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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524173EnglishN-0001November30HealthcareEFFICACY OF NARROW BAND VERSUS BROAD BAND IN TREATMENT OF PITYRIASIS ROSEA
English0107Intsar S. WakedEnglish Abdel Hamid N. DeghidiEnglishBackground: UV phototherapy has recently demonstrated high levels of efficacy and tolerability for treating a variety of inflammatory skin diseases.
Objective: The purpose of the present study was to evaluate the efficacy of narrow band versus broad band in the treatment of pityriasis rosea.
Methods: Twenty patients (12 female & 8 male) with extensive pityriasis rosea type III & IV were participated in the study. Their ages ranged between 18 and 35 years.The right half of the body of each patient was irradiated with NB-UVB ,while left side of each patient is exposed to broadband BB-UVB for 3 times alternatively per week until clearing of lesions or for 6 weeks. The rate of clearing was monitored by estimating the pityriasis rosea severity (PRSS) score and the pruritus score.
Results: The extent of disease (PRSS) for Rt side decreased from (34.30±10.16vs. 10.50±7.00, respectivelyEnglishPityriasis rosea, Pityriasis rosea severity score, UVNB and UVBBINTRODUCTION
Pityriasis rosea (PR) is a skin disorder that describes a sudden appearance of discrete plaques (patches) of skin rash in a distinctive pattern over the body and limbs. ’Pityriasis’ (meaning bran-like), indicates that there are scales in the skin lesions. ‘Rosea’ means rose-like and describes the typical colour of the rash, although the colour varies to a wide extent in different races. [1] Pityriasis rosea (also known as pityriasis rosea Gibert) is a skin rash. It is benign but may inflict substantial discomfort in certain cases. Classically, it begins with a single “herald patch” lesion, followed in 1 or 2 weeks by a generalized body rash lasting up to 12 weeks [2-5] Pityriasis rosea (PR) is an acute, self-limited papulosquamous disorder that begins with the appearance of an initial plaque most often on the trunk, and this is followed in about a week or two by the development of an analogous spotty rash and it usually persists for 4~7 weeks. The exact etiology of the disease is still unknown, although active infection with both human herpes viruses 6 and 7 is thought to play a role in PR.[6] Pityriasis rosea is a harmless skin disease that causes scaly patches that sometimes itch over the torso, neck, arms and legs. Anyone can get it, but it is most common in people ages 10 to 35. About 50% of all people with PR have itching of moderate to severe intensity. The quality of life of people with PR is significantly affected. Parents of children with PR also have significant anxieties about the cause, nature, and possible infectivity of the eruption.[7, 8] No specific therapy is available and in many cases none is needed; however, some patients have an extensive eruption and considerable pruritus. For patients with severe pruritus, experts have recommended treatment with zinc oxide, calamine lotion, topical steroids, oral antihistamines and even oral steroids. Ultraviolet radiation, through artificial sources or intentional exposure to natural sunlight, has been recommended to decrease the duration of the rash and the intensity of itching in patients with pityriasis rosea [9,10] The American Academy of Dermatology defines phototherapy as the exposure to nonionizing radiation for therapeutic benefit. It may involve exposure to ultraviolet (UV)A, UVB, or various combinations. Phototherapy can be administered in inpatient hospital settings, hospital clinics, daycare centers, and doctor’s offices, as well as for home therapy. Many diseases have been reported to respond to this treatment, including psoriasis, hand dermatitis, mycosis fungoides, pruritus, pityriasis rosea, lichen planus, pityriasis lichenoides, and many more. [11-14] Phototherapy with ultraviolet (UV) radiation of wavelengths between 280 and 320 nm (UVB) is a safe and effective treatment for a variety of diseases. There are two types of UVB treatment, broadband (bUVB) and narrowband (nUVB) (TL /01). Phototherapy with bUVB or nUVB has been reported to be effective and safe for the treatment of a large number of skin diseases. Narrowband UVB is similar to broad-band UVB in many ways. The major difference between them is that narrowband UVB is light energy which is emitted in a narrow portion of the UVB range which is concentrated in the therapeutic range, with an optimum peak at 311 nm.[15-19] The aim of this study was to evaluate the efficacy of narrow band versus broad band in the treatment of pityriasis rosea.
Patients & Methods
Twenty patients ( 12 female & 8 male ) with extensive pityriasis rosea were participated in the study. Their ages ranged between 18 and 35 years and had skin type III & IV. Diagnosis of pityriasis rosea was made by two dermatologists for all patients, based on characteristic clinical features. Signed informed consent was obtained from each patient before enrollment in the study. Reasons of exclusion are pregnant women, patients had history of photosensitivity, skin malignancy, abnormal reactions to sunlight or immunosuppression, patients were taking potentially phototoxic or immunosuppressive medication. Also if either of the dermatologists did not agree with the diagnosis of pityriasis rosea, the patient was not eligible for enrollment. and those with the absence of pruritus at the time of diagnosis were excluded from the study. Standardized case record forms were used for the purpose of collecting basic characteristics of the patients, which included age, sex, duration of rash, the season during presentation, history of preceding upper respiratory infection, exposure to a patient of pityriasis rosea, and herald patch. Complete blood counts and antistreptolysin-O titers were carried out in all patients and venereal disease research laboratory (VDRL) test was performed to exclude secondary syphilis. The experimental protocol was explained in details for each patient before the initial assessment.
Measurement Methods
The severity of the disease was determined according to the Pityriasis Rosea Severity Score (PRSS). Intensity of pruritus was determined by visual analogue scale (VAS).
Measurement the severity of pityriasis rosea [20]
Two areas were assessed for determining the PRSS (1) the head and trunk (t) and (2) the upper and lower extremities (e). The extent of the disease was first assessed with a 0 to 3 scale (0=absence of lesions, 1=1 to 9 lesions, 2=10 to 19 lesions, 3=≥20 lesions). To evaluate the severity of the lesions, three target symptoms termed erythema (E), infiltration (I) and scale (S) were assessed according to a scale of 0 to 3, in which 0 means a complete lack of cutaneous involvement and 3 represents the most severe possible involvement. To calculate the PRSS, the sum of the severity rating for these three main changes was multiplied with the numeric value (N) of the extent of the disease. The formula can be written as: PRSS=Nt (Et+It+St)+Ne (Ee+Ie+Se). The subscript “t” indicates one side of the trunk and the head, and the subscript “e” indicates one side of the extremities. Improvement in PRSS was graded as the percentage reduction as follows: minimal, ≤25%; good, 26-50%; very good, 51-75% and >75%, was excellent. A patient’s condition was defined as clearing if he or she had a PRSS score of 2 or less Assessment the pruritus a 100-mm visual analog scale was used to assess the severity of pruritus pre and post treatment. This scale has been extensively used and demonstrated to be a valid instrument for the measurement of intensity of pruritus . A horizontal line made on a sheet of paper with the left end marked as no symptoms and the right end marked as worst imaginable symptoms. The patient was asked to draw a vertical line to indicate the intensity of the symptom. The length from the left end to the vertical mark made by the patient was measured in millimeters.[21]
Treatment Procedures
Determination of the initial dose: Before initiating phototherapy, the initial irradiation dose for the individual patient must be determined. The dosage of UV light is prescribed according to an individual’s skin sensitivity. Thus, to establish the proper dosage of UV light to administer to a patient, the patient is screened to determine a minimal erythema dose (MED).The patient’s MED is determined by exposing six small template areas (eg, circles of 1 cm diameter) of nonexposed skin (lower back, buttocks) to an incremental series of UVB irradiations. Increases are made by fixed values (eg, 10 mJ/cm2). The MED is defined as the lowest dose that causes a minimally perceptible erythema reaction 24 hours after irradiation. Sunbathing or exposure to solaria must be avoided before phototesting. The type of lamp used for MED determination should be documented, since values obtained with broadband or narrowband sources are markedly different.
Treatment protocol
The right half of the body of each patient was irradiated with NB-UVB (311-313nm) with the average peak at 313 nm. by Philips UVB Narrowband TL100W/01 with output 17.7 w, Lamp voltage is 126, Lamp current 0.97 and with cap base R17d. The left side of each patient is exposed to broadband ultraviolet B 290-325nm (BB-UVB) by Philips UVB Broadband TL100W/12 with output 12.7 w, Lamp voltage is 126, Lamp current 0.97 The initial treatment dose was 70% of the MED and the dose was increased by 10% if no erythema or discomfort developed from the prior irradiation, 5% with minor erythema not lasting longer than 24 h, and no increments if the erythema lasted more than 24 h. Therapy was given 6 times weekly ( 3 times for Rt side & 3 times for Lt side alternatively ) until clearing of lesions or for 6 weeks. At the day of session ask patient to wear protective goggles, not put perfumes, deodorants, aftershave lotions or other cosmetic products. Some of these contain additives which make the skin more sensitive to light as this may cause burn. The patients were asked not to expose themselves to ambient sunlight during the study. No other treatment had been given for at least 3 months prior to the start of study.
Statistical Analysis
Frequencies are used to describe the variables (Sex , skin type, occurrence of herald patch). Student t test was used to assess the difference between the studied parameters (PRSS, IP) between two sides of body while paired t test was used to analyze these parameters within each side pre and post treatment. Data were coded and entered to a statistical package of social science (SPSS, version 16). All P values less than 0.05 were considered to be statistically significant.
RESULTS
Figure 1, presents the flow chart for patients throughout the study. A total of 28 patients was screened for eligibility, and 20 subjects fulfilled the inclusion criteria and were completed the study and continued to the final analysis. Table 1 presents the demographic and clinical characteristics of the patients completing the study
Pitryiasis Rosea Severity Score Measurements (PRSS)
The severity of pitryiasis rosea disease was summarized in Table 2, as determined by Pitryiasis Rosea Severity Score (PRSS). The reductions in severity of disease were observed in NBUVB (Rt side) and BBUVB (Lt side) from initial (W0), to subsequent measurement at 6thweek (W6). Significant differences were found between two sides (10.50±7.00 versus 16.00±9.06, P0.05).
DISCUSSION
Today, phototherapy is a valuable option in the treatment of many non-psoriatic conditions including AD, sclerosing skin conditions such as morphea, vitiligo, and mycosis fungoides. Due to its relative safety, phototherapy may be used in most populations, including children and pregnant women. The UV range (10 to 400 nm) is further sub-divided into UVA and UVB, each of which has been particularly useful in a number of skin conditions. The most commonly used forms of UV irradiation are UVA1, PUVA, and NB-UVB, BBUVB. Each of these modalities differ in their mechanism of action, indications, and side effect profiles, and it is important that clinicians be familiar with these differences.[22] There have been a few reports of successfully treating pityriasis rosea using UV phototherapy, but there are currently no reports on comparing Narrow and broad band UVB in treating pityriasis rosea. [20] The purpose of this study to compare the efficacy of narrow band UVB versus broad band UVB in treating pitryiasis rosea. Twenty patients with extensive pityriasis rosea were participated in the study. The right half of the body of each patient was irradiated with NB-UVB (311-313nm) with the average peak at 313 nm. The left side of each patient is exposed to broadband ultraviolet B 290-325nm. Assessment was done through pitryiasis rosea severity score (PRSS) and visual analogue scale to assess severity of disease and pruritus. In our present study, out of 20 patients, 8 cases ( 40 % ) were males and 12 cases ( 60 % ) were female giving rise to male to female ratio of 1:1.5. This result was in accordance with a large study of Chuang et al, [23] who reported that the sex ratio was 1.5 females to 1 male patient. Crissey found twice as many females than males [24] while Cohen reported that both sexes were affected equally.[25] In most of the series reported, females preponderate over male but not so greatly.[26] On the other hand, Bjornberg and Hellgren reported a slight male preponderance.[27] Sharma et al as well as Vijyeeta reported a slight male preponderance.[28,29] preponderance. In our study there was a slight female preponderance. As regard to the duration of illness before entering the study varied from few days to few weeks. In our study most of the cases reported within 1st week illness (55 %) and ( 45% ) of the cases reported within 2nd week of illness. Early reporting to hospital was due to the presence of pruritus and anxiety caused by generalized appearance of the lesions over the body surface. In most of cases presented to us it was the first episode of pitryiasis rosea before the treatment could be initiated. Only 3 had episode of recurrence. History of upper respiratory tract was present in only 2 cases of pitryiasis rosea (10%). Chuang et al reported that history of cutaneous and non-cutaneous infections prior to onset of pitryiasis rosea was present in 16% of their cases and he found no association of pitryiasis rosea with atopy and sebborrheic dermatitis while Vijyeeta [29] reported 70% of cases had upper respiratory tract. Presence of herald patch was reported in about 85% cases and most commonly seen on the trunk (40%). This was in accordance with Vijyeeta [29] who reported that about 82% of cases demonstrated herald patch. Dambalkar K et al and various other authors in different studies have reported the incidence of herald patch to be 40- 76%. [23,30,31] Although the etiology of pityriasis rosea is unclear, several indicate an infectious cause. First, outbreak of the condition occur in clusters, suggesting an infectious agent is circulating within a community. Second, recurrence of pityriasis rosea outside the acute phase is rare, suggesting that there is long- lasting immunity after the infection. Third, up to 69 percent of patients with pityriasis rosea have a prodromal illness before the herald patch appear. Finally, some patients with pityriasis rosea show an increase in B lymphocytes, a decrease in T lymphocytes, and an elevated sedimentation rate. [32,33] The histologic features of pityriasis rosea are non-specific. In epidermis, mild hyperkeratosis with focal parakeratosis, minimal acanthosis with variable spongiosis, and a moderate exocytosis of lymphocytes with a thinned granular layer is present. In the dermis, extravasated red blood cells are accompanied by a perivascular infiltrate of lymphocytes and eosinophils with occasional monocytes. Similar findings are demonstrating in the herald patch with a deeper infiltrate and more pronounced acanthosis. Dyskeratotic cells are present in 50% of cases.[34-36] The results of the study showed that there were significant reduction in PRSS & VAS post treatment in both sides from W0 to subsequent W6 for both Rt (NBUVB) and Lt (BBUVB) side and this suggest efficacy of ultraviolet B in treating pitryiasis rosea controlling pruritus whatever the type of band . Valkova in his bilateral comparison study between UVA and UVB phototherapy in treatment of pityriasis rosea confirmed that the UVA irradiation in the dose mentioned earlier had no effect on the course of the disease but significant clinical improvement according to PRSS with total clearing of the rash was observed after UVB phototherapy[37], which is correlating with our study. Our study correlated with Leenutaphonga et al who in his study used a bilateral comparison experimental demonstrated that 10 daily erythemogenic exposures of UVB resulted in substantially decreased severity of disease in comparison with the control side in 15 of 17 patients. The overall reduction of PRSS showed a significant differences, the UVB irradiation was superior to UVA irradiation.[20] The results of this study was in accordance with a previous bilateral comparison study by Amdt et al in which five consecutive erythemogenic UVB phototherapy exposures were administered to one half of the bodies of 20 patients. It was shown that the extent of disease and pruritus on the treated side decreased more than on the untreated side [38]. As regard to the type of UVB band, the results of our study showed that NBUVB was more effective than BBUVB in reduction of PRSS with percentage of improvement was 69%, 55% respectively while there was no significant differences between NBUVB & BBUVB in reduction the degree of pruritus with percentage of improvement 53%& 49% respectively. Gambichler et al, [39] stated that Because NB-UVB may have a wider indication spectrum, including AD, vitiligo, and early-stage CTCL, and appears to be equally effective or even more effective than broad-band UVB (BB-UVB), a switch from BB-UVB to NB-UVB seems to be justified. On the other hand Pugashetti and colleagues[40] noted that BB-UVB phototherapy has demonstrated effectiveness in the treatment of cutaneous disorders including psoriasis, AD, uremic pruritus and idiopathic pruritus. Also they high-lighted in their report, that there was a small but significant proportion of psoriasis and AD patients who do not tolerate NB-UVB but demonstrated an excellent clinical response to BB-UVB. They reported that it is critical for dermatologists to recognize the role of BB-UVB as a complement to NB-UVB phototherapy for patients who cannot tolerate or experience an inadequate therapeutic response from NB-UVB. Our study was in accordance with Weiming Hui and other [41] who reported in their study good patient compliance and fewer adverse reactions, safe, reliable, and worthy of clinical application after 6 or 7 times of NBUVB irradiation treatment of pityriasis rosea. Also Samson et al reported that Narrow-band UVB phototherapy was well-tolerated, with no serious adverse effects and concluded that NB-UVB may be considered as a viable therapeutic option in the treatment of vitiligo, pruritus, and other inflammatory dermatoses. Several studies reported the immunomodulatory effects of nUVB appear to be more pronounced than bUVB [42]. Multiple studies have shown the effectiveness of narrowband UVB treatment to be superior to that of conventional broadband UVB treatment.[43,44] As regard to incidence of side effects, no significant sideeffect were noted during the treatment course by both types of UVB band except for slight burning sensation, darkening of the skin and dryness of the skin.
CONCLUSION
On conclusion our study showed that NBUVB was more effective than BBUVB in reduction of PRSS and the degree of pruritus in pityriasis rosea.
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44. Storbeck K, Holzle E, Schurer N, et al. Narrowband UVB versus conventional broad-band UV-B in phototherapy for psoriasis. J Am Acad Dermatol. 1993;28:227–231.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524173EnglishN-0001November30HealthcareFISSURES AND LOBES OF LUNG - AN ANATOMICAL STUDY AND ITS CLINICAL SIGNIFICANCE
English0812Amit MagadumEnglish Daksha DixitEnglish Shilpa BhimalliEnglishIntroduction: The fissures facilitate the movement of the lobes in relation to one another, which accommodates greater distention and movement of the lobes during respiration. The fissures may be complete, incomplete or absent altogether.
Aim of the Study: To study the morphology of fissures and lobes, to note the variations, to compare them with previous studies and to find their clinical significances.
Materials and Methods: Forty pairs of lungs obtained from formalin-fixed adult cadavers removed during routine dissection at J. N. Medical College, Belagavi were studied. These lungs were meticulously observed for the patterns of lobes and fissures, variations were noted and photographed.
Results: In the present study oblique fissure was absent in 10% of right lungs and 7.5% of left lungs. Incomplete horizontal fissure was seen in 52.5% of right sided lungs.
Conclusion: This study also shows that parenchymal fusion of various extents is a very common entity of oblique fissure of lung. This implies that a variety of genetic and environmental factors might affect development of these fissures.
EnglishCadavers, Lobectomy, Fissure, Parenchymal fusionINTRODUCTION
The lungs are the essential organs of respiration. Fissures are an integral part of human lung. Right lung has 2 fissures; oblique and horizontal, dividing it into superior, middle and inferior lobes. Left lung has only oblique fissure dividing it into superior and inferior lobes1 . The lung fissures ease the movement of the lobes, which helps in greater distention and movement of the lobes during respiration2 . Thus, they help in a more uniform expansion of the whole lung. The fissures may be complete, when the lobes remain held together only at the hilum by the bronchi and pulmonary vessels, or they may be incomplete when there are areas of parenchymal fusion between the lobes, or, they may be absent altogether2 . In the region of an incomplete fissure, the adjacent lobes are connected by a sizeable chunk of pulmonary tissue as the cleft fails to reach the hilum. Parenchymal fusion of varied extent along the floor is also found in case of incomplete fissures3 . Accessory fissures of the lung are commonly observed in lung specimens, but are often unappreciated or misinterpreted on radiographs and computerized tomographic (CT) scans4 . Anatomically, an accessory fissure is a cleft of varying depth lined by visceral pleura. These accessory fissures usually occur at the boundaries of the broncho-pulmonary segments. As per Godwin, the most common accessory fissures are the inferior accessory fissure4 . Radiologically an accessory fissure appears as a thin white line, resembling the major or minor fissure, except for its location4 . A fissure appearing complete on X-ray might be seen as an incomplete one on CT scan5 . The knowledge of anatomical variations of the lobes and fissures of lung is important for identifying broncho-pulmonary segments and surgical resections involving individual segments.
AIM OF THE STUDY
Aim of the present study was to examine lung specimens with respect to the morphology of fissures and lobes, to note the variations, to compare them with previous studies and to find their clinical significances.
MATERIALS AND METHODS
Forty pairs of lungs obtained from formalin-fixed adult cadavers removed during routine dissection at J. N. Medical College, Belagavi were studied. The specimens having pathological lesions, marks of previous surgery, and those that were damaged during removal were excluded from the study. Of the 80 lung specimens, 40 were of the right side and 40 were of the left. These lungs were examined for the patterns of lobes and fissures. Later, variations in these lungs were observed and photographed. The anatomical classification based on the degree of completeness of the fissures proposed by Craig and Walker6 was followed to determine the presence and completeness of fissure (table 1).
RESULTS
The observations regarding incidence of oblique and horizontal fissures are shown in table 2. Figure 1 shows absence of horizontal fissure & grade 3 oblique fissure in right lung. Grade 3 horizontal fissure of right lung is seen in figure 2. Accessory fissures of lung are shown in figure 3, 4 and 5.
EMBRYOLOGICAL BASIS:
In prenatal life fissures separate individual broncho-pulmonary segments. All fissures gradually get obliterated. The fissures along the inter-lobar planes persist and give rise to major (oblique) and minor (horizontal) fissures7 . Absence or incompleteness of a fissure could be due to obliteration of these prenatal fissures either completely or partially. Incomplete fissures indicate partial fusion between lobes. Accessory fissures could be the result of non-obliteration or persistence of the prenatal fissures. Any variation in the morphological pattern of the fissures indicates variations from normal pattern of development of lung8 .
DISCUSSION
The present study showed that, in majority of cases the fissures were incomplete, more on the right side than on the left (Table 2). These findings were compared with those of other studies as shown in table 4. Increased incidence of incomplete oblique fissures on the right side might indicate early commencement of fusion of the prenatal fissures which may proceed further before birth, leading to fusion along floor of the oblique fissure9. Table 4 shows wide variability which may be due to the regional variation. In the present study oblique fissure was absent in 10% of right lungs and 7.5% of left lungs. Dutta S et al9 reported absence of oblique fissure in 11.4% of right lungs and 8% of left. But Medlar EM et al 10 reported absence of oblique fissure as 4.8% and 7.3% in specimens of right and left lungs respectively. These results do not match with our data as oblique fissure was absent more on the right side.
Surgically the gradation of fissure is important. The surgeon approaches to ligate the vessels and bronchi through the depth of the fissure. Grade 1 oblique fissure facilitates the approach while doing lobectomy and video assisted thoracoscopic surgery15. But otherwise the lung parenchyma has to be dissected to reach those structures leading to intra-operative hemorrhage and more postoperative complications16. On the other hand, while performing right upper lobectomy, middle lobe has the chance of undergoing torsion if the oblique fissure is of grade 1 variety. So, preventive fixation of the middle lobe is essential to avoid this complication17. An incomplete fissure is also a cause for postoperative air leakage during lobectomies6. In the present study incomplete horizontal fissure was seen in 52.5% of right sided lungs which was comparable with the results of study done by Prakash et al13 (50%). The presence of fissures in normal lung enhances uniform expansion, and their position could be used as reliable landmarks in specifying lesions within the thorax, in general, and within the lungs in particular18. Accessory fissures of the lung are commonly observed in lung specimens, but are often unappreciated or misinterpreted on radiographs and CT scans. In the present study superior accessory fissures were observed more commonly on the left side (3 specimens) than on the right side (1 specimen). Also, in our study we found 2 inferior accessory fissures in right sided lungs. Accessory fissures can be mistakenly confused with areas of linear atelectasis, pleural scars, or walls of bullae4 . In patients with endobronchial lesion, an accessory fissure might alter the usual pattern of lung collapse and pose difficulty in diagnosing a lesion and its extent. Pneumonia in a particular lobe is contained within the confines of the lobe by complete fissures. In patients with incomplete fissures, pneumonia may spread to adjacent lobes through the parenchymal continuation19.
CONCLUSION
The results of present study and its comparison with the previous studies showed a wide range of difference in occurrence of fissures among different populations. This implies that a variety of genetic and environmental factors might affect development of these fissures. This study also shows that parenchymal fusion of various extents is a very common entity in oblique fissure of lung.
ACKNOWLEDGEMENT
The authors are highly thankful to the KLE University’s J. N. Medical College, Belagavi, for providing the necessary support and infrastructure facility to carry out this study. 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.
Source of Funding: Nil
Conflict of interest: Nil
Figure 4: Right lung showing Inferior accessory fissure
Englishhttp://ijcrr.com/abstract.php?article_id=627http://ijcrr.com/article_html.php?did=6271. Gatzoulis M A. Thorax. In: Gray’s Anatomy. 40th ed. Edinburg: Churchill Livingstone: 2008, p.993-94.
2. Meenakshi S, Manjunath K.Y, Balasubramanyam V. Morphological variations of the lung fissures and lobes. Indian J. Chest Dis Allied Sci 2004; 46: 179-182.
3. Rosse C, Gaddum-Rosse P. Hollinshed’s Textbook of Anatomy. Philadelphia: Lipincott-Raven; 1997: 441-61.
4. Godwin JD, Tarver RD. Accessory fissures of the lung. Am J Roentgenol.1985;144:39-47.
5. Berkmen T, Berkmen YM, Austin JH. Accessory fissures of the upper lobe of the left lung: CT and plain film appearance. Am J Roentgenol 1994;162: 1287-93.
6. Craig SR, Walker WS. A proposed anatomical classification of the pulmonary fissures. J R Coll Surg (Edin).1997;42: 233-34.
7. Larsen WJ. Human Embryology. New York: Churchill Livingstone; 1993; p.111-30.
8. Modgil V, Das S, Suri R. Anamolus lobar pattern of right lung: a case report. Int. J. Mophol. 2006; 24: 5-6.
9. Dutta S, Mandal L, Mandal SK, Biswas J, Ray A, Bandopadhyay M. Natural fissures of lung- anatomical basis of surgical techniques and imaging. Nat J Med Res. 2013; 3(2): 117-21.
10. Medlar EM. Variations in interlobar fissures.AJR. 1947; 57 :723-25.
11. Lukose R, Paul S, Sunitha DM, et al. Morphology of the lungs: variations in the lobes and fissures. Biomedicine 1999;19:227-32.
12. Bergman RA, Afifi AK, Miyauchi R. Variations in peripheral segmentation of right lung and the base of the right and left lungs. In: Illustrated Encyclopedia of Human Anatomic Variation.http://www.anatomyatlases.org/AnatomicVariants/OrganSystem/Text/LungsTrachea.shtml (28th of November, 2010).
13. Prakash, Bhardwaj AK, Sashirekha M, Suma HY, Gowtham Krishna G, Singh G. Lung Morphology: a cadaveric study in Indian Population. Ital J Anat Embryol. 2010; 115(3): 235- 40.
14. Nene AR, Gajendra KS, Sarma MVR. Lung lobes and fissures: a morphological study. Anatomy 2011; 5: 30-38.
15. Jennifer M.J. Richards, Joel Dunning, Jonathan Oparka, Fiona M. Carnochan, William S. Walker. Video–assisted thoracoscopic lobectomy:The Edinburg posterior approach. Annals of Cardiothoracic Surgery.2012;1(1).
16. John A.Waldhausen,William S.Pierce, David B.Campbell. Thoracic Surgery.In: Surgery of the Chest. 6th ed. Mosby,St Louis,Missouri.1996. p.134.
17. Pimpec-Barthes F L, Arame A, Pricopi C, Riquet M. Prevention of middle lobe torsion or bronchial plication using anti-adhesive membrane: a simple,safe and uncomplicated technique. Eur J Cardiothoracic Surg.2011;39(6):1059- 1069.
18. Kent EM, Blades B. The surgical anatomy of the pulmonary lobes. J Thoracic Surg.1942; 12 : 18-30.
19. Tarver RD. How common are incomplete pulmonary fissures, and what is their clinical significance? ARJ Am J Roentgenol.1995;164:761.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524173EnglishN-0001November30HealthcareFINE NEEDLE ASPIRATION CYTOLOGY OF HEPATIC LESIONS IN IRAQI PATIENTS
English1316Esam Mohamed Abdul RaheemEnglishStudy design and Objective: This was a cross- sectional hospital-based descriptive study aimed to assess the role of Fine Needle Aspiration Cytology (FNAC) indiagnosis of the hepatic lesions in Iraqi patients
Material and Methods: During a period of six months, percutaneous fine needle aspirations, either blindly or under ultrasoundguidance , were performed preoperatively on 34 patients with hepatic lesions attended Mosul hospitals.
Results: Cytological diagnosis revealed 33 malignant lesions and one liver abscess. Diagnosis of all cases was confirmed by histopathological examination of tissue biopsies. The sensitivity, specificity, and overall accuracy of the technique were 100%.
Conclusion: FNAC of the liver has proved to bereliable, accurate, safe, economic, and can save the patient unnecessary surgical approach.
EnglishFNAC, Liver, IraqINTRODUCTION
Investigation of liver lesions detected by clinical and/or ultrasound examination may necessitate wide bore needle biopsy and even open liver biopsy. [1, 2]Such techniques may need hospitalization and application of anesthesia; they are associated with considerable rates of complications such as bleeding and tumor spread. [3, 4, 5]Fine needle aspiration of such lesions provides quick, easy, painless, and accurate method of preoperative diagnosis; in experienced hands, no complications are faced. [6, 7, 8] The aim of the current study was to evaluate the technique and assess its role in Iraqi patients with liver mass lesions. MATERIAL AND METHODS This was a cross- sectional hospital-based descriptive study conducted at Mosul City during the period between January and July 1998.Preoperativepercutaneous FNAC was performed on 34 clinically or ultrasonically detected hepatic mass lesions. The aspirates were obtained from patients in departments of pediatric surgery at Al-Khansahospital, general surgery at Al-Zahrawi hospital,and internal medicine at Ibn-Sina hospital. All patients were suspected of having malignancy. Verbal permission and approval for all aspirates were obtained from head departments at the mentioned hospitals and from patients and/or co-patients. Aspirations were done without any routine fasting or premedication. Prothrombin time, PTT, and platelet counts or any other laboratory investigations were not evaluated routinely before the procedure. Prior to the aspiration, labeled glass slides were put ready for the samples. The skin overlying the mass was cleaned with alcohol or iodine. Topical or local anesthesia was not administered. The technique was performed by the use of 10 ml disposable syringe with 21-22 gauge needles.Palpable lesions were aspirated directly without the need for ultrasound control (13 cases). Deeper and smaller lesions required more precise localization by ultrasound (21 cases); the largest and most superficial one was selected for aspiration. After localization of the mass, the needle was introduced into the lesion and negative pressure was applied; the needle was then moved back and forth and in different directions several times during maximumaspiration to soften the lesion. When material appeared into the needle, suction was stopped, and the needle was withdrawn.
No case needed more than one pass to get the material. The patient was kept lying down for 10 minutesand reexamined by ultrasound to notice any possible complications, such as bleeding or hematoma at the site of aspiration. Two to four thin or central concentrated smears were then made from each aspirate, fixed immediately into 95 % ethanol for 15 minutes and stained with Hematoxylin and eosin staining technique. Slides were then evaluated under a light microscope and results were compared with the histological diagnosis which was considered as the conclusive diagnosis. The histological diagnosis was made by open liver biopsy in 14 patients and by core needle biopsy in the remaining 20 patients.
RESULTS
All the aspirates were prepared, stained,and reported within 45- 60 minutes of obtaining the material.The patients included 30 adults and 4 children, 9 females and 25 males, ranged in age between 7 and 62 years. The presenting clinical findings were dyspepsia in 7 patients, palpable mass in 12 patients, general ill health with loss of weight in 10 patients, and in the remaining 5 patients the lesion was discovered accidently during follow up after resection of a malignant lesion. The cytological diagnosis of the aspirated hepatic lesions included 33 malignant lesions and one benign lesion; this is shown in table 1. The primary sources of the metastatic lesions are shown in table 2. The cytological diagnosis was consistent with the histological diagnosis in all cases. The sensitivity, specificity, and overall accuracy were 100%. A mild dizziness followed by fever was noticed in a 50 years old female with hepatic secondaries from carcinoma of the breast. The technique was acceptable by all the patients. Reexamination of the sites of aspiration by ultrasound showed no signs of bleeding or hematoma in any of the guided aspirations.
DISCUSSION
FNAC has proved to be effective preoperative diagnostic tool in superficial lesions [9, 10],however, it is now extended to diagnosesuch deep lesions as liver masses. In this site, its role as preoperative diagnostic method can be even more important than the superficial organs; it may save the patient a major surgical operation. In some cases the technique may abolish the need for surgery when the lesion is inoperable or the treatment of choice is radiotherapy or chemotherapy [11, 12, and 13]. The results of this study indicate that FNAC of the liver is very reliable and highly accurate in diagnosis of hepatic lesions, especially malignant ones.It is safe, quick, and economic technique. These results are compatible with several other studies performed on lesions of the liver [14 - 17]. The sensitivity, specificity, and overall accuracy of this study were similar to several studies. [18 - 21]. Comparing the accuracy of FNAC of liver lesions with the accuracy of tru-cut needle biopsy, it was found that FNAC is more accurate, safe, and economic. [4]. Ultrasound guidance during aspiration was especially important in small and deep lesions [22], added to that it is helpful in avoiding aspiration of hydatid cyst in which FNAC is contraindicated. [23]. The complications of FNAC of liver in this study were negligible. [24]. Bile peritonitis and intraperitoneal bleeding reported with core needle biopsy [5] were not observed in this study.
CONCLUSIONS
It can be concluded from this study that FNAC of the liver, especially when guided by ultrasound, is accurate,safe, quick and economic preoperative test. It is useful in differentiating neoplastic from nonneoplastic lesions, and benign from malignant ones.It is trusted by surgeons; they usually depend on FNAC results and refer the patient to treatment by radiotherapy or chemotherapy. It can help to predict the primary ofan aspirated metastatic tumor.
Source of Funding
This work was supported by the department of pathology college of medicine, Mosul university, Iraq.
Conflict of Interest
The author declares that there is no conflict of interest.
Author’s Contribution:
The author is responsible for conception and design of the study, data collection, interpretation of the findings, and review of the whole manuscript.
ACKNOWLEDGEMENTS
Author acknowledges the immense help received from the scholars whose articles are cited and included in references of this manuscript. The author is 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=628http://ijcrr.com/article_html.php?did=6281. Lundquist A. 1970. Liver biopsy with a needle of 0.7 mm outer diameter. Acta Med. Scand; 188: 471-474.
2. Gilmore IT, Burroughs A, Murray-Lyon IM, Roger Williams, Jenkins D, and Hopkins A. 1995. Indications, methods, and outcomes of percutaneous liver biopsy in England and Wales: an audit by the British Society of Gastroenterology and Royal College of physicians of London. Gut, 36: 437- 41.
3. Edoute Y, Haim SB, and Malberger E. Liver histology and cytology in the diagnosis of malignant liver disease. 1990. Am J Gastroenterol, 85: 285-287.
4. Prior C, Kathrein H, Mikuz G, and Judmaier G. 1988. Differential diagnosis of malignant intrahepatic tumor by U/S guided FNAB and by laparoscopic / intraoperative biopsy: a comparative study. Acta cytol, 32: 892-895.
5. Haaga JR and Vanek J. 1979. CT-guided liver biopsy using the Menghini needle. Radiology, 133: 405-408.
6. Angeles AA, Dominguez G, and Fernandez M. 1994. Hepatic fine needle aspiration biopsy: experience in the study of hepatic masses at the Salvador Zubrian National institute of Nutrition. Rev. Invest. Clin, 46: 279-285.
7. Herszenyi L, Farinati F, Marafin C, and Cardin R. 1995. Fine needle biopsy in focal liver lesions: the usefulness of a screening programme and the role of cytology and micro histology. Ital. J. Gastroenterol, 27: 473-478.
8. Whitlatch S, Nunez C, and Pitlik DA. 1984. Fine needle aspiration biopsy of the liver: a study of 102 consecutive cases. Acta cytol. 28: 719-725.
9. Gupta RK, Naran S, Lallu S, and Fauck R. 2003. The diagnostic value of FNAC in the assessment of palpable supraclavicular lymph nodes: a study of 218 cases. Cytopathology, 14:201-7.
10. Sharma R and Mathur D. 2012. FINE NEEDLE ASPIRATION CYTOLOGY (FNAC) OF PALPABLE LESIONS OF HEAD AND NECK REGION. IJCRR. 4(22): 74-84.
11. Abdul-Raheem EM, Elfaki EM. The role of fine needle aspirationcytology in the diagnosis of deep-seated lesions in Sudanese patients. Int J Health Sci Res.2013; 3(10):1-9.
12. Nasuti JF, Gupta PK, Baloch ZW. 2002. Diagnostic value and cost-effectiveness of on-site evaluation of fine-needle aspiration specimens: review of 5,688 cases. Diagnostic Cytopathology. 27(1):1–4.
13. Rosa M. 2008. Fine-needle aspiration biopsy: a historical overview. Diagnostic Cytopathology. 36(11):773–775.
14. Matricardi L, Lovati R, Capra S, Casoni S, and Callea F. 1996. Peripheral intrahepatic cholangiocarcinoma: the role of imaging diagnosis and fine needle biopsy. Radiol. Med. Torino; 91: 413-419.
15. Hakim JG, Kiire CF, Weinig M, Gudza I, Muronda C, and siziya S. 1995. FNAC in the diagnosis of hepatocellular carcinoma. Cent. Afr. J Med. (Zimbabwe), 41: 237-241.
16. Khanna AK, Mishra MK, Khanna A, Mishra VK, Khanna S, et al. 1990. Fine needle aspiration cytology of abdominal masses. Journal of surgical oncology, 44:15–19.
17. Krishna SR, Ananthakrisnan N, Narasimhan R, and Veliath AJ. 1993. Accuracy of needle aspiration cytology of abdominal masses without radiological guidance. Indian J.Pathol. Microbiol, 36(4):442–52.
18. Perry MD and Johnston WW. 1985. Needle biopsy of the liver for the diagnosis of nonneoplastic liver disease. Acta cytol. 29: 385-390.
19. Giorgio A, Trantino L, Marmiollo N, Francica G, Scala E, Amoroso P, Nuzzo A, and Rizzatto G. 1995. Pyogenic liver abscesses: 13 years of experience in percutaneous needle aspiration with US guidance. Radiology, 1: 122-124.
20. Pinto MM, Avila NA, Heller CI, and Criscuomo EM. 1988. Fine needle aspiration of the liver. Acta Cytol. 32: 15 - 21.
21. Zornoza J, Wallace S, Ordonez N, and Lukerman J. 1980. Fine needle aspiration biopsy of the liver. AJR. 134: 331- 334.
22. Santos GC, Morini SR, Granero LC, Chojniak R, and Longatto-Filbo A. 1997. Computed tomography guided fine needle aspiration biopsy. Rev Paul Med, 115 (1): 1343-8.
23. Sinner WN, Nyman R, Linjawi T, and Ali AM. 1995. Fine needle aspiration biopsy of hydatid cysts. Acta Radiol. 36: 168-172.
24. Roy M, Dasgupta S, and Sanyal S. 1994. Fallacies of the FNAC of surgical lesions of liver. J. Indian Med Assoc. 92: 285-287.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524173EnglishN-0001November30HealthcareA CROSS SECTIONAL STUDY TO ASSESS FLEXIBILITY AND AGILITY LEVELS IN INDIAN JUDO PLAYERS
English1721Jayasudha KatralliEnglish Shivaprasad S. GoudarEnglish Veeresh ItagiEnglishIntroduction: Judo is the sport in which movements are powerful, delivered in a short period of time, usually against the force of the opponent. Judo athletes ought to be speedy, tough and supple. Flexibility and agility are two indispensible physical fitness characteristics which are neglected and where there is lack of information regarding the testing and the training exercises in Indian scenario.
Methodology: This cross sectional study included 31 Judo players with minimum 3yrs of practice and of age 18-25years. Players were divided into A and B group depending on > or ? 5 years of judo training. Flexibility was tested using sit and reach tester and agility by side step test. Statistical analysis done using Students unpaired ‘t’ test.
Results: 20 players belonged to A group and 11 players to B group. Mean Flexibility score was found higher for Judo B group compared to Judo A group with statistically significant difference (p EnglishFlexibility, Agility, Sit and reach, Side step test
INTRODUCTION
Judo is a sport where apart from technical skill and tactics, physiological characteristics also play important role for success in competition.1 Judo athletes ought to be speedy, tough and supple. Flexibility and agility are two indispensible physical fitness characteristics which are neglected and where there is lack of information regarding the testing and the training exercises in Indian scenario. Judo is the sport in which movements are powerful, delivered in a short period of time, usually against the force of the opponent.2 It is a sport of changeable intensity of effort and the sportsperson should be flexible and agile to match the opponent. Flexibility may be defined as the maximal passive physiological range of motion in a given joint movement. Lack of flexibility will affect the athlete’s ability to do certain Judo techniques. The more flexible the muscle, the more is the range of motion present in differing parts of the body and also less likely the injury to occur during the game.3 When a player stretches a muscle, it lengthen the tendons, which attach it to the bone. The longer these fibers are the more player can increase the size of his muscle during strength training. This means that a flexible muscle is a stronger muscle. Therefore adding flexibility training increases fitness level of the player. Stretching also increases circulation, increasing blood flow to the muscles. Agility is the physical ability which enables a player to rapidly change body position and direction in a precise manner which is very much needed to perform complex sequences of techniques such as counters, combinations and any other linking skills whether offensive or defensive. The poor performance of Indian Judokas at the International competition has been of great concern especially to coaches, physical educationist and sports scientists. Efforts have been made to improve the standards of our sportsmen since long, however little success has so far been achieved in this respect. In this view this study was undertaken to scientifically contribute to assessment of the flexibility and agility levels of Indian Judokas which will help the coaches to direct the training program.
METHODS
This cross sectional study was conducted in the Department of Physiology, Jawaharlal Nehru Medical College, Belgaum. Study was carried out in 31 Judo players practicing regularly for a minimum period of 3 years and who were in the age group of 18-25yrs. Players with medical history of neuromuscular, cardiac, respiratory and endocrine illness were excluded from the study. Descriptive data of the participant’s age, training schedule and dietary history were obtained by interviewing the participants. Institution’s Ethical and Research Committee approval and written informed consent from the players was obtained. Depending on number of years of judo training players were divided into Judo A group consisted of players ≤ 5 years of Judo and Judo B group consisted of the senior players with > 5 years of training. 4 Training sessions and the diet given was same for both the groups. FLEXIBILITY was tested using Sit and Reach flexibility tester manufactured by Anand agencies, Pune. This test involved subject sitting on the floor with legs stretched out straight ahead. Shoes were removed and toes pointed upwards. The soles of the feet were placed flat against the centre limbs of the tester. Both knees were to be locked and pressed flat to the floor - the examiner assisted by holding them down. With the palms facing downwards and the hands on top of each other or side by side, the subject reached forward along the measuring line as far as possible. It was seen to that the push was smooth and static, no bouncing or lunging was allowed. Care was taken that the hands remained at the same level, not one reaching further forward than the other. After some practice, the subject reached out and held that position for one-two seconds while the distance was recorded. The score was recorded to the nearest centimeter as the distance reached by the hand. The level of the feet was the zero mark on the scale. 5,6,7 Agility was assessed by side step test where we drew lines accordingly as shown in the figure 1 on the plane ground. A centre line was drawn on the ground where the test has to be conducted. Two more lines on each side of the centre line which were 3 feet and 6 feet apart from the centre line were drawn using a measuring tape. To start with from the position on the centre line. The participant side stepped on the signal went to the right until his foot had reached or touched the outside line to the right. Participant then sidestepped to the left until his left foot had touched or crossed the outside line to the left. The participant repeated these movements as rapidly as possible for 10 seconds. Scoring: One foot tick mark placed between center line and outside line, each trip from center line across marker counts as follows: moving across right crosses tick (1), outside line to right (2), then back tick (3), center (4), across left tick (5), outside line to left (6), back tick (7) and center (8). One completed cycle gives a score of eight points. Total score within ten seconds was taken. 5,7,8 Statistical analysis involved quantitative variables summarized through mean and standard deviation. Difference between mean of the two groups was tested using Students unpaired‘t’ test, where significance of the p value was < 0.05.
RESULTS
Out of 31 Judo players (19 males and 12 females), the number of players with less than or equal to five years of judo practice were found to be 20 players and were included in JUDO A group. Number of players with more than 5 years of judo practice were 11 players included in JUDO B group (Table 1). Basal parameters of the players (Table 2) showed mean height of A group significantly higher than B group. Mean Flexibility score measured by Sit and reach test was found higher for Judo B group compared to Judo A group and the difference was statistically significant (p Englishhttp://ijcrr.com/abstract.php?article_id=629http://ijcrr.com/article_html.php?did=6291. Poceceo E, Burtscher M. Physiological profiles of judo athletes. Institute of Sports Science - University of Innsbruck (Austria) 2005. Available at: www.ftvs.cuni.cz/pds/konference05/data/ sbornik.pdf. Access date: Dec 2006.
2. Drapsin M, Drid P, Grujic N, Trivic T. Fitness level of male competitive judo players. Journal of Combat Sports and Martial Arts 2009; vol. 1(2): 27-29.
3. McArdle WD, Katch FI, Katch VL. Essentials of Exercise Physiology. 7th Ed. Pennsylvania: Lea and Febiger Publications; 1994.
4. Katralli J, Goudar SS. Anthropometric Profile and Special Judo Fitness levels of Indian Judo Players. Asian Journal of Sports Medicine 2012; 3 (2):113-118. 5. Johnson BL, Nelson JK. Practical Measurements for Evaluation In physical Education. 3rd Ed. New Delhi: Surjeet publications; 1988.
6. Yobu A. Test measurement and evaluation. 1st Ed. Madras: Rajmohan pathippagam; 1998.
7. Balady JG, Berra AK, Golding AL, Gordon FN, Mahler AD, Myers NJ. et al. ACSM’S Guidelines for Exercise Testing and Prescription. 7th Ed. Philadelphia: Lippincott Williams and Wilkins; 2006.
8. Stephen R. Bird. Exercise physiology for health professionals.1st Ed. London: Chapman and hall; 1995
9. David K Millar. Fitness a lifetime commitment, University of North Karoline at Wilmington. 2nd Ed. New Delhi: Surjeet; 1989.
10. Azoury J. A descriptive study of Australian elite Judo players. Journal of science and medicine in sport 2002; 5 (4): 36.
11. Sertic H, Sterkowicz S, Vuleta D. Influence of latent motor abilities on performance in Judo. Kinesiology. 2009; 41(1): 76-87.
12. Moriwaki Y, Oizumi Y, Koyama Y, Saitho H, Yamauchi N, Tanaka C, et al. Fundamental physical fitness in female college judoists. The annual reports of health,tion and sport science. 2000; 19: 71-78.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524173EnglishN-0001November30HealthcareDETERMINATION OF SEX USING DRY ADULT HUMAN SACRUM- A MORPHOMETRIC STUDY
English2228Nisha YadavEnglish Kopal SainiEnglish Kalpana PatilEnglishAim: To find out similarities and differences in the metrical values of different sacral parameters in males and females and to
highlight the best parameter that could be used to study sexual dimorphism of sacrum.
Materials and methods: 140 (83 male and 57 female) adult human sacra were collected from Department of Anatomy, Government Medical College, Aurangabad, Maharashtra. The measurements included ventral straight length and maximum breath of sacrum, sacral index, maximum transverse and antero-posterior diameter and index of body of first sacral vertebra. Demarking points for these parameters were used for identification of sex of sacrum.
Results: The average values of sacrum for ventral straight length was found to be 104.7±5.94 mm in male and 92.6±6.1 mm in female, maximum breadth was 102.93±4.83 mm in male and 104.77±6.48 mm in female and sacral index was 98.44±4.69 mm in male and 113.23±5.61 mm in female. The average values of first sacral vertebra for transverse diameter was 48.48±4.21 mm
in male and 40.75±3.51 mm in female, antero-posterior diameter was 29.12±2.47 mm in male and 26.93±2 mm in female and index was 60.28±4.96 mm in male and 66.36±5.04 mm in female.
Conclusion: Sacral index was found to be the best parameter for sex determination of sacrum amongst the parameter studied. Using sacral index alone 27.71% of bones in males and 57.9% of bones in females could be identified. However not a single parameter could identify 100% of the bones.
EnglishSacrum, Sacral index, VertebraINTRODUCTION
Determination of sex is an integral part and first step in the development of the biological profile in human osteology. Sex determination is necessary to make age, ancestry and stature estimations.1 Anatomists and anthropologists since long acknowledged the importance of sacrum in identifying the sex of a deceased person. Sexual dimorphic characters of sacrum can be studied both morphologically and metrically. Sacrum is a large triangular bone forming the posterosuperior wall of the pelvic cavity, wedged between the two innominate bones. It is formed by the fusion of five sacral vertebrae and forms the caudal end of the vertebral column.2 The well known method for determination of male or female type of sacrum has always been the “Sacral Index”. The Sacral Index is calculated by the following formula: Sacral Index = Width of Sacrum x 100 / Height of Sacrum.2 The present study was undertaken to find out similarities and differences in the metrical values of different sacral parameters in males and females and also to highlight the best parameter that could be used to study sexual dimorphism of sacrum.
MATERIALS AND METHODS
The present study was performed on 140 (83 male and 57 female) adult human sacra of known sex. Sacra were dry and free from deformity and fully ossified. Sacra were obtained from Department of Anatomy, Government Medical College, Aurangabad, Maharashtra. Each sacrum was studied for different features of sexual dimorphism. The parameters were measured using sliding vernier callipers, pair of divider and steel measuring scale. The following parameters were considered:
1. Maximum length of sacrum (Ventral straight length) was measured from the midpoint of the anterosuperior margin of sacral promontory, in the midsagittal plane, to the midpoint of anteroinferior margin of the last sacral vertebra. (Photograph 1)
2. Maximum breadth of sacrum was noted at midpoint of left and right alae of sacrum. (Photograph 2)
3. Sacral index for each sacrum was calculated using formula: Sacral index = (sacral width / sacral ventral straight length) x 100
4. Maximum transverse diameter of first sacral body (T-S1) was recorded. (Photograph 3)
5. Maximum antero-posterior diameter of 1st sacral body (AP-S1) was noted. (Photograph 4)
6. Index for body of 1st sacral vertebra was calculated using formula: A-P Diameter of body of S1 / Transverse diameter of S1 x 100 For identification of Male sacrum, the demarking point (D.P.) of a particular measurement was more than 3 S.D. of mean value for female, and, for identification of Female sacrum, the D.P. of same measurement was less than 3 S.D. of mean value for male.3 Data were tabulated and statistically analyzed for mean, standard deviation, range, student t test, demarking points and percentage of identified bones.
RESULTS
DISCUSSION
Jit and Singh3 (1966) identified sex of sacrum with 100% accuracy by calculating demarking points from the observed values. They suggested for identification of Male sacrum, the D.P. of a particular measurement was more than 3 S.D. of mean value for female, and, for identification of Female sacrum, the D.P. of same measurement was less than 3 S.D. of mean value for male. In the present study, most of the values for parameters like sacral index, index of first sacral vertebra, width of sacrum were higher in female and other parameters like length of sacrum and diameters of first sacral vertebra were higher in male. The mean value of sacral index was 98.44 in males and 113.23 in females. The demarking points in males was 112.51 in females. Of the specimens studied, 27.71% of bones in males and 57.9% of bones in females were identified correctly using this parameter alone with high level of significance (P < 0.0001). Gray’s Anatomy2 (40th edition) gives the mean value of sacral index to be 105 in males and 115 in females. Mishra SR4 et al (2003) obtained mean value of sacral index to be 98.21 in males and 117.84 in females in their study conducted on 74 male and 42 female sacra. Patel MM5 et al (2005) in their study on 32 male and 32 female sacra found the mean value to be 96.25 in males and 113.25 in females. Shailaja MC6 et al (2010) in their study on 190 male and 64 female sacra showed the mean value to be 94.24 in males and 113.19 in females. On the contrary, the studies conducted by Jana7 et al (1987), Singh8 et al (1988) and Mazumdar9 S et al (2012) showed the mean value of sacral index to be on lower side in both sexes as compared to present study. Nevertheless sacral index still remains to be the best parameter for sex determination amongst the parameters studied. Other parameters studies showed low level of significance compared to sacral index. Perhaps sacral index can be used in combination with other parameters to improve the accuracy of sex determination.
CONCLUSION
The present study shows that the sacral index is the best criterion for sex determination of sacrum. Using sacral index alone 27.71% of bones in males and 57.9% of bones in females could be identified. Other parameters studied like ventral straight length, maximum breadth, diameters and index of first sacral body were less significant for sex determination of sacrum. However not a single parameter could identify 100% of the bones. Hence it could be concluded that for determination of sex of sacrum, maximum number of parameters should be taken into consideration to attain 100% accuracy.
ACKNOWLEDGEMENT
Authors would like to thank Department of Anatomy, Government Medical College, Aurangabad for their support and co-operation. 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.
Conflict of interest: none
Funding: none
Englishhttp://ijcrr.com/abstract.php?article_id=630http://ijcrr.com/article_html.php?did=6301. Kothapalli J, Velichety SD, Desai V, Zammer MR. Morphometric study of sexual dimorphism in adult sacra of south Indian population. Int J Bio Med Res. 2012; 3(3): 2076- 2081.
2. Standring S, editor. Gray’s Anatomy: The Anatomical basis of Clinical Practice. 40th edition. Spain: Churchill Livingstone Elsevier; 2008. p. 724-728.
3. Jit and Singh. Sexing of adult clavicles. Indian journal of medical research.1966; 54: 551-571.
4. Mishra SR, Singh PJ, Agarwal AK, Gupta RN. Identification of sex of sacrum of Agra Region. J.Anat.Soc.India. 2003; 52(2): 132-36.
5. Patel MM, Gupta BD, Singel TC. Sexing of sacrum by sacral index and Kimura’s base-wing index. J. Indian Acad Forensic Med. 2005; 27(1): 5-9.
6. Math SC, Nandyal VB., Shetty VB, Pawar JD, Raj Kumar KR. Study of sexual dimorphism in human sacrum- in North Karnataka. Indian Journal of Forensic Medicine and Pathology. 2010; 3(1): 13-19.
7. Jana TK., Koley TK., Saha SB., Basu SK. Variation and sexing of adult human sacrum. Journal of Anatomical society of India.1988; 37:2-3.
8. Singh H, Singh J, Bargotra RN. Sacral index as observed anthropometrically in the region of Jammu. Journal of Anatomical society of India.1988; 37(1).
9. Mazumdar S, Ray A, Mazumdar A, Mazumdar S, Sinha A, Vasisht S. Sexual dimorphism and regional difference in size of sacrum: A study in Eastern India. Al Ameen J Med Sci. 2012; 5(3): 298-307.
10. Davivongs V. The pelvic girdle of Australian AboriginesSex difference and sex determination. American Journal of Physical Anthropology.1963; 21: 443-455.
11. Flander LB. Univariate and multivariate methods for sexing the sacrum. Am. J.Phys.Anthrop.1978; 49: 103-110.
12. Raju PB, Singh S, Padmanabhan R. Sex determination and sacrum. Journal of Anatomical Society of India.1980; 30:13-15.
13. Arora AK, Gupta P, Mahajan S, Kapoor SS. Significance of sacral index in estimation of sex in sacra of cadavers in Punjab. J. Indian Acad Forensic Med. 2010; 32(2): 104- 107.
14. Sachdeva K, Singla RK, Kalsey G, Sharma G. Role of sa- Sachdeva K, Singla RK, Kalsey G, Sharma G. Role of sacrum in sexual dimorphism- A morphometric study. J. Indian Acad Forensic Med. 2011; 33(3): 206-210
. 15. Shree Krishna HK, Yatraj S, Vijaya Kumari. Credibility of various Indices of sacrum in identification of sex of sacrum. International Journal of Medical Toxicology and Forensic Medicine. 2013; 3(2): 58-63.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524173EnglishN-0001November30HealthcareOSTEOMA CUTIS -A CASE REPORT
English2931C. NirmalaEnglish Lakshmi S.English Dayananda S. BiligiEnglish A. R. RaghupathiEnglishCase report: We present an interesting case of Osteoma Cutis in a 70 year old women with a large plaque lesion on the scalp
and multiple nodules with discharging sinuses in the fingers of both the hands since 30 years.
Discussion: Osteoma Cutis is a rare slow growing, benign ossifying disorder characterized by deposition of bony nodules in the dermis and occurs more frequently in women. There are two types of Osteoma cutis ,Primary and Secondary. Primary Osteoma Cutis is characterized by denovo bone formation in the skin. Secondary Osteoma Cutis is more common, seen in 85% of cases, as a sequel of various disorders.
Conclusion: The final diagnosis of Osteoma Cutis cases are based on clinical features, clinical evaluation, phosphorous- calcium metabolism, skin biopsy and radiological imaging.
EnglishOsteoma cutis, Benign ossifying disorderINTRODUCTION
Osteoma Cutis is a rare benign ossifying disorder characterized by deposition of bony nodules in the dermis and occurs more frequently in women. In Osteoma Cutis, mesenchymal stem cells differentiate into bone outside the normal skeletal system(4).There are two types of Osteoma Cutis Primary and Secondary. Primary Osteoma Cutis is less common and occurs in 15% of patients and Secondary Osteoma Cutis is common and occurs in 85% of patients(1).
CASE REPORT
A 70 year old female presented with slow growing plaque like lesions over the scalp and multiple nodules over the hands of 30 years duration. The scalp lesion is seen extending into the frontal region of the face. On examination Scalp lesion measured 12 x 10 cms, solitary with irregular margins (Figure 1). The skin over the surface was eroded, underlying tissue appeared pinkish in colour. On palpation the lesion was bony hard in consistency and fixed to the underling skull bone. Margins showed multiple discharging sinuses and discharging chalky white material. Multiple tiny hard nodules measuring 0.5 – 1cm with discharging sinuses were also seen in fingers of both the hands (Figure 2). Skin biopsy from both the scalp and hand lesions was taken and subjected to histopathological examination. Microscopy on routine Haemotoxylin and Eosin staining showed presence of islands of well formed calcified lamellar bone tissue in the dermis with presence of few osteocytes (Figure 3 & Figure 4). The over lying epidermis appears unremarkable. No other underlying cutaneous pathology was observed. Various investigation of complete blood counts, Serum calcium, phosphorous, electrolytes, Liver and Renal function tests were normal. There was no history of trauma or previous cutaneous lesions. Based on the medical history, clinical and histopathological findings, diagnosis of Primary Osteoma Cutis was confirmed.
DISCUSSION
Osteoma Cutis is characterized by formation of morphologically normal bone within the dermis or in the subcutaneous tissue. In Osteoma Cutis, mesenchymal stem cells differentiate into bone outside the normal skeletal system(4). There are two types of Osteoma Cutis Primary and Secondary. Primary Osteoma Cutis is less common and seen in 15% of patients and secondary Osteoma Cutis is commoner and seen in 85% (1). Histological evaluation of the lesions on skin biopsy show lamellar bone completely calcified and inhabited by osteocytes in the deepest layer of the skin (reticular layer), the area around the nodules are less calcified and presents metaplastic areaof fibroblast to osteoblast which is confirmed on electron microscopy(1). Primary Osteoma Cutis is characterized by denovo bone formation in the skin without a known associated or pre-existing cutaneous disorder . Primary Osteoma Cutis has four different clinical variants – solitary, widespread, plaque like and multiple miliary osteomas of the face(3). Four main syndromes associated with Primary Osteoma Cutis are Albrights hereditary Osteodystrophy, Fibrodysplasia of Progressive Ossification, Osseous Progressive Heteroplasia and Plate like Osteoma Cutis(5). Albright’s Hereditary Osteodystrophy includes features of Pseudohypoparathyroidism , pseudo pseudohypoparathyroidism. Clinical features includes obesity, short stature, brachydactyly, round Facies(4). In the Genetic level, there is heterozygous inactivating germ line mutation of the GNAS gene causing abnormal expression or function of the α-subunit of the stimulatory G-protein adenyl cyclase. This results in reduced inhibitory control of cellular induction to osteoblast differentiation in ectopic sites(4) resulting in heterotrophic ossification originating in fat cells(6). Progressive osseous heteroplasia is characterized by dermal ossification of cutaneous, subcutaneous and deep connective tissues(6). Fibrodysplasia of Progressive Ossification is unique in the mechanism of bone formation is endochondral. The other three entities show more clinical overlap as they all involve intramembranous ossification that begins in dermis(4). Secondary Osteoma Cutis occurs as a sequel to multiple disorders including nevi, scleroderma, pilomatricoma, dermatomyositis, basal cells carcinoma, scars, cutaneous inflammation, trauma, calcification, fibrous proliferation and venous stasis, syringoma ,epidermoid cyst(1). In some cases transepidermal elimination of fragments of bone within the channels lined by epidermis and leading to the surface is seen. The patient in the present study presented with lesion in scalp and fingers of both hands. The most affected areas reported are the scalp, face, chest, breast, extremities and buttocks(7). Lesions do not cause pain or any other symptoms .They arise as single or multiple papules, nodules, plaques or miliary lesions. In a review of literature seven cases of non-congenital forms that had no abnormalities in calcium or phosphate metabolism were detected and no inflammatory conditions preceded the disease(8). Pathogenesis of Osteoma Cutis is still obscure. Some feel Primary Osteoma Cutis may be nevoid and may develop from embryonal nest. Where as in metaplastic osteomas, trauma and inflammation lead to damage of the tissue in course of time, some of the foci damage may become calcified, eventually ossified to masses of bone. Treatment: These patients are treated with topical application of Retinoic acid and surgical excision. Surgical excision was a simple treatment with a quick recovery, minimal scarring and no local recurrence(1).
CONCLUSION
The final diagnosis of these cases are based on clinical features,clinical evaluation,phosphorous –calcium metabolism,skin biopsy and radiological imaging.
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.
Source of Funding: Nil
Conflict of Interest: None
Englishhttp://ijcrr.com/abstract.php?article_id=631http://ijcrr.com/article_html.php?did=6311. NA Montecionos Ayariri, FX Nahas, MV Jardini Barbosa, AB Farah, J de Arimatéia Mendes, LM Ferreira. Isolated primary osteoma cutis of the head: Case report. Can J Plast Surg 2006;14(1): 33-36.
2. Osteoma cutis. Indian J Dermatol Venereol Leprol 1996;62:178-9.
3. Sethuraman G, Malhotra AK, Khaitan BK, Kumar R, Sharma VK, Kabra M, et al. Osteoma cutis in pseudohypoparathyroidism. Clin Exp Dermatol 2006;31:225-7.
4. Acquired platelike osteo ma cutis Neelam Vashi MD, Julie Chu MD, Rishi Patel MD, Dermatology online Journal 17 (10):1, 2011.
5. Bowman PH, Lesher JL Jr. Primary multiple military osteoma cutis and exogenous ochronosis Cutis 2001; 68:103.
6. Unilateral progressive osseous heteroplasia Eur J Dermatol 2009; 19 (3): 214-5
7. Boschert MT, Puckett CL. Osteoma cutis of the hand. Plast Reconstr Surg 2000; 105:1017-8.
8. Haro R, et al. Plaque-like osteoma cutis with transepidermal elimination. J Cutan Pathol 2009;36:591.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524173EnglishN-0001November30HealthcareA RARE PRESENTATION OF CARCINOMA ANAL CANAL PRESENTING WITH DISTANT AXILLARY LYMPH NODE METASTASIS
English3235P. Ravindra KumarEnglish Siva Sankar KotneEnglish P. B. Ananda RaoEnglish SurendraEnglishIntroduction: Anal carcinomas present as a locoregional disease with regional lymph node metastases. Distant vascular metastasis to liver, lung , etc. is less than 10% and distant lymphatic spread to supraclavicular, paraaortic or mediastinal lymph nodes is less than 1%. Axillary lymph node metastasis is extremely unusual in anal carcinomas and we couldn’t find any literature review.
Case Report: Here we report a 34 years old female who was diagnosed to have moderately differentiated squamous cell carcinoma of anal canal with bilateral inguinal lymph nodes. Regular general examination revealed a left axillary lymph node which on cytology showed squamous cell carcinomatous deposits. Possibility of lymphoma, second primary and contiguous lymphatic spread was ruled out on thorough examination and investigations.
Treatment Policy: In view of unusual rare presentation of carcinoma anal canal with distant solitary lymph node metastasis, the case is staged as stage IV disease. We planned as a case based planning and started with chemotherapy (neoadjuvant) followed by concurrent chemo radiotherapy and then by surgery if essential. Patient presently had good response after two cycles of neoadjuvant chemotherapy.
Conclusion: In conclusion, although local lymph nodes in anal carcinomas are common and initial sites of spread, distant metastasis to axillary lymph node is unlikely without involvement of para aortic or mediastinal or supraclavicular lymph nodes. Hence, this case is an unusual presentation of carcinoma anal canal with skipped lymph node metastasis.
EnglishAnal carcinoma, Metastatic axillary lymph node, Squamous cell carcinomaINTRODUCTION
In accordance with the American Joint Committee on Cancer (AJCC)1 and the International Union Against Cancer (UICC)2 , the anal canal can be defined as the anatomic region located between the anorectal ring, which is a palpable area corresponding to the puborectalis muscle, and the anal verge, which is visible spontaneously on clinical examination of the perineum. The dentate line subdivides the anal canal into two parts:-
(1) Leisons occurring below the true mucocutaneous junction and at the anal margin are usually well differentiated keratinizing squamous carcinomas with inguinal lymph node metastases and are called anal margin cancers
. (2) Lesions arising near or above the dentate line are generally highly anaplastic nonkeratinizing squamous carcinomas (cloacogenic, basaloid, transitional) with rapid growth characteristics demonstrating early invasion of contiguous soft tissue and early spread to regional lymph nodes and are called anal canal cancers. Anal carcinomas3,4 present as a locoregional disease with regional lymph node metastases5,6. Distant vascular metastasis to liver, lung , etc. is less than 10% and distant lymphatic spread to supraclavicular, paraaortic or mediastinal lymph nodes is less than 1%. Axillary lymph node metastasis is extremely unusual in anal carcinomas and we couldn’t find any literature review.
INITIAL PRESENTATION
We report a 35 year old female presented with complaint of right ulcerated inguinal swelling since 8 months and left inguinal swelling since 10 days. She has no other associated systemic complaints. Past history and family history did not contribute any further information. On regular general examination a left solitary axillary lymph node was found and on per rectal examination ulceroproliferative hard mass can be felt 5cm away from the anal verge. Haematological profile was within normal limits. Trucut biopsy of anal canal showed moderately differentiated squamous cell carcinoma. FNAC of right and left inguinal lymph node showed metastatic squamous cell carcinomatous deposits. FNAC was also done for left axillary lymph node which showed metastatic squamous cell carcinomatous deposit. Ultrasound abdomen is normal, no abdominal or pelvic lymph nodes can be felt. CT scan of thorax and abdomen is normal with only left axillary lymph node 1.5*1.5cm and bilateral inguinal lymph nodes present. Possibility of lymphoma is excluded by doing cytokeratin(CK) and leucocyte common antigen(LCA) which showed positivity for CK and negativity for LCA. Second primary and contiguous lymphatic spread is excluded by thorough general examination, ultrasound abdomen and CT scan of thorax and abdomen.
DIAGNOSIS
Patient was finally diagnosed as carcinoma anal canal with bilateral inguinal lymph nodes and with an solitary axillary lymph node.
TNM STAGING-cT1N3M1-STAGEIV
Treatment Policy: Carcinoma of the anal canal is a relatively rare gastrointestinal tract malignancy. The historical standard of treatment was an abdominoperineal resection7 and it has evolved over years and now chemoradiation therapy has become the treatment of choice. Nigro et al8 . demonstrated that it was possible to control disease and preserve anal sphincter function with chemoradiation9 . In view of unusual rare presentation of carcinoma anal canal with distant solitary lymph node metastasis, the case is staged as stage IV disease. We planned as a case based planning and started with chemotherapy (neoadjuvant) followed by concurrent chemo radiotherapy and then by surgery if possible. Patient presently had good response after two cycles of neoadjuvant chemotherapy.
DISCUSSION
Because of the rarity of this disease and the confusion regarding its diagnosis and treatment, little attention to anal cancer has been paid in the literature. In particular, there has been a paucity of studies after the use of chemoradiation in the primary management of anal canal cancers became widespread. Many histologic types of anal canal cancer are described, including squamous cell carcinoma, adenocarcinoma, cloacogenic or basaloid carcinoma, melanoma, leiomyosarcoma, and carcinoid tumors. Nearly 80% of anal canal tumors are squamous cell carcinomas. Cloacogenic, basaloid, or transitional tumors are considered variants of squamous cell carcinoma as they all exhibit a similar natural history, response to treatment, and prognosis. Another 10% of anal cancer tumors are adenocarcinomas. Nigro et al. demonstrated that anal carcinoma could be cured without the morbidity and functional consequences of an APR. Since their report in 1974, concurrent 5-FU and mitomycin-C has been established as the standard by several randomized trials. However, this regimen is associated with significant acute toxicity in 25–50% of patients and a mortality rate of 1–3%10,11. Anal cancers are rare tumours; however, the incidence is increasing in both men and women. Changing trends in sexual behaviour, smoking, and infection with the human papillomavirus are thought to be responsible for the increase. Patients with metastatic disease have a poor prognosis, with 5-year median overall survival rates of 10% in men and 20% in women. The standard systemic treatment of metastatic disease remains cisplatin and 5-fluorouracil.
CONCLUSION
In conclusion, although local lymph nodes in anal carcinomas are common and initial sites of spread, distant metastasis to axillary lymph node is unlikely without involvement of para aortic or mediastinal or supraclavicular lymph nodes. Hence, this case is an unusual presentation of carcinoma anal canal with skipped lymph node metastasis
Englishhttp://ijcrr.com/abstract.php?article_id=632http://ijcrr.com/article_html.php?did=6321. American Joint Committee on Cancer. AJCC cancer staging handbook. Philadelphia: Lippincott-Williams & Wilkins.
2. International Union Against Cancer. UICC TNM atlas. 7th ed. Berlin: Springer, 2010.
3. BRUCE M. BOMAN, MD, CHARLES G. MOERTEL,et al. Carcinoma of the Anal Canal A Clinical and Pathologic Study of 188 Cases Cancer 54:114-125, 1984.
4. James V. Klas, M.D.et.alMalignant Tumors of the Anal Canal The Spectrum of Disease, Treatment, and OutcomesCancer 1999;85:1686–93. © 1999 American Cancer Society.
5. Attili VSS, Rama Chandra C*, Dadhich HK, Sahoo TP, Anupama G, Bapsy PP Unusual metastasis in colorectal cancer www.indianjcancer.com/ April–June 2006 | Volume 43 | Issue 2.
6. Lookingbill DP, Spauler N, Helm KF. Cutaneous metastases in patients with metastatic carcinoma: A retrospective analysis of 4020 patients. J Am Acad Dermat 1993:29:228- 36.
7. Cortese AF. Surgical approach for treatment of epidermoid anal carcinoma. Cuncer 1975: 36: 1869- 1875.
8. Nigro ND, Vaitkevicius VK, Considine B Jr. Combined therapy for cancer of the anal canal: A preliminary report. Dis Colon Recritm 1974; 3:354.
9. NORMAN D. NIGRO MD,* H. GUNTER SEYDEL, MD,et.al Combined Preoperative Radiation and Chemotherapy for Squamous Cell Carcinoma of the Anal CanalCancer 51 : 1826-1829, 1983.
10. Arthur Hung, M.D.,et.al.Cisplatin-Based Combined Modality Therapy for Anal Carcinoma A Wider Therapeutic IndexCancer 2003;97:1195–202.© 2003 American Cancer Society.
11. Robert Glynne-Jones, MD, et,al; for the United Kingdom Coordinating Committee on Cancer Research Anal Cancer Trial Working PartyPrognostic Factors for Recurrence and Survival in Anal CancerCancer 2013;119:748-55. VC 2012 American Cancer Society
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524173EnglishN-0001November30HealthcareRETINAL AND MACULAR HEMORRHAGES IN PLASMODIUM VIVAX INFECTION: AN UNCOMMON COMPLICATION
English3638Rajalakshmi A. R.English Srikanth K.English Maithreyee V.EnglishAim: To study the association between retinal hemorrhages in Plasmodium vivax malaria infection.
Case report: A 29 - year -old male patient with fever and hepatosplenomegaly, diagnosed with Plasmodium vivax (P. vivax) malaria
infection developed sudden loss of vision in left eye during the course of illness. He was found to have retinal and macular
intra-retinal hemorrhage and was managed conservatively with serial follow up. The condition resolved spontaneously with no
residual defective vision.
Discussion: Retinal and macular hemorrhages are very rare in P. vivax infections and very few cases have been reported in
literature.
Conclusion: Recognition of this rare, yet serious and vision threatening complication in P. vivax malaria infection is emphasized
for the need to be aware of the protean manifestations of P. vivax malaria infections.
EnglishRetinal hemorrhage, Macular hemorrhage, P. vivaxINTRODUCTION
Malaria is an infective disease caused by protozoa of Plasmodium species- vivax, falciparum, ovale and malariae. Malarial retinopathy consists of retinal whitening, retinal hemorrhages, and papilledema. [1] In P. vivax malaria, retinal hemorrhages are very rare and only nine cases have been reported so far. [2-6,8,9] We herein describe a 29- year- old male with P. vivax infection who developed retinal and macular hemorrhages. This case is being reported for its rarity and the need to be aware of the protean manifestations in P. vivax malaria.
CASE REPORT
A 29 year old male was brought with complaints of high grade fever with chills for 5 days. On the fourth day of illness he had developed yellowish discoloration of the sclera; however the urine colour was normal. There was no history of altered sensorium, seizures, oliguria or bleeding manifestations. His relatives noted that he had become extremely pale during the period. On examination, he had severe pallor and icterus but no organomegaly. Soon after admission he developed hypotension and was shifted to the intensive care unit. Investigations were as follows: Hemoglobin was 4.1 g/dl, Total leucocyte count 18,500/mm3 , while platelet count was 54,000/mm3 . Serum bilirubin was 11mg/dl (indirect bilirubin 10.2 mg/ dl) with normal liver enzymes. Prothrombin time was normal. Blood urea was 95mg/dl while serum creatinine was 2 g/dl. Blood glucose and venous blood gas were normal. Peripheral blood smear was positive for Plasmodium vivax -ring form (Figure 1). He was managed in the intensive care unit with inotropes (dopamine and adrenaline) and packed red blood cell transfusions (twice). He never developed altered sensorium, oliguria or seizures. Artesunate combination therapy (intravenous artesunate with doxycycline) was administered for seven days in view of severe malaria followed by primaquine for 14 days. During the third day of intensive care unit stay, he developed ocular symptoms in the form of sudden painless diminution of vision in his left eye. His ocular examination showed a Best Corrected Visual Acuity (BCVA) 20/20 in Right Eye (RE) and 20/120 in the Left Eye (LE). Anterior segment examination was normal in both the eyes. Fundus examination of the right eye was normal and in the left eye, showed an intra- retinal hemorrhage two disc diameter away from the disc along the inferior temporal arcade and a hemorrhage involving the fovea measuring about one disc diameter (Figure 2). The patient was managed conservatively and kept under serial observation. He was shifted out of the intensive care unit on the sixth day of admission. Icterus resolved and fever subsided. Blood urea and serum creatinine normalized at discharge after 10 days. At discharge, the intra-retinal hemorrhage along the infero-temporal arcade was slightly smaller and resolving while the hemorrhage at the fovea remained the same with visual acuity of 20/120 in left eye and right eye was normal. On follow up after four weeks, there was complete resolution of the hemorrhage in the left eye and visual acuity was 20/20 (Figure 3). Optical coherence tomography at follow up was done which showed a normal retina and no residual changes (Figure 4).
DISCUSSION
Malaria is a highly prevalent disease caused by various species of Plasmodium. P. vivax and P. falciparum are the common pathogens in our part of the world with P. vivax being more common in south India. [7] Ocular complications in malaria have been reported in 10% to 20% of patients. [10] Ocular manifestations are more with P. falciparum than with other types. The severity of malarial retinopathy correlates with the mortality associated with malaria. [1] The retina is embryologically a part of the central nervous system and shares a common cellular structure and blood retina barrier which predisposes the retina and neurological structures to complications of malaria. Ocular manifestations of malarial retinopathy include retinal whitening, vessel discoloration, retinal hemorrhages and papilloedema. Retinal hemorrhages can be intra retinal white centered, similar to Roth’s spots, flame shaped and also large blot hemorrhages. Reduced blood flow and cyto-adherent erythrocytes sequestrated in microvasculature with resultant non-perfusion are hypothesized to be the cause for these retinal changes. [1] Thrombocytopenia and anaemia, as observed in our patient, also may contribute to intra-retinal hemorrhage. There is a paucity of cases of P.vivax in association with intra-retinal hemorrhages. Overall very few anecdotal reports of cases of retinal hemorrhages in P. vivax malaria have been reported so far in the literature[2-6,8,9] of which five were from India and rest four from South Korea. All the reported cases had retinal hemorrhages and six also had sub- hyaloid hemorrhage in addition. Cotton wool spot was reported in only one of the cases. In all these cases there was spontaneous resolution of the hemorrhages in 1-6 weeks and good functional recovery of vision. However 2 cases had foveal hemorrhage which lasted longer than other lesions and these patients had a decrease in visual acuity and hemotoxicity to photoreceptors was considered as a possible cause. A notable feature of our patient was that he had retinal as well as foveal haemorrhage. Inspite of this, there was complete resolution of the lesions with complete morphological and functional recovery. This case is being reported for its rarity and also to be aware of the retinal complications of P. vivax malaria by the treating physicians, since they contribute to significant morbidity. There have been only anecdotal reports of retinal hemorrhages in P. vivax malaria. Hence this ocular complication is not well recognised among Ophthalmologists. Through this report we wish to emphasise that there is a need to be aware of complications such as retinal hemorrhages even in malaria due to “seemingly benign” Plasmodium species such as P. vivax. In fact the term “benign tertiary malaria”, classically caused by P. vivax is increasingly considered a misnomer due to such serious complications associated with the condition.
CONCLUSION
The authors emphasize that although retinal manifestations are exceedingly rare in P. vivax infections, recognition of such complications would help in further delineation and expansion of the varied clinical presentations of P. vivax malaria.
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=633http://ijcrr.com/article_html.php?did=6331. Sithole HL. A review of malarial retinopathy in severe malaria. S Afr Optom 2011; 70:129-35.
2. Biswas J, Fogla R , Srinivasan P , Narayan S , Haranath K , Badrinath V . Ocular malaria. A clinical and histopathologic study. Ophthalmology 1996; 103: 1471-5.
3. Kim SM, Kim KB, Jung HJ, Kim WJ, Kim MJ, Park SC. Retinal hemorrhage in an adult with P. vivax malaria. Korean J Infect Dis 1997; 29: 323-6.
4. Chung C, Kim Y, Chung M. Retinal hemorrhage in a patient with tertian malaria. Korean J Infect Dis 1998; 30: 115.
5. Choi HJ, Lee SY, Yang H, Bang JK. Retinal haemorrhage in vivax malaria. Trans R Soc Trop Med Hyg 2004; 98: 387-9.
6. Lee JH, Chin HS, Chung MH, Moon YS Retinal hemorrhage in Plasmodium vivax malaria. Am J Trop Med Hyg. 2010; 82: 219-22.
7. Kumar A, Valecha N, Jain T, Dash AP. Burden of Malaria in India: Retrospective and Prospective View. In: Breman JG, Alilio MS, White NJ, editors. Defining and Defeating the Intolerable Burden of Malaria III: Progress and Perspectives: Supplement to Volume 77(6) of American Journal of Tropical Medicine and Hygiene. Northbrook (IL): American Society of Tropical Medicine and Hygiene; 2007 Dec. Available from: http://www.ncbi.nlm.nih.gov/books/NBK1720/
8. Sharma S, Maheshwari U, Bansal N. Retinal haemorrhage in plasmodium vivax patients-2 rare case reports. J Evolution Med Dent Sci .2012:1;929-31
9. Kochar A, Kalra P, Kochar S, Kochar SK, Kochar D. K. Retinal haemorrhage: An unusual presentation of vivax malaria. J Vector Borne Dis: 2013: 50; 321-322.
10. Hidayat AA, Nalbandian RM, Sammons DW, Fleischman JA, Johnson TE. The diagnostic histopathologic features of ocular malaria. Ophthalmology.1993; 100:1183-6.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524173EnglishN-0001November30HealthcareAN AGGRESSIVE PRESENTATION OF EXOPHYTIC MARJOLIN'S ULCER AND IMPORTANCE OF RADIOTHERAPY IN ITS TREATMENT
English3942Ravindra NandhanaEnglish Sivasankar KotneEnglish PB Anand RaoEnglish Surendra ManamEnglish SPV TurlapatiEnglishMarjolin’s ulcer is a rare squamous cell cancer that is most often associated with chronic burn wounds. Wide local excision or amputation remains the first treatment of choice. We present here a case of squamous cell carcinoma of thumb in a 39 year old female. In view of aggressive spread to regional nodes we feel the need for thorough evaluation of regional lymph nodes before
surgery and consider adjuvant concomitant chemoradiation and need to include infraclavicular (deltopectoral) lymph nodes in treatment volume in view of direct drainage of lymphatics from thumb malignancy.
EnglishChronic fistulas, Exophytic papillary carcinoma, Cell carcinomaINTRODUCTION
Marjolin’s ulcer is a malignant tumor that usually develops in a chronic skin lesion (especially burn scars in 75% cases, also include vaccination scars, venous stasis ulcers, chronic fistulas and osteomyelitis scars, etc.).(1) Pathologically most of cases are squamous cell carcinoma, few cases are basal cell carcinoma and malignant melanoma.(2) The incidence of burn scar undergoing malignant transformation has been reported to be 0.77 – 2 %.(3)Marjolin’s ulcer is of two clinical types – 1) flat, indurated, infiltrative, ulcerative carcinoma (most common) and 2) exophytic papillary carcinoma. Exophytic form is infrequent and generally less severe with low probability of metastasis. Well differentiated exophytic lesions have a better prognosis than poorly differentiated infiltrating forms. When confined to scar the growth is slow and it can be completely cured. Once it breaks free of scar it metastasizes rapidly to the regional nodes.(4)
CASE REPORT
We present here a case of marjolin’s ulcer of right thumb in a 39 year old female. She initially presented to a private practitioner with complaints of large exophytic growth on dorsal aspect of distal phalange of right thumb on a 15 year old post burn scar. She underwent amputation of thumb. Histopathology reported as well differentiated squamous cell carcinoma invading into underlying tissues (Figure 1 and 2). One month after surgery she developed axillary lymph nodes and a small ulcerated lesion at the surgical site for which she was referred to GSL Medical College, Rajahmundry Andhra Pradesh (Figure 3 and 4). In view of axillary lymph node metastasis and local recurrence, revision amputations of 1st metacarpal and axillary lymph node dissection were performed. Histopathological examination showed negative margins with squamous cell carcinomatous deposits in right axillary lymph nodes (Figure 5). By the time patient planned for adjuvant radiotherapy she developed infraclavicular swelling(Figure 6). Hence excision of right infraclavicular lymph node was done. Histopathological examination showed squamous cell carcinomatous deposits in right infraclavicular lymph nodes (Figure 7). In view of rapid progression adjuvant radiotherapy was given to right axillary, infraclavicular and supraclavicular regions. Patient is under follow-up for last 6 months without any further recurrence.
DISCUSSION
Etiology of marjolin’s ulcer is not yet clear.(5) Squamous cell carcinomas resulting from the marjolin’s ulcer have a greater tendency to metastasis than squamous cell carcinoma resulting from other causes. Poorly differentiated squamous cell carcinomas have a greater tendency to spread to lymph nodes earlier. Regional node metastasis and recurrence after surgery is not uncommon. Metastasis to regional lymph nodes is seen in 30% cases and local recurrence occurs in 17% cases.(6) Surgery (wide local excision or amputation) is remains the first treatment of choice. Marjolin’s ulcer should be excised with a 2 cm margin of normal healthy tissue (which may necessitate amputation with lesion involving joint space).(7) Sentinel lymph node biopsy is recommended in patients with squamous cell carcinoma. Lymph node block dissection should be done if nodes are clinically palpable or sentinel lymph node biopsy positive and analyzed pathologically. Prophylactic lymph node resection has not been recommended.(8) radiotherapy is not indicated because of poorly vascularized tumor tissue. Radiotherapy must be used as an adjuvant therapy only and should not replace aggressive resection. Indications of radiotherapy include 1) Inoperable lymph node metastasis, 2) high grade lesions with positive lymph nodes after regional lymph node dissection (RLND), 3) Tumor diameter greater than 10 cm, with positive lymph nodes after RLND, 4) High grade lesions, with tumor diameter greater than 10 cm and no positive lymph nodes after RLND, 5) Lesions of head and neck, with positive lymph nodes after RLND.(9)
CONCLUSION
In view of aggressive spread to regional nodes we feel the need for thorough evaluation of regional lymph nodes before surgery and consider adjuvant concomitant chemoradiation and need to include infraclavicular (deltopectoral) lymph nodes in treatment volume in view of direct drainage of lymphatics from thumb malignancy.
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=634http://ijcrr.com/article_html.php?did=634 1. Wojciech MW, Andrzej LK, et al. Two Different Cases of Marjolin’s Ulcer and Recommendations for Practice. The Open Surgical Oncology Journal, 2010; 2: 83-85.
2. Interesting Case Series, Chronic Ulcer. Correspondence: williamaboumd@hotmail.com William Abouhassan, MD, Johns Hopkins Burn Center, Johns Hopkins University, Baltimore, Md.
3. Copcu, Eray. Marjolin’s Ulcer: A Preventable Complication of Burns? Plastic & Reconstructive Surgery, July2009; 124(1): 156e-164e.
4. Aydogdu E, Yildirim S, Akoz T. Is surgery an effective and adequate treatment in advanced Marjolin’s ulcer? Burns. Jun2005; 31(4):421-31.
5. Ifeanyi IO, BismarkOkwor, Wilson IBO. Penetrating scalp Marjolin’s ulcer involving bone and dura mater in a Nigerian hospital: Case report and literature review. Burns (2009), doi:10.1016/j.burns.2009.04.010.
6. Dr A. Ero?lu, S. Çamlibel. Risk factors for locoregional recurrence of scar carcinoma British Journal of Surgery 1997; 84(12): 1744–6.
7. AbdolazimGhalambor. Marjolin ulcer: How much of safety margin needs resection along marjolin ulcer squamous cell carcinoma in recurrence cases Pak J Med Sci MayJune 2007; 23(3): 394-397.
8. Eastman AL, Erdman WA, Lindberg GM, Hunt JL, Purdue GF, Fleming JB. Sentinel lymph node biopsy identifies occult nodal metastases in patients with Marjolin’s ulcer. J Burn Care Rehabil. 2004; 25(3): 241- 245.
9. Ozek C, Cankayali R, Bilkay U, Cagdas A. Marjolin’s ulcers arising in burn scars. J Burn Care Rehabil 2001;22:384-9
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524173EnglishN-0001November30HealthcareINCREASE IN ANTIBIOTIC RESISTANCE: ARE BACTERIA GROWING WITH PAN
RESISTANCE?
English4347V. S. DeotaleEnglish Ruchita AttalEnglish P. NarangEnglishIntroduction: Pan Drug Resistant (PDR) bacteria are currently the leading cause of concern to the clinicians as they pose serious therapeutic challenges. A bacteria that is non-susceptible to all agents in all antimicrobial categories has been defined as PDR. This retrospective study has been undertaken to determine the prevalence of PDR –GNRs (Gram negative rods) and to assess the risk factors associated with that in hospitalized patients of our rural hospital.
Material & Method: A total of 1748 GNRs isolated and identified by standard phenotypic methods from various clinical specimens received in this laboratory between 1st June 2011 to 31st May 2012 from IPD patients were enrolled in this study. Antibiotic susceptibility of these isolates was done using Kirby-Bauer disk diffusion method as per CLSI guidelines. Predisposing factors for acquisition of PDR isolates were also studied.
Results: A total of 32 (1.8%) of the 1748 GNRs studied were found to be PDR and these were recovered predominantly from surgical units (31.3%). Among these 45.5% were Acinetobacter species, 24.2% Klebsiella species, 15.2% Pseudomonas aeruginosa and 12.1% E.coli. 53.1% isolates were from pus & wound swabs followed by 21.9% from tracheal swabs. Prolonged hospital stay and patients with surgical interventions were found to be important predisposing factors.
Conclusions: PDR-GNRs are originating in our rural hospital and particularly in patients with having prolonged stay in the hospital.
EnglishPAN drug, PDR-GNR, AcinetobacterINTRODUCTION
The fight between a mankind and microorganism is going on since ages. Microorganisms keep on acquiring new methods of resistance to the existing antibiotics and to cope up with these phenomenon human beings keep on discovering new antibiotics. It is constantly observed that microorganisms are slowly getting supremacy in their method of acquiring resistance and mankind is lagging behind at times with the discovery of new antibiotics and both them are trying to discover new defence to tackle with each other. Patients who are admitted in the hospital, having suppressed immune system have a greater risk of acquiring bacteria from environment of hospitals. Most of the nosocomial infections arise due to improper hand washings, improper sterilization of instruments and cross infections through patients wearing, IV stand, beddings, leading to surgical wound infections. In the hospital environment amongst many resistant bacteria, Gram negative bacilli are increasingly prevailing1-3. Amongst the Gram Negative bacilli considerable resistance are observed in Enterobacteriaceae and Nonfermenters4 .One of the common mechanism by which these Gram negative bacilli acquires resistance is via production of enzymes “betalactamases”. These betalactamases include ESBLs, AmpC & MBLs. In Indian hospitals, ESBL producing Klebsiella spp are predominant organism responsible for high morbidity. As per the definitions published in the article of Journal European Society of Clinical Microbiology and Infectious diseases 2012. Definition of MDR means “resistant to more than one antimicrobial agent” but no standardized definitions for MDR have been agreed upon yet by the medical community. XDR means: Bacteria, which are epidemiologically significant due to not only to their resistance to multiple antimicrobial agents but also to their ominous likelihood of being resistant to all. Extensively resistant Bacteria (XDR) are resistant to all but 1 or 2 classes of antibacterial agents and Pan drug resistant (PDR) means resistant to all antibiotic classes available for empirical treatment” 5 . Amongst the all Gram negative bacilli Acinetobacter, Pseudomonas and Klebsiella are the predominantly important cause of nosocomial infections due to pneumonia, bactereamia wound infections, nosocomial infections which shows PDR pattern. Globally,prevalent Pan drug resistant-Gram Negative (PDR-GNRs) are Acinetobacter, Pseudomonas & Klebsiella sp.6 The prevalence of PDR-Acinetobacter worldwide is about 0-20% of all Acinetobacter sp.infection.7, 8 In India, prevalence of MDR-GNR vary from 9-90% & PDR- GNR from 2-5%.9,10 The risk factors found to be associated with PDR –GNR infection depends on severity of the illness, admission to ICU, use of invasive interventions, duration of hospital and previous antibiotic use7,8.
MATERIAL AND METHODS:
This observational study was carried out on isolates to study the prevalence of PDR in E.coli, Klebsiella, Pseudomonas & Acinetobacter species isolated from hospitalised patients and to assess the risk factors associated with these organisms from 1st June 2011 to 31st May 2012 in tertiary care rural hospital of central India. Data was collected from case records of all patients from whom PDR-GNR isolates were isolated. Details were included as date of admission, demographic information (sex and age), medical history (underlying diseases, previous use of antibiotic(s), medical devices and corticosteroids), admission to Intensive Care Unit (ICU), site of infection or colonization, laboratory data (the pathogenic organism isolated and their antibiotic susceptibility pattern), mortality, treatment and outcome. E. coli, Klebsiella, Pseudomonas & Acinetobacter isolates from the clinical samples viz: pus & wound swab, endotracheal tube secretions, urine, blood, different body fluids, catheter tips, sputum, vaginal swab, from patients admitted in hospital. Isolates were identified & confirmed by using Standard laboratory techniques,and antibiotics were tested as per CLSI guidelines. Interpretation of zone diameter was done as per CLSI guidelines.11As per the reading of antibiotics, isolate were placed into categories of MDR, XDR and PDR (MDR as: one agent in three or more antimicrobial categories, XDR: resistant to at least one agent in all but two or fewer antimicrobial, PDR: Resistant to all available antibiotics in all antimicrobial groups). Information regarding associated risk factors in patients was retrieved from patient’s Case records.
RESULTS
During the study period a total of 1,748 Gram Negative Bacilli were isolated. Amongst 1748, 1616 (92.44) were E.coli, Klebsiella, Pseudomonas and Acinetobacter while 132(7.55) were Salmonella-(3.03), Proteus-(28.03), Shigellaflexnerii-(10.60), Citrobacter-(50.75), Enterobacter-(5.30), Serratia-.(75), Vibrio cholerae –(1.51) and Gram positive positive ( ) organisms. (Table 1) 16.2% isolates were sensitive to all the antibiotics to which isolate was subjected for testing.11.1% isolates were resistant to 2 and > 2 drugs.(Table 2) 26.9% were MDR, 7.4% were XDR & 1.9% were PDR Gram negative bacilli. In E.coli 31.40% were MDR and .5% were PDR while in Klebsiella 26.3% were MDR and 2.10% were PDR. In Pseudomonas and Acinetobacter maximum resistance was seen to drugs of all the categories. In these two organisms 10.20% and 10.30% were XDR while PDR was noted in 2.30% and 6.30%. Acinetobacter showing 10.30% PDR was isolated from Pus, wound swab, tracheal swab and urine samples. PDR from blood sample was isolated from E.coli and pseudomonas .53.1% PDR& 28.3% XDR was isolated from pus and wound swab. Maximum number of MDR was isolated from urine (60%) and E.coli (31.4%). Maximum number of XDR was isolated from tracheal swabs (24.2%).
DISCUSSION
The medical community has been witnessing growing outbreaks of infections due to Gram-negative bacteria resistant to many classes of antibiotics in most countries of the world (Sharma et al., 2005; Canton et al., 2003; Hsueh et al., 2002; Landman et al., 2002). The control of nosocomial infections due to antibiotic-resistant organisms is a public health priority worldwide. It has been documented that bloodstream infection caused by Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin- resistant enterococci (VRE), extendedspectrum lactamase- producing Enterobacteriaceae, and multidrug-resistant Acinetobacter baumannii are associated significantly with mortality.Numerous papers have demonstrated that prior antimicrobial drug exposure is a strong risk factor for colonization and infection due to a drug-resistant pathogen.12 Studies have identified the risk factors for acquiring infection or colonization with PDR isolates which include the severity of the illness, admission to ICU, use of invasive interventions, duration of hospital stay before specimen collection, previous antibiotic use of especially third-generation cephalosporins, fluoroquinolones, amikacin and carbapenems and use of mechanical ventilator, central venous catheter, Foley catheter and total parenteral nutrition invasive interventions can lead to environmental contamination 13-20. However, the association between antibiotic therapy and the acquisition of antibiotic-resistant bacteria is still unclear and is often confounded by insufficient data on antibiotic usage. We could demonstrate that patients with PDR infection or colonization had a significantly longer length of hospital stay, compared to those infected or colonized with non-PDR. However, the mortality was not significantly different between the two groups. In our study, it was observed that Acinetobactor sp., Pseudomonas, E. Coli and Klebsiella were the organisms showing the resistance to many classes of antibiotics and similar pattern of resistance were observed in other studies done with similar objectives. These organisms are commonly associated with various nosocomial infections including septicaemia, pneumonia, bacteriemia, wound infections; hence, their isolation is more in majority of the studies done with the similar objectives. India currently produces at least 30% of the world’s oral & inject able antibiotics, and could rightly argue they are supporting the WHO agenda of supplying the world with affordable medicines. However, overuse of antibiotics that are excreted by the patients and find their way into hospital and community waste-water systems provides an environmental selection pressure for the emergence and persistence of multi-drug-resistant (MDR) and pandrug-resistance (PDR) bacteria. Thus, at a time when PDR-GNRs are fast becoming a global reality, both academia and pharmaceutical industry are ill equipped to respond. PDR GNRs is an emerging nosocomial pathogen especially in tertiary care settings. Risk factor for PDR-GNR acquisition includes those associated with the patients such as severity of the illness, inappropriate use of antibiotics, surgical interventions, prolonged hospitalization. The prevalence of PDR-Acinetobacter baumanii worldwide is about 0-20 percent of all A. baumannii infections. In Thailand, a report from Siriraj Hospital in Bangkok revealed the prevalence of MDR-AB to be 57.6 percentduring1996 and 1997. No PDR-AB was described during that period.14 The incidence of PDR-AB has been increasing in Maharaj Nakorn Chiang Mai Hospital. From 1998 to 2002, Acinetobacter spp. were either the fifth or sixth most common cause of nosocomial nfections at Maharaj Nakorn Chiang Mai Hospital. However, in 2003 Acinetobacter spp. had become the leading cause of nosocomial infections, followed by Pseudomonas aeruginosa, Klebsiella pneumoniae and E. coli.
CONCLUSION
In our study, the proportion of of PDR- and MDR-Acinetobacter was 6.8% and 15.3%. PDR Acinetobacter mostly isolated from pus and wound swab 7(21.9%) followed by from tracheal swab 5(15.6%). Prolonged hospital stay, surgical interventions and admission to ICU are the factors found to be associated with PDR- GNRs.To know the details regarding prior antibiotic use is very essential.
Englishhttp://ijcrr.com/abstract.php?article_id=635http://ijcrr.com/article_html.php?did=6351. Diekema D.J.,. Pfaller M.A, Jones R. N. et al. Survey of bloodstream infections in Gram negative bacilli; frequency of occurrence and antimicrobial susceptibility of isolates collected in United States, Canada and Latin America for the SENTRY Antimicrobial Surveillance Programme, 1997. Clinical Infectious Diseases, vol.29, no.3, pp.595-607, 1999.
2. Daoud Z. and Afif C.Escherichia coli isolated from urinary tract infections of Lebanese patients between 2000-2009: epidemiology and profile of resistance Chemotherapy Research and practice, vol.2011, Article ID218431, 6pages, 2011.
3. Nass T, Cuzon G.,. Bogaerts P, Glupczynski Y., and Nordmann P. Evaluation of a DNA microarray(check-MDR CT 102) for rapid detection of TEM, SHV and CTX-M extended spectrum beta-lactamases and of KPC, OXA-48 AND VIM, IMP and NDM-1 carbapenemases. Journal of Clinical Microbiology, vol.49, no.4, pp.1608-1613, 2011.
4. Livermore D.M. and. Woodford N. The Betalactamase threat in Enterobacteriaceae, Pseudomonas and Acinetobacter. Trends in Microbiology, vol.14, no.9, pp413-420, 2006.
5. .Falagas M. E.,. Karageorgopoulos D.E. Pandrug resistance (PDR), extensive drug resistance (XDR), and multidrug resistance (MDR) among gram-negative bacilli: need for international harmonization in terminology. Clin Infect Dis ; vol 46: pp.1121–1122, 2008.
6. Fawzia E. Al Otaibi* and Fatma F. Al-Hulaily Imipenemresistant Psedomonas aeruginosa: Epidemiology and susceptibility patterns at a Teaching Hospital in Riyadh, Saudi ArabiaAfrican Journal of Microbiology Research Vol. 6(7), pp. 1527-1533, 23 February, 2012.
7. Salem SE, Dahdouh E, Daoud Z. Resistance of Gram-neg- Salem SE, Dahdouh E, Daoud Z. Resistance of Gram-negative bacilli in Lebanon. ISRN Infectious diseases Volume 2013, Article ID759208, 6 pages.
8. Elham A.M. Retrospective Analysis of Neonatal Bacteremia and Antimicrobial Resistance Pattern in Neonatal Intensive Care Unit Research Journal of Medicine and Medical Sciences, 6(2): 62-68, 2011.
9. Jaykumar S, Appalaraju B Prevalence of multi and pan drug resistant Pseudomonas aeruginosa with respect to ESBL and MBL in a tertiary care hospital Indian J Pathol Microbiol 2007 Oct;50(4):922-5.
10. Sharma J, Gulati N, Chander J. Drug resistant urinary iso- Sharma J, Gulati N, Chander J. Drug resistant urinary isolates of Pseudomonas Aeruginosa and Acinetobacter species. J Global Infect Dis 2010;2:315-7.
11. Clinical and Laboratory Standard Institute. Performance standards for antimicrobial susceptibility testing: sixteenthinformational supplement. CLSI document M100-S16. Wayne, Pa: CLSI; 2006.
12. Hsueh PR, Teng LJ, Chen CY, et al. Pandrug-resistant Aci- Hsueh PR, Teng LJ, Chen CY, et al. Pandrug-resistant Acinetobacter baumannii causing nosocomial infec -tions in a university hospital, Taiwan. Emerg Infect Dis 2002;8:827- 32.
13. Corbella X, Montero A, Pujol M, et al. Emergence and rap- Corbella X, Montero A, Pujol M, et al. Emergence and rapid spread of carbapenem resistance during a large and sustained hospital outbreak of multiresist-ant Acinetobacter baumannii. J Clin Microbial 2000;38:4086-95.
14. 5. Manikal VM, Landman D, Saurina G, Oydna E, Lal H, Quale J. Endemic carbapenem-resistant Aci-netobacter species in Brooklyn, New York: citywide prevalence. Interinstitutional spread and relation to antibiotic usage. Clin Infect Dis 2000;31:101-6.
15. Kuo LC, Yu CJ, Lee LN, et al. Clinical features of pandrugresistant Acinetobacter baumannii bacteremia at a university hospital in Taiwan. J Formos Med Assoc 2003;102:601- 6.
16. Wang SH, Shengy WH, Chang YY, et al. Healthcare-asso- Wang SH, Shengy WH, Chang YY, et al. Healthcare-associated outbreak due to pan-drug resistant Acineto-bacter baumannii in a surgical intensive care unit. J Hosp Infect 2003;53:97-102.
17. Mahgoub S, Ahmed J, Glatt AE. Completely resist-ant Aci- Mahgoub S, Ahmed J, Glatt AE. Completely resist-ant Acinetobacter baumannii strains. Infect Control Hosp Epidemiol 2002;23:477-9.
18. Koeleman JG, Parlevliet GA, Dijkshoorn L, Savelkoul PH, Vandenbroucke-Grauls CM. Nosocomial outbreak of multiresistant Acinetobacter baumannii on a surgi -cal ward: epidemiology and risk factors for acquisition. J Hosp Infect 1997;37:113-23.
19. Simor AE, Lee M, Vearncombe M, et al. An outbreak due to multiresistant Acinetobacter baumannii in a burn unit: risk factors for acquisition and management. Infect Control Hosp Epidemiol 2002;23:261-7.
20. Gupta N, Yadav A, Saini S, et al. Biotyping and resisto- Gupta N, Yadav A, Saini S, et al. Biotyping and resistogram of Acinetobacter spp. in a tertiary care hospital. J Infect Dis Antimicrob Agents 2002;19: 57-61.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524173EnglishN-0001November30HealthcareUPSTREAM DETERMINANTS OF HEALTH AND BREAST CANCER SCREENING AMONG NIGERIAN WOMEN
English4853NdukaEnglish Uzoma C.EnglishMacro level variables could help determine health outcomes for Nigerian women. Screening for breast cancer is first step to early detection. The core aim of this paper is to provoke discussion about the significance of breast screening among Nigerian women and the development of breast cancer health improvement strategies by focusing on education, income and unemployment, neighborhood conditions, and transportation. Outcome of this article could influence policy-makers and healthcare providers in establishing ways to improve contemporary health situations. It could also lead to increased awareness of the fundamental circumstances affecting population’s health.
EnglishBreast cancer, Nigerian womenINTRODUCTION
Inequities in breast cancer screening could be propelled by macro level health determinants. Micro level health determinants like age, race, ethnicity, smoking, diet, and physical exercise have been linked with cancer stage (Mandelblatt et al., 1991; WHO, 2010). Socioeconomic and cultural indices have hindered breast cancer prevention and control among African-American women (Gerend & Pai, 2008). In 2012, the global estimated number of people diagnosed with breast cancer was 676, 633 with 25.5 per 100, 000 mortality rate in Sub-Saharan Africa (Mvila et al., 2013). Along the black-white divide, African-American women are, 40% more likely to die of breast cancer disease than any other group of women (CDC, 2012). However, white women had the highest rate of getting breast cancer, followed by black, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native women (CDC, 2014a). As the most female malignancy in Nigeria (Anyanwu, Egwuonwu, & Ihekwoba, 2011), death through breast cancer among Nigerian women usually presents as late stage breast cancer (Obajimi et al., 2013). Prevalence of breast cancer in Nigeria is 116 cases per 100,000 women annually (Abazie & Abimbola, 2014), and age standardized incidence of 36.3-50.2 per 100,000 in 2008 (Ajayi, Onibokun, & Soyannwo, 2013). As the second leading cause of cancer deaths among African-American women, studies have shown that this population continues to suffer excessively from this disease (Akhigbe & Omuemu, 2009; Jones & Chilton, 2002). In 2010, 73.2% Black/African American women aged 50- 74 had mammography as compared to 72.8% Whites, 69.4% American Indian/Alaska Native, 64.15 Asian women (CDC, 2014b). Azubuike & Okwuokei (2013) noted that by 2020 about 70% of new cancer cases will be recorded in developing nations like Nigeria. Due to the copying of western lifestyle in Nigeria, the peak age of breast cancer is about ten years earlier than in western countries (Azubuike & Okwuokei, 2013). Okobia, Bunker, Okonofua, & Osime (2006) suggested that Nigerian women who have acquired education above high school as well as those who are gainfully employed in skilled jobs like nursing and teaching had greater knowledge of breast cancer than those who do not have high school education and do not have professional jobs. Inadequate knowledge about symptoms of breast cancer and the various types of screening methods available have equally been reported by many studies (Akhigbe & Omuemu, 2009). Odusanya & Tayo, (2001) suggested that approximately 32% of women in Nigeria had knowledge that a lump in the breast signifies cancer, 58.5% were not aware of numerous warning signs of breast cancer, 9.8% had knowledge of the methods of detecting breast cancer, and roughly 50% were unaware that breast cancer was curable even after detection. Early detection through mammography and other screenings could lead to diminished breast cancer mortality among women (Patel et al., 2014).
Conceptual
Framework The Health Belief Model (HBM) is a good fit for preventive health behavior like breast cancer screening (Rahman, Dignan, & Shelton, 2005). Developed in the early 50s, the HBM hinges on two frameworks. First, HBM emphasizes the individual’s value on a given outcome or goal, otherwise known as value expectancy. Secondly, the HBM illustrates the individual’s estimate that an action will result into an outcome. This is also described as the decision-making (Janz & Becker, 1984). The HBM explains why people do or do not take part in a healthbased or health-related action (Janz & Becker, 1984). HBM has been used by many researchers to deal with preventive health actions, perceptions of such actions, and modification of variables (Fulton et al., 1991). Fulton, Rakowski, & Jones (1995) used HBM to identify and associate determinants of breast cancer screening such as screening cost, cues to screening, perceived susceptibility to breast cancer, socio-demographic indicators, and utilization of healthcare. Perceived susceptibility to breast cancer and threats/benefits of breast cancer screening could help the individual ascertain if transportation, education, income, neighborhood conditions pose any barrier to the prevention and control of breast cancer. For women (the individual) in Nigeria to engage or participate in breast cancer screening (the health-based behavior) for health reasons (the expected or perceived outcome), they must believe that participating in breast cancer screening will benefit their health. They must also believe that they will be capable of modifying some of the perceived barriers (education, income, neighborhood conditions, employment) to the health efficacy outcome (Rosenstock, Strecher, & Becker, 1988). Upstream determinants of health could constitute perceived barriers to breast cancer screening among Nigerian women. Inability to obtain health information from healthcare providers or lack of health literacy, income and employment status, transportation, and neighborhood conditions could all be visible barriers for women not to seek breast cancer care and screening in Nigeria.
Education
Education could be viewed in terms of health literacy. Health literacy implies the capacity to collate and collect, process and explain, digest and comprehend the basic health material, facts and figures, and services necessary to making informed health decisions (Oldach & Katz, 2014). Health education could be seen as the relationship between patient literacy levels and compliance with prescribed therapeutic regimens (Nutbeam, 2000). Austin, McNally, & Stewart (2002) suggested that limited proficiency in language could determine the use or otherwise of preventive health care by women. Obajimi et al., (2013) submitted that education was strongly associated with mammography awareness. Most Nigerian women residing in the village speak only their mothertongue and can communicate easily that way. In most cases, medical information are not translated into these multiple languages that exist in Nigeria, rarely are the medical information translated into the 3 major languages in Nigeria i.e. Igbo, Hausa, and Yoruba. This makes it herculean for women to seek breast cancer screening. Davis, Williams, Marin, & Parker (2002) recommended that poor health literacy could be associated with difficulty in comprehending both oral and written health instructions and education among cancer patients. This situation is worsened by the fact that 60% of the 40 million illiterates in Nigeria are women according to the 2006 census figures (Oyitso & Olomukoro, 2012). Two thirds of the 68, 293, 63 million women in Nigeria are illiterates. This illiteracy figures among women declines region-by-region. Knowledge of breast cancer self-examination constitutes another big problem for women in Nigeria. Makanjuola, Amoo, Ajibade, & Makinde (2013) suggested that almost 60% of women in their studies were not aware of breast cancer self-examination. Knowledge of breast cancer risk variables is poor among female healthcare professionals, excluding physicians (Ibrahim & Odusanya, 2009). Most often, healthcare workers fail to educate clients about breast cancer screening (Obajimi et al., 2013). Akhigbe & Omoemu (2009) reported that Nigerian women have very poor knowledge of symptoms and signs of breast cancer and screening methods. Uche (1999) discoursed that 33% of literate women knew that a breast lump was a warning sign of breast cancer and only 50% recognized that cancer could be cured when detected at a very early stage. Osime, Okojie, Aigbekaen, & Aigbekaen (2008) proposed that out of the 400 female civil servants enlisted in their study, 35% or 135 have heard of mammography and 7% or 27 go for annual breast cancer screening. In addition, 37.5% of the study participants were aware that family history of breast cancer is a risk factor, 59.7% knew that breast cancer could metastasize, and 6% would ignore a lump in the breast. Park et al., (2011) submitted that higher education was significantly associated with higher rate of breast cancer screening among women. Flores et al., (2013) reported that living in areas of higher numbers of high school experience was correlated with higher percentage of early stage breast cancer diagnosis and lower range of advanced-stage breast cancer.
Income and unemployment
Lantz, Beversdorf, & Remington (1995) recommended that when compared with the general population, women who have low incomes have reduced rates of breast cancer screening. Garbers et al., (2003) reported that apart from fear, inadequate information, pain, logistical barriers, and descuido, cost has been a weighing barrier to most Mexican and Dominican women who have never had mammogram. In a low-income country like Nigeria where breast cancer disease is often diagnosed at a very late stage, limited resources remains a barrier (WHO, 2014). Approximately 70% of Nigerians live below a dollar a day (Anyanwu, Egwuonwu, & Ihekwoaba, 2011). Being in a survival mood has been seen as an economic impediment to breast cancer screening among low-income populations (Kingsley, 2010). Due to financial incapacitation, breast cancer screening is not often embarked upon by most women in Nigeria (Okobia et al., 2006). Cunningham et al., (2013) suggested that lower socioeconomic condition and financial barriers contributes to advanced stage and poor prognosis of breast cancer disease. While various studies have identified household income as a key determinant in breast cancer screening, Park et al., (2011) concluded that household income was not significantly associated with mammogram. Chor et al., (2014) identified that women who had a monthly income of HK$30000 or above had a higher detection rate of early stage cancer than those having a monthly household income of less than HK$10000. Calle, Flanders, Thun, & Martin (1993) proffered that women below the poverty rate stand the greatest risk of underutilization of mammography. When people lose their jobs, they lose their employerprovided healthcare insurance and may not be able to make hospital visits or attend an already scheduled physician appointment (Catalano & Satariano, 1998). Female unemployment rate in Nigeria, in 2012, was 55.42% (Akande, 2014). Being unemployed is associated with psychological and non-specified physiological illness, and thus may have an impact on early breast cancer detection (Catalano, Satariano, & Ciemins, 2003). Tsunematsu, Kawasaki, Masuoka, & Kakehashi (2013) suggested that there was low rate of breast cancer screening among women with non-regular employment. Litaker & Tomolo (2007) advocated that communities or populations with high per capita income and employment rates could support access to medical services.
Neighborhood Conditions
Mostly, physical and built aspects of the social milieu impacts cancer outcomes (Hiatt & Breen, 2008). Cho et al., (2011) posited that individuals living in neighborhood with low socioeconomic indicators are prone to late stage diagnosis of breast cancer disease. Keegan et al., (2014) suggested that those women who live in areas where there is no fast-food restaurant, high traffic density were less likely to meet physical activity as recommended by the American Cancer Society. Neighborhood socioeconomic deprivation was related to increased and extended time to resolution (TTR) following an abnormal breast cancer screening (Plascak et al., 2014). Zenk, Tarlov, & Sun (2006), proposed that places with less economic endowments are associated with decreased chances of participating in breast cancer screening and increased risk of late-stage breast cancer diagnosis. Akinyemiju (2012) suggested that women who live in the cities and are classified as middle socioeconomic status households are less likely to receive mammography than women belonging to middle socioeconomic status households in rural areas. Gerend & Pai (2008) recognized that women living in disadvantaged and economically deprived areas, such as the Riverine areas of the Niger-Delta region in Nigeria, could be made to travel long distances and may have to endure long waiting times in order to be seen for breast cancer screening.
Transportation
Kim, Chukwudozie, & Calhoun (2013) suggested that there could be a relationship between distance to screening for breast cancer disease and access to care, especially for women who reside in low-income areas with little or no means of transportation. Lack of transportation constitutes a barrier to breast cancer screening (Alexandraki & Mooradian, 2010; Khaliq, Visvanathan, Landis, & Wright, 2013; Todd & Stuifbergen, 2011). Populations living about 15 minutes away from the facility for screening had no missed mammograms prior to diagnosis but those who missed their appointments lived almost twice as far from the nearest facility (Onitilo et al., 2014). Distance to mammography clinics or sites affects women living in disadvantaged locations because it is associated with breast cancer screening uptake Chukwudozie, & Calhoun, 2013; Onitilo et al., 2014 ). Travel time could be associated with breast cancer screening. Onega et al., (2011) reported that travel time was related to primary therapy but not related to stage, the size of tumor, or nodal involvement. In tandem with the above study, Celaya et al., (2010) suggested that there was no indication that travel distance to mammography was significantly impacted by stage at cancer diagnosis. Transportation could have a big impact in whether a women goes for breast cancer screening or not. Coughlin & King (2010) noted that women living in regions where less than 2% of the population had no access to a car were probably more likely to have had a Pap test in the past 3 years than women in areas where greater than or equal to 3% of the residents had no access to a car. In their study, Patel et al., (2014) reported that about 60% of participants in Nashville, 56% in Chattanooga, and 83% in Memphis stated transportation issues as a major hindrance to getting a mammogram. Jerome-D’Emilia, & Chittams (2014) iden-tified lack of transportation as a cultural element barring women from early breast cancer screening in a sample of Hispanic and white women in Southern California.
Discussion and Implications for Social Change
Increasing breast cancer awareness, screening services, and education among Nigerian women living in both the urban and rural areas is paramount. Organizing special events and parties, educational workshops, mass marketing, and the use of social media such as Facebook, LinkedIn, YouTube, and FaceTime can increase the number of people who regularly receive cancer screenings (Escoffery et al., 2014). Giving out monthly, quarterly, or annual transportation vouchers or even making free mass transportation available for women could be another good method of encouraging Nigerian women to participate in breast cancer screening (Pruthi et al., 2010). Policies could be made to target women with low-level or no education. Targeted health education could be helpful in increasing breast cancer screening awareness among rural dwellers as well as urban dwellers in Nigeria. This article could also ginger stronger government involvement through increasing health expenditure, building of small-scale specialized local or rural health facilities for breast cancer screening, and educating and training locals to manage, facilitate, and administer breast cancer screening to rural women. Knowledge of the methods and types of breast cancer screening among urban and rural Nigerian women could lead to increased social support via social media and word-of-mouth or conversational relationship. Unnecessary testing and improper treatment of breast cancer could be prevented as well.
CONCLUSION
In conclusion, various studies have shown that breast cancer screening rates in developing countries are generally very low. Understanding the various upstream determinants of health, such as income and employment status, education, neighborhood conditions, and transportation, could help minimize the growing number of breast cancer patients in the developing worlds. Challenges like fighting infectious diseases, dwindling infrastructure, and socioeconomic barriers could deter developing nations from dealing with some or all of these upstream health determinants to breast cancer screening. However, increasing healthcare budgets to target breast cancer screening could be an effective way of curtailing some of these hurdles.
ACKNOWLEDGEMENT
Authors wish to acknowledge the numerous authors whose works were referenced in this article. Furthermore, Authors would also like to extend their gratitude to International Journal of Current Research and Review (IJCRR) reviewers and editors who deemed this manuscript fit for scientific publication.
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