with the spiral method is effective in cutting the posterior capsule with good visual results and low rate of complications in our Institute.
EnglishNeodynium: Yttrium Aluminium Garnet posterior capsulotomy, Visual outcome, ComplicationsINTRODUCTION
In the age where the femtosecond laser is being used for anterior capsulotomy in cataract surgery, we revisit the cold cutting laser i.e. Neodynium : Yttrium Aluminium Garnetlaser. Posterior capsular opacification is the most common delayed complication following cataract surgery.1 Neodynium: Yttrium Aluminium Garnet laser posterior capsulotomy is the standard treatment of posterior capsular opacification.2,3 The ND YAG laser offers a safe ,non invasive method of cutting the posterior capsule with good visual outcomes. Complications as rise in intra ocular pressure, cystoid macular edema and retinal detachment have been reported after the procedure.4,5A number of ways have been used to minimize energy delivery into the eye and minimize complications of the procedure. These include accurate focussing, cutting across tension lines along with a number of ways for cutting the posterior capsule including cross technique, can opener, inverted U, circular and spiral.6,7The present study aims at determining the visual outcome and complications of Neodynium : Yttrium Aluminium Garnet laser posterior capsulotomy in our Institute using spiral method of capsulotomy.
AIM
To determine the visual outcome and complications of Neodynium : Yttrium Aluminium Garnet laser posterior capsulotomy in pseudophakic patients with visually significant posterior capsular opacification using the spiral method of capsulotomy
MATERIAL AND METHODS
Fifty pseudophakic eyes of fifty cases (28males) and (22 Females) with visually significant posterior capsular opacification were enrolled . The study was carried out at our regional Institute of Ophthalmology from April 2014 to September 2014.The study is a prospective observational study. Ethical approval was obtained from the institutional review board. Informed consent was obtained from each enrolled subject for the procedure. The mean age (+/-SD) was 59.14+/-9.18 years(range 35-77 years). These cases had different types of PCO Elschnig pearls, mixed type and thick fibrotic membrane type.(Table I). All patients with corneal opacities, corneal edema, active intraocular inflammation, cystoid macular edema, retinal detachment, high myopia, lattice degeneration and history of retinal detachment in the fellow eye and other ocular comorbidities were excluded from the study. The meantime from cataract surgery was 22.42+/-16.32 months (range: 6–68). All patients were examined before Neodynium: Yttrium Aluminium Garnet laser capsulotomy and 1week, 4weeks, and 12 weeks after Nd: YAG laser capsulotomy. All patients underwent a complete ocular examination on all visits, including bestcorrected visual acuity, refraction, slit-lamp, intraocular pressure measurement, and posterior segment examination. Intraocular pressure was measured one hour after the laser. Tropicamide 1% and phenylephrine 2.5% were administered for pupillary dilatation prior to procedure. The capsulotomy size was kept slightly larger than the size of the mesopic pupil.The VISULAS II plus Q switched Neodynium: Yttrium Aluminium Garnet laser (Carl Zeiss Germany)was used. The capsulotomy was done in a spiral fashion. After capsulotomy, prednisolone acetate 1% four times daily and timolol maleate 0.5% eye drops twice daily for 15 days were prescribed. The chi square test was used for statistical analysis. p/= 6/12 best corrected visual acuity one week post laser and 94%patients 3 months post laser. The p value is 0 i.e. Englishhttp://ijcrr.com/abstract.php?article_id=543http://ijcrr.com/article_html.php?did=5431. Aslam TM, Devlin H, Dhillon B. Use of Nd:YAG laser capsulotomy. Surv Ophthalmol 2003;48(6):594-612.
2. Aron Rosa D, Aron JJ, Griesemann M, Thyzel R. Use of neodymium yag laser to open the posterior capsule after lens implant surgery: a preliminary report. Am Intraoc Implant Soc Journal 1980;6(4):352-354.
3. Frankhauser F, Roussel P, Steffen J. Clinical studies on the efficiency of high power laser radiation upon some structures of the anterior segment of the eye. First experiences of the treatment of some pathological conditions of the anterior segment of the human eye by means of a Q-switched laser system .Int Ophthalmol 1981;3(3):129-139.
4. Steinert RF, Puliafito CA, Kumar SR, Dudak SD, Patel S. Cystoid macular edema, retinal detachment, and glaucoma after Nd:YAG laser posterior capsulotomy. Am J Ophthalmol1991;112(4):373-380.
5. Channel MM, Beckman H. Intraocular pressure changes after neodymium-YAG laser posterior capsulotomy. Arch ophthalmol 1984;102(7):1024-1026.
6. M Vella,S Wickhermansinghe, N Gupta, P Andreou, A Sinha.YAG laser capsulotomy, an unusual complication. Eye2009;18:193-194.
7. Jung KM, Jae HA, Jim HY.A new technique for Nd YAG laser posterior capsulotomy. Int J Ophthalmol 2014;7(2):345- 349.
8. Newland TJ, McDermott ML, Eliott D, Hazlett LD, Apple DJ, Lambert RJ, Barrett RP. Experimental neodymium:YAG laser damage to acrylic, poly(methyl methacrylate), and silicone intraocular lens materials. J Cataract Refract Surg 1999;25(1):72–76.
9. Trinavarat A, Atchaneeyasakul L, Udompunturak S. Neodymium:YAG laser damage threshold of foldable intraocular lenses. J Cataract Refract Surg 2001;27(5):775– 780.
10. Ge J, Wand M, Chiang R, Paranhos A, Shields MB. Longterm effect of Nd:YAG laser posterior capsulotomy on intraocular pressure. Arch Ophthalmol 2000;118(10):1334– 1337.
11. Krauss JM, Puliafito CA, Miglior S, Steinert RF, Cheng HM. Vitreous changes after neodymium-YAG laser photodisruption. Arch Ophthalmol 1986;104(4):592–597.
12. Bath PE, Fankhauser F. Long-term results of Nd: YAG laser posterior capsulotomy with the Swiss laser. J Cataract Refract Surg 1986;12(2):150–153.
13. Dardenne MU, Gerten GJ, Kokkas K, Kermani O. Retrospective study of retinal detachment following neodymium: YAG laser posterior capsulotomy. J Cataract Refract Surg 1989;15(6):676–680.
14. Javitt JC, Tielsch JM, Canner JK, Kolb MM, Sommer A, Steinberg EP. National outcomes of cataract extraction. Increased risk of retinal complications associated with Nd:YAG laser capsulotomy. The Cataract Patient Outcomes Research Team. Ophthalmology 1992;99(10):1487–1498.
15. Powell SK, Olson RJ. Incidence of retinal detachment after cataract surgery and neodymium:YAG laser capsulotomy. J Cataract Refract Surg 1995;21(2):132–135.
16. Shah GR, Gills JP, Durham DG, Ausmus WH. Three thousand YAG lasers in posterior capsulotomies: an analysis of complications and comparison to polishing and surgical discission. Ophthalmic Surg 1986;17(8):473–477.
17. Nielsen NE, Naeser K. Epidemiology of retinal detachment following extracapsular cataract extraction: a follow-up study with an analysis of risk factors. J Cataract Refract Surg 1993;19(6):675–680.
18. Hayashi K, Nakao F, Hayashi H. Influence of size of neodymium:yttrium-aluminium-garnet laser posterior capsulotomy on visual function. Eye 2010;24(1):101–106.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241710EnglishN-0001November30General SciencesIS CAROTID ATHEROSCLEROSIS AN INDICATOR OF GENERALIZED ATHEROSCLEROSIS: AN AUTOPSY STUDY
English4348Lokesh HaswaniEnglish Harendra Kumar M.L.English Kiran J.EnglishBackground: Atherosclerosis is one of the major causes of morbidity and mortality worldwide. Autopsy study is a gold standard for atherosclerosis. None of the study done on autopsy to prove the carotid atherosclerosis has the generalized nature.
Objective: To examine the association between carotid atherosclerosis with coronary, aorta and renal arteries in non cardiac patients using histological analysis.
Methods: We histologically examined 91 patients died of non cardiac cause. Atherosclerotic lesion in carotid, coronary, aorta and renal arteries were noted and graded according to modified AHA classification of atherosclerosis using morphological descriptions
(2000).
Results: Mean of carotid atherosclerosis was 11.5±0.71, in coronary it was 37.33±7.57, in aorta the mean we found was 27±9. The mean of renal artery atherosclerosis was 2.75±0.71. The association of carotid atherosclerosis with coronary, aorta and
renal arteries was statistically significant (p < 0.05).
Conclusion: In present study we conclude that if carotid atherosclerosis is present, patient will be having coronary, aortic atherosclerosis but patient might have renal atherosclerosis. If carotid atherosclerosis is absent it doesn’t mean that patient won’t be having atherosclerosis in any other vessels.
EnglishAtherosclerosis, Autopsy, Carotid arteryINTRODUCTION
Atherosclerosis is a major cause of morbidity and mortality worldwide and it account for one third of all deaths from heart disease.[1] The most serious outcome of atherosclerosis are stroke, myocardial infarction and death. [2] Autopsy is a tool of real value rather than an exercise of tradition, when done selectively and efficiently. [2] Autopsy series are often quoted as an unbiased information source. [3] As study of atherosclerosis in the living population is difficult in many ways including its cost-effectiveness, autopsy studies have been regarded as one good way of dealing with the problem. [4] Given the limited ability of current clinical imaging methods to visualize the vessel wall, as opposed to the lumen, we are highly dependent on autopsy material for describing various different stages of atherosclerosis. [5] Atherosclerosis is a generalized vascular disease. [6] Although there is asymmetry in involvement of various arteries in atherosclerosis but the disease usually proceeds in parallel in various organ system in our body. [3] Once the disease apparent in one territory, there is increased risk of adverse events in the vascular territories including those supplying the brain, kidneys, mesentery, and limbs. [8] Atherosclerosis has the distinctive topographical distribution in the intimal surface of each artery of various organs.[7] Hypothesis which explain the difference in atherosclerotic lesions in every organ are hemodynamic stresses related to arterial geometry; anatomic, cellular or biochemical variation in arterial wall, particularly in the endothelium, smooth muscle cell mutations leading to monoclonal proliferation and infectious agent. [7] Atherosclerosis affects the Indian population at a younger age than in any other ethnic groups with more severe and extensive angiographic involvement. [8] By imaging technique only few superficial vessels like carotid can be studied for the atherosclerosis. [9] Sever al radiological studies show that carotid intima media thickness can be regarded as an indicator of generalized atherosclerosis which can predict the future cardiovascular and cerebrovascular events. [9, 10] Radiological studies had shown that there is close association of carotid atherosclerosis with aortic and coronary artery atherosclerosis. [9] Several studies done angiographically had shown that renal artery atherosclerosis usually exits as one manifestation of generalized atherosclerosis. [11] So it is very important to see whether the extent of disease correlates in different arterial beds same as in carotid artery or not. [12] Till now none of the radiological or autopsy study had correlated carotid atherosclerosis with coronary aorta and renal atherosclerosis. So here the study had been conducted, to see whether the carotid atherosclerosis can be correlated with the atherosclerosis of other major vessels using gold standard technique of histomorphological analysis on the autopsy specimens. So that carotid atherosclerosis can be used as a screening tool to predict the future cardiovascular, cerebrovascular and kidney disease. This is to help to start early intervention for these diseases and thus decreases the disease burden.
MATERIAL AND METHODS
Patient selection
The study was descriptive, cross sectional done on the autopsy cases in which patient died without morphological evidence of atherosclerotic catastrophe, during the period of January 2011 to August 2013.
Histological preparation: Specimen of heart and the whole length of aorta along with carotids, upto the bifurcation of common carotid artery and the renal arteries was removed and fixed in 10% formalin. The heart was dissected by inflow outflow technique, along the direction of flow of blood and aorta along the posterior surface. The three major coronary arteries were identified and cut transversely at 0.5 cm intervals until their entry into the musculature. Bits from the suspicious or definite atherosclerotic lesions were taken. All arteries were processed by routine tissue processing and stain with hematoxylin and eosin stain.
Pathological Assessment and Morphological Analysis: The microscopic grading of atherosclerosis was done according to the modified American Heart Association Classification(AHA) of atherosclerosis using morphological descriptions (2000) which is better than the earlier AHA classification with regard to the description of intermediate lesions which was prone for future development of complicated atherosclerosis.[5] The atherosclerotic lesions were divided into non-atheromatous lesions (Intimal thickening and Intimal Xanthoma) and progressive atheromatous lesions like [Pathological intimal thickening (PIT), Thick Fibrous cap atheroma (FCA) and Thin fibrous cap atheroma (TFCA), Calcified nodule (CN) and Fibrocalcific plaque (FCP)]. (Figure-2,3,4)
Statistical Analysis: Statistical analysis was done using chi square test using SPSS software.
RESULTS
In the present study, the ages ranged from 7 to 72 years and mean age were 39.23±14.24 years. Number of males and female were 67(74%) and 24 (26%) respectively. The most common cause of death was road traffic Accidents 42(46.1%), followed by poisoning 21(23.1%), then hanging and burns 5(5.5%) each. For comparing the atherosclerosis between the arteries, we have divided our results into two broad category i.e Non atherosclerotic lesion (NAL) and progressive atherosclerotic lesion (PAL) which was given in the classification because most NAL has potential to regress.[7] In present study, the atherosclerosis(which has PAL) in carotid was 12.6%. In case of coronaries atherosclerosis in LAD is about 51% followed by RCA 35% and last LCA was 37%. Atherosclerosis was 40% in ascending aorta, 20% in thoracic aorta and 30% in the abdominal aorta Atherosclerosis in renal arteries was only 3 %.The number and percent of PAL in all arteries was given in the (Table-1) When comparing the association of significance of atherosclerosis in carotid with coronaries, aorta and renal arteries, the P value was < 0.05, which was statistically significant.
DISCUSSION
Atherosclerosis is generalized systemic disease, affected by multiple risk factors such as age, gender, race, smoking, personality, hyperlipidemia etc. Atherosclerosis usually proceeds in parallel in various organ systems but there is asymmetry in involvement of various arteries by this disease. [3] The reason may be that the magnitude of the effect of each risk factor varies among the arterial beds for example- smoking selective augments abdominal aorta and thoracic more commonly affect the younger age group. [7] Many earlier studies had mention that carotid intima media thickness can be regarded as an indicator of generalized atherosclerosis. [9, 10] So it is very important to see whether the extent of disease cor-relates in different arterial beds same as in carotid artery or not. [12]
Association between carotid and coronary atherosclerosis: In the present, study mean of carotid atherosclerosis was 11.5±0.71 (12.6%) and mean of coronary atherosclerosis was 37.33±7.57 (41%). Nazarat et al had reported 50% and 85% of carotid and coronary atherosclerosis respectively. [14] Most Indian studies has shown steep rise in coronary atherosclerosis after second decade of life. [13] Advanced lesion in the coronary artery start appearing as early as in third decade. [15] In present study the none of the patient less than 34 years had carotid atherosclerosis. Prati et al. also reported none of the carotid atherosclerosis in less than 30 years. [16] Both above studies show that carotid atherosclerosis may start appearing after fourth decade compare to coronary which show steep rise after second decade. It was observed in our study that the coronary arteries were invariably involved showing atherosclerosis when carotid artery was affected and the percentage distribution of both arteries being involved when carotid artery showed atherosclerotic changes was 100%. The association between two arteries was statically significant.
Association between carotid and aortic atherosclerosis: The mean of aortic atherosclerosis was 27±9(29.9%) which was higher compared to the carotid atherosclerosis which was observed in this study. Earliest age of aortic atherosclerosis was observed is 20 year, whereas earliest age of carotid atherosclerosis was observed at 40 years. Siraj Ahmed et al had observed earliest aortic atherosclerosis in the second decade. [17] When carotid had atherosclerotic lesion 100% of patient had aortic involvement and most frequently associated with the ascending and abdominal aorta. Kallikazaros et al had found74.3% of incidence of carotid plaque in the subgroup with aortic plaque.[18] and also found that absence of carotid plaque may not reflect the absence of aortic plaque. [18] The association between the two arteries were statically significant.
Association between carotid and renal artery atherosclerosis: The mean of renal artery atherosclerosis was 2.75 ± 0.71(2.7%) which was much lower compared to the carotid atherosclerosis observed in our study. Only 25% of cases of carotid atherosclerosis had renal atherosclerosis. The difference may be due to the prevalence of renal artery atherosclerosis was much lower than the carotid atherosclerosis. Kuroda et al had reported 22.8% patient with carotid atherosclerosis had renal atherosclerosis. [11] Aggarwal et al reported advanced lesion like fibrous plaque was rarely observed before fifth decade. [19] When atherosclerosis presents in renal artery all (100%) the cases also had carotid atherosclerosis. It had been seen that 45%-100% of patient with renal atherosclerosis had co-morbid carotid artery atherosclerosis. [11] Studies had shown that severe carotid atherosclerosis associated with renal atherosclerosis and also the chronic kidney disease. [20] The wide difference in atherosclerotic lesions between the present study and other studies might be due to the fact that they have used the earlier AHA classification which considered even grade I and II lesions as atherosclerosis. In the present study since we have used the modified AHA classification of atherosclerosis, the earliest lesions like intimal thickening and intimal xanthoma were not considered as atherosclerotic lesions, partly explaining the difference in the prevelance of atherosclerosis. From above discussion we conclude that if carotid atherosclerosis is present, patient will be having coronary, aortic atherosclerosis but patient might have renal atherosclerosis. If carotid atherosclerosis is absent it doesn’t mean that patient won’t be having atherosclerosis in any other vessels.
CONCLUSION
From above study we conclude that carotid atherosclerosis is the indicator of generalized atherosclerosis. Assessing the carotid atherosclerosis using non-invasive technique can be used as screening tool for cardiovascular, cereberovascular and kidney disease due to renal artery atherosclerosis. The use anti-atherogenic preventive measures may be implemented as soon as carotid atherosclerosis is detected. So as to prevent premature death caused by cardiovascular, cereberovascular and kidney disease, burdening the national economy.
ACKNOWLEDGEMENT
The authors would like to thank Mr Ravishankar for statistical analysis and lab technicians from Histopathology division for processing the samples for this study. Authors acknowledge the immense help received from scholars whose article are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publisher of all those articles, journals and books from where the literature for the article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=544http://ijcrr.com/article_html.php?did=5441. Shah PK. Screening asymptomatic subjects for subclinical atherosclerosis: can we, does it matter, and should we? J Am Coll Cardiol. 2010;56:98–105.
2. Fausto N. Atherosclerosis in young people. Am J Pathol 1998;153:4.
3. Zoccali C, Mallamaci F, Finocchiaro P. Atherosclerotic renal artery stenosis: epidemiology, cardiovascular outcomes, and clinical prediction rules. J Am Soc Nephrol2002; 13: S179–83.
4. Naher S, Naushaba H, Muktadir G, Rahman MA, Khatun S, Begum M. Percentage area of intimal surface of the abdominal aorta affected by atherosclerosis: A postmortem study. J Med Sci Res 2007; 9 (1):26-30.
5. Virmani R, Kolodgie FD, Burke AP, Farb A, Schwartz SM. Lessons From Sudden Coronary Death: A Comprehensive Morphological Classification Scheme for Atherosclerotic Lesions. Arterioscler Thromb Vasc Biol 2000;20:1262- 1275.
6. Prince MR. Is there replacement for percentage stenosis in characterizing occlusive vascular disease? Radiology. 2007;245(3):617-8
7. McGill HC Jr, McManhan CA, Herderick EE, Tracy RE, Malcom GT, Zieske AW, et al. Effects of coronary heart disease risk factors on atherosclerosis of selected regions of the aorta and right coronary artery. PDAY Research Group. Pathobiological Determinants of Atherosclerosis in Youth. Arterioscler Thromb Vasc Biol. 2000;20:836–45.
8. Faxon DP, Creager MA, Smith SC, Jr, et al. Atherosclerotic Vascular Disease Conference: Executive summary: Atherosclerotic Vascular Disease Conference proceeding for healthcare professionals from a special writing group of the American Heart Association. Circulation. 2004;109:2595– 2604.
9. Bots ML, Hoes AW, Koudstaal PJ, Hofman A, Grobbee DE. Common carotid intima-media thickness and risk of stroke and myocardial infarction: the Rotterdam Study. Circulation. 1997;5(5):1432–1437.
10. Mattace-Raso F, van Popele NM, Schalekamp MA, van der Cammen TJ. Intima-media thickness of the common carotid arteries is related to coronary atherosclerosis and left ventricular hypertrophy in older adults. Angiology. 2002;53(5):569–74
11. Kuroda S, Nishida N, Uzu T, Takeji M, Nishimura M, Fujii T et al. Prevalence of renal artery stenosis in autopsy patients with stroke. Stroke. 2000;31:61–65
12. Finn AV, Kolodgie FD, Virmani R. Correlation between carotid intimal/medial thickness and atherosclerosis: a point of view from pathology. Arterioscler Thromb Vasc Biol. 2010;30:177–181
13. Singh H, Oberoi SS, Gorea RK, Bal MS. Atherosclerosis in coronaries in Malwa region of Punjab. J Indian Acad Forencis Med. 2005;27(4):236-239
14. Nezarat N, Sadeghi M, Rabiel K, Afshar Moghadam N , Satareh M, Ezadinezhad M, et al The effect of body fat distribution on coronary and carotid atherosclerosis: an autopsy study. J Res Med Sci. 2012;17(Spec 1):S125-S130.
15. Keche AS, Tirpude BH, Bobade HJ. Progressive atherosclerosis in central India – A modern epidemic. Al Ameen J Med Sci. 2013;6(4):342-349.
16. Prati P, Vanuzzo D, Casaroli M, Di Chiara A, De Biasi F, Feruglio GA, Touboul PJ. Prevalence and determinants of carotid atherosclerosis in a general population. Stroke. 1992;23:1705–1711.
17. Ahmed S, Prabhu MH, begum A. Atherosclerosis of aortaan autopsy study. J Biomed Pharm Res. 2013;2(5):52-58.
18. Kallikazaros IE, Tsioufis CP, Stefanadis CI, Pitsavos CE, Toutouzas PK. Closed relation between carotid and ascending aortic atherosclerosis in cardiac patients. Circulation.2 000;102:III263–268
19. Aggarwal A, Kapoor K, Singh B. Prevalence and severity of atherosclerosis in renal artery in Northwest Indian population: an autopsy study. Surg Rad Anat. 2009;31(5):349- 346.
20. Iwakiri T, Sato Y, Matsuura Y, Hatakeyama K, Marutsuka K, Yasashit A, et al. Association between renal vasculature changes and generalized atherosclerosis: An autopsy survey. J Atheroscler Thromb. 2014;21(2):99-107
Abbreviations:
LAD - Left anterior descending artery
RCA – Right coronary artery
LCA – Left circumflex coronary artery
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241710EnglishN-0001November30General SciencesGIANT CELL TUMOUR OF TENDON SHEATH OF THE ANKLE - A CASE REPORT
English4950Ashish K. JoseEnglish Sandeep MMR EnglishSurendher Kumar R.English Krishnagopal R.English Ravikumar N.EnglishAim: To study an ankle swelling following a trivial trauma in a young female.
Case Report: A 30 year old patient presented with pain and swelling in the right ankle following a trivial injury 4 months back. Radiograph showed soft tissue swelling and USG showed a cystic swelling over the flexor tendon. We did an excision biopsy and the histopathology report was consistent with Giant Cell Tumour of the tendon sheath.
Discussion: Giant cell tumour of the tendon sheath is a benign tumour usually arising in the limbs. It occurs more commonly in the hand and rarely in the foot. Patients usually present to the hospital because of pain and swelling. The masses arising from the tendons are of soft tissue density and calcification is uncommon. GCT-TS is histologically similar to pigmented villonodularsynovitis as haemosiderin deposits and numerous macrophages are seen in both.
Conclusion: Giant Cell Tumours of tendon sheath are similar to pigmented villo nodular synovitis (PVNS). They are the second most common benign tumor next to ganglions. The treatment is surgical excision of the mass.
EnglishGiant cell tumour, Histopathological examination, Pigmented villonodularsynovitis (PVNS)INTRODUCTION
Giant cell tumour of the tendon sheath (GCT-TS) isa benign solitary tumour that occurs more often in the hand and less commonly in the foot (1).There are 2 types: the localized type which is more common and the diffuse type which is rare. The diffuse type is considered to be the localized form of pigmented villonodularsynovitis (PVNS) of tendons. When the pathology is in the joint it is called PVNS. Both are benignproliferative conditions of unknown etiology that tend to affect patients younger than 40 years old. The diffuse form can be aggressive locally and has a high recurrence rate(2). GCT-TS and PVNS are histopathologically similar, but clinically distinct (3). Mononuclear and giant cells histologically resembleosteoclasts and are non-neoplastic (3) . Final diagnosis relies on a pathology specimen from excision although a recent study indicates that a fine-needle aspiration may provide a reliable diagnosis (4). The mass will often be hypervascular on Doppler imaging with ultrasound (5). Ultrasound may confirm the presence of a soft tissue tumor adjacent to a tendon but it can be difficult to differentiate between a solid and a cysticmass accurately (6). MRI appearance of these extra-articular lesions (and PVNS) are distinctive compared to other soft tissue tumors because of the intermediate to low signal intensity areas on both T1- and T2-weighted images. This reflects the hemosiderin deposition that is common to GCT-TS and PVNS tumors (although PVNS tends to have higher hemosiderin content and therefore tends to be darker)(2).
CASE REPORT
A 30 year female patient named Mrs. Gowri presented to the Orthopaedics OPD of Mahatma Gandhi Medical College and Research Institute Pondicherry, with pain and swelling over her right ankle for 4 months.She gave a history of trivial twisting injury to her ankle 4 months back. Following the injury she developed a small swelling which gradually increased in size.On examination there was a swelling over the anterior aspect of the lateral malleolus measuring 3 x 3 centimeters.Tenderness was present over the swelling. The swelling was firm to hard in consistency, mobile, non pulsatile and the skin over the swelling was pinchable.
Radiograph of right ankle revealed soft tissue swelling below the lateral malleolus.USG showed cystic swelling due to hematoma over the flexor tendon. We planned an excision biopsy. Intra-operativelythe swelling measured 3 x 3 cm and was found over the flexor digitorum tendon (Fig. 1). It was firm in consistency and haemorrhagic. No fluid collection was seen. The excised mass (Fig.2) was sent for histopathological examination. The histopathological changes were typicalof GCT-TS with the presence of numerous fibroblasts, macrophages and scattered giant cells.
DISCUSSION
Patients affected by giant cell tumour usually present to the hospital because of pain and swelling. Radiographic assessment involves both anteroposterior and lateralviews of the affected limb and compared with films of the contralateral side. During the evolution, masses arising from the tendons are of soft tissue density. Calcification is uncommon . Trauma is considered to be one of the etiological factors in GCT. Rodrigues et al (7) reported a history of trauma in 21% cases of GCT-TS of the hand. Our patient also gave a history of twisting injury to her ankle. GCT-TS is histologically similar to pigmented villonodularsynovitis as haemosiderin deposits and numerous macrophages are seen in both.
CONCLUSION
Giant Cell Tumours of tendon sheath are not really tumors but reactive lesions which are similar to PVNS. They can arise from the synovium instead of the tendon sheath. They are the second most common benign tumor next to ganglions. The treatment is surgical excision of the mass.
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=545http://ijcrr.com/article_html.php?did=5451. C. L. M. H. Gibbons, H. A. Khwaja, A. S. Cole,P.H. Cooke, N. A. Athanasou Giant-cell tumour of the tendon sheath in the foot and ankle . J Bone Joint Surg [Br] 2002;84-B:1000-3.
2. Annette D. Filiatrault, Joe T. Southerland, William D. Fishco,Giant Cell Tumor of Tendon Sheath: Case Studies.
3. Verheyden, JR, Damron TA. Giant Cell Tumor of Tendon Sheath. Emedecine. Jun26, 2009.
4. Jakowski JD, Mayerson J, Wakely PE Jr. Fine-needle aspirationbiopsy of the distal extremities: a study of 141 cases. Am J ClinPathol 2010;133:224-31.
5. Wan JM, Magarelli N, PehWC, Guglielmi G, Shek TW. Imagingof giant cell tumour or the tendon sheath. Radiol Med .2010;115:141-51.
6. Lee MH, Kim NR, Ryu JA. Cyst-like solid tumors of themusculoskeletal system: an analysis of ultrasound findings. SkeletalRadiol 2010;39:981-6.
7. Rodrigues C, Desai S, Chinoy R. Giant cell tumor of tendon sheath:a retrospective study of 28 cases. J SurgOncol1998;68:100-3.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241710EnglishN-0001November30General SciencesHYSTERECTOMY: A CLINICOPATHOLOGICAL CORRRELATION
English5154V. ArunadeviEnglishObjectives: To correlate indications of hysterectomy with the histopathological findings, in order to determine the percentage of preoperative diagnosis that was confirmed on histopathology and to determine the frequency of unexpected pathologies.
Methods: A retrospective study of 200 patients who had elective hysterectomy performed for various indications during the study period from January 2014 to December 2014 was conducted.
Settings: Karpaga Vinayaga Institute of Medical Sciences and Research Institute.
Results: 97.5% of hysterectomies were done for benign indications. The most common pathology identified was Leiomyoma in 32% of cases. Hysterectomies done for UV prolapse showed atrophic endometrium in 62.7% of cases. Other less frequent pathologies identified included endometrial hyperplasia, disordered proliferative phase and endometrial polyps.
Conclusion: Histopathological analysis correlated well with preoperative clinical diagnosis for hysterectomy. Benign pathologies were more common than their malignant counterparts. The commonest indication and histological finding in our setting was leiomyoma. The clinical and pathological correlation is 91.8% in case of leiomyoma. Histological diagnosis is considered the definitive method of evaluating tumours.
EnglishLeiomyoma, Adenomyosis, HysterectomyINTRODUCTION
Hysterectomy is the most commonly performed gynecological surgical procedure. It is estimated that over 500,000 hysterectomies are performed each year. The vast majority of these procedures are still performed via an abdominal approach (64%) with vaginal (22%) and laparoscopic (14%) approaches being less common (Jacoby etal1 ., 2009). The Society of Pelvic Reconstructive Surgeons issued guidance on choosing hysterectomy route in 1999. Since then vaginal hysterectomy has again gained favor2,3. The advantages of laparoscopic hysterectomy are shortterm hospital stay and recovery time. A systematic review and meta-analysis reports the average length of hospital stay to be 2 days less (95% CI 1.9-2.2) when compared to abdominal hysterectomy4 . However, a systematic review based on 5RCTs and 4 large case series reported laparoscopic hysterectomy to be more expensive and time-consuming than abdominal or vaginal hysterectomy5 . Laparoscopic techniques are not without risks and are associated with more complications than open operations, notable amongst which are bladder and ureteric injuries5 . Whether to remove the cervix remains unclear in both open and laparoscopic hysterectomy procedures5 . The disadvantages of a subtotal hysterectomy are possible in on-going menstrual bleeding and requirement of continued cervical surveillance (eg. smears)5 . Fibroids are the most common indication (39%) cited for performance of hysterectomy (Whiteman et al6 ., 2008). The purpose of this study is to correlate various indications of hysterectomy with the histopathological examination.
METHODS
The retrospective study analysis of 200 hysterectomy cases over a period of one year from January 2014 to December 2014 was reviewed in Department of OBG. Patient’s age, type of hysterectomy ,indication of surgery as well as true pathological diagnosis were reviewed , analyzed and correlated.
This study was approved by ethical committee.
RESULTS AND ANALYSIS
200 hysterectomies were studied. Hysterectomies were distributed over a wide age ranging from 20 years to 80 years. Of this 46% of cases were encountered in 40-49 years, which is the most common age group 22.5% of women were in age group of 30-39 years and 16.5% were 50-59 years. The relationship between age and number of hysterectomies is illustrated in Table 1.
The most common type of hysterectomies was Total Abdominal Hysterectomy with Bilateral Salphingo Ophorectomy (TAH with BSO) and Vaginal Hysterectomy (VH) , followed by Total Abdominal Hysterectomy (TAH). The most common age group for TAH with BSO was 40-49 years and Vaginal hysterectomy was 60-69 years, as shown in Table 2.
The various indications for hysterectomy are depicted in Table 3. 97.5% were benign and2.5% were for malignant indications. Leiomyoma was the most common preoperative clinical diagnosis found in 61 (30.5%) cases, followed by UV prolapse diagnosed in 59 (29.5%) cases. Other benign clinical indications included DUB (20.5%), Adenomyosis (4%), CIN (5.5%), Benign ovarian tumours (5%). 5 hysterectomies were performed for malignant indications which included CA endometrium, CA cervix and CA ovary
Leiomyoma was the commonest pathology found in 32% of cases as illustrated inTable 4. Hysterectomies for UV prolapse showed atrophic endometrium in 62.7% of cases. Other less frequent pathologies identified included endometrial hyperplasia, disordered proliferative phase and endometrial polyps. 7 cases of Benign serous cystadenomas, 2 cases of ovarian endometriosis and 1 case of hydrosalphix was found. 2 cases of endometrial adenocarcinoma, 2 cases of squamous cell carcinoma of cervix and 1 case of malignant mixed germ cell tumour of ovary was identified.
The final pathologic diagnosis confirmed the clinical indication in 91.8% in cases of leiomyomas, 75% in case of adenomyosis. The 41 cases diagnosed clinically as DUB were pathologically proven as follows: 9 adenomyosis, 8 as fibroid, 8 had endometrial hyperplasia and 2 showed endometrial polyps.
DISCUSSION
Hysterectomy still remains the widely used treatment modality even in developed countries. The complications of hysterectomy are often underestimated. Minor pyrexial morbidity was found in 47% of women after abdominal hysterectomy in the Pinion study with 5% requiring a blood transfusion7 .Common complications after hysterectomy include hemorrahage (2.4%), genitourinary disorders (eg. urinary retention, renal or ureteral injury) (1.9%), urinary tract infection (1.6%) and infection other than that in the urinary tract (1.6%)8 In a retrospective study including over 62,000 hysterectomies, the total incidence of ureteral injury after all hysterectomies was 1.0 of 1000 procedures and only 0.4 of 1000 procedures after total abdominal procedures (Harkki – Siren etal9 ., 1998). It has been shown that hysterectomy increase risk for subsequent stress urinary Incontinence (SUI). The true incidence of SUI caused by hysterectomy remains controversial (Roovers et at.,10 2000) Adhesion after an abdominal operation is very common, infact, 94% of patients develop intra-abdominal adhesions following a laparotomy 11,12. Al-Sunaidi and Tulandi13, studying small bowel obstruction (SBO) after hysterectomy for benign conditions, reported that TAHrelated adhesions accounted for 98% of SBO. The pooled rate for surgical site Infections (SSIs) after abdominal hysterectomy is reported at 1.7% by the National Health care Safety Network but ranged from 1% to 11% (olsen et at., 14 2009). The incidence of vault prolapse after vaginal hysterectomy for prolapse is approximately 12% but only 2% when the indication was other than prolapse15. Larger uteri are associated with a higher complication rate, primarily due to blood loss. When comparing uterine weights of less than 500 g, 500-999g, and greater than 1000g, risk of experiencing blood loss over 500ml, blood transfusion, major organ injury, and hospital readmission all increased as weight of the uterus increased (Unger et al., 16 2002). In 4% of women who die of cancer of the ovary, cervix and uterus hysterectomy should be seen as a life saving as well as life enhancing procedure.17 Hysterectomy has a high patient satisfaction rate because it is curative, usually performed when medical or minimal access management has failed, and repeated procedures or prolonged follow up is not needed. 18, 19-21
CONCLUSION
While confirming the preoperative diagnosis by histopathological examination, high confirmation rates were found for leiomyomas, malignancy and adenomyosis. Out of 41 cases , clinically diagnosed as DUB, histopathological examination revealed leiomyoma in 8 cases, adenomyosis in 9 cases, endometrial polyp in 2 cases.
ABBREVIATIONS
RCT – Randomised Controlled Trial
TAH with BSO- Total Abdominal Hysterectomy with Bilateral Salphingo Ophorectomy
VH - Vaginal Hysterectomy
CIN - Cervical Intraepithelial Neoplasia
DUB – Dysfunctional Uterine Bleeding
SUI - Stress Urinary Incontinence
SBO - Small Bowel Obstruction
SSI - Surgical Site Infection
ACKNOWLEDGEMENT
Author acknowledges the enormous help received from the scholars whose articles have been cited and incorporated in references. Author is also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this articles has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=546http://ijcrr.com/article_html.php?did=5461. Jocoby VL, Autry A, Jacobson G, et al Nation wide use of laparoscopic hysterectomy compared with abdominal and vaginal approaches. Obstet Gynecol 2009: 114: 1041- 1048.
2. Babalola EO, Bharucha AE, Schleck CD, et al. Decreasing utilization of hysterectomy, a population based study in Olmsted country, Minnesota, 1965-2002. Am J obstetric Gynecol 2007; 196; 214, e1-7
.3. National Guideline Clearing house (NGC). Guideline synthesis; guidelines for determining the route of hysterectomy for benign conditions.
4. Laparoscopic techniques for hysterectomy. National Institute for Health and Clinical Excellence, November 2007.
5. Luesley DM. Obstetrics and Gynaecology. An Evidence – Based Text for MRCOG 2nd ed. Hodder Arnold, 09/2010; 571-2.
6. Whiteman MK ,Hillis SD, Jamieson D, et al. Inpatient hysterectomy surveillance in the united states, 2000-2004. Am J Obstet Gynecol 2008; 31-37.
7. Pinion SB, Parkin DE, Abramovich DR et al. Randomised trial of hysterectomy, endometrial laser ablation and transcervical resection for dysfunctional uterine bleeding .BMJ 1994; 309; 979-983.
8. Spilsbury K, Hammond I, Bulsara M, Semmens JB. Morbidity outcomes of 78, 577 hysterectomies for benign reasons over 23 years. BJOG 2008; 115; 1473-83.
9. Harkki – siren P, sjoberg J, Tiitinen A. Urinary tract injuries after hysterectomy. Obstet Gynecol 1998; 92, 113-118.
10. Roovers JP, van der Vaart CH, van der Bom JG, Heintz AP.Urinary incontinence after hysterectomy. Lancet 2000;356:2012-2013.
11. Tulandi T, Al-Shahrani A, Adhesion prevention in gynecologic surgery . Curr Opin Obstet Gynecol 2005;17:395-398.
12. Ellis H, Moran BJ, Thompson JN et al. Adhesion-related hospital readmissions after abdominal and pelvic surgery; a retrospective cohort study. Lancet 1999;353;1476-1480.
13. Al-Sunaidi M, Tulandi T. Adhesion-related bowel obstruction after hysterectomy for benign conditions. Obstet Gynecol 2006;108:1162-1166.
14. Olsen MA, Higham-Kessler J, Yokoe DS, et al.Developing a risk stratification model for surgical site infection after abdominal hysterectomy. Infect Control Hosp Epidemiol 2009;30;1077-1083.
15. Marchionni M, Bracco GL, Checcuci V et al. The true incidence of vaginal vault prolapse: thirteen years experience, J Reprod Med 1999;44;679-684.
16. Unger JB, Paul R, Caldito G. Hysterectomy for the massive leiomyomatous uterus. Obstet Gynecol 2002;100:1271- 1275.
17. Studd J Hysterectomy A life saving as well as life enhancing operation. Menopause Int 2009; 15:2-3.
18. Lethaby A, Hickey M, Garry R, Penninx J. Endometrial resection / ablation techniques for having menstrual bleeding. Cochrane Database syst Rev 2009;CD001501.
19. A randomized trial of endometrial ablation versus hysterectomy for the treatment of dysfunctional uterine bleeding: outcome at four years. Aberdeen Endometrial Ablation Trials Group. Br J Obstet Gynaecol 1999;106:360-6.
20. Reich H, Ribeiro SC, Vidalia A. Hysterectomy as treatment for dysfunctional uterine bleeding. Baillieres Best Pract Res clin obstet Gynaecol 1999;13:257-67.
21. Ballard L, Lyon DS, Jones JL. Inpatients with menometrorrhagia : etiologies, treatments and outcomes. South Med J 2000;93:571-4.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241710EnglishN-0001November30General SciencesA COMPARATIVE STUDY OF OXACILLIN SCREEN AGAR, OXACILLIN DISC DIFFUSION AND CEFOXITIN DISC DIFFUSION, OXACILLIN E-TEST METHOD FOR ROUTINE SCREENING OF METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS
English5560Anamika VyasEnglish Megha SharmaEnglish Sanjeev KumarEnglish Mrityunjay KumarEnglish Sudhir Kumar MehraEnglishBackground: Methicillin resistant staphylococcus aureus (MRSA) has been recognized as one of the major pathogen in both hospital and community settings. MRSA strains are frequently resistant to different class of antibiotics. Multi drug antimicrobial resistance among MRSA is a matter of concern for clinicians. Therefore, an accurate detection of MRSA in microbiology laboratory is essential for patient management and epidemiological purpose including hospital infection control.
Aim: The present study was undertaken to compare various phenotypic methods (oxacillin disc diffusion, cefoxitin disc diffusion, oxacillin screen agar) for detection of MRSA using E test MIC oxacillin as gold standard method. We also aimed to study the resistance pattern of the MRSA isolates.
Materials and Methods: A total of 50 staphylococcus aureus strain which were isolated from different clinical specimens were included in this study. All isolates were tested for methicillin resistance by oxacillin disc diffusion, cefoxitin disc diffusion and oxacillin screen agar test considering E test MIC for oxacillin as gold standard. All the isolates were tested for antibiotic susceptibility testing by kirby bauer disc diffusion method against a predefined panel of antimicrobials and intepretation was done according to CLSI guidelines.
Result: Among the 50 staphylococcus auresus isolates 23 (46%) isolate were identified as MRSA by E test MIC method. Cefoxitin disc diffusion test showed 100% sensitivity and 92% specificity while oxacillin disc diffusion test and oxacillin screen agar test showed 100% sensitivity and 74% specificity. The resistance percentage of MRSA isolate to erythromycin, ciprofloxacin, levofloxacin, cotrimoxazole and gentamycin was 70%, 96%, 57%, 52% and 43% respectively. All isolates were sensitive to vancomycin, linezolid and tigecycline.
Conclusion: Our study revealed that cefoxitin disc diffusion test had high sensitivity and high specificity as compared to other phenotypic methods used routinely to detect MRSA. This method is technically less demanding even can be used along with antibiotic sensitivity testing, cost effective and can be the best option to detect MRSA in clinical settings with constraint facilities. Vancomycin is still the drug of choice for treatment of MRSA, However regular monitoring of vancomycin sensitivity should be done as reduced susceptibility to vancomycin has been reported from all over the globe and is a matter of concern for clinicians.
EnglishMRSA, Cefoxitin disc diffusion, Oxacillin disc diffusionINTRODUCTION
Methicillin Resistant Staphylococcus aureus (MRSA) was first discovered in U.K. in 1961 soon after the introduction of methicillin into the clinical practice. Since then MRSA have spread throughout hospitals and other chronic health care facilities worldwide, to the extent that it is now the most commonly isolated antimicrobial resistant pathogen in many countries.1,2 The incidence of MRSA in India ranges from 30-70%.3,4 Traditionally, most strains of MRSA were isolated from hospitalized patients, However MRSA have now appeared in the community world wide in patients with or without risk factor for MRSA infections suggesting a changing epidemiology.5 The importance of MRSA as a nosocomial as well as community acquired pathogen is well documented.6,7 Methicillin resistance in S. aureus is based on production of an additional penicillin binding protein, PBP2 or PBP2a, which is encoded by mecA gene.8 mecA gene is an additional gene found in methicillin resistant S.aureus with no allelic equivalent in methicillin susceptible S. aureus. The major problem in routine screening of MRSA is the heterogeneous population of MRSA. This heterogeneous expression of methicillin resistance in sub population of MRSA can occasionally result in minimum inhibitory concentration that appears to be borderline and consequently the isolate may be interpreted as susceptible.9 Errors in the detection of methicillin resistance can have serious adverse clinical consequences as false susceptibility may result in treatment failure and increased nosocomial and community spread of this deadly microbe if infection control practices are not followed meticulously, on other hand false resistance may not only increase health care cost following unnecessary isolation precautions and over use of glycopeptides but also leads for emergence of clinical isolates with reduced susceptibility to vancomycin. Another major concern about MRSA is that these isolates are frequently resistant to many different classes of antibiotics.10 thus limiting the treatment options to fewer and expensive antibiotics like vancomycin, linezolid and tigecycline. Hence, an accurate identification of MRSA by microbiology lab is essential for institution of effective antimicrobial therapy, infection control measures, epidemiological purpose, and for provision of cost effective health care facilities. Detection of the mecA gene by PCR is the gold standard for identifying MRSA. . However this is a costly and time consuming method and use of this assay is restricted to reference centre and is not routinely carried out in all laboratories.12 Several studies have reported different phenotypic methods developed for detection of MRSA which are widely used in clinical microbiology laboratories.11,12 but the optimum method for the detection remains controversial. Most of the laboratories uses oxacillin disc diffusion method as a routine test for MRSA detection. Cefoxitin,a cephamycin, is potent inducer of mecA regulatory system than oxacillin therefore it is considered better than oxacillin for detection of heterogeneous MRSA. In the present study, we evaluated methicillin resistance in S.aureus isolates by three different phenotypic methods namely oxacillin disc diffusion method, cefoxitin disc diffusion method, oxacillin screen agar method considering E test MIC (oxacillin) as a gold standard . The sensitivity and specificity of each test was determined with the aim to find out a cost effective and easily applicable method or combination there of, for detection of MRSA in a routine diagnostic laboratory. We also aimed to study the resistance pattern of MRSA isolates.
MATERIALS AND METHODS
Study design: This prospective study included 50 staphylococcus aureus strains which were isolated from various clinical specimens submitted to microbiology department of Geetanjali Medical College and Hospital, Udaipur. The specimens included were pus, swabs from surgical wounds, pleural fluid, ascitic fluid, CSF ,Urine, sputum, endotracheal aspirate and blood etc. No duplicate clinical isolates from the same patient and no environmental isolates were included in the study.
Isolation and identification of staphylococci from clinical specimen: All the clinical specimens were first inoculated on Blood agar and McConkey agar plates (Hi media Mumbai,India). Plates were incubated at 37 degree centigrade for 18-24 hrs. S.aureus was identified and differentiated from related organisms on the basis of colony morphology, gram stain, catalase test, slide and tube coagulase test and mannitol fermentation.13
Antibiotic susceptibility testing by Kirby Bauer disc diffusion method: Antibiotic susceptibility testing was performed for all the S.aureus isolates against a predetermined panel of antibiotics by Kirby Bauer disc diffusion method on Muller-Hinton agar plates and the results were interpreted according to the guidelines of the CLSI.14 The antibiotics which were tested included Penicillin(10u), Gentamycin (30µg), Erythromycin(15µg), Clindamycin (2µg), Cotrimoxazole (1.25/23.70µg), Ciprofloxacin (5µg), Levofloxacin (5µg), Vancomycin (30µg), Linezolid(30µg), Tigecycline(15µg), Tetracycline(30µg), Rifampicin (5µg), Chloremphenicol(30µg). S.aureus ATCC25923 was used as a control strain.
Detection of Methicillin resistance by pheno-typic methods: All the S. aureus isolates were tested for methicillin resistance by oxacillin disc diffusion test, cefoxitin disc diffusion test and oxacillin screen agar test. MIC for oxacillin was determined with the E test – strips (Hi-Media Mumbai), which was used as a gold standard method in the present study. The oxacillin disc diffusion test: The oxacillin disc (1µg) diffusion test was carried out on Muller-Hinton agar plates which were supplemented with 2% NaCl to detect MRSA according to the CLSI guideline.14 For each strain a bacterial suspension adjusted to 0.5 McFarland was used. The plates were incubated at 35°C and the results were recorded after 24 hrs. of incubation. The isolates were considered as resistant when the diameter of inhibition was ≤ 10mm, as intermediate resistant when diameter was 11-12mm and as sensitive when the diameter was ≥ 13mm.14
The cefoxitin disc diffusion test: All the isolates were subjected to cefoxitin disc diffusion test using a 30µgm disc. A 0.5 McFarland standard suspension of the isolate was made and lawn culture was done on MHA plates. Plates were incubated at 37°C for 18 hrs. and zone diameter was measured. An inhibition zone diameter of ≤ 21mm was reported as methicillin resistant and a diameter of ≥ 22mm was considered as methicillin sensitive.14 The oxacillin screen agar test: The test was performed by inoculating a direct colony suspension (0.5 McFarland standard) with a swab spotting an area of 10- 15mm in diameter on MHA Plate containg 4% NaCl and 6 µgm/ml oxacillin. Plates were incubated at 35°C for 24 hrs. The plates were observed carefully in transmitted light for any growth. Any growth after 24 hrs was interpreted as oxacillin resistant.15
Determination of MIC by E-Test: MIC for oxacillin was determined with the E-Strip (Hi-media,Mumbai, India) using 0.5 McFarland inoculum according to manufacturers instruction. MHA plates supplemented with 2% NaCl were used. By using cotton swab a lawn culture of standardized bacterial suspension was done on MHA plate. Oxacillin E-strip was then placed on plate and plate was kept in incubation at 35° for 24 hrs. After incubation formation of elliptical zone of inhibition growth occurs. MIC was read where the ellipse intersect the MIC scale on the strip. According to the CLSI standards, S. aureus isolate with oxacillin MIC of ≤ 2µg/ml and ≥ 4µg/ml are defined as methicillin susceptible Staphylococcus aureus (MSSA) and methicillin resistant Staphylococcus aureus (MRSA). MHA plates without antimicrobial were used as control of bacteria growth. S. aureus ATCC 25923 was used as control strain. E-Test MIC was our gold standard method in present study and sensitivity and specificity of other methods were compared with it.
RESULTS
Among the 50 S.aureus isolates 23 (46%) were identified as MRSA by E-Test MIC method. Of 23 MRSA isolates, 16 (69%) strains were isolated from pus, 2 (9%) from urine, blood, and fluids each and 1 (4%) from sputum. Methicillin resistance was detected by oxacillin disc diffusion, cefoxitin disc diffusion and oxacillin screen agar test in 30, 25, 30 isolates respectively. The sensitivity, specificity and the positive and negative predictive values of various phenotypic methods in comparision to E-Test MIC (gold standard), for the detection of MRSA, are Summarized in (Table-1)
The result of antibiotic resistant rates of MRSA isolates to various antibiotics are shown in table-2. In our study all the strains were sensitive to vancomycin, linezolid,tigecycline, rifampicin and chloremphenicol.
DISCUSSION
Despite the introduction of effective antimicrobial agents and improvements in infection control measures specially hand hygiene, staphylococcus aureus has persisted as important hospital and community pathogen causing superficial skin and soft tissue infections to serious systemic infection leading to illness and death of a person. This problem is further compounded by development of methicillin resistance. Resistance to this antibiotic implies resistance to all β-lactam antibiotics including cephalosporins and monobactams, the most important group of antibiotics to treat staphylococcal infection. Infection with MRSA strains has not only caused therapeutic problems in hospital but also put a tremendous pressure on resources controlling their spread. Thus it is important that clinical microbiology laboratories identify the organism accurately. This will help in determining the appropriate antimicrobial therapy ,shortens the hospital stay, lower hospital cost (by preventing unnecessary use of glycopeptides and isolation precautions), prevent cross transmission in wards and thus in turn will decreases morbidity and mortality. Polymerase chain reaction (PCR) for amplification of the mecA gene is presently considered as the gold standard for detecting methicillin resistance in S.aureus. Inspite of growing consensus in the literature for this method, it is not yet available in all clinical laboratories due to financial and technical constraints, therefore phenotypic methods, although dependent on many environmental and conditional factors still remains a method of choice in resource constraint laboratories. Our study revealed that, overall rate of methicillin resistance with S.aureus was 46%. Similar isolation rates were found in studies from different parts of India, ranging from 45.36 to 59.3%.16,17,18 In contrast 26.4% and 19.5% prevalence rates has also been reported in some studies.19,20 which is comparatively less then that reported in present study. This discrepancy could be due to difference in the study design i.e. Population under study and geographical distribution ,variation in antibiotic usage and infection control practices in different hospitals as well as due to differential clonal expansion and drug pressure in community. MRSA isolates were predominantly isolated from the pus (69%), similar findings were reported by Anupurba et al.17 and Sasirekha et al.21 In present study E-Test MIC determination for oxacillin was used as a gold standard for MRSA detection. The advantage of E-Test method is that it is easy to perform as a disk diffusion test and approaches the accuracy of PCR for mecA gene. There are many studies comparing E-Test MIC with broth dilution and PCR methods which has yielded satisfactory results.22 In present study cefoxitin disc diffusion was found to be highly sensitive 100% and specific 92.59% while sensitivity of oxacillin disc diffusion was 100% and specificity was 74.07%. Similar results were quoted by several other studies.12,16,23,24 Cefoxitin is a better inducer of the expression of the mecA gene, so the heterogeneous population that variably express the mecA gene is better detected by disc diffusion with cefoxitin then with oxacillin, which is a weak inducer of PBP2a production. Several workers have reported that the result of cefoxitin disc diffusion test co-relates better with the presence of mecA gene than the result of oxacillin disc diffusion test.12,25 There are a number of studies stating that cefoxitin disc diffusion method is a reliable method for detection of MRSA and the result were found to be in concordance with PCR mecA gene detection method.24,26,27. Our study also strengthens the fact that cefoxitin is superior to oxacillin as indicator of MRSA for the detection of methicillin resistance. In our study, oxacillin disc diffusion method was only 74.07% specific. The high false positivity of oxacillin disc diffusion method in present study could be due to hyper production of β-lactamase which may lead to phenotypic expression of oxacillin resistance resulting in a clinical isolate which is oxacillin resistant but do not possess the usual genetic mechanism for such resistance. Probably such strains under antibiotic pressure may eventually turn into fully resistant strain. The oxacillin screen agar medium showed 100%.sensitivity and 74.07% specificity. Similar finding of high sensitivity and low specificity using oxacillin screen agar medium was reported by other workers also.12 Difficulty in MRSA detection by oxacillin screen agar base occur if the organism have their MIC near break points i.e. (borderline resistance strain) . The test also performed less well in studies where hetero resistant strains were included in study group, as it is subjected to many environmental conditions such as temperature, pH, salt concentration, incubation time.26 Swenson et al.15 also noted that sensitivity is decreased when hetero resistant strains were tested and specificity decreased with strains having borderline MIC.
Some of the studies have shown different sensitivity and specificity for these three phenotypic tests for detection of MRSA. Baddour et al.31 reported that the sensitivity and specificity of the cefoxitin and oxacillin disk diffusion test were 84.6%, 84.6%, 87.5% and 79.2% respectively. They found that the oxacillin agar screening was 92.3% sensitive and 45.8% specific. In another study by Jain et al.32 the sensitivity and specificity of the cefoxitin and oxacillin disk diffusion test were 94.44%, 100%, 95.83% and 58.33% respectively. Matos et al.33showed the cefoxitin and oxacillin disk diffusion test and oxacillin agar screening was 100% specific but only the cefoxitin and oxacillin disk diffusion test had 100% sensitivity. They reported that the oxacillin agar screening had the lowest sensitivity (82.2%). In general, in the most conducted studies, cefoxitin disk diffusion test has shown the highest specificity compared to oxacillin disk diffusion and agar screening. In a laboratory where it is not possible to carry out molecular method as a routine, cefoxitin disk diffusion test is a good surrogate marker for detecting methicillin resistance. It is far superior to most of the currently recommended phenotypic method like oxacillin disc diffusion and oxacillin screen agar method. No special medium or incubation temperature is required for cefoxitin as is required for oxacillin and results are easy to read in both transmitted and reflected light. It is now an acceptable method for detection of MRSA by many reference groups including CLSI. Considerable variations were found in the reported resistance profile among MRSA isolates from different countries and from different hospitals with in a country. Keeping in view this fact we determined the resistance pattern of MRSA isolates against a pre-determined panel of antimicrobials. Among MRSA isolates high degree of resistance was encountered for ciprofloxacin (96%), levofloxacin (57%), erythromycin (70%), cotrimoxzole (53%). This is similar to the finding of studies carried out by Sasirekha et al21 and Udo et al30 which also found high level of resistance to erythromycin and ciprofloxacin. The present study revealed high percentage of sensitivity to gentamycin (57%). Similar finding was also reported in a study carried out by Sasirekha et.al.21 This is in contrast to the studies done by Quereshi et al28 and Kandle et al.29 They reported 97.8% and 91% resistance to gentamycin. The reason which could justify these finding is that gentamycin is not used frequently to treat staphylococcus infection in our set up thus decreasing selection pressure for drug resistance, at the same time macrolides and quinolones are broad spectrum antibiotics, frequently used in the treatment of common staphylococcal infection. This change in antibiotic usage pattern would have led to the development of gentamycin sensitive and macrolide, quinolones resistant isolates. In our study no strain was found resistant to vancomycin, linezolid which was similar to other studies.4,11,14,16,17 Sensitivity to tigecycline was also 100%. This may be due to the fact that due to high cost these drugs were not used frequently in our setup thus decreasing the selection pressure for drug resistance. However MRSA strains with reduced susceptibility to vancomycin have been reported recently from various parts of country.
CONCLUSION
It is concluded from the present study that cefoxitin disc diffusion method had a high sensitivity and specificity compared to other phenotypic methods for detection of MRSA. Cefoxitin disc diffusion method can be the preferred option to detect MRSA in clinical settings with resource constraint facilities as it is easy to perform, do not require special technique, media preparation and finally more cost effective than PCR and latex agglutination test for PBP2a detection. Vancomycin, linezolid, tigecycline are effective drugs for treatment of MRSA. We suggest that these drugs should be considered as reserve drugs and should not be used as empirical therapy in treatment of staphylococcus aureus and other gram positive infections. Regular monitoring of vancomycin sensitivity should be carried out to find out early emergence of VISA or VRSA strains in clinical setup. It was noted that MRSA isolates showed resistance to most of the antibiotics. This finding calls, for urgent attention where by strict antibiotic policy should be enforced to curtail irrational use of antibiotics. Constant surveillance of antimicrobial profile of MRSA isolates should be carried out which will help the clinicians for selection of appropriate antimicrobial therapy.
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors/editors/publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=547http://ijcrr.com/article_html.php?did=5471. Diekema DJ, BootsMiller DJ, Vaughn TE, Woolson RF, Yankey JW. Antimicrobial resistance trends and outbreak frequency in United States hospitals. Clin. Infect. Dis.2004; 38:78-85.
2. Goosens H. European Status of resistance in nosocomial infections. Chemotherapy.2004; 51:177-181.
3. Verma S, Joshi S, Chitnis V, Hemwani N, Chitnis D. Growing problems of Methicillin Resistance Staphylococci-Indian Scenario Indian J. Med Sci 2000;54(12):535-40.
4. Rajaduraipandi K, Mani KR, Panneerselvam K, Mani M, Bhaskar M and Manikandan P. Prevalence and antimicrobial susceptibility pattern of methicillin resistant Staphylococcus aureus: A multicentre study. Indian J. Med. Microbiol 2006;24(1):34-8.
5. Chambers HF. The changing epidemiology of staphylococcus aureus Emerg. Infec. Dis.2001;7:178-182.
6. Brown DF, Edward DI, Hawkey PM, Morrison D, Ridgway GL, Towner KJ, et.al. Guidelines for the laboratory diagnosis and susceptibility testing of methicillin-resistant staphylococcus aureus (MRSA). J. Antimicrob chemother 2005; 56(6):1000-18
7. Rabhar M, Yaghoobi M, Fattahi A.Comparision of different laboratory methods for detection of Methicillin Resistant Staphylococcus aureus.Pak J med Sci. 2006;22(4):442-5.
8. Brown D.F. Detection of methicillin/oxacillin Resistance in staphylococci. J Antimicrob chemother. 2001;48 suppl 1:65-70.
9. Swenson JM, Patel JB, Jorgensen JK. Special phenotypic methods for detecting antibacterial resistance, chapter 74. In:Murray PR, Baron ES, Jorgensen JH, Landry ML Pfaller MA, editors. Manual of Clinical Microbiology. 9th ed. Washington DC:ASM Press 2007 P.1175-76.
10. Tiemersma EW, Bronzwaer SL, Lyytikainen O, Degener JE, Schrijnemakers P, Bruinsma N, et.al. Methicillin-resistant staphylococcus aureus in Europe, 1999-2002. Emerg. Inf. Dis. 2004; 10(9):34-7.
11. Tiwari HK, Sapkota D, Das AK, Sen MR. Assesment of different methods to detect Methicillin Resistnt Staphylococus aureus. Southeast Asian J.Trop Med Public Health 2009;40:801-06
12. Velasco D, Mar Tomas MD, Cartelle M, Beciero A, Perez A, Molina F et al Evaluation of different methods for detecting methicillin (oxcillin) resistance in staphylococcus aureus. J. Antimicrob Chemother 2005; 55(3):379-82.
13. Baird D, Staphylococcus : Cluster forming gram positive cocci. In:Mackie and McCartney Practical Medical Microbiology, Colle J.G, Fraser A.G., Marmion BP., Simmons A, (14th Ed) Churchill Livingstone, 1996, PP:245-261.
14. Clinical Laboratory Standard Institute. Performance standard for Antimicrobial susceptibility testing ; twentieth Informational supplement CLSI documentM100-S20.Wayne, PA:CLSI;2009
15. Swenson J.M., Williams, P.P., Killgore, G., O’Hara C.M. and Tenover FC . Performance of eight methods, including two new rapid methods, for detection of oxacillin resistance in a challenge set of staphylococcus aureus organisms J. Clin Microbial.2001; 39: 3785-3788.
16. Oberoi L, Kaur R. and Aggarwal A. Prevalence and antimicrobial susceptibility pattern of Methicillin Resistant Staphylococcus aureus (MRSA) in a rural tertiary care hospital in North India . IJABPT 2012;3(1):200-05.
17. Anupurba S, Sen MR, Nath G, Sharma BM, Gulati AK, Mohapatra T.M. Prevalence of methicillin resistant Staphylococcus aureus in tertiary referral hospital in Eastern Uttar Pradesh, Indin J. Med Microbial 2003;21(1):49-51.
18. Tiwari H.K, Sen M.R. emergence of vancomycin resistant Staphylococcus aureus (VRSA) from a tertiary care hospital from northern part of India. BMC Infect Dis 2006;6:156.
19. Kumari N, Mohapatra TM, Singh YI. Prevalence of Methicillin Resistant Staphylococcus aureus (MRSA) in a tertiary - care hospital in Eastern Nepal. J. Nepal Med Assoc 2008; 47(170):53-56.
20. Tahnkiwale SS, Roy S, Jalgaonkar SV Methicillin reistance among isolates of staphylococcus aureus: Antibiotic sensitivity pattern and phage typing. Ind J Med Sci 2002;56:330- 334.
21. Sasirekha B, Usha M.S., Amruta A.J., Ankit S, Brinda N, Dviya R. Evaluation and Comparision of different phenotypic tests to detect Methicillin Resistant Staphylococcus aureus and their Biofilm Production. Int J.PharmTech Res.2012 ; 4(2) : 532-541.
22. Ercis S, Sancak B, Hascelik G. A comparision of PCR detection of mec A with oxacillin disk susceptibility testing in different media and sceptor automated system for both staphylococcus aureus and coagulase negative staphylococci isolates. Indian J Med Microbial 2008;26(1):21-24.
23. Tiwari HK, Sapkota D, Das AK and Sen MR. Assesment of different methods to detect Methicillin Resistant Staphylococcus aureus. Southeast Asian J. Trop Med Public Health 2009;40(4):801-06.
24. Mathews A.A., Thomas M., Appalaraju B., Jayalakshmi J., Evaluation and Comparision of tests to detect methicillin Resistant S. aureus. Ind J. Pathol Microbial 2010;53(1):79- 82
25. Cauwelier B, Gordts B, Descheemaecker P, Van Landuyt H, Evaluation of a disk diffusion method with cefoxitin (30µg) for detection of methicillin resistant Staphylococcus aureus Eur. J. Clin Microbial. Infect Dis.2004; 23(5):389-392.
26. Anand K.B., Agarwal P., Kumar S., Kapila K., Comparison of cefoxitin disc dffusion test, oxacillin screen agar, and PCR for mecA gene for detection of MRSA. Ind. J. Med. Microbiol. 200; 27(1):27-29.
27. Rahbar M., Safadel N., Evalution of cefoxitin disk diffusion test for routine detection of methicillin resistant Staphylococcus aureus. Iran J. Patholol.2006;1(4):145-148.
28. Qureshi A.H., Rafi S., Qureshi S.M., Ali A.M., The current susceptibility patterns of MRSA to conventional antistaphylococcal antimicrobials at Rawalpindi. Pak. J. Med. Sci. 2004; 20:361-364.
29. Kandle S.K., Ghatole M.P., Takpare A.Y., Hittinhalli V.B., Yemul V.L., Bacteriophage typing and antibiotic sensitivity pattern of staphylococcus aureus from clinical specimen in and around Solapur (South Maharashtra). J. commun. dis. 2003; 35:17-23.
30. Udo E.E., Sweih A.N., Mokaddas e., Johny M., Dhar R., Gomaa H.H., Obaid I.A., Rotimi V.O., Antibacterial resistance and their genetic location in MRSA isolated in Kuwait hospitals, 1994-2004. BMC Infect. Dis.;2006, 6(1):168.
31.Baddour MM, Abuelkheir MM, Fatani AJ. Comparison of mecA polymerase chain reaction with phenotypic methods for the detection of methicillin-resistant Staphylococcus aureus. Curr. Microbiol.2007; 55: 73-479.
32. Jain A, Agarwal A, Verma RK . Cefoxitin disc diffusion test for detection of meticillin-resistant Staphylococci. J. Med. Microbiol.2008; 57:957-961.
33. Matos PD, Schuenck RP, Cavalcante FS, Caboclo RM, Santos KR . Accuracy of phenotypic methicillin susceptibility methods in the detection of Staphylococcus aureus isolates carrying different SCCmec types. Mem. Inst. Oswaldo. Cruz.2010; 105:931-934.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241710EnglishN-0001November30General SciencesA STUDY ON MYOPIA AMONG THE STUDENTS OF A DENTAL COLLEGE IN KERALA
English6165Shiny GeorgeEnglish Biju Baby JosephEnglish Mrs. Kavitha PaulEnglishBackground: Myopia is one of the leading causes of vision loss around the world .Various studies from different parts of the world show a dramatic increase in refractive error, especially myopia among school and college students. Higher levels of education like medical education have been repeatedly associated with greater myopia prevalence.
Objective: To study the prevalence and the underlying factors of myopia in BDS students of a Dental College in Kerala.
Research methodology: Eighty nine BDS students (2012 - 2012 batches) were examined. Students were selected from each class by systematic random sampling technique, their visual acuity was checked using Snellen’s Chart and Diopters were obtained. Details of factors were obtained using a questionnaire.
Results: Prevalence of myopia was observed as 40.4%. First and second year students had a greater percentage of myopia with 46.4 % and 56.7% respectively. There was a strong relationship with years after diagnosing myopia which indicates that majority of them developed it in less than 5 years (p=0.000). Siblings of most of myopics also had myopia (p=0.002). Sleeping habits showed a significant relationship with myopia (0.037). Duration of TV watching, duration of computer use, Reading hours, type of light used and playing or texting with cell phone were not significant.
Conclusion: Prevalence of myopia was high among dental students (40.4%).
EnglishMyopia, Refractive error, Visual acuityINTRODUCTION
According to the WHO report, uncorrected refractive error is the second commonest cause of global visual impairment first being the cataract 1 . Refractive error may be defined as a state in which the optical system of the non accommodating eye fails to bring parallel rays of light to focus on the retina. Myopia is a refractive error in which eye fails to see distant objects properly. Several studies describe an increasing prevalence of myopia in recent years. The prevalence of myopia in USA is estimated to be 25% and in India to be 19% 2,3. Myopia has been associated with socioeconomic status, level and length of education, parental myopia, exposure to near work and early lifestyle risk factors4-8. The lifestyle factors which may play a role in myopia development include reading for pleasure9 , variations in lighting,10 watching television and playing video games,11 use of the computers,12 time spent indoors, and less time spent in sports.13 There has been a dramatic increase in myopia prevalence rates over the past few decades in different parts of Asia 14. There are some studies showing that the academically active professionals are the major sufferers of myopia 15and the severity of myopia has been reported to be associated with the level of educational attainment16,17 . The prevalence rate of myopia in Singapore medical students has been reported to be more than 82% 18. Similar studies have been reported from Norway and Denmark where the prevalence among medical students came out to be 50.3% and 50% respectively19,20. Increasing near work like reading, use of microscope etc have frequently been blamed for the development of myopia 21. Medical and dental curriculum demands prolonged hours of reading and related visual tasks for many years. Many studies are reported from different parts of the world about the development of myopia among medical students, but we couldnot find studies among dental students. This study was designed to determine the occurrence of myopia in dental students of a College in Kerala.
MATERIALS AND METHODS
The study was conducted on 89 dental students of Azeezia College of Dental Sciences and Research. The study was conducted in three batches, admitted in the years from 2010 to 2012. After getting informed consent from each student, they were examined for their height, weight and visual acuity. Height in centimeter and weight in kilogram of each student is measured using anthropometric scale and weight machine. The body mass index was calculated using the formula as follows. Body Mass Index = Height (m2) /Weight (Kg). Snellen’s chart was used to test the visual acuity for distant vision. Power in diopters were obtained based on the information furnished by the students or from their current spectacle prescription. Newly diagnosed students were sent to ophthalmology department and their power was checked. Different habits of the students and family histories of refractive errors in their parents were obtained by a questionnare. Statistical analysis was carried out by Chi square test. P value of 5 hours/day. 58.3 % of the students watched television for more than 1 hour to 5 hours per day. 27.8 % watched for less than 1 hour/day. Among the myopics , 7 students used to watch TV for more than 2 hours and 19 students for 1-2 hours and only 10 students for less than 1 hour. Statistically it didnot show any significant relationship (p 0.234). Similarly, our study didn’t show a significant relationship between the duration of computer use and myopia (p=0.382). 16 students (44 %) of the students were using computer for -2 to-5 diopters) and high myopia (power > -5 diopters). Among the 36 myopic students, 21 had low myopia, 13 had moderate myopia and 2 had high myopia of both the eyes. Out of 36 students suffering from myopia , 6 students were in 2010-11batch (19.4%), 17 students in 2011-12batch ( 56.7 %) and 13 students were in 2012-13 batch (46.4 %) (fig 2 and 3). The percentage of students with myopia is more in the 2011 and 2012 admission which indicates a definite increase in no. of students in the recent years .
DISCUSSION
Refractive errors are extremely common in the young Population with high academic activity. 15 There are many studies from different parts of the world showing the increased occurrence of myopia among the medical students18-20. Increased near work as in reading and related visual tasks and long duration of medical curriculum are blamed for this increase in the occurrence of Myopia development in Medical students. Some authors, in a sample of medical students in Singapore, discovered that 82% were myopic 18. As the dental curriculum is also vast and also demands the same things even though not as much as the medical , we attempted to study the prevalence in the dental students in a college in Kerala and also their associated life style factors. Our study revealed a prevalence rate of 40.4% which shows that there is an alarming increase in myopia prevalence among the dental students . Batch wise analysis showed an increase in the 1st and 2nd year students, which indicates a definite increase in the prevalence in the recent years. Most of the students developed myopia in less than 6 years duration which indicates that they developed the condition in their late childhood may be because of the life style factors which play a role in the development of myopia. Sleeping habits of the students also showed a significant relationship with the development of myopia. Students who slept for less hours are tend to develop myopia may be because they are involved in reading or other visual tasks which cause eye strain even though we did not get a statistical significance with duration of reading ( p=0.084) , duration of TV watching (p 0.234), computer use (p=0.382) etc. Educational qualification of mother and occurrence of myopia showed a significant relationship ( p 0.04) . This may be because educated mothers are more worried about the academic activities of their children and forcing them to spend more hours on reading. Though the results of our study did not reveal any significant relationship between near work activity and myopia, it can be explained on the fact that basically these factors determine the age of onset of myopia. Most of the students studying in dental colleges have acquired myopia in their late childhood ages as mentioned above. Some studies like those of Kinge et al shows a significant association between myopic changes and time spent on near work among university students whereas some other studies like those of Adams and Mc Brien shows no association between the amount of near work done and the myopia progression 24-25 Therefore further investigations are required to better understand about the factors that may explain the myopic shifts not only among dental but also in medical and other university students.
CONCLUSION:
Prevalence of myopia was found to be high among all the 3 year batch students ( 40.4 %) . 1st and 2nd year BDS students had a greater percentage which shows that it is increasing in the this age group .However the amount of near work involved in reading did not show any significant relationship with myopia which may be because of the fact that majority of students developed myopia in late childhood years and stabilization of the refractive status has occurred. As we are getting a high prevalence rate of myopia among dental students we are arriving at a conclusion that myopia is as high as among medical students as shown in different studies , hence further studies in a large sample warranted in this regard .
ACKNOWLEDGEMENT:
We acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also greatful to authors / editors / publishers of all those articles and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=548http://ijcrr.com/article_html.php?did=5481. See JL, Wong TY, Yeo KT. Trends in the patterns of blindness and major ocular diseases in Singapore and Asia. Ann Acad Med Singapore1998; 27: 540-6.
2. Sperduto RD, Seigel D, Roberts J, Rowland M. Prevalence of myopia in the United States. Arch Ophthalmol 1983; 101: 405-7.
3. Dandona R, Dandona L, Naduvilath TJ, Srinivas M, et al. Refractive errors in an urban population in Southern India: The Andhra Pradesh Eye Disease Study. Invest Ophthalmol Vis Sci 1999; 40: 2810-8.
4. Lewallen S, Lowdon R, Courtright P, et al. A populationbased survey of the prevalence of refractive error in Malawi. Ophthalmic Epidemiol 1995;2:145–9.
5. Gilbert CE. A pilot study to evaluate logistics and methods for a prevalence and cause survey of visual impairment and hearing impairment in children. London: unpublished report to the Ministry of Health, Gaborone, Botswana, 1995:1–34.
6. Yap M, Wu M, Liu ZM, et al. Role of heredity in the genesis of myopia. Ophthalmic Physiol Opt 1993;13:316–9.
7. Angle J, Wissmann DA. The epidemiology of myopia. Am J Epidemiol 1980;111:220–8
8. Saw SM, Chua WH, Hong CY, Wu HM, Chan WY, Chia KS, et al. Nearwork in early-onset myopia. Invest Ophthalmol Vis Sci 2002; 43: 332-339.
9. Simensen, B and LO Thorud, ‘Adult-onset myopia and occupation’, Acta Ophthalmologica Scandinavica, vol. 72, 1994, pp. 469–71.
10. Tan, NWH, S-M Saw, DSC Lam, H-M Cheng, U Rajan, and S-J Chew, ‘Temporal variations in myopia progression in Singaporean children within an academic year’, Optometry and Vision Science, vol. 77, 2000, pp. 465-472.
11. Ting, PWK, CSY Lam, MH Edwards and KL Schmid, ‘Prevalence of myopia in a Group of Hong Kong microscopists’, Optometry and Vision Science, vol. 81, 2004, pp. 88-93.
12. Von Noorden, GK and RA Lewis, ‘Ocular axial length in unilateral congenital cataracts and blepharoptosis’, Investigative Ophthalmology and Visual Science, vol.28, 1987, pp. 750-752.
13. Wildsoet, CF and KL Schmid, ‘Optical correction of form deprivation myopia inhibits refractive recovery in chick eyes with intact or sectioned optic nerves’, Vision Research, vol. 40, 2000, pp. 3273-3282.
14. Lin LL, Shih YF, Tsai CB, Chen CJ, Lee LA, Hung PT, et al. Epidemiologic study of ocular refraction among schoolchildren in Taiwan in 1995.Optom Vis Sci 1999;76:275-281,2
15. Kinge B and Midelfart A. Refractive changes among Norwegian university students. A threeyear longitudinal study. Acta Ophthalmol Scand 1999; 77: 302-305.
16. Au Eong KG, Tay TH, Lim MK. Race, culture and myopia in 110,236 young Singaporean males. Singapore Med J 1993; 34: 29-32.
17. Saw SM, Katz J, Schein OD, Chew SJ, Chan TK. Epidemiology of myopia. Epidemiol Rev 1996; 18:175-87.
18. Chow YC, Dhillon B, Chew PTK, Chew SJ. Refractive errors in Singapore medical students. Singapore Med J 1990; 31:472-3. 19. Midelfart A, Aamo B, Sjohaug KA, Dysthe BE. Myopia among medical students in Norway. Acta Ophthalmol 2007; 70: 317-22.
20. Fledelius HC (2000) Myopia profile in Copenhagen medical students 1996–1998. Refractive stability over a century is suggested. Acta Ophthalmol Scand 78:501–505
21. Richler A and Bear JC. Refraction, nearwork and education: a population study in Newfoundland. Acta Ophthalmol (Copenh) 1980; 58: 468-478.
22. Zhan MZ, Saw SM, Hong RZ, Fu ZF, Yang H, Shui YB, et al. Refractive errors in Singapore and Xiamen, China - a comparative study in school children aged 6 to 7 years. Optom Vis Sci. 2000; 77: 302-308
23. Seet B, Wong TY, Tan DTH, Saw SM, et al. Myopia in Singapore: taking a public health approach. Br J Ophthalmol 2001; 85: 521-6.
24. Kinge B, Midelfart A, Jacobsen G and Rystad J. The influence of near-work on development of myopia among university students. A three-year longitudinal study among engineering students in Norway. Acta Ophthalmol Scand 2000; 78: 26-29.
25. McBrien NA, Adams DW. A longitudinal investigation of adult onset and adult progression of myopia in an occupational group. Refractive and biometric findings. Invest Ophthalmol Vis Sci 2008; 38: 321-33
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241710EnglishN-0001November30General SciencesPREVALENCE OF DIFFERENT MENSTRUAL IRREGULARITIES IN WOMEN WITH ABNORMAL UTERINE BLEEDING(AUB)- AN OBSERVATIONAL STUDY
English6670Tabassum KotagastiEnglishIntroduction: Abnormal Uterine Bleeding (AUB) is a term which refers to menstrual bleeding of abnormal frequency, duration or quantity. It is a common gynecological complaint accounting one third of outpatient visits to gynecologist. Abnormal Uterine Bleeding includes Oligomenorrhoea, Polymenorrhoea, Hypomenorrhoea, Menorrhagia, Metrorrhagia and Dysfunctional Uterine Bleeding. This paper elicits the prevalence of different menstrual disorders among women with Abnormal Uterine Bleeding.
Objective: To observe the prevalence of different menstrual irregularities in patients with Abnormal Uterine Bleeding.
Methodology: The study was carried out in the Gynaec out Patient Department of National Institute Unani Medicine Hospital during the years of 2014–2015.Total 1362 patients of Abnormal Uterine Bleeding were included in the study on basis of clinical sign and symptoms and history.
Results: Among 7471 Gynaec patients 1362 (18.23%) patients were found with Abnormal Uterine Bleeding (AUB) and out of 1362 patients of Abnormal Uterine Bleeding highest were with menorrhagia i.e. 450 (33%) and least were with hypomenorrhoea i.e. 162 (11.89%). Prevalence of menorrhagia was highest between the ages of 25-34 years.
Conclusion: It is concluded that the prevalence of menorrhagia is high among all Abnormal Uterine Bleeding and it affects woman health status, quality of life and social integration. It is suggested that menstrual complaints should be thoroughly evaluated
and treated on a top priority.
EnglishAbnormal uterine bleeding, Menstrual irregularities, Different age group, PrevalenceINTRODUCTION
Menstrual disorders are common gynecological problem for medical visits among women of reproductive age.(1) Heavy menstrual bleeding affects up to 30% of women in their reproductive period.(2)Abnormal Uterine Bleeding may be defined as any variation from the normal menstrual cycle such as changes in regularity and frequency, duration of flow or amount of flow and it accounts for one third of patients to visits gynecologists. (3) It occurs in 9-14% of women between menarche to menopause, significantly impacting quality of life and imposing financial burden.(4-6) Abnormal Uterine Bleeding by definitions may be subdivided into subcategories based on volume of menstruation, regularity, frequency, duration, chronicity and reproductive status. International Federation of Gynecology and Obstetrics revised terminology system, for Abnormal Uterine Bleeding in reproductive age women was introduced in 2011.(7)Previously terms such as Menorrhagia, Menometrorrhagia, Oligomenorrhoea, Polymenorrhoea, Hypomenorrhoea and Dysfunctional Uterine Bleeding were used. Now it is referenced as Polyp, Adenomyosis, Leiomyoma, Malignancy and Hyperplasia- Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic and Not yet classified. Abnormal Uterine Bleeding may be due to some pelvic pathology. (8) In different menstrual disorders menorrhagia is a common gynecological condition which adversely affects quality of life of many women. Heavy menstrual bleeding or menorrhagia is the most common complaint among Abnormal Uterine Bleeding. It has been defined as excessive menstrual blood loss more than 80ml and it significantly interferes with the woman’s physical, social and emotional status. It can occur alone or in combination with other symptoms.(9, 10)Over 5% of women ages between 30-49 years consult gynecologist each year with this complaint.(11) There are a number of etiological factors responsible for Abnormal Uterine Bleeding and gynecological evaluation is essential. History and physical examination will help to establish the causes to adapt management to the individual patient to prevent unnecessary invasive procedures which may have their limitations. In this paper the prevalence of different menstrual disorder, especially of menorrhagia was worked out among patients with Abnormal Uterine Bleeding.
METHODOLOGY
The present study was undertaken in Gynae Out Patient Department, National Institute of Unani Medicine Hospital, Bangalore during the year of 2014-2015 to find out prevalence of menstrual disorders in reproductive age women with Abnormal Uterine Bleeding. In this study out of 7471 patient of different gynaec complaints 1362 (18.23%) patients both unmarried and married were found with various menstrual disorders. A detailed history regarding the age, menstrual irregularities like frequency of cycle, duration of flow and amount of flow were enquired and were recorded. The data presented in the study are based on clinical examination and on history.
RESULTS
In the present study it was observed that the prevalence of menorrhagia was high as compared to other Abnormal Uterine Bleeding, followed by oligomenorrhoea, polymenorrhoea, Dysfunctional Uterine Bleeding and hypomenorrhoea. The observed data are as: Out of 7471gynecological patients1362 were found with Abnormal Uterine Bleeding. (Figure.1). Out of 1362 patients of Abnormal Uterine Bleeding, 450 (33%) patients had menorrhagia followed by 272 (19.97%) had oligomenorrhoea, 250 (18.35%) had polymenorrhoea, 228 (16.74%) patients had dysfunctional uterine bleeding and least i.e. 162 (11.89%) patients had hypomenorrhoea. (Figure.2) Out of 450 patients of menorrhagia maximum patients were found in the age group of 25-34 years i.e. 177 (39.33%) followed by 120 i.e. 26.66% in the age group of 35- 44 years, 101 patients i.e. 22.44% were in the age group of 15-24 years and least were in the age group of 45-54 years i.e. 52 (11.55%). (Figure.3)
DISCUSSION
In the present study out of 1362 patients with Abnormal Uterine Bleeding the highest prevalence of patients were with menorrhagia i.e. 450(33%) followed by 272 (19.97%) patients with oligomenorrhoea, 250 (18.35%) patients with polymenorrhoea,228(16.74%) patients with dysfunctional uterine bleeding and least i.e. 162 (11.89%) patients were with hypomenorrhoea found. According to studies conducted in India by Bang RA, Bhatia JC, Jayaseelam et al. among women of reproductive age group the prevalence of oligomenorrhoea or cycles longer than 35 days ranged from 8-22%. (12-17) Reports of irregular bleeding in the past three months in the WHO multicentric study ranged from 8-83%. In their study Hernandez I, Cervera-Aguilar R et al they reported the frequency of irregular cycles as 9-16 %.( 18) However, the highest prevalence of irregular cycles was reported 30% in a selected population of Vietnamese factory workers. (19) In Lebanon 15% of women reported menstrual irregularity at their last gynecological visit. (20) In the adolescent study the frequency of oligomenorrhoea was reported to be 1.1% in Chile, 4.5% in Nigeria(21) 8% in Turkey (22) and 42% in Thailand. (23) Menorrhagia accounts for 12% of gynecological referrals for surgical intervention. A study by Coulter A, Bradlow J, Agass M, et al. revealed that 60% of women underwent a hysterectomy within five years of referral.(24) In the present study among other Abnormal Uterine Bleeding the highest prevalence of menorrhagia was seen between the ages of 25-34 years, but Coulter A, Kelland J, Peto V et al. reported in their study that the prevalence of heavy bleeding was 15% in the age group of 30-40 years. (25) The prevalence of Abnormal Uterine Bleeding is estimated to be 11-13% and it increases 24% with age in those aged 36-40 years. (8)A survey was done in woman age between 18-50 years the rate was 53 per 1000 women. (26)Abnormal Uterine Bleeding and menorrhagia directly affects women’s quality of life (27-30) and ultimately has a significant impact on health. (31) In developing countries prevalence Abnormal Uterine Bleeding appears to affect about 5-15% of women of reproductive age and probably a higher percentage of women in older age groups. Data on prevalence of Abnormal Uterine Bleeding is limited, but it is a major cause of gynecological morbidity, affecting up to 1 in 5 women at some point during their reproductive lifespan. (32) Nine to fourteen percent of reproductive age women have blood loss that exceeds 80 ml(33)and Abnormal Uterine Bleeding is a leading indication or hysterectomy, the most common major gynecological operation in women. (34, 35) Abnormal Uterine Bleeding is of more concern, because excessive or prolonged bleeding may cause undue disruption of women’s daily activities. Prolonged and excessive bleeding may provoke serious medical consequences or exacerbate anaemia and in a certain percentage of cases may eventually be life threatening if left untreated.
CONCLUSION
The present study revealed the prevalence of menorrhagia is high in patients with Abnormal Uterine Bleeding. The highest prevalence of menorrhagia was seen between the ages of 25-34 years. Patients presenting with menstrual irregularities must be screened properly as incidence of menorrhagia is high in reproductive age group. Frequency of menstrual disorders and their impact on women’s health status, quality of life and social integration suggest that proper evaluation and treatment should be given a higher priority. Prophylactic treatment should focus on reducing the quantity of blood loss in addition iron supplement prevents or reduces the risk of bleeding complications in haemostatic challenges such as surgery.
ACKNOWLEDGMENT
The author acknowledged all the editors and authors of the journal for choosing their articles for reference
Conflict of interest: The author has no conflict of interest
Source of funding: For this study funding is not required. It is based on observation of the collected data.
Englishhttp://ijcrr.com/abstract.php?article_id=549http://ijcrr.com/article_html.php?did=5491. Kjerulff KH, Erickson BA, Langenberg PW. Chronic gynecological conditions reported by US women: findings from the national health interview survey, 1984 to 1992. Am. J Public Health, 1996; 86:195–9.
2. Market Opinion and Research International (MORI). Women’s health in 1990.Research study conducted on behalf of Parke-Davis Laboratories]. London: MORI; 1990.
3. Barnard K, Frayne SM, Skinner KM, Sullivan LM. Health status among women with menstrual symptoms. J Women’s Health (Larchmt), 2003; 12:911-9.
4. Cote I, Jacobs P, Cumming D. Work loss associated with increased menstrual loss in the United States. Obstet Gynecol, 2002; 100:683–7
. 5. Mahmoud Aseel Ghazi Rifat, Endometrial Histo-pathological Changes in Women with Abnormal Uterine Bleeding in Kirkuk City, a Clinico-pathological Study, Medical Journal of Babylon, Vol. 10, No. 3, 2013, 1023
6. Mary Gayle Sweet, MD, Tarin A. Schmidt-Dalton, MD, Patrice M. et al, Evaluation and Management of Abnormal Uterine Bleeding in Premenopausal Women, Am Fam Physician, 1;85(1), 2012, 35-43.
7. Millar W. Hysterectomy, 1981/82 to 1996/97. Health Rep, 2001; 12:9–22.
8. Frick KD, Clark MA, Steinwachs DM, Langenberg P, Stovall D, Munro MG et al. Financial and quality-of-life burden of dysfunctional uterine bleeding among women agreeing to obtain surgical treatment. Women’s Health Issues, 2009; 19:70–8.
9. Committee on Practice Bulletins—Gynecology. Practice bulletin no. 128: diagnosis of Abnormal Uterine Bleeding in reproductive-aged women. Obstet Gynecol, 2012; 120:197.
10. National Collaborating Centre for Women’s and Children’s Health; National Institute for Health and Care Excellence. NICE guideline CG44: heavy menstrual bleeding. London: Royal College of Obstetricians and Gynecologists, 2007.
11. Effective health care. The management of menorrhagia, Effective Health Care Bulletin 2013, 9:1-14.
12. Matteson KA, Boardman LA, Munro MG, Clark MA. Abnormal Uterine Bleeding: a review of patient-based outcome measures. Fertil Steril, 2009; 92:205.
13. Bang RA, Bang AT, Baitule M, Choudhary Y, Sarmukaddam S, Tale O.High prevalence of gynecological diseases in rural Indian women. Lancet, 1989; 1:85-88.
14. Jeyaseelan L, Rao PS. Effect of occupation on menstrual cycle length: causal model. Hum Biol, 1995; 67:283– 290.
15. Bhatia JC, Cleland J, Bhagavan L, Rao NSN. Levels and determinants of gynecological morbidity in a district in south India. Stud Fam Plann, 1997; 28:95– 103.
16. Hernandez I, Cervera-Aguilar R, Verdara MD, Ayala AR. Prevalence and etiology of secondary amenorrhea in a selected Mexican population. Ginecol Obstet Mex, 1999; 67:374- 376.
17. Nunez Troconis J, Amesty N, Sandoval J. Trastornos menstruales en estudiantes universitarias. Amenorrhoea, Oligomenorrea. Rev Obstet Ginecol Venez, 1990; 50:138– 141.
18. Deeb M, Ghorayeb F, Kabakian-Khasholian T, Yeretzian J, Aswad N. Measuring gynecological morbidity: evaluating two different data sources from Beirut. Healthc Women Int, 2003; 24:254- 265.
19. Walraven G, Ekpo G, Coleman C, Scherf C, Morison L, Harlow SD. Menstrual disorders in rural Gambia. Stud Fam Plann, 2002; 33:261–268.
20. Intermediate Technology Bangladesh. Investigation into the Sanitary, Protection Needs of Poor Women in Bangladesh. Dhaka: Intermediate Technology Bangladesh, 1992.
21. Matsuda S, Luong NA, Hoai NV et al. A study of complaints of fatigue by workers employed in Vietnamese factories with newly imported technologies. Ind. Health, 1997;35:16- 28
22. Fakeye O, Adegoke A. The characteristics of the menstrual cycle in Nigerian schoolgirls and the implications for school health programmes. Afr J Med Med Sci 1994; 23:13-17.
23. Vicdan K, Kukner S, Dabakoglu T, Ergin T, Keles G, Gokmen O. Demographic and epidemiologic features of female adolescents in Turkey. J Adolesc Health 1996; 8:54-58.
24. Coulter A, Bradlow J, Agass M et al. Outcomes of referrals to gynaecology outpatient clinics for menstrual problems: an audit of general practice records. Br J Obstet. Gynaecol,1998:789–796.
25. Coulter A, Kelland J, Peto V et al. Treating menorrhagia in primary care. An overview of drug trials and a survey of prescribing practice. Int. J Technol Assess Health Care,1995, 11:456–471.
26. Kadir RA, Lukes AS, Kouides PA, Fernandez H, Goudemand J. Management of excessive menstrual bleeding in women with hemostatic disorders. Fertil Steril, 2005; 84: 1352–9.
27. Kjerulff KH, Erickson BA, Langenberg PW. Chronic gynecological conditions reported by US women: findings from the National Health Interview Survey, 1984 to 1992. Am J Public Health, 1996; 86:195.
28. Barnard K, Frayne SM, Skinner KM, Sullivan LM. Health status among women with menstrual symptoms. J Women’s Health (Larchmt), 2003; 12:911–9.
29. Cote I, Jacobs P, Cumming D. Work loss associated with increased menstrual loss in the United States. Obstet Gynecol, 2002; 100:683–7.
30. Millar W. Hysterectomy, 1981/82 to 1996/97. Health Rep, 2001; 12:9–22.
31. Frick KD, Clark MA, Steinwachs DM et al. Financial and quality-of-life burden of dysfunctional uterine bleeding among women agreeing to obtain surgical treatment. Women’s Health Issues, 2009; 19:70–8.
32. Coulter A, Noone A, Goldacre M. General practitioners’ referrals to specialist outpatient clinics. BMJ, 1989; 299:304– 308.
33. Hallberg L, Hogdahl AM, Nilsson L, Rybo G. Menstrual blood loss- a population study. Variation at different ages and attempts to define normality. Acta Obstet Gynecol Scand, 1966; 45:320–351.
34. Bernstein SJ, McGlynn EA, Siu AL. The appropriateness of hysterectomy, a comparison of care in seven health plans. Health Maintenance Organization Quality of Care Consortium. JAMA, 1993; 269: 2398– 2402.
35. Santha Ram NV, Murthy NVA. Abdominal hysterectomies at area hospital, Point Fortin, Trinidad, West Indies. Int J Gynecol Obstet, 1989; 28:137–141.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241710EnglishN-0001November30General SciencesEVALUATION OF APGAR SCORE IN NEONATES BORN TO TEENAGE MOTHERS
English7174P. Padmasri DeviEnglish Ch. Ganapathi SwamyEnglish M. Kiran DeediEnglishBackground: Apgar score is measured after the baby is born. This will give the idea of the health status of the neonate. The aim of the study is to assess the association of birth weight and the Apgar score.
Methods: We collected data on the birth weights and the 1 min and 5 min Apgar score of new born infants in department of gynecology and obstetrics GSL Medical College and General hospital. Antenatal woman with age 15-19 years were registered from June 2013 to july2014were included as the study subjects Compared to babies with normal Apgar score, infants with low Apgar Scores were found to born with low and very low birth weights.
Results: Totally 123 individuals are in normal birth weight category. zero individuals are comes under poor apgar score category, one individuals are in normal apgar score category comprising about 8% with in total normal birth weight category, 122 individuals are in good apgar score category comprising about 99.2.%with in total normal birth weight category. Out of 238 neonates individual born 14 (5.9%) in low score category, 30 (12.6%) in intermediate score and 194 (81.5%) in normal score. Apgar score was statistically highly significant association with age of the mother (p=0.001).
Conclusion: Apgar score is a useful, early indicator of health and birth weight of new born infants
EnglishLow birth weight, Teenage mothers, Apgar scoreINTRODUCTION
To asses, neonates in 1953 Apgar score were developed and it has been widely adopted1 . It was used not too predict resuscitation in their long term prognosis, and its main purpose to determine the need for resuscitation. An estimated18million babies are born with LBW and half of them are born in South Asia2 . Apgar scoring system intended to predicts survival and to compare, method of resuscitation and prenatal experiences across hospitals and obstetrics practices.3 the score is from zero to ten and there is rating like zero, one, and two for each sign depending upon the weather it was present or absent. Five sign of Apgar score is heart rate, respiratory effort, muscle tone, reflex irritability and colour. There is a evidence that relationship between apgar score and rates of neonatal deaths are in inverse ratio,4 Apgar score was quickly adopted for use worldwide, becoming “common currency”5 among perinatologists. The score was initially measured at one minute after birth, a second measurement, at five minutes of age. Apgar score is categorized as low (0-5), intermediate (4-6) and normal (7-10). A number of studies have been conducted to assess the predictive value of scoring system in preterm/low birth infants. several studies have seen association between neonatal mortality and the Apgar score in the infants 6. The aim of this study was to determine the predictive value of the Apgar score, including, with regard to infants with low birth weight
MATERIALS AND METHODS:
A longitudinal study of was conducted in department of gynecology and obstetrics GSL Medical College and General hospital. The Universal sampling method was employed and every antenatal woman with age 15-19 years were registered in the department gynecology and obstetrics, GSL medical college, Rajahmundry of June 2013 to July 2014 were included as the study subjects. Inclusion and Exclusion criteria: All ANC subjects with in age of 15-19 year within 32weeks of their gestational age were included as the study subjects. Those subjects with history of any congenital malformed child, twins, or with any preexisting co morbid illness such as Diabetes mellitus, Hypertension, HIV, Bronchial asthma, Heart disease, Cancer, etc., were excluded from the study. 238 pregnant women registered, at the time of registration, after the delivery of each individual weight of the baby was noted with standard weighing machine and Apgar score was noted. Statistical analysis was performed by using SPSS trail version 16.0 and p value Englishhttp://ijcrr.com/abstract.php?article_id=550http://ijcrr.com/article_html.php?did=5501. Apgar V. Proposal for new method of evaluation of newborn infant. AnesthAnalg, 1953; 32: 260–7.
2. United Nations Children’s Fund (UNICEF), The State of the World’s Children, NewYork, NY,USA, 2005.
3. Apgar V. Evaluation of the newbor
4. vandeRiet JE, Vandenbussche FP, LeCessie S, Keirse MJ. New born assessment and long-term adverse outcome: A systematic review. Am J Obstet Gynecol 1999; 180: 1024– 9.
5. Chong DS, Karlberg J. Refining the Apgar score cut-off point for newborns at risk. Acta Paediatr 2004: 93: 53–9.
6. Casey BM, McIntire DD, Leveno KJ. The continuing value of the Apgar score for the assessment of newborn infants. New Eng J Med 2001; 344: 467–71.
7. Rintaro Mori, Jun Shiraishi, Hirokuni Negishi, Masanori Fujimura Predictive value of Apgar score in infants with very low birth weight; Acta Pædiatrica 2008 97, pp. 720– 723.
8. VeraEhrenstein; Association of Apgar scores with deathand neurologic disability ClinicalEpidemiology 2009:1 45–53
9. Greenough A, Lagercrantz H, Pool J, Dahlin I.; Plasma catecholamine levels in preterm infants. Effect of birth asphyxia and Apgar score. Acta Paediatr Scan 1987; 76: 54–9.
10. Angela Andréia França Gravena, Meliana Gisleine de Paula,Sonia Silva Marcon, Maria Dalva Barros de Carvalho,Sandra Marisa Pelloso; Maternal age and factors associatedwith perinatal outcomes; Acta Paul Enferm. 2013; 26(2):130-5.
11. Chen XK, Wen WS, Fleming N, Demissie K, Rhoads GG, WalkerM. Teenage pregnancy and adverse birth outcomes: a large population based retrospective cohort study. Inter J Epidemiol. 2007;36: 368-73.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241710EnglishN-0001November30General SciencesCLINICO LABORATORY PROFILE OF SCRUBTYPHUS AT A RURAL TERTIARY CARE HOSPITAL IN SOUTH INDIA
English7578Saleem M.English Shivekar S.English Gopal R.EnglishScrub typhus is a reemerging rickettsial infection caused by Orientia tsutsugamushi transmitted through the bite of larval forms of a trombiculid mite. The clinical presentation of scrub typhus mimics other acute febrile illnesses thus making it difficult to diagnose clinically. The present work is a retrospective study of clinico - laboratory profile of seropositive cases of scrub typhus presenting to our hospital over a period of 2 months. The clinical and laboratory profile of all cases of scrub typhus positive by ELISA (IgM) over a period of 2 months were studied retrospectively. Out of 364 cases tested for scrub typhus, 103(27.57%) were positive for scrub typhus by serology. The incidence was high among women than men. The most common symptoms reported were fever with chills and rigor followed by diarrhea and vomiting. Among the laboratory parameters thrombocytopenia and elevated serum transaminase was the most common abnormality. Majority of them responded to doxycycline. Scrub typhus is an important cause of acute undifferentiated pyrexial illness, therefore all the clinically suspected cases should be confirmed by a relatively sensitive method and specific test. In present study one third of clinically suspected cases were turned out positive for
scrub typhus by serology.
EnglishScrub typhus, Rural hospital, South IndiaINTRODUCTION
Scrub typhus is a Rickettsial infection caused by Orientia tsutsugamushi, mainly transmitted by the bite of larvae of a trombiculid mite. (1) The symptoms of scrub typhus are indistinguishable from other illnesses like leptospirosis, malaria, and dengue fever.(2) Epidemics of scrub typhus have been documented worldwide. In India, Goa, North eastern states and south India have reported the disease. (3-9). It is wide spread in Japan, Taiwan, China, South Korea, Nepal, Australia and Indonesia (10-12) The common symptoms and signs seen in scrub typhus cases is fever, chills with rigors , mylagia, headache and rash with dysfunction of organs such as kidney (acute renal failure), liver (hepatitis), lungs (acute respiratory distress syndrome, central nervous system (meningitis),GIT (vomiting and diarrhea) or circulatory collapse with haemorrhagic features (13). Eschar is a characteristic features of scrub typhus (14, 15). Although it is characteristic, many studies have reported scrub typhus without eschar.(4) Puducherry is a small coastal town surrounded by many villages from Tamil Nadu. Presently there is an increase in number of cases of scrub typhus presenting with fever, rash and hepatorenal involvement. In the present study, the clinical profile and laboratory findings of these patients were studied.
MATERIALS AND METHODS
The present retrospective study was carried out in a rural tertiary care hospital of Puducherry, South India. All patients who tested positive for IgM antibody against the 56kDa protein of O.tsutsugamushi by ELISA during the study period of two months, were included in this study. A total number of 364 blood samples were received for serological testing for scrub typhus from the patients with fever from various outpatient departments, emergency services and indoor patients of our hospital. All the samples were screened for IgM antibodie by using ELISA kit (Scrub Typhus Detect TM, InBios International USA). Clinical and laboratory test results of all positive cases were studied from case records.
RESULTS
The patients attending our hospital are mostly from the rural areas of Puducherry and adjacent areas of Tamil Nadu (Villupurum district). Out of 364 cases studied, 103(27.6%) tested positive for scrub typhus. All the positive cases were in the age group of 1 – 70 years. There were 64 (62%) women and 39 (38%) men. (Figure 1) Table 1 shows the signs and symptoms of positive cases. In the present study most of the patients presented with one or more of the following symptoms viz fever, chills, rigors, cough, headache, diarrhea, vomiting, loss of appetite, and myalgia. The most common sign was hepatosplenomegaly and lymphadenopathy. Eschar and skin rashes were present only in three cases. Table 2 shows the laboratory findings of these patients. Thrombocytopenia, leukocytosis, elevated liver enzymes i.e. SGOT and SGPT, raised serum urea and creatinine were the common findings. Serum bilirubin was elevated only in two cases. The result of present study showed maximum cross reactivity between typhoid and scrub typhus. one case was positive for dengue IgM antibody also . A majority of the patients responded dramatically to treatment with doxycycline.
DISCUSSION
In India scrub typhus has been reported from the period of World War II. The first major outbreak was recorded among the soldiers deployed along the India- Myanmar border.(16) Ever since subsequently scrub typhus has been observed all over the country. In the present study 103 (27.57%) patients with fever were diagnosed as scrub typhus. A similar positivity was also observed in other area i.e. Goa (34%) (4) North Western India (24.7%) (17) and Tirupati (39%).(18) In the present study scrub typhus seropositivity was comparatively high in women. This may be because of occupational exposure to the vector in the fields. Clinically patients with scrub typhus present with acute febrile illness with non-specific signs and symptoms (19). In our study, the commonest presentation seen was fever with chills (100%), rigors (75%) and cough with respiratory distress. The other predominant symptoms were diarrhea, vomiting and abdominal pain. Hepatosplenomegaly and lymph node enlargement was also observed in few cases. Eschar with skin rash is diagnostic feature of scrub typhus, (20,21) however, in our study only three patients had eschar. A similar presentation was also reported in earlier studies RR. The clinical presentation of scrub typhus mimics dengue and leptosprosis (22). In the present study gastrointestinal symptoms were frequently reported among scrub typhus patients, which probably is a differentiating feature from similar infections. Similar to other studies (14, 23) majority of patients had elevated serum transaminases, serum urea and creatinine without evidence of multiorgan involvement; however serum bilirubin was normal in all patients except two. Other laboratory findings noted were thrombocytopenia and leukocytosis. Widal test showed maximum positivity (13.6%) among the scrub cases. This shows the possibility of production of cross reacting antibodies between the two pathogens. Even though 56 kDa protein is specific to scrub typhus a detailed molecular study typhus has to be carried out to assess the antigenic piracy between these two pathogens. (24) In conclusion Scrub typhus is a reemerging rickettsial infection in most parts of India with increasing case reports in the last one decade. Scrub typhus should be considered in the differential diagnosis of all cases of acute undifferentiated pyrexia. Early diagnosis and treatment reduces the morbidity and mortality associated with the disease.
ACKNOWLEDGEMENT
Authors acknowledge the great help received from the scholars whose articles cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Authors are grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=551http://ijcrr.com/article_html.php?did=5511. Mahajan SK. Scrub typhus. J Assoc Physicians India 2005; 53: 954-8.
2. Kothari VM, Karnad DR, Bichile LS. Tropical infections in the ICU J Assoc Physicians India 2006; 54 : 291-8.
3. Chogle AR. Diagnosis and treatment of scrub typhus - the Indian scenario. J Assoc Physicians India 2010; 58 : 11-2.
4. Kedareshwar PS, Rodrigues S, Nevrekar RP, Dias L, Dias A, Vaz M and Gomes E. Scrub typhus in patients reporting with acute febrile illnessat a tertiary health care institution in Goa Indian J Med Res, 2012 Dec;136: 1020-24.
5. Sharma A, Mahajan S, Gupta ML, Kanga A, Sharma V. Investigation of an outbreak of scrub typhus in the himalayan region of India Jpn J Infect Dis 2005; 58 : 208-10
.6. Batra HV. Spotted fevers and typhus fever in Tamil Nadu. Indian J Med Res 2007; 126 : 101-3.
7. Mathai E, Lloyd G, Cherian T, Abraham OC, Cherian AM. 4. Serological evidence for the continued presence of human rickettsioses in southern India. Ann Trop Med Parasitol 2001; 95 : 395-8.
8. Ittyachen AM. Emerging infections in Kerala: a case of scrub typhus Natl Med J India 2009; 22 : 333-4.
9. Varghese GM, Abraham OC, Mathai D, Thomas K, Aaron R, 5. Kavitha ML, et al. Scrub typhus among hospitalised patients with febrile illness in South India: magnitude and clinical predictors J Infect 2006; 52: 56-60.
10. Lee YS, Wang PH, Tseng SJ, Ko CF, Teng HJ, 2006. Epidemiology of scrub typhus in eastern Taiwan Jpn J Infect Dis 2004; 59: 235–238.
11. Nagano I, Kasuya S, Noda N, Yamashita T. Virulence in mice of O. tsutsugamushi isolated from patients in a new endemic area in Japan. Microbiol Immunol 1996 ; 40: 743– 47.
12. Zhang LJ, He S, Jin YM, Li L, Li XM, Liu LY, Yu HL, Yu Q, Chen CF, Wang SW,. A rapid, sensitive and reliable diagnostic test for scrub typhus in China. Indian J Med Microbiol 2011; 29: 368–371.
13. Buddha BT, Belbase RH, Zimmerman MD, Woods CW, Reller LB, and Murdoch DR. Clinical Features of Scrub Typhus. Clin Infect Dis 2006; 42 (10): 1505-06.
14. Kim DM, Won KJ, Park CY, Yu KD, Kim HS, Yang TY, Lee JH, Kim HK, Song HJ, Lee SH, Shin H. Distribution of eschars on the body of scrub typhus patients: a prospective study. Am J Trop Med Hyg. 2007 May;76(5):806-9.
15. Sourabh Aggarwal; Alka Sharma; Vishal Sharma. Eschar: a cutaneous clue to scrub typhus. Braz J Infect Dis 2012; 16(4) 407-408.
16. Singh P. Scrub typhus, a case report: Military and regional significance. Med J Armed Forces India 2004;60:89-90.
17. Sinha P, Gupta S, Dawra R, Rijhawan P. Recent outbreak of scrub typhus in North Western part of India Indian. Journal of Medical Microbiology 2014; 32(3): 247-50.
18. Ramyasree A, Kalawat U, Rani ND, Chaudhury A. Seroprevalence of Scrub typhus at a tertiary care hospital in Andhra Pradesh Indian J Med Microbiol 2015;33:68-72.
19. Rajapakse S, Rodrigo C, Fernando D. Scrub typhus: pathophysiology, clinical manifestations and prognosis Asian Pac J Trop Med. 2012 Apr;5(4):261-4.
20. Lee SH, Kim DM,Cho YS,Yoon SH, and Shim SK.Usefulness of Eschar PCR for Diagnosis of Scrub Typhus J Clin Microbiol. 2006 Mar; 44(3): 1169–1171.
21. Kundavaram AP, Jonathan AJ, Nathaniel SD, Varghese GM. Eschar in scrub typhus: a valuable clue to the diagnosis M. J Postgrad Med. 2013 Jul-Sep;59(3):177-8.
22. Girija S, Rajan A, Sathiyanarayanan J, Mangaiyarkarasi T. , Saban P, Sunil S, Gopal R Scrub typhus- An emerging disease in South India IJRRMS 2013;3(4):11-13.
23. Sankhyan N , Saptharishi LG, Sasidaran K, Kanga A and Singh SC. Clinical profile of scrub typhus in children and its association with hemophagocytic lymphohistiocytosis Indian Pediatrics , 2014 august ;(51): 15651-653.
24. Chao CC, Huber ES, Porter TB, Zhang Z, and Ching WM. Analysis of the Cross-Reactivity of Various 56 kDa Recombinant Protein Antigens with Serum Samples Collected after Orientia tsutsugamushi Infection by ELISA Am J Trop Med Hyg 2011 Jun 1; 84(6): 967-72.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241710EnglishN-0001November30General SciencesDIAGNOSTIC CHALLENGES IN ASSESSMENT OF REACTIVE SOFT TISSUE LESIONS OF ORAL CAVITY
English7986Farhat KazmiEnglish Wajiha AlamgirEnglish Muhammad MumtazEnglishObjective: The study emphasizes on the features which lead to diagnostic complexities of localized reactive hyperplastic lesions (LRHL) in clinical settings thus making histolopathological examination imperative for definite diagnosis.
Materials and Methods: A total of 314patients presenting with reactive hyperplastic lesions in out-patient department of University College of Dentistry from June 2012 to January 2015 were included in the study. After provisional diagnosis, lesions were excised and specimens were submitted for definite histopathological diagnosis. Descriptive statistics and Chi-square test was applied using SPSS version 20.0.
Results: Most common age group was 30-39 years (n=147, 50.6%) with male to female ratio of 1:3. Most affected site was maxillary gingivae (n=140, 49.3%) while poor oral hygiene (n=152, 52.4%) was most frequent aetiological factor. Provisional diagnoses included pyogenic granuloma (PG) with maximum number of cases (n=141, 45%) followed by focal fibrous hyperplasia(FFH) (n=118, 37%), peripheral giant cell granuloma(PGCG) (n= 34, 11%) and peripheral ossifying fibroma (POF) (n=21, 7%). After definite diagnosis, the order of occurrence of LRHL remained the same but the number of cases of each individual lesion carried a significant discrepancy with 157 histopathologically proven cases of PG (50%) followed by FFH (n=111, 36%), PGCG (n=29, 9%) and POF (n=17, 5%) respectively.
Conclusion: Variations in subjective assessment of LRHL could be lessened if histopathological examination is incorporated as a mandatory component in diagnostic protocol. Oral hygiene maintenance may also significantly improve the status of oral health
and diminish possible chances of development of pathologies.
EnglishHyperplastic lesions, Pyogenic granuloma, Focal fibrous hyperplasia, Peripheral giant cell granuloma, Peripheral ossifying fibromaINTRODUCTION
A collection of reactive hyperplastic lesions presenting as gingival and mucosal localized overgrowths pose a diagnostic tight spot to clinician due to closeimitationin their clinical appearance. In such circumstances, histopathologists provide an aid to clinicians to rule out the possibility of these lesions being malignant in nature and therefore establishing a definite diagnosis.1,2 Chronic trauma subjected to oral cavity can induce inflammation that leads to formation of granulation tissue along with endothelial cells, chronic inflammatory cells and later fibroblasts which proliferate and manifest as an overgrowth called ‘Reactive hyperplasia’3 . Localized factors which can lead to chronic local traumatisation include; calculus, food impaction, restorations with irregular margins and iatrogenic factors 4 . Underlying systemic disease, drug-induced stimulus or endocrine hormonesmay also play a contributing role in development of LRHL 5,6,7. Several investigators have classified reactive lesions on histopathological basis as fibrous, vascular or hemorrhagic and giant cell types1,2,7-9. Some others claim that all these entities represent same lesion at different developmental stages4,5,7. Currently, accepted classification of reactive lesions is given by Neville pertaining to four categories: 1. Focal fibrous hyperplasia (FFH) 2. Pyogenic granuloma (PG) 3. Peripheral ossifying fibroma (POF) 4. Peripheral giant cell granuloma (PGCG) 4,5,7,10. The prevalence of these lesions as reported in the literature is rather most common with focal fibrous hyperplasia comprising 56-61% followed by pyogenic granuloma (19-27%), peripheral ossifying fibroma (10-18%) and peripheral giant cell granuloma (1.5 – 7%) 10-12. These LRHL share many similarities on clinical examination that makes physician indecisive in making a definite clinical diagnosis. Table 1 elaborates intimately mimicking clinical features of LRHL of the gingiva.13-16 FFH represents the most common localized, reactive proliferation of oral soft tissues in response to injury or local irritation 13,14 followed by PG representing as an exuberant tissue response 10,13. Researchers have divided PG in two types namely lobular capillary hemangioma (LCH type) and non – LCH type which differ in their histological picture 17. LCH type is currently categorized as vascular tumors under the classification scheme of international society for the study of vascular anomalies 13. Among pregnant females, 5% develop PG which regress after delivery, indicating a definite role of female sex hormones in the etiology of this lesion 2,17,18. POF has mostly solitary occurrence, multicentric lesions have also been reported in the literature18.Current studies refer this le Current studies refer this lesion as POF (WHO type) and it is recognized separately from POF of gingiva 7,10. In 1953, Jaffe proposed the term “giant cell reparative granuloma” to distinguish PGCG from giant cell tumor 20. This term was used to show the association of development of this lesion to chronic irritation 21.Development of POF and PGCG in children has also been reported in the literature 19,22. In present study, emphasis is made on the features which lead to diagnostic complexities of LRHL in clinical settings thus making histolopathological examination imperative for definite diagnosis. Moreover, focus is made on the etiological factors involved in the development of these lesions especially those which are related to oral hygiene status of the patients.
MATERIALS AND METHODS
The study was conducted in Oral Diagnostic, Oral pathology and Oral Surgery department of University College of Dentistry, University of Lahore, Pakistan between June 2012 to March 2014 after approval from the ethical review committee (Approval No. 101/UCD/2012). A total of 314 patients presenting with exophytic hyperplastic lesions were examined in Oral Diagnostic department. Clinical data including age, gender, chief complaint at the time of presentation, etiology, site and size of the lesion, lesion attachment, surface and color was gathered and provisional diagnosis was made after clinical examination. Further referral was made to Oral Surgery department and biopsy was taken after making written informed consent from the patients. Biopsy specimens were submitted to Oral Pathology department. Microscopic evaluation for definite diagnosis was done by two oral pathologists to minimize the inter-observer bias.
Statistical analysis was done using SPSS software version 20.0. Descriptive statistics were employed to report the findings. Chi-square test was applied for evaluation of differences in frequencies among groups. P- valueEnglishhttp://ijcrr.com/abstract.php?article_id=552http://ijcrr.com/article_html.php?did=5521. Bataineh A, Nawaf Z. Localized lesions of oral tissues: A clinicopathological study. J Contemp Dent Pract2005; 6: 1-8.
2. Al-Rawi NH. Localized reactive hyperplastic lesions of the gingiva: A clinicopathological study of 636 lesions from Iraq. Internet Journal of Dental Science2008; 7.
3. Reddy V, SaxenaS, Sexena S, Reddy M. Reactive hyperplastic lesions of the oral cavity: A ten year observational study on North Indian population. J Clin Exp Dent2012; 4: e136- 40.
4. Buchner A, Shnaiderman-Shapiro A, Vered M. Relative frequency of localized reactive hyperplastic lesions of the gingiva: a retrospective study of 1675 cases from Israel. J Oral Pathol Med2010;39: 631-8.
5. Ramu S, Rodrigues C. Reactive hyperplastic lesions of the gingiva: A retrospective study of 260 cases. World J Dent2012; 3: 126-30.
6. Zarei MR, Chamani G, Amanpoor S. Reactive hyperplastic lesions of the oral cavity in Kerman Province, Iran: a review of 172 cases. Br J Oral Maxillofac Surg 2007;45: 288-92.
7. Kashyap B, Reddy PS,Nalini P. Reactive lesions of oral cavity: a survey of 100cases in Eluru, West Godavari. Contemp Clin Dent 2012; 3: 294-7.
8. Pour MAH, Rad M, Mojtahedi A. A survey of soft tissue tumor-like lesions of oral cavity: A clinicopathological study. Iranian Journal of Pathology2008;3: 81-7.
9. Shahsavari F, Khourkiaee SS, Moridani SG. Epidemiologic study of benign softtissue tumors of oral cavity in Iranian population. Journal of Dentomaxillofacial Radiology, Pathology and Surgery 2012; 1: 10-15.
10. Rossmann JA. Reactive lesions of the gingiva: Diagnosis and treatment options. The Open Pathology Journal2011;5: 23- 32.
11. Buchner A, Calderon S, Ramon Y. Localized hyperplastic lesions of the gingiva: A clinicopathological study of 302 lesions. J Periodontol1977;48: 101-4.
12. Kfir Y, Buchner A, Hansen L. Reactive lesions of the gingiva: A clinicopathological study of 741 cases. J Periodontol1980;51: 655-61.
13. Sudarshan R, Vijayabala GS, Kumar KSP. Inflammatory hyperplasia of oral cavity. Archives Medical Review Journal 2012; 21(4): 299-307.
14. Kale TA. Focal fibrous hyperplasia: a reactive lesion. Int J dent Clinics.2013;5: 29-30.
15. Peralles PG, Vianaa PB, Azevedo ALdR, Pires FR. Gingival and alveolar hyperplastic reactive lesions: clinicopathological study of 90 cases. Braz J Oral Sci 2006;5: 1085-9.
16. Akinyamoju AO, Adeyemi BF, Kolude B. Localized reactive lesions of the oral cavity: A review of 246 cases in Ibadan. The Internet Journal of Dental Science 2013; 12(1).
17. Jafarzadeh H, Snatkhani M, Mohtasham N. Oral pyogenic granuloma: a review. J Oral Sci2006; 48: 167-75.
18. Eversole LR. Pregnancy tumor: an anlysis. Oral Surg Oral Med Oral Pathol(1991;72: 196-9.
19. Kohli K, Christian A, Howell R. Peripheral ossifying fibroma associated with aneonatal tooth: case report. Pediatr Dent1998;20: 428-9.
20. Motamedi MHK, Eshghyar N. Peripheral and central giant cell granulomas of thejaws: a demographic study. Oral Surg Oral Med Oral Pathol Oral RadiolEndod2007;103: e39- e43.
21. Krahl D, Altenburg A, Zouboulis CC. Reactive hyperplasia, precancerous andmalignant lesions of the oral mucosa. J DtchDermatolGes2008;3: 217-30.
22. Flaitz CM. Peripheral giant cell granuloma: a potentially aggressive lesion in children. Pediatr Dent2000;22: 232- 33.
23. Effiom OA, Adeyemo WL, Soyele OO. Focal reactive lesions of the gingiva: Ananalysis of 314 cases at a tertiary health institution in Nigeria. Niger Med J2011;52: 35-40.
24. Naderi NJ, Eshghyar N, Esfehanian H. Reactive lesions of the oral cavity: A retrospective study on 2068 cases. Dent Res J2012;9: 251-5.
25. Aghbali AA, Hosseini SV, Harasi B, Janani M, Mahmoudi SM. Reactive hyperplasia of the oral cavity: A survey of 197 cases in Tabriz, Northwest Iran. J Dent Res Dent Clin Dent Prospects 2010;4: 87-9.
26. Amirchaghmaghi M, Mohtasham N, Mozafari PM, Dalisrani Z. Survey of reactive hyperplastic lesions of the oral cavity in Mashhad, Northeast Iran. J Dent Res Dent Clin DentProspects2011;5: 128-31.
27. Prasanna JS, Sehrawat S. Fibroepithelial hyperplasia: Rare, Self-limiting condition – Two case reports. J Adv Oral Research 2011; 2(3):63-9.
28. Karhl D, Altenburg A, Zouboulis CC. Reactive hyperplasia, Precancerous and Malignant lesions of the Oral mucosa. JDDG 2008; 3(6): 217-32.
29. Correa L, Moreira ML, Frigerio A, Cantanhede S, de Sousa OM, Noveli MD. Oral lesions in elderly population: a biopsy survey using 2250 histopathological records. Gerodontology 2006; 23(1): 48-54.