Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241620EnglishN2014October20TechnologyFREE AND FORCED VIBRATION ANALYSIS OF EXTRADOSED BRIDGE
English0110M. V. SardesaiEnglish A. K. DesaiEnglishCable supported structures have distinctive dynamic behaviour. Extradosed bridge, which is intermediate to Girder Bridge and cable stayed bridge, owing to its shallow cables, the structure behaviour of Extradosed Bridge differs from that of cable stayed bridge. The shallower cables add to the prestress in the deck. While there are many articles available on the design of specific extradosed bridges, very little has been published on their dynamic behaviour from a general perspective. The paper highlights the free vibration and forced vibration behaviour of the extradosed Bridge.
EnglishExtradosed bridge, Girder bridgeINTRODUCTION
The recent research has shown that a Extradosed bridge, which is intermediate to Girder Bridge and a cable stayed bridge, adds substantial prestress to the deck because of the shallow pylon, are found to be economical for spans upto 250m. Dynamic response prediction has been the matter of research for many authors, in particular as the structural design of many structures is governed by the earthquake load cases or combinations thereof. The intrados is defined as the interior curve of an arch, or in the case of cantilever-constructed girder bridge, the soffit of the girder. Similarly, the extrados is defined as the uppermost surface of the arch. The term ‘extradosed’ was coined by Jacques Mathivat (1988) to appropriately describe an innovative cabling concept he developed for the Arrêt-Darré Viaduct , in which external tendons were placed above the deck instead of within the cross-section as would be the case in a girder bridge. To differentiate these shallow external tendons, which define the uppermost surface of the bridge, from the stay cables found in a cable-stayed bridge, Mathivat called them ‘extradosed’ prestressing.
Some features of extradosed bridge as given below;
• External appearance resembles cable-stayed bridge – but structural characteristics are comparable to those of conventional girder bridge
• The Girder Depth are lesser than that of conventional girder bridges
• The stay cables (prestressing tendons outside the girder) need no tension adjustment necessary for cable-stayed bridges, and can be treated as usual tendons as in girder bridges
• The height of pylon is half as that of cable-stayed bridge and hence easier to construct
• With small stress fluctuation under live load the anchorage method for stay cables can be same as that of tendons inside girder and thereby achieve economy
The reduced cable inclination in an extradosed bridge leads to an increase in the axial load in the deck and a decrease in vertical component of force at the cable anchorages. Thus, the function of the extradosed cables is also to prestress the deck, not only to provide vertical support as in a cable-stayed bridge. Extradosed bridges are characterised by a low live load stress range in the stay cables. With the rapid increase in span length, combined trend and also trend of using high strength materials have resulted in slender structures and a concern is being raised over dynamic behavior of such structures, in case of cable supported structures it is more pronounced as this further includes vibrations of cable elements also. An accurate analysis of natural frequencies is fundamental to the solution of its dynamic responses due to seismic and wind and traffic loads.
Highlights on Static Behaviour
The basic difference between cable stayed bridge and Extradosed Bridge is its tower height. For Cable stayed bridge the span to tower height ratio is generally kept at 5, whereas for Extradosed Bridge it is 10, which means Extradosed bridges have half the tower height than cable stayed bridge. The stiffer, lower towers enable the use of the full range of effective depth of cross-section. Since the short towers act as cantilevers, effectively prestressed by the dead load of the girder acting through the cables, they require relatively little reinforcement to resist bending due to live load. Neither a flexurally stiff girder nor backstays are required in order to provide adequate system stiffness to control deformations due to live load. With short towers, larger stay cables are required, but the towers are more economical than the tall towers normally found in cable-stayed bridges. The methods of providing stiffness in cable supported structures are shown in figure 2.
SETRA (2001) published recommended allowable stress limits that cover the full range of external cables. In that document, external prestressing tendons are defined as being subjected to a stress range of up to 15 MPa under live load while stays for cable-stayed bridges are subjected to a stress range of around 100 MPa and above. Extradosed cables are characterised as being subjected to a live load stress range between 30 MPa and 100 MPa and are not sensitive to wind vibrations. These specifications resulted from a need for design recommendations for bridges that do not fall into distinct categories, and they propose design limits and approximations based on rational principles. This explains use of 0.6fu allowable stress in the Extradosed cables, which leads to material economy
Governing Equations
A) Vibration of structure When finite element is used, each stay cable is modeled as either a single truss element with an equivalent modulus or number of cable elements with the original modulus. The deck and tower are modeled as BernoulliEuler beam elements with axial forces due to prestress imparted by horizontal component of cable force due to its shallow cables. Consider a typical Extradosed bridge as shown in figure 1; let us take a small section as shown in the figure 3 below. The boundary conditions for this element can be considered as that of beam on elastic the provided by cable. Further this beam will be subjected to prestressing force due to horizontal component of cable forces, as shown in figure 3 foundation to relate effect of elastic support below;
Now, consider an element i-j of length L of a beam on an elastic foundation as shown in Figure.3 having a uniform width b and a linearly varying thickness h(x). It will be a simple matter to consider an element having a linearly varying width if the need arises. Neglecting axial deformations this beam on an elastic foundation element has two degrees of freedom per node a lateral translation and a rotation about an axis normal to the plane of the paper and thus possesses a total of four degrees of freedom. The (4x4) stiffness matrix k of the element is obtained by adding the (4x4) stiffness matrices kB, kF and kQ pertaining to the usual beam bending stiffness and foundation stiffness and stiffness due to prestressing force (Q) respectively Since, there are four end displacements or degrees of freedom a cubic variation in displacement is assumed in the form v Aa = Eq. (1) Where, A= (1 x x2 x3 ) and aT= (a1 a2 a3 a4 ) (Displacement variation within element) The four degrees of freedom corresponding to the displacements v1 , v3 and the rotations v2 v4 at the longitudi nal nodes are given by q=Ca (Nodal displacements) Eq. (2) Where qT= (v0 v1 v2 v3 ) and C is the connectivity matrix for an element ij between x=0 and x=L as given in Figure 2 From equations (Eq.1) and (Eq.2) V=AC-1q Eq. (3) If E is the Young|s modulus and I=bh(x)3 /12 is the second moment of area of the beam Cross-section about an axis normal to the plane of the paper the bending moment M in the element is given by
B) Vibration of Cables
i) With equivalent modulus
In global analysis of cable stayed / Extradosed bridges, one common practice is to model each cable as a single truss element with an equivalent modulus to allow for sag. The element stiffness matrix in local coordinates for such a cable element can be written as,
Where, Hc is chord length, Hc is the horizontal projection length, Ac is the cross-sectional area, w is the effective material modulus of elasticity, w is the weight per unit length and T is the updated cable tension of the cable. A certain cable profile has been assumed to account for the effect of cable sag. However, once the equivalent modulus has been obtained, the profile will not have a role to play in the final analysis, and hence the method cannot model transverse vibrations of the cable.
ii) With original modulus
Another approach for accounting for the transverse vibrations of cables is to model each cable by number of cables elements with the original modulus. Following the sign conventions adopted by Broughton and Ndumbara (1994), the element incremental stiffness matrix in local coordinates can be written as Where the updated element basic tension T and the element extension e along the deformed element longitudinal axis are given, respectively, by
C) Vibration of stay cables To demonstrate the abilities of various methods in predicting local cable vibrations, each stay cable was analyzed as an inclined stay cable fixed/pinned at both ends to evaluate the natural frequencies of local vibrations. It is noted however that the real situation is slightly different, as the end anchorages themselves are movable. The first symmetric and anti-symmetric in-plane transverse vibration frequencies ω in radians per second can be computed, respectively, as Where l denotes the chord length, Tθ is static cable tension, m is the cable mass per unit length.
FREE AND FORCED VIBRATION ANALYSIS
Research methodology:
To study dynamic behavior of Extradosed Bridge, 3 numbers of models with variable parameters are prepared. Basic span configuration as applicable for Extradosed span is selected to be 120, 200 and 260m main span, the side span is about 0.45 of main span. The pylon height is varied from 8 to 12 to account for the effect of varying cable inclinations. The cable inclination varies from 17 to 30 degrees. The requirement of cable area and prestressing is as per preliminary design. Box beam superstructure is adopted with solid rectangular pylon designed by working stress method. For details of model refer table-1
The dynamic response of structure for free vibrations as well as forced vibration has been studied. Software SAP2000 V14 has been verified and used in the study. Deck is modelled as Euler Bernoulli Beam and the stay cables have been modelled as single truss elements in static/ dynamic analysis.
Free Vibrations of Extradosed Bridge
With the rapid increase in span length, combined trend and also trend of using high strength materials have resulted in slender structures and a concern is being raised over dynamic behaviour of such structures, in case of cable supported structures it is more pronounced as this further includes vibrations of cable elements also. An accurate analysis of natural frequencies is fundamental to the solution of its dynamic responses due to seismic and wind and traffic loads. The modal shapes and frequencies for above listed models are presented below;
Free Vibrations of Extradosed cables
Each stay cable is analyzed as an inclined stay cable fixed & pinned at both ends to evaluate the natural frequencies of local vibrations. It is noted however that the real situation is slightly different, as the end anchorages themselves are movable. The first symmetric and antisymmetric in-plane transverse vibration frequencies are computed considering pinned and fixed end conditions. The results are summarised in fig 12 and fig 13.
By looking at the mode shapes of the stay cables, it is possible to relate these natural frequencies of the “”fixed/free end’’ cables to those obtained by analyzing the whole bridge using the finite element method. The results are shown in fig 12 & 13. Apart from those natural frequencies that are obviously outside the range under consideration, all local cable vibrations can be reflected by finite element analysis with multiple-element modelling of stay cables. In addition to those pure local vibrations of stay cables, some new frequencies are also discovered indicating strongly the existence of coupled vibration modes. Obviously, these coupled vibration modes cannot be predicted by Equations. For investigating the possibility of coupled mode of vibration the time periods for various modes of vibration are superimposed for structure and cables. Forced Vibrations of Extradosed Bridge Forced vibration is studied for selected earthquakes; the earthquakes selected were having different characteristics as given in table 1
The time history analysis for these was performed on selected models and force effects at various points were recorded
Non-Dimensionalizing of parameters
Forced vibration analysis for three earthquake time histories having different characteristics are undertaken. To compare the results all parameter have been non dimensionalised using equivalent factors as mentioned below;
Where, V & M are non dimensioning factors for shear force, bending moment. Where, r = Mass Density, g= Gravitational acceleration, A= Cross section area of component and L= Half span length of the component.
Span and pylon height are non-dimensionlalized by using parametric length. The results obtained from the time history analysis in terms of bending moment and shear forced in the structure are non-dimensionalised and superimposed and presented in Fig 14 to 18
due to vibration of the deck. Due to the infinite number of damping values and angles of inclination that a cable may take, several values can be selected to represent typical cables. It is evident that zones of large-amplitude cable vibrations do tend to change with varying angles of inclination, when the geometric nonlinearity of the cable lessens, as the angle of inclination moves towards 90. Also, the onset of these regions of large-amplitude cable vibrations required higher amplitudes of cable end excitation as the damping of the cable increases. It was considered important that the stochastic excitation or parametric excitations, which may be occur due to various reason, but the main reason being the vehicles plying on the bridge, which was to be imposed on the cables, be representative of a prototype stochastic timehistory that might be imposed on a stay by a full-scale cable structure such as an extradosed bridge. Even though an approximation, cable structures, such as telecommunications masts and cable-stayed bridges, are subject to random wind forces, which have time-histories that are very similar to random normal distribution, for the lowfrequency bandwidth under examination. An extradosed bridge or other similar structure will act as a signal filter, by filtering wind signals (or white noise signals) through its own structural characteristics. The resulting dynamic response input will be the actual response of the structure to the wind load. This filtered signal or structural response can then be used as a stochastic time-history (stochastic support excitation) for the examination of a cable’s response to that time-history. As the wind will have varying characteristics, such as wind speed and wind direction, the force acting on the structure will also have varying characteristics. These will excite the structure at different frequencies with varying amplitudes of force. DISCUSSIONS Free Vibrations: - An accurate analysis of natural frequencies and mode shapes of cable supported structures such as Extradosed Bridge is fundamental to the solution of its dynamic responses due to seismic, wind and traffic loads. Now days, from economic considerations, the stay cables are often closely spaced, with the cable lengths and tensions gradually varying from position to position. The natural frequencies of their self-vibrations are therefore rather closely spaced. This may cause boundaryinduced vibrations of the stay cables. This complicates the overall dynamic behavior of cable stayed structures. In addition to pure local vibrations of stay cables, some new frequencies are also present indicating strongly the existence of coupled vibration modes, these coupled vibration modes cannot be predicted by equations. The frequencies of cables with actual boundary conditions are expected to lie in-between those of with fixed and pinned ends. For investigating the possibility of coupled mode of vibration the time periods for various modes of vibration are superimposed for structure and cables. The intersection zone (intersection of stay cable vibrations and bridge vibrations) suggests the possibility of coupled vibrations. Forced Vibrations: - Forced vibration studies of deck and pylon of three types of bridges reaffirms following facts for extradosed bridge, 1. Magnitude of bending moment / shear force is directly proportional to the magnitude of forcing function / PGA. 2. With increase in the distance between cables sup- With increase in the distance between cables supports the shear force in deck also increases. 3. Pylon stiffness does not have any effect on the deck moments/shear. 4. With increase in the pylon height/slenderness the shear force changes its sign in the upper part of pylon. 5. It is observed that only for cable stayed bridge with harp shape cable arrangement the shear force reduces at the junction of deck It is observed that there is some relationship between Peak Ground Accelerations and the response of structure, relationship between these needs to be established by further study
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=727http://ijcrr.com/article_html.php?did=727Katsuhiko Takami and Sumio Hamada (2005); Behavior of extradosed bridge with composite Girder; ASCE / Journal of Bridge Engineering.
H. Otsuka, T. Wakasa, J. Ogata, W. Yabuki and D. Takemura (2003); Comparison of structural characteristics for different types of cable-supported prestressed concrete bridges; Structural Concrete Mar-2002.
F T K Au, Y S Cheng, Y K Cheung, D Y Zheng (2000); On determination of natural frequency and mode shapes of cable stayed bridges; Applied methametical modeling.
A K Desai, J A Desai, H S Patil (2005); Co-relationship of Seismic (EDR) & (PGA) for Cable Stayed Bridge; NMB media
Anil K Chopra. (2003), “Dynamics of Structures”. Pearson Education, Inc. Second edition 1 – 844, Singapore.
Ito M. (1991), “Cable Stayed Bridges” – Recent Developments and their Future”, Elsevier Science Publishers B.V. 1 – 356, Amsterdam.
Gimisng N. J. (1983), “Cable Supported Bridges: Concept & Design”, John Wiley & Sons, 1 – 257, New York.
Y. Hikami, N. Shiraishi, Rain-wind induced vibrations of cables in cable stayed bridges, Journal of Wind Engineering and Industrial Aerodynamics 29 (1988) 409–418.
P. Broughton, P Ndumbaro, The analysis of cable and catanary structures, Thomas Telford, London, 1994.
Konstantinos Kris Mermigas, Behaviour and Design of Extradosed Bridges, MAsc thesis.
M V Sardesai, A K Desai, Investigation into Cable-Structure Interaction For Extradosed Bridge, International Journal of Engineering Research and Applications 2013.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241620EnglishN2014October20HealthcareMORPHOMETRIC ANALYSIS OF FORAMEN MAGNUM IN ADULT HUMAN SKULLS AND CT IMAGES
English1115Arthi GanapathyEnglish Sadeesh T.English Sudha RaoEnglishAim: To provide basic osteometric data of the following diameters anteroposterior, transverse, right and left oblique, and shape of human foramen magnum in Indian skulls and CT images. A total of 100 adult human skulls from the Department of Anatomy and 100 CT Brain images taken in the Department of Radiology, Mahatma Gandhi Medical College and RI, Pondicherry were evaluated. Methodology: Maximum transverse, anteroposterior, right and left oblique diameters of foramen magnum were calculated using sliding vernier calipers to an accuracy of 0.1mm and visually assessed for foramen magnum shape classification into- oval, round, tetragonal, hexagonal and irregular. The same parameters were also evaluated in adult CT Brain images after 3D reconstruction. Results: The mean anteroposterior, transverse, right oblique and left oblique diameters in dry skulls and CT images were 3.39cm, 2.87cm, 2.90cm, 2.92cm and 3.49cm, 2.98cm, 3.04cm, 3.04cm respectively. The dimensions in CT images were significantly higher than dry skull and significantly higher in CT images of males compared to females. Commonest shape noted was oval followed by irregular and the least was round in both dry skull and CT images. Conclusion: The foramen magnum plays an important role as a landmark because of its close relationship to key structures such as the brain stem and the spinal cord. It is of particular interest in field of forensic medicine to identify fire victims and also used for intracranial surgical approaches. Size of foramen magnum has an etiological significance in herniaton of cerebellar tonsil. With such clinical significance there is paucity of literature regarding its variations in size and shape in context to different races. Hence the present study.
EnglishForamen magnum, AP- anteroposterior, TR- transverse, RO- right oblique and LO- left obliqueINTRODUCTION
Cranial morphometry is used for human studies like age estimation, stature, and ethnicity. These parameters are important for forensic investigations and anthropological examinations of unknown individuals 1, 2, 3. Foramen magnum plays an important role as a landmark in the region of skull and spine because it transmits key structures like the lower end of the medulla oblongata, meninges, vertebral arteries and the spinal accessory nerve. It is situated in the occipital bone2 . The foramen magnum in apes and in humans is formed by the fusion of the four individual parts of the occipital bone (pars squama, left and right pars lateralis, and pars basilaris)4 . Studies comparing the shape of human foramen magnum with other primates have been done earlier5 .The position of the foramen magnum in humans is unique compared to other mammals. In humans it has migrated well forward in the occipital bone from the back of the skull, to a position beneath the center mass of the skull and brain 6 . It is of particular interest for anthropology, anatomy, forensic medicine and other medical fields. Recent studies report that morphometry is a fast and efficient method for the evaluation of morphological characteristics, such as ethnicity, gender, age, genetic factors, dietary habits, and regional variations which can alter the shape and size of bone structures 1, 3. These aspects are significantly important in determining the anthropometric changes between different populations. Anatomical variations of morphology of foramen magnum are of clinical significance 7 . Dimensions of foramen magnum are of significance in field of forensic medicine to identify fire victims. This is because skull base is covered by a large mass of tissues that preserves the region of foramen magnum especially in standing position 1, 8. Hence morphometric study of foramen magnum has been done to assist in determining the ethinicity and gender when there is loss of other parts of the skeleton due to trauma, fire or severe destruction. It is also noted that the foramen magnum dimensions are specific for a particular population and becomes low when applied to populations with a large ethnic mix 9 . Size of foramen magnum has an etiological significance in cerebellar tonsil herniaton10. It has also been noted that longer antero-posterior dimension of foramen magnum permitted greater contralateral surgical exposure for condylar resection thus enhancing the feasibility of various intracranial surgical approaches11. Determining the size of foramen magnum in conditions like achondroplasia is of utmost importance to detect the risk of foramen magnum stenosis. Some authors have used the absolute dimensions of the foramen magnum as a guideline, and have found this to be helpful. In another study of patients with achondroplasia, it was found that anteroposterior and transverse measurements of the foramen magnum on computerized tomography scans aided to determine the risk factor for the need of a cervicomedullary decompression in case of foramen magnum stenosis 12. Despite such anatomical and clinical significance, there is still a lack of basic osteometric data of foramen magnum pertaining to a particular ethnic group. With the present study an attempt has been made to throw some light on the morphometry of foramen magnum in south indian population.
MATERIALS AND METHODS
100 adult human skulls of both sex (including occipital bones with intact foramen magnum) from the Department of Anatomy Mahatma Gandhi Medical College and Research Institute, Pondicherry and medical colleges in and around Pondicherry were evaluated. 100 CT Brain images taken from the Department of Radiology, Mahatma Gandhi Medical College and RI, Pondicherry were also evaluated.The fetal & children skulls, incomplete/ broken skulls were excluded. Anteroposterior, transverse, right and left oblique diameters of foramen magnum were measured using a Vernier Calliper to an accuracy of 0.1mm (figure 1). Anteroposterior diameter of foramen magnum is the distance between the opisthion(posterior border) and the basion (anterior border) in the mid sagittal plane. Transverse diameter is the maximum distance along the transverse plane. The right and left oblique diameters were measured from the midpoint of the corresponding occipital condyle to the point midway between posterior ends of opposite condyle to the opisthion. The same parameters were also evaluated in adult CT Brain images after 3D reconstruction (figure 2). All the dry bones were visually assessed to determine the shape of foramen magnum. Each foramen magnum was classified into one of the following five shapes- oval (figure 3), round (figure 4), tetragonal (figure 5), hexagonal (figure 6) and irregular.
STATISTICAL ANALYSIS
The mean and standard deviation were measured. The differences were analyzed using student’s t- test and a p value of Englishhttp://ijcrr.com/abstract.php?article_id=728http://ijcrr.com/article_html.php?did=7281. Manoel C, Prado FB, Caria PHF, Grappo FC: Morphometric analysis of foramen mangnum in Human skulls of Brazillian individuals in relation to gender.Braz.J.Morphol. Sci.,2009;26(2):104.
2. Uthman A T, Al- Rawi N H, Al- Timmimi J F: Evaluation of Foramen Magnum in gender determination using helical CT scanning. Dentomaxillofac Radio.,2012; 41(3): 197- 202. Avcl E, Kim A H, Ozturk H, Kara E: Anatomical Variations of the Foramen Magnum,Occipital Condyle and Jugular Tubercle. Turkish Neurosurgery, 2011; 21(2): 181- 90.
3. Radhakrishnan SK, Shivaraman CH, Ramakrishna A, Bhagya B: Morphometric analysis of foramen magnum for sex determination in South Indian population. NJUHS, 2012; 2:20-2.
4. Avci E, Kara E, Ozturk N C, Uluc K: Anatomical variation of the foramen magnum, occipital condyle and jugular tubercle. Turkish Neurosurgery, 2011;2(2): 181-90.
5. Luboga SA, Wood BA: Position and orientation of foramen magnum in higher primates. American Journal of Physical Antvropology, 1990;81: 67-76.
6. Kimbel WH, Rak Y: The cranial base of Australopithecus afarensis: new insights from the female skull. Phil. Trans. R. Soc. B, 2010; 365: 3365-76.
7. Tubbs RS, Greissenever CJ, Loukar M, Shoja MM, Cohen Gadol AA: Morphological analysis of the foramen magnum: an anatomical study. Neurosurgery, 2010; 66(2):385-8.
8. Ukoha U, Egwu OA, Okafor IJ, Angabolu AE, Ndukwe GU: Sexual dimorphism in the foramen magnum of Nigerian adult.Int J Biol Med Res.,2011;2(4):878-81.
9. Galdames ICS, Russo PP, Matamala DAZ, Smith RL: Sexual Dimorphism in the Foramen Magnum Dimensions. Int. J. Morphol, 2009; 27(1):21-23.
10. Milhorat TH, Nishikawa M, Kula RW, D lugaz YD: Mechanism of cerebellar tonsillar herniation in patients with Arnold Chiari Malformations as a guide to clinical management. Acta Neurochir, 2010; 152: 1117-27.
11. Chethan P, Prakash JA, Murlimanju BV, Prashanth KV: Morphological analysis and morphometry of the foramen magnum: an anatomical investigation. Turkish neurosurg, 2012; 22(4): 416-9.
12. Bagley CA, Pindrik JA, Bookland MJ,Joaquin Q: Cervicomedullary Decompression for foramen magnum stenosis in Achondroplasia.J Neurosurg, 2006; 104:166-72.
13. Gruber P, Henneberg M, Boni T, Ruhli FJ: Variability of Human foramen magnum size. The Anatomical Record, 2009; 292:1713-9.
14. Mushed KA, Emine A, Tuncer I: Morphometric evaluation of the foramen magnum and variations in its shape: a study of CT images of normal adults. Turk J Sci., 2003; 33:301- 6.
15. Edril FH, Saban V, Cimen M, Isik O: Morphometric Evaluation of the foramen magnum by CT. Ericyes Medical Journal, 2010; 32(3): 167-70.
16. Muthukumar N, Swaminathan R, Venkatesh G, Bhanumathy SP: A Morphological Analysis of Foramen Magnum region as it relates to transcondylar approach. Acta Neurochir(Wien) 2005; 147(8): 889-95.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241620EnglishN2014October20HealthcareA RARE CASE OF TAKAYASU ARTERITIS WITH SECONDARY SUBCLAVIAN STEAL SYNDROME
English1620BasavarajEnglish Shashikumar M. R.English Pradeep H. N.English Pradeep C.N.English Ismail M.EnglishTakayasu arteritis (also known as pulseless disease, aortoarteritis, and aortic arch syndrome) is a chronic, inflammatory and
occlusive vasculitis of the aorta and its primary branches as well as the pulmonary arteries. It predominantly affects young
females, particularly from India and South East Asia.Subclavian steal syndrome secondary to takayasu arteritis occurs when there is severe stenosis or occlusion in subclavian artery which usually causes symptoms of vertebrobasilar territory. A case of Takayasu arteritis with thrombosis of bilateral subclavian arteries with subclavian steal syndrome affecting right subclavian artery is being reported here.
EnglishTakayasu arteritis, Colour doppler ultrasonography, Carotid artery, Subclavian artery, ThrombosisINTRODUCTION
Takayasu arteritis (TA) is a well-known yet rare form of large-vessel, chronic, progressive, inflammatory, and occlusive vasculitis. It involves primarily aorta and its main branches as well as coronary and pulmonary arteries, causing stenosis and/or obstruction due to thrombus formation, or dilatation due to aneurysmal formation and/ or rupture of involved arteries.[1–4] It is an idiopathic inflammatory disease of the large elastic arteries occurring in the young and resulting in occlusive or ectatic changes mainly in the aorta and its immediate branches as well as the pulmonary artery and its branches. Takayasu arteritis has multivessel involvement as seen by the frequent involvement of the arch of the aorta and its major branches, usually at the points of origin from the aorta, the most frequently affected arteries being the subclavian (90%), carotid (45%), vertebral (25%), and renal (20%)[2]. Color-coded Doppler sonography can facilitate the accurate diagnosis of Takayasu arteritis by the characteristic appearance.
CASE REPORT
A 23 year old female with pain in both upper limbs, absent pulses in both upper limbs, dizziness, headache, and elevated erythrocyte sedimentation rate was examined with color Doppler imaging ,duplex Doppler imaging and Magnetic Resonance Angiography(MRA).
FINDINGS
• Longitudinal and transverse color Doppler images of both the proximal common carotid arteries demonstrated a long segment of diffuse, homogenous, circumferential thickening of vessel wall, described as the “macaroni sign” with uniform color assignment within narrowed lumen (figure 1 & 2)
• Doppler waveform of both the proximal common carotid arteries showed increased flow velocities and turbulence and spectral broadening due to luminal narrowing caused by the thickened wall. Distal part of common carotid arteries on both sides appeared normal in calibre.Internal carotid arteries on both sides revealed dampened waveforms (fig 2).
• Right vertebral artery showed reversal of flow with reduced flow velocity.(fig 5)
• Left vertebral artery was normal with mildly reduced flow velocity.
• Loss of the triphasic pattern in the right upper extremity arteries was noted.
Monophasic low flow velocities in both the upper extremity arteries due to proximal SCA occlusion and filling through the collaterals on both sides was noted.(fig 3) MRA of neck revealed complete non visualization of both subclavian from its origin on right side and just distal to its origin on left side with soft tissue signal intensities filling and occluding both lumen indicating complete thrombotic occlusion of both subclavian arteries.(fig 6)
DISCUSSION
TAKAYASU’S ARTERITIS
Takayasu arteritis is a chronic vasculitis of the aorta and its primary branches[1]. It predominantly affects young females, particularly from India and South East Asia. In the past, depending on some clinical manifestations,it was termed pulseless disease (Takayasu disease),aortic arch syndrome or atypical coarctation of the aorta, stenosing or constricting aortitis, and primaryarteritis[2]. Aortoarteritis has multivessel involvement , as seen by the frequent involvement of the arch of the aorta and its major branches, usually at the points of origin from the aorta, the most frequently affected arteries being the subclavian (90%), carotid (45%), vertebral (25%), and renal (20%)[2]. In 1990, aortoarteritis was defined and classified by the American College of Rheumatology as follows:“Takayasu’s arteritis is an idiopathic inflammatory disease of the large elastic arteries occurring in the young and resulting in occlusive or ectatic changes mainly in the aorta and its immediate branches as well as the pulmonary artery and its branches[3].” The most commonly affected artery in patients after initial diagnosis was found to be the left subclavian artery (SCA), followed by the right subclavian artery and the left common carotid artery (CCA).[3,4] In India, the female-male ratio varies from 1:1 to 3:1,[5] and the age of first appearance varies from 3 to 48 years.
PATHOLOGY
The pathology is a panarteritis characterized by mononuclear cells and occasionally giant cells, with marked intimal hyperplasia, medial and adventitial thickening, and, in the chronic form, fibrotic occlusion.Classically, the natural history of Takayasu arteritis has been described in 3 phases. The early prepulseless phase is characterized by systemic symptoms (ie, malaise, low-grade fever, weight loss, and arthralgia). It is followed by the phase of active vascular inflammation, when the clinical picture is dominated by pain localized over the affected area and the appearance of symptoms and signs of vascular insufficiency. Finally, fibrotic and stenotic lesions characterize the so-called burnout disease. However, the triphasic pattern of the disease can no longer be considered a rule, and the absence of systemic clinical features does not exclude ongoing vascular inflammation, nor does the presence of ischemic symptoms always indicate active inflammation of vessels.[6]
Sonographic Findings
Sonography is often the primary modality of investigation in a patient with signs and symptoms of aortoarteritis. Sonographic findings can be divided into the following according to the nature of the lesion,as described below[7].
Wall Thickening
This is the earliest finding in aortoarteritis and is universally seen in all patients with aortoarteritis. There is uniform thickening of the wall of the vessels involved . The earliest wall thickening is seen in the subclavian arteries, most commonly the left subclavian artery. The arch of the aorta is also involved early; however, because of difficulty in visualization of the aortic arch, the presence of aortoarteritis is inferred from assessment of the major aortic arch branches.[7,8] In Takayasu arteritis, long segments of diffuse, homogeneous, moderately echoeic circumferential vessel wall thickening are found. This is seen more commonly in the Common carotid artery in Takayasu arteritis and has been described as the “macaroni sign”. It can be distinguished from arteriosclerosis, which is more inhomogeneous.[9,10] An increase in wall thickness is associated with secondary signs such as decreased pulsatility and loss of a normal triphasic flow pattern. The involved vessels reveal loss of the triphasic pattern, with a monophasic or biphasic parvus tardus type of spectral flow pattern. This type of pattern is also seen distal to an occlusion when there is reformation of vessels by collaterals, but wall thickening associated with dampened flow suggests the diagnosis of aortoarteritis. Luminal Narrowing or Stenosis Luminal narrowing or stenosis is common in aortoarteritis because of wall thickening, which leads to a decrease in the luminal diameter. This stenosis or narrowing is commonly seen as a long segment, compared with atherosclerosis or fibromuscular dysplasia, in which the stenoses are commonly short segments.
Luminal Dilatation and Aneurysms Luminal dilatation and aneurysms are not as common as narrowing. It is suggested to be due to inadequate supportive fibrous tissue or focal intima weakness.[11] The aorta is most commonly affected, especially the thoracic and abdominal portions . Calcification Calcification is uncommon in aortoarteritis and more commonly seen in atherosclerosis. Occlusions Occlusions are seen in the later stages of the disease . Smaller vessels such as the carotid, subclavian, vertebral, and renal arteries are commonly involved. Because of the chronicity and slow progression of the disease, occlusions are commonly associated with collateral flow.[12] Pulsatility Pulsatility or compliance of the involved arteries has been found to be decreased in the pulseless stage of the disease in all cases of aortoarteritis. Changes in compliance have been known to precede the angiographic changes in vessels affected by aortoarteritis. Measurement of arterial compliance may provide indices of early vascular changes that predispose to the development of major vascular disease. Measurement of arterial stiffness could be useful in identifying the proliferative stage, the identification of which could be critical in early institution of treatment, which could prevent the further progression of the disease. Arterial compliance can be studied by various invasive and noninvasive methods.[13,14] Similar methods could be applied to the study of arterial compliance in patients with aortoarteritis.
Associated Organ Involvement
Heart Involvement of the heart is usually secondary to longstanding hypertension and ensuing congestive heart failure or left ventricular hypertrophy.[15] Congestive heart failure has been postulated to be a result of hypertension, rapidly developing pressure overload, and high levels of aldosterone and angiotensin II. Lung and Pulmonary Artery Various autopsy series have described involvement of the pulmonary arteries in aortoarteritis.[15,16] The pulmonary trunk is found to be more commonly involved compared with the intrapulmonary arteries. Cases appearing primarily as pulmonary hypertension without any involvement of the aorta have been described.[17] The differential diagnosis would include atherosclerosis, temporal arteritis, fibromuscular dysplasia, and idiopathic carotid dissection. Atherosclerosis may involve the common carotid artery ,but atherosclerotic plaque is usually more focal and asymmetric, occurs in an older patient population, and is accompanied by a normal erythrocyte sedimentation rate. In active temporal arteritis ,the erythrocyte sedimentation rate is elevated ,but the common carotid artery is not involved. Fibromuscular dysplasia affects the internal carotid artery but not the common carotid artery. Idiopathic carotid dissection typically involves only the internal carotid artery.[18] Subclavian Steal Syndrome[SSS]. Although incidence of TA associated with SSS is poorly documented in recent literature,actual occurrence of subclavian steal was more common than the associated syndrome.[19] Subclavian Steal Syndrome was generally characterized by neurologic symptoms of vertebral-basilar arterial distribution. Blood was siphoned along the vertebral artery because of low pressures distal to occlusion. The resulting steal phenomenon led to common symptoms of vertigo, syncope, and intermittent claudication of involved upper extremity. However, these symptoms alone rarely if ever resulted in permanent neurologic damage.[20] Doppler ultrasound was a noninvasive diagnostic tool currently used for diagnosis of Subclavian Steal Syndrome.[21,22] and was a good complement to angiography, still considered the gold standard. Both tools proved very helpful for diagnosis of Subclavian Steal Syndrome and Takayasu arteritis.[23]
TREATMENT
The process is progressive, and there is no definitive therapy. Glucocorticoids and immunosuppressive agents have been reported to be effective in some patients during the acute phase.[24] Surgical bypass or endovascular intervention of a critically stenotic artery may be necessary.[24]
CONCLUSION
In summary, takayasu arteritis has a characteristic set of findings at duplex sonography, and in the proper clinical setting , these findings appear to be diagnostic. Sonography of the carotid and subclavian arteries can be used to detect early Takayasu arteritis, but also to monitor disease progression and the effects of therapy. It is a quick, non-invasive technique without any radiation. The characteristic wall thickening of the carotid arteries and of the arteries of the limbs can even be evaluated by grey-scale ultrasonography whereas colour Doppler and duplex sonography are superior for other vessels and for the evaluation of flow characteristics.
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=729http://ijcrr.com/article_html.php?did=729Schmidt WA, Nerenheim A,Seipelt E, Poehls C,Gromnica-Ihle E.Diagnosis of early Takayasu arteritis with sonography. Rheumatology 2002;41:496-502.
Eagle KA, De Sanctis RW. Diseases of the aorta. In: Braunwald E (ed). Heart Disease: A Textbook of Cardiovascular Medicine. 4th ed. Philadelphia, PA: WB Saunders Co; 1992:1528–1553.
Kinare SG, Gandhi MS, Deshpande JR. Nonspecific Aortoarteritis (Pathology and Radiology). Mumbai, India: Quest Publications; 1998.
Arrend WP, Michael BA, Block DA, et al. The American College of Rheumatology 1990 criteria for the classification of Takayasu’s arteritis. Arthritis Rheum 1990; 33:1129–1134.
Padmavati S, Aurora AP, Kasliwal RR. Aortoarteritis in India. J Assoc Physicians India 1987; 35:442–444.
Nasu T. Takayasu’s truncoarteritis: pulseless disease on aortitis syndrome. Acta PatholJpn 1982; 2(suppl 1):117–131.
Nitin Chaubal, Manjiri Dighe, Mohit Shah. Sonographic and Color Doppler Findings in Aortoarteritis(Takayasu Arteritis) .J Ultrasound Med 2004; 23:937–944 Matsunaga N, Hayashi K, Sakamoto I.Takayasu’s arteritis: protean radiologic manifestations and diagnosis. Radiographics 1997; 17:579–594. Kerr G. Takayasu’s arteritis. Curr Opin Rheumatol 1994; 6:32– 38. Maeda H, Handa N, Matsumoto M, et al.Carotid lesions detected by B-mode ultrasonography in Takayasu’s arteritis: “macaroni sign” as an indicator of the disease.Ultrasound Med Biol 1991; 17:695–701. Kozuka T, Nosaki T, Sato K, Tachiiri H.Aneurysm-associated aortitis syndrome.Acta Radiol 1968; 7:314–320. Sharma S, Rajani M. Aortic occlusion in nonspecific aortoarteritis (Takayasu disease):incidence and spectrum of involvement.Australas Radiol 1993; 37:57–59. Gamble G, Zorn J, Sanders G, et al. Estimation of arterial stiffness, compliance and distensibility from M-mode ultrasound measurements of the common carotid artery. Stroke 1994; 25:11–16. Emoto M, Nishizawa Y, Kawagishi T, et al. Stiffness index of the common carotid and femoral arteries are associated with insulin resistance in NIDDM. Diabetes Care 1998; 21:1178–1182. Arora P, Shankar J, Sethi KK, et al. Congestive cardiomyopathy in nonspecific aortoarteritis. J Assoc Physicians India 1985 3:589–591. Lupi-Herrera E, Sanchez-Torres G, Horwitz S.Gutierrez FE. Pulmonary artery involvement in Takayasu’s arteritis. Chest 1975; 67:69–74. Tyagi S, Kaul UA, Gambhir DS, et al. Pulmonary artery involvement in aortoarteritis. Indian Heart J1987; 39:415–419. Bond JR, Charboneau JW, Stanson AW. Takayasu’s arteritis:carotid duplex sonographic appearance including color doppler.Radiographics 1990;10:725-727 Lacey KO. Subclavian steal syndrome: a review. J Vasc Nurs 1996; 14:1–7. Smith JM, Koury HI, Hafner CD, Welling RE. Subclavian steal syndrome. A review of 59 consecutive cases. J Cardiovasc Surg (Torino) 1994;35:11–14. Kaneko A, Ohno R, Hattori K, Furuya D, Asano Y, Yamamoto T, Kim H, Shimazu K, Hamaguchi K. Color-coded Doppler imaging of subclavian steal syndrome. Intern Med 1998;37:259–264.34. Paivansalo M, Heikkila O, Tikkakoski T, Leinonen S, Merikanto J, Suramo I. Duplex ultrasound in the subclavian steal syndrome. Acta Radiol 1998;39:183–188. Rolda´n-Valade´z E, Herna´ndez-Mart?´nez P, Osorio-Peralta S, Espinoza-Cruz V and Casia´n-Castellanos G. Imaging Diagnosis of Subclavian Steal Syndrome Secondary to Takayasu Arteritis Affecting a Left-Side Subclavian Artery;Archives of Medical Research 2003;34: 433–438. Mark A.Creager,Joseph Loscalzo (2011) ‘Diseases of the Aorta’, in Dan Longo, Anthony Fauci, Dennis Kasper, Stephen Hauser, J. Jameson, Joseph Loscalzo (ed.)Harrison’s Principles of Internal Medicine 18th ed.. Newyork: McGraw Hill, pp. 2065.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241620EnglishN2014October20HealthcareTOTAL ANTIOXIDANT ACTIVITY - A BIOMARKER IN ORAL PRECANCER PATIENTS
English2124Chitra PurohitEnglish Suman JainEnglish Jaspreet KaurEnglishWith weakened antioxidant defenses, body cells and tissues become prone to develop dysfunction and/or disease. Then, the maintainance of adequate antioxidant levels, but not overdosage, is essential to prevent or even manage a great number of disease conditions. Total antioxidant activity (TAA) could be a reliable biomarker of diagnosis and prognosis of oral precancerous lesions like oral leukoplakia (OL) and oral submucous fibrosis (OSMF), although several cautions for its use should be carefully done ( choice of appropriate method, use of other antioxidant biomarkers such as cell antioxidants, genetic antioxidant – response elements or antioxidant vitamins and use of valuable oxidative biomarkers ). TAA could be useful to evaluate nutritional interventions with antioxidant – rich foods on disease risk and prevention. The present study was thus undertaken and an attempt was made to correlate the serum levels of lipid peroxidation, assessed by thio barbituric acid reactive substances (TBARS) and total antioxidant activity (TAA) in relation to oral precancer lesions. The results of this study indicate that imbalance in the redox status of oral precancer patients may be due to enhanced lipid peroxidation and compromised antioxidant defenses.
EnglishOral leukoplakia, Total antioxidant activity, Oral submucous fibrosis, Oxidative stress, Oral precancerINTRODUCTION
Exceptional advances in biomedical sciences since the past century gives opportunities to understand the molecular basis of disease that could result in new strategies for treatment and prevention of diseases. Today, more than 70 pathologies are intrinsically associated with oxidative stress and its biochemical consequences, like peroxidation of lipids (1) measured by assessing thio barbituric acid reactive substances (TBARS). OSMF is a premalignant (2) and crippling (3) condition of the oral mucosa. Leukoplakia is the most common precancerous lesion of the oral mucosa. Oral cancer is generally preceded by benign lesions or conditions that share the same etiologic factors with oral cancer and exhibit the same site-habit relationships. Individuals with oral precancer such as OSMF and leukoplakia run a 69 times higher risk to develop oral cancer compared to tobacco users who do not have precancer (4). Into the origin of these pathophysiologies, there is a mitochondrial dysfunction and subsequent imbalance between releasing of reactive oxygen and synthesis of defective antioxidant systems, resulting in oxidative stress (5). The total antioxidant activity (TAA) measures the antioxidant capacity of all antioxidants in a biological sample and not just the antioxidant capacity of a single compound. Thus measurement of lipid peroxidation product, TBARS and total antioxidant activity is valuable in oral premalignant diseases to assess oxidative burden because they reflect the bioavailability of antioxidants as well as their increased utilization to scavenge lipid peroxidation products.
MATERIALS AND METHODS
The present study was carried out in department of Biochemistry, Darshan Dental College and Hospital, Udaipur. The ethical committee of Darshan Dental College approved the study. Of the routine OPD patients reporting to department of Oral Medicine and Oral Pathology, Darshan Dental College and Hospital, Udaipur, patients suspicious of OSMF and oral leukoplakia were selected. The relevant history of each patient was recorded. Only those patients who did not have any systemic diseases and/or not received any therapy prior to study were subjected to punch biopsy from buccal mucosa. After confirmation from histopathology, they were included in the OSMF/ oral leukoplakia (OL) group. 60 age and sex matched healthy subjects without any clinically obvious oral le sions or systemic diseases were selected as the control group. The subjects for the study were grouped asGroup 1 (OSMF): 55 patients having oral submucous fibrosis. Group 2 (OL): 45 patients having oral leukoplakia. 5 ml. fasting venous blood was collected from antecubital vein of each individual into plain sterile tube. The sample was then allowed to clot at room temperature and was then centrifuged at 3000 rpm for 10 min. to separate the serum. Immediately this serum was used for estimation of lipid peroxidation as evidenced by the formation of thio barbituric acid reactive substances (TBARS) which was estimated in serum by the method of Buege and Aust, 1978 (6). The pink colored chromogen formed by the reaction of 2-thiobarbituric acid with the breakdown products of lipid peroxidation was read at 535 nm. Total antioxidant activity (TAA) was assessed by the method of Benzie and Strain, 1999 (7) in serum. At low pH, reduction of a ferric tripyridyl-triazine (Fe+3TPTZ) complex to the ferrous form can be monitored by measuring the change in absorption at 593 nm. The reaction is non-specific and therefore the change in absorbance corresponds to the combined or ‘Total’ reducing power of the electron donating antioxidants present in the reaction mixture. The results thus obtained were tabulated and analyzed using student’s unpaired ‘t’ test. RESULTS The personal profiles and clinical parameters of all the subjects under study are shown in Table-1. In the present study, the levels of TBARS and TAA were compared between the control group and OSMF group and also between the control group and OL group. Comparison among control and OSMF group showed a statistically significant increased levels (p < 0.001) of TBARS and decreased levels (p < 0.001) of TAA among OSMF group (Table -2). Similar significant increased levels (p < 0.001) of TBARS and decreased levels (p < 0.001) of TAA among OL group (Table -3).
DISCUSSION
In the present study, mean serum levels of TBARS and TAA were compared between control and OSMF group and between control and OL group. The mean level of TBARS was increased in the OSMF group (Table -2) and OL (Table -3) compared to control . The statistical evaluation by using student’s ‘t’ test , showed that the difference in levels of TBARS between control and OSMF group and also between control and OL group was statistically significant ( p < 0.001 ) . These findings were similar to Gupta et al (8) and Metkari et al (9) who also reported similar significant increase in the lipid peroxidation in OSMF cases as compared to controls. It is established that lipid peroxidation increases with severity of the disease reflecting the extent of tissue injury. The increase in lipid peroxidation product in OSMF and OL as compared to control group may be due to poor antioxidant system, excessive free radical formation due to various tissue abuse habits and decomposition of PUFA present in membrane (9, 10). TAA was found to be significantly decreased in case of oral precancer (both OSMF and OL) patients. Positive correlation between low plasma antioxidant level and tumour burden have been reported by Subapriya et al (10). Functional compromise of antioxidant defense mechanisms has been documented in a wide variety of malignancies (11, 12). Malignant cells may sequester antioxidants from the circulation to supply the demands of a growing tumour (13). The increase in blood lipid peroxides and decrease in TAA seen in oral precancer patients , place these patients in a high – risk category. Thus, determination of TAA and lipid peroxidation may be useful in evaluating oral precancer disease. Further studies on patho-mechanism of ROS-mediated carcinogenesis and implication of protective dietary antioxidants may be beneficial for chemoprevention of oral precancer and thus oral cancer.
SUMMARY AND CONCLUSION :
It is evident from the present study that by estimation of lipid peroxidation and total antioxidant activity in circulation of oral precancer patients, the degree of oxidative damage of the disease can be assessed. Further, TAA evaluation, used with other oxidative stress and antioxidant defense biomarkers, may constitute the first step in search for a healthy oral status. The treatment plan can be improved by correcting the underlying deficiency of antioxidants. It might help for successful management of this condition, thereby arresting it in early stages and avoiding the possible consequences of oral precancer and oral cancer.
ACKNOWLEDGEMENT
Authors sincerely thank Darshan Dental College and Hospital, Udaipur for extending all the facilities for conducting the work. Authors acknowledge the immense help received from the scholars whose articles are cited & included in reference 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=730http://ijcrr.com/article_html.php?did=7301. Ferrari CKB. Oxidative stress pathophysiology: Searching for an effective antioxidant protection. Int Med J. 2001; 8:175-184.
2. Pindborg JJ. Oral submucous fibrosis as a precancerous condition. J Dent Res. 1966; 45: 546-53.
3. Dave RP. Oral submucous fibrosis. A clinical and etiological study. J Indian Dent Assoc. 1987; 59: 46-51.
4. Melrose RJ. Premalignant oral mucosal diseases. J Calif Dent Assoc. 2001; 29: 593-600.
5. Kusano C, Ferrari B. Total Antioxidant capacity : a biomarker in biomedical and nutritional studies. J of Cell and Mol Biol. 2008; 7: 1-15.
6. Buege JA, Aust SD. The Thiobarbituric Acid assay methods. Enzymol. 1978; 52: 306.
7. Benzie I, Strain JJ. Ferric reducing/ antioxidant power (FRAP) assay. Methods in enzymology (oxidation stress). 1999; 299: 15-27.
8. Gupta S, Reddy MV, Harinath BC. Role of oxidative stress and antioxidants in aetiopathogenesis and management of oral submucous fibrosis. Ind J Clin Biochem. 2004; 19: 138-141.
9. Metkari SB, Tupkari JV, Barpande SR. An estimation of serum malondialdehyde, superoxide dismutase and vitamin A in oral submucous fibrosis and its clinicopathologic correlation. J oral Maxillofac Pathol. 2007; 11: 23-7.
10. Subapriya R, Kumaraguruparan R, Nagini S. Oxidant-Antioxidant Status in Oral Precancer and Oral Cancer Patients. Toxicology Mechanisms and Methods. 2003; 13: 77-81.
11. Balasenthil S, Sahoo GC, Nagini S. Circulatory lipid peroxidation and antioxidants in pharyngeal cancer patients. J Biochem Mol Biol Biophys 2000; 4: 359-362.
12. Skrzydlewska E, Stakiewicz A, Sulkowska M, Kasacka I. Antioxidant status and lipid peroxidation in colorectal cancer. J Toxicol Environ Health. 2001; 62:213-222.
13. Buzby GP, Mullen JL, Steih TP, Roasto EF. Host tumour interactions and nutrient supply. Cancer. 1980; 45:2940- 2947.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241620EnglishN2014October20HealthcareCLINICAL ASSESSMENT OF ABSENCE OF PALMARIS LONGUS IN WESTERN MAHARASHTRA REGION
English2528Deepti O. KulkarniEnglish Sonali V. KhanapurkarEnglish Deepak JoshiEnglishBackground: Palmaris Longus (PL) is a thin, tendinous superficial flexor muscle of forearm. In non-human primates, it is functionally active but considered as vestigial and showing ethnic variations in humans10. But it is commonly used in different hand and plastic surgeries 4. So clinical tests to detect the presence of tendon are found to be very useful for surgeons. Aim: The present study is done to assess the agenesis of Palmaris Longus, unilateral and bilateral by using simple clinical tests. Method: For this study, 240 medical and nursing students of 1st years(boys and girls) were assessed using standard clinical tests. Those with deformities, injuries were excluded. Result: The study showed unilateral absence in 15% and bilateral absence in 8.33%. Absence was more common on left side but not statistically significant. Absence of tendon was more common in females and found statically significant. Conclusion: the present study correlates with previous findings. Combination of all clinical tests is found to be useful to detect the absence of Palmaris Longus
EnglishVariations, Flexor, Vestigial, Tendon, EthnicallyINTRODUCTION
Palmaris Longus is a vestigial muscle which also shows ethnic variations in prevalence of its absence.It is a muscle in superficial flexor compartment of forearm and is mainly tendinous. It is weak flexor of wrist and tensor of Palmar Aponeurosis.10 It is commonly used muscle in different surgeries like tendon graft, lip augmentation/ escalation4 , ptosis correction.6 Various tests are there to detect the presence of Palmaris Longus in living patients, and have been studied in different ethnic population. Its correlation with body side and sex was also studied.3 10 11 Present study is to determine the incidence of unilateral and bilateral agenesis of Palmaris Longus & its association with hand dominance and sex in western Maharashtra population.
MATERIAL AND METHOD
We examined 240 Medical & nursing students (114 males & 126 females) of 1st year, in western Maharashtra region. The average age was between 17-21 years. Those with obvious hand & wrist deformities or injuries, any history of surgery were excluded. Informed consent was taken from participants. The study was approved by ethical committee of concerned institute. Clinical tests which were done
1. Schaeffer’s test1 - opposition of thumb to little finger with flexion at wrist.
2. Thompson’s test2 - opposition of thumb over clenched fist with flexion at wrist.
3. Mishra’s 1st test7 - hyperextension of fingers at metacarpophalengeal joint with flexion of wrist.
4. Mishra’s 2nd test7 - abduction of thumb against resistance with slight palmar flexion of wrist.
5. Pushpakumar’s 2 finger sign9 - full extension of index and middle finger with opposed thumb over medial 2 fingers.
The tendon of Palmaris Longus is seen by using standard test of Schaeffer’s. if it is not visible, then other 4 tests were also done to confirm the result, also to differentiate it from tendon of Flexor Carpi Radialis. Photo: Black arrow- Palmaris Longus.
White arrow- Flexor carpi Radialis.
DISCUSSION
Long tendon of Palmaris Longus is commonly used as a graft, because of its length, diameter, and easy availability. When harvested it does not produce any deformity.3 Its identification is also useful during administration of medicine/ corticosteroids, to relieve pain in carpal tunnel syndrome or arthritis and in median nerve wrist block.8 During evolution, Palmaris Longus has become retrogressive degenerating muscle. Its position, size can be altered or may be completely absent. The tendon may be weak, which makes it difficult to identify using clinical tests. In that case USG, MRI can be used. Schaeffer’s test was 1st to be used in 1909 and considered as a standard test. But is difficult to demonstrate and perform. So combination of tests is found to be useful. As Palmaris Longus is a wrist flexor and tensor of palmar Aponeurosis, and abductor of thumb (as sends slip to abductor pollicis brevis), tests which help in wrist and finger flexion, thumb abduction and opposition help to make the tendon of Palmaris Longus prominent. Only precaution is to differentiate it from flexor carpi radialis tendon lateral to it in forearm, which is not abductor of thumb, as it ends in forearm. Some tests cannot be used, in median nerve palsy as there is loss of opposition. Schaffer & Reimann1 found absence of Palmaris Longus tendon more common on left side, while Thompson found it more common in females also. Racial variation was also found in absence of Palmaris Longus tendon like in North Americans- 24% by Troha, in Chinese- 4.6% 10
In present study, we have found unilateral absence of Palmaris Longus in 15%, while bilateral absence in 8.33%. Absence of tendon in females was found statistically significant.
CONCLUSION
According to present study, Palmaris Longus is absent in 15% unilaterally and in 8.33% bilaterally. Thus it shows ethnic variations in its absence. This correlates with previous studies in other ethnic population. This should be kept in mind when using it for surgical procedures. In present study its absence in females is found statistically significant (9.52%), but its relation with body side was not significant. These findings are different from previous studies. So its correlation with body side and sex needs more study.
ACKNOWLEDGMENT
Authors would like to acknowledge their colleagues, staff, and friends from department of Anatomy and students who participated in this study. They also acknowledge scholars whose articles are cited and included in reference, and authors, editors, publishers whose articles, journals, books from where literature is reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=731http://ijcrr.com/article_html.php?did=7311. Schaeffer JP. On the variations of the Palmaris longus muscle. Anat Rec. 1909; 3:275–8.
2. Thompson JW, McBatts J, Danforth CH. Hereditary and racial Variations in the musculus Palmaris longus. Am J Phys Anthropol 1921; 4:205–20.
3. Troha F, Baibalu G J, Kelleher J C. Frequency of Palmaris Longus tendon in North American Caucasians. Ann Plast Surg 1990; 25:477-8.
4 Davidson BA. Lip augmentation using the Palmaris longus tendon. Plast Reconstr Surg 1995;5:1108-10.
5. Ceyhan O, Mavt A. Distribution of agenesis of the Palmaris longus muscle in 12-18 years old age groups. Indian J Med Sci 1997;51:156-60.
6. Naugle TC Jr, Faust DC. Autogeneous Palmaris longus tendon as frontalis suspension material for ptosis correction in children. Am J Ophthal 1999;127:488.
7.Mishra S. Alternative tests in demonstrating the presence of Palmaris longus. Indian J Plast Surg. 2001;34:12–4.
8. Tallia AF, Cardone DA. Diagnostic and therapeutic injection of the wrist and hand region. Am Fam Physician 2003;67:745-50.
9. Pushpakumar SB, Hanson RP, Carroll S. The ‘two finger’ sign. Clinical examination of Palmaris longus (PL) tendon. Br J Plast Surg. 2004;57:184–5.
10. Sebastin SJ, Lim AY, Wong HB. Clinical assessment of absence of the Palmaris longus and its association with other anatomical anomalies: A Chinese population study. Ann Acad Med Sing 2006;35:249-53.
11. Gangata H. The clinical surface anatomy anomalies of the Palmaris longus muscle in the Black African population of Zimbabwe and a proposed new testing technique. Clin Anat. 2009 ;22(2):230-5.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241620EnglishN2014October20HealthcareSTANDARDIZATION OF CEREAL AND PSEUDOCEREAL FLOUR FOR PITTU PREPARATION
English2934Kalai R.English R. Jagan MohanEnglishThe cereal and pseudo-cereal such as raw brown rice, parboiled brown rice, Italian millet and samai were selected for pittu preparation. In the preparation of cereal and pseudo-cereal flour the moisture percentage after washing with respect to parboiled brown rice was comparatively higher moisture percentage of 11.88 % and 11.46 % after shade drying. The shade dried cereal and pseudo-cereal were powdered using plate mill. The cereal and pseudo-cereal flour obtained from the different mesh sizes was observed (BSS 30, 60, 85, 100 and >100) and BSS 60 and 85 used to prepare pittu was organoleptically evaluated. The study revealed that the sieve size BSS 60 for pittu preparation found to possess the highest overall sensory acceptability score compared to other sieve size. The standardized steaming time for cereal pittu control, raw brown rice, parboiled brown rice and samai was 20 minutes. The pittu made from Italian millet was 25 minutes.
EnglishCereal and pseudo-cereal, Raw brown rice, Parboiled brown rice, Italian millet, Samai, Sieve retention, pittuINTRODUCTION
Cereal grains are consumed as staple foods throughout the world (Khatkar et. al., 2009). India is the second largest rice producing country in the world next to China. The production alone is not enough to meet growing demand of the quality rice and its products. The newer techniques of processing are equally important to maintain quality of the milled rice and produce high quality products. In recent years, a number of processing technologies have been developed for rice milling and its products (Patil and Singh, 2008). The coarse cereals contain tough and fibrous seed coat, and the seed coat contains polyphenols, phytate and astringent components. Because of these, the food items prepared from their whole meal have low consumer appeal. Processing (dehusk and polishing) of these cereals has overcome these disadvantages and improves their overall acceptability and nutritional quality (Desikachar, 1980; Klopfenstein, 1991 and Dendy, 1995). Rice is one of the important cereals in the world and largest consumed calorie source among the food grains. With a per capita availability of 73.8 kg it meets 31% of the total caloric requirement of the population. It is commonly used as milled (white) rice produced by removing the hull and bran layer of the rough rice kernel (paddy) (Perdon et al., 2001). In India 65% of rice consumed is after parboiling. Millet is being cultivated in the temperate zones of Asia, China, East Asia and also in the tropics of the continent; India, Indochina and Malaysia. Little millet is cooked like rice and sometimes it is also milled and baked. The protein content of this grain is 7.7% (German Wikipedia; Heywood, 1978). Foxtail millet ranks second in the total world production of millets and it continues to have an important place in the field of agriculture all over the world providing approximately six million tons of food to millions of people, mainly on poor or marginal soils in the Southern Europe and in the temperate subtropical and tropical Asia (Marathee, 2003). In light of the above literature, the present study was designed “Standardization of cereal and pseudocereal flour for pittu preparation” with the following objectives:
1. To study the characteristics of selected cereal and pseudo-cereal pittu flour.
2. To develop and standardization of cereal and pseudo-cereal pittu
MATERIALS AND METHODS
MATERIALS
The raw materials selected for this study was Paddy (Var. ADT 36), Italian millet, Samai (Panicum miliare), raw milled rice and salt which were purchased from the local departmental stores.
Equipment used
Petit Balance, Top pan balance, Hot air oven, Muffle Furnace, Plate mill, Sieve, and Utensil were used for this study.
METHODS
1. Processing of cereal and pseudo-cereal flour The raw rice, raw brown rice, parboiled brown rice, Italian millet and samai were separately washed thoroughly with cold water, then drained the water and shade dried for 20 min. The shade dried cereals are powdered using plate mill. Then the flour was passed through the British Standard Sieves (BSS) of different mesh size (BSS 30, 60, 85, 100 and above BSS 100). 1.1 Moisture content of cereal and pseudo-cereal during flour preparation The raw rice, raw brown rice, parboiled brown rice, Italian millet and samai were washed thoroughly in cold water, drained the water and shade dried for 20 minutes. The initial moisture, after washing and drying was estimated. 1.2 preparation of cereal and pseudo-cereal flour in plate mill The shade dried cereals was passed through the plate mill for size reduction, adjusted to the grain ¾ size, to prevent heat damage of the grain. The milled flour was sieved through British Standard Sieves of different mesh sizes BSS 30, 60, 85, 100 and >100 The BSS 30 sieve retention flour was again passed to the plate mill adjusted to grain 2 /4 size, then sieved through BSS 30. The different mesh size sieved flour was collected. The same procedure was followed one more time. 1.3 Selection of flour for pittu The cereal flour passed through BSS 30 sieve flour, suitable for the preparation of pittu, possessed granules of bigger size and cereal flour passed through sieves BSS 100 and > BSS 100 was fine in nature. So, the BSS 30, BSS 100 and > BSS 100 sieve flour was rejected for the preparation of pittu. The BSS 60 and BSS 85 sieve retention flour used to prepare pittu was organoleptically evaluated. From this BSS 60 sieve retention flour had the highest overall acceptability score compared to BSS 85. From the evaluation, for the preparation of pittu, BSS 60 sieve retention flour was selected for the study. 1.4 Physical characteristics of pittu in different steaming time Physical characteristics such as smell, appearance, texture and chewability of control, raw brown rice, parboiled brown rice, Italian millets and samai pittu in different steaming time was observed.
STATISTICAL ANALYSIS
The data collected from the various experiments were analysed, statistically, using mean and Standard deviation (SD) was used to compare the means. The one way analyses of variance with critical difference was used compare and determine moisture content and Size reduction characteristics of cereal and pseudo-cereal during flour preparation as per the methods described by Dhamu and Ramamoorthy, (2007).
RESULTS AND DISCUSSION
PROCESSING OF CEREAL AND PSEUDO-CEREAL FLOUR
Moisture content of cereal and pseudo-cereal during flour preparation Moisture content of cereal during flour preparation is presented in Table 1. From the Table-1, the grain samples T1 - T5 ranged from a minimum of 9.60 % in control (T1 ) to a maximum of 10.90 % in (T3 ). The percentage of moisture changes after washing was found to be the maximum in T3 (11.88 %) followed by T4 (11.05 %) and T2 (10.68 %) whereas, minimum gain in moisture percentage was reported in the control (10.56 %) followed by T5 (10.60 %) compared to other cereals. The percentage of moisture content of the grain after shade drying was reported to be maximum in T3 (11.46 %) followed by T4 (10.83%) and T5 (10.30 %). The minimum value of 10.08 % was reported in control and followed by T2 (10.29 %). The statistical analysis revealed that the treatments of different cereals were highly significant with respect to percentage of moisture content. The different levels of moisture content of cereals, during cereal flour preparation, were also highly significant. Kebakile et al., (2007) reported grains with harder endosperms give higher flour yields than those with softer endosperms, the softer the grain, the more the meal was contaminated with bran; the harder the grain, the less germ was removed.
Selection of flour for pittu The BSS 60 and BSS 85 sieve retention flour used to prepare pittu was organoleptically evaluated and statistically analysed and presented in the Table-2 and Table-3. It was found that the BSS 60 sieve retention flour used to prepare pittu had the highest overall acceptability score compared to BSS 85. After the evaluation, the BSS 60 sieve retention flour was selected for the preparation of pittu in the study. The statistical analysis, namely one way analysis of variance for BSS 60 and BSS 85 flour pittu, with respect to various organoleptic characteristics such as appearance, colour, flavor, texture, taste and overall acceptability, was done. The results are furnished in Table-2 and Table-3.
Standardized steaming time for pittu
Physical characteristics of pittu in different steaming time are presented in table-4. Standardized steaming time for cereal pittu control, raw brown rice, parboiled brown rice and samai was 20 min. whereas for the Italian millet it was 25 min. Varadharaju et al., (2001) observed the cooking times of raw rice samples ranging between 22 and 25 min and those optimum parboiled samples ranging between 25.33 and 30.33 min. The increase of cooking time of the optimum parboiled rice over the raw rice was to the extent of 18 to 24%. The increase in the cooking time in the parboiled samples may be because of the low hydration capacity with temperatures above their gelatinization temperature.
SUMMARY
The selected cereal and pseudo-cereal percentage of moisture content after shade drying was higher compare to the initial moisture content of the grains. The cereal flour obtained from the mesh sizes (BSS 60 and 85) used to prepare pittu was organoleptically evaluated. From this evaluation, BSS 60 sieve retention flour used to prepare pittu had the highest overall acceptability score compared to BSS 85 sieve retention flour. Raw brown rice used to prepare pittu had a highly acceptable score when compared to control and other cereals. The statistical analysis revealed that the significant difference was observed in the texture among the treatments and organoleptic characteristics. Standardized pittu steaming time for control, raw brown rice and parboiled brown rice and samai was 20 min. The Italian millet took 25 min. It showed that the cereal containing high fibre required a longer steaming time.
CONCLUSION
The selected cereal and pseudo-cereal pittu, methods of preparation is easy and no special equipments are required for preparing the product. We can use these cereals in the place of polished, refined cereals. From the results of the study, it can be concluded that the selected cereal and pseudo-cereal are suitable for different age groups and more suitable for old age people
ACKNOWLEDGEMENT
Authors are extremely grateful to Dr. R. Jagan MOHAN, Associate professor and Head, Department of Food Product Development, Indian Institute of Crop Processing Technology, Thanjavur for his valuable and erudite guidance. Authors extend their sincere thanks to Dr. S.
Kalavathi, Principal, Rani Meyyammai College of Nursing, Annamalai University for her valuable suggestions. Authors also like to thank the Editors and Publishers of International Journal of Current Research and Review.
Englishhttp://ijcrr.com/abstract.php?article_id=732http://ijcrr.com/article_html.php?did=732Dendy, D.A.1995. Production and important of millets. In Sorghum and millets: Chemistry and Technology. Am. Assoc. Cereal Chemists, Inc. St. Paul, Minnesota, USA. p. 11-26.
Desikachar, H.S.R. 1980. Three decades of research on the processing and utilization of food grains. Journal of Food Science Technology. 17:24-32.
Dhamu, K.P and Ramamoorthy, K. 2007. Statistical methods. First edition, AGROBIOS Publishes, India. Heywood, V.H. 1978.
Blutenpflazen der welt. Based Boston – Stuttgart. Kebakile, M.M., Rooney, L.W. and Taylor, J.R.N. 2007.
Effects of hand pounding, abrasive decortications-hammer milling , roller milling and sorghum type on sorghum meal extraction and quality. Cereal Foods World. 52(3):129-137.
Khatkar, B.S., Anil Panghal. and Umed singh. 2009.
Applications of cereal in food processing. Indian Food Industry. p. 37. Klopfenstein, C.F., Leipold, H.W and Cecil, J.E. 1991.
Semi- wet milling of pearl millet for reduced goitrogenicity. Cereal chemistry. 68:177-179.
Marathee, J.P. 2003. “Advance in small millets”. In structure and characteristics of the world millet economy. Sixth Edition, Oxford and IBH Publishers, Co. Pvt., New Delhi. p. 159-178.
Patil, R.T and Singh, K.K. 2008. Innovations in rice processing. Agricultural Engineering Today. 32(4):13-15.
Perdon, A.A., Siebenmorgen, T.J., Mauromoustakos, A., Griffin, V.K and Johnson, E.R. 2001. Degree of milling effect on rice pasting properties. Cereal Chemistry.78:205–209.
Varadharaju, N., Sreenarayanan and Thayumanavan, B. 2001.
Effect of moisture content, temperature and contact time on milling and cooking qualities of rice in conduction parboiling. Journal of Food Science Technology. 38(5):509- 511.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241620EnglishN2014October20HealthcareADENOMATOID ODONTOGENIC TUMOR OF MANDIBLE MIMICKING AMELOBLASTOMA: A DIAGNOSTIC CHALLENGE
English3538K. Vinay Kumar ReddyEnglish R. MounicaEnglish Kotya Naik MalothEnglish K. SunithaEnglish Govindraj S.J.EnglishAdenomatoid odontogenic tumor is an uncommon benign Hamartomatous lesion of odontogenic origin, which affects young individuals, with female predilection and mainly occurring in second decade of life. Maxillary anterior region is most often involved, and associated with unerupted or impacted canine. We report a rare case of treated multilocular adenomatoid odontogenic tumor of posterior mandible in a 31 year old female patient.
EnglishAdenomatoid Odontogenic tumor, Hamartoma, True neoplasmINTRODUCTION
Adenomatoid odontogenic tumor (AOT) is a benign odontogenic lesion hypothesized develops from the enamel organ, dental lamina, reduced enamel epithelium or their remnants. It was first described by Dreibaldtin in 1907 as a Psuedo-adenoameloblastoma.1,2 Harbitz in 1915 reported AOT as cystic adamantoma.3 In 1948 Stafne considered it a distinct entity, but it was classified by others as a variant of ameloblastoma. The lesion is known by many names, including adenoameloblastoma, adenoameloblastic odontoma, and epithelial tumour associated with developmental cysts, ameloblastic adenomatoid tumour, adenomatoid or pseudo-adenomatous ameloblastoma, and teratomatous odontoma.4 The term AOT was proposed by Philipsen and Birn in 1969, was suggested that it is not to be regarded as a variant of ameloblastoma because of its different behaviour. In 1971 the term AOT was adopted in the initial edition of WHO histological typing of odontogenic tumors jaw cysts and allied lesions.4 WHO described the histological features of the tumor as follows: “A tumor of odontogenic epithelium with duct like structures and with varying degree of inductive changes in the connective tissue . The tumor may be partly cystic and in some cases the solid lesion may be present only as masses in the wall of a large cyst.1,2 It is generally believed that the lesion is not a neoplasm”. AOT accounts for 2.2 to 7.1 % of all odontogenic tumors and ranks for 4th or 5th among the odontogenic tumors. It is generally believed to be a hamartoma rather than a neoplasm.1,2
CASE REPORT
A 31 year old female patient presented with a chief complaint of swelling on her right lower one third of face since 1 year. Patient was asymptomatic 1 year back then she noticed a swelling on her right lower one third of face, which was initially small in size and gradually increased to present day size, with no history of pain, discharge and trauma. Patient gave a history of extraction of her lower right back tooth 3 years back. On extraoral examination a solitary diffuse swelling was seen on her right lower one third of face, which is roughly oval to dome shape, measuring about 5×4cm in size, extending anterio-posteriorly 2cm below the chin to angle of mandible, superiorly from the lower border of the mandible to inferiorly 5 cm below the lower border of mandible, surface over the swelling was smooth and skin over the swelling was stretched. On palpation it was mild tender, firm in consistency, compressible, non reducible with lo cal rise of temperature [Figure 1]. On intraoral examination buccal and lingual vestibular tenderness in relation to 45- 48 was noted with buccal vestibular obliteration in relation to 46, 47, 48 region [Figure 2]. Orthopantomograph was taken which revealed single well-defined multilocular radiolucency measuring about 6.5x6cm in size, extending anterio-posteriorly from mesial aspect of 45 to 1cm below sigmoid notch, superior-inferiorly 1.5cm above right alveolar ridge to 2cm below the lower border of the mandible with thinning of inferior border of mandible [Figure 3] CT-scan revealed a well-defined multiple radiolucent area with well-defined radiopaque border on right side of mandible with buccal and lingual cortical plate expansion [Figure 4]. Based on history, clinical and radiographic examination a provisional diagnosis of ameloblastoma on right body and ramus of mandible was given. Complete Surgical excision of the lesion was done under general anaesthesia [Figure 5]. Excised specimen was sent to histopathological examination which revealed epithelial and connective tissue components, solid nodules of epithelium arranged in the form of whorles which are cuboidal to columnar in nature. Some duct like spaces are noted with eosinophilic material and cords of the epithelium extending into the stroma. Cribriform pattern like tumor cell strands are also noted which are filled by dysplastic dentine/ amorphous eosinophilic like material. In addition connective tissue stroma showed odontogenic cell rests, proliferating blood vessels, large areas of haemorrhagic and few inflammatory cells. Bony trabeculae and surface epithelium are also noted [Figure 6: A, B]. Based on clinical, radiographic, and histopathological examination a final diagnosis of Adenomatoid Odontogenic tumour of Right body and ramus of mandible was given. Patient is under follow-up since 1 year without any recurrence [Figure 7].
DISCUSSION
Adenomatoid odontogenic tumour is a benign, noninvasive odontogenic lesion, with a predilection for the anterior maxilla (ratio of cases 2:1 relative to mandible) of young females.5 63% of AOT’s are diagnosed in the second decade of life, but in our case it was found to be in third decade of life. The maxilla is the predominant site of occurrence than mandible, and the anterior part of the jaw is more frequently involved than the posterior part.6 An unerupted tooth is most commonly associated with AOT but in our case it occurred in right posterior region of mandible and is not associated with an impacted tooth. Generally the tumors do not exceed 1–3 cm in greatest diameter, but they can be larger, as in the case reported here.7 The lesions are typically asymptomatic and growth results in cortical expansion, with displacement of adjacent teeth as in the case reported here.2 There are 3 variants of AOTs, it can occur both intraosseously and extraosseously. Intraosseous AOT may be radiographically divided into 2-types follicular / Pericoronal (73%) characterized as a well-defined unilocular radiolucent lesion surrounding the crown, and is a part of unerupted tooth, extrafollicular / (extra-coronal (24%) characterised as a well defined radiolucent lesion, but located between above, or superimposed upon the root of an erupted tooth. Minute radiopacities are frequently found within the lesion, but there are cases where the lesion has no radiopaque component as in our case.6 The extraosseous / peripheral, or gingival types of AOT (3%) are rarely detected radiographically, but there may be slight erosion of alveolar bone cortex, this lesion usually surrounds the crown of an impacted tooth.8 AOT is usually surrounded by a well-defined connective tissue capsule. It may present as a solid mass, a single large cystic space, or as a numerous small cystic spaces.3 AOT’s, accounting for approximately 3% of all odontogenic tumours, are less frequent than odontoma, cementoma, myxoma and ameloblastoma. It has been suggested that this tumor may be a hamartoma rather than a true neoplasm,9 but there is currently no evidence to resolve this dispute. For cases in which the lesion appears to surround an unerupted tooth and has no radiopaque component, dentigerous cyst may also be considered in the differential diagnosis. AOT often appears to envelop the crown as well as the root, whereas dentigerous cysts do not envelop the roots.10 The origin of AOTs is controversial. Because of its exclusive occurrence within the tooth bearing areas of jaws (most closely associates with an unerupted or impacted tooth) and its resemblance to the dental lamina, reduced enamel epithelium, enamel organ and or their remnants there is an agreement that the AOT is of odontogenic origin.1,2 The histological appearance of all variants is identical and exhibits a remarkable consistency. At low magnification most striking pattern is that of various sizes of solid nodules of columnar or cuboidal epithelial cells forming nests or rosette-like structures with minimal stromal connective tissue. Between the epithelial cells of the nodules and in the centre of the rosette-like configuration is found eosinophilic amorphous material, often described as tumour deposits. Conspicuous within the cellular areas are structures of tubular or duct-like appearance.11 A third characteristic cellular pattern consists of nodules of polyhedral, eosinophilic epithelial cells with squamous appearance and exhibiting well-defined cell boundaries and prominent intracellular bridges, islands may contain pools of amorphous amyloid-like material and globular masses of calcified material (thus the suggestion of a combination of calcifying epithelial odontogenic tumour and AOT). Another epithelial pattern has a trabecular or cribriform configuration. Ultra structurally, tumour epithelial cell types have been recognized, corresponding to the types that are evident on light microscopy.11 Immuno-histochemical studies of the lesion suggest expression of keratin and vimentin in the tumour cells at the periphery of the ductal, tubular or whorled structures. As all variants of AOT reveal an entirely benign biologic behaviour and are well encapsulated, conservative surgical enucleation or curettage has proven to be the treatment of choice.12 Recurrence has been reported in very few cases. In present case complete surgical excision was done under general anaesthesia and patient is under follow up since one year without any recurrence.
CONCLUSION
Our case report supports the general description of adenomatoid odontogenic tumor as in the previous studies except the multilocular variant mimicking ameloblastoma. So we conclude that the rarity of adenomatoid odontogenic tumor may be associated with its slowly growing pattern and symptomless behavior. Therefore, it should be distinguished from more common lesions of odontogenic origin.
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. Authors are grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=733http://ijcrr.com/article_html.php?did=7331. Bhullar RPK, Brar RS, Sandhu SV, Bansal H, Bhandari R. Mandibular adenomatoid odontogenic tumor: A Report of an unusual case. Contemporary Clinical Dentistry 2011; 2(3):230-33.
2. Batra P, Prasad S, Parkash H. Adenomatoid Odontogenic Tumor: Review and Case Report J Can Dent Assoc 2005;71(4):250-53.
3. Garg D, Palaskar S, Shetty VP and Bhushan A. Adenomatoid Odontogenic Tumor – Harmatoma or True neoplasm: A case report. Journal of Oral Science 2009; 51(1):155-59.
4. Guruprasad Y and Prabhu PR. Adenomatoid Odontogenic Tumor of the Mandible. Indian J Stomatol 2011; 2 (3):190- 92.
5. Philipsen HP, Srisuwan T, Reichart PA. Adenomatoid odontogenic tumor mimicking a periapical (radicular) cyst: a case report. Oral SurgOral Med Oral Pathol Oral Radiol Endod2002; 94(2):246–48.
6. Philipsen HP, Reichart PA. Adenomatoid Odontogenic Tumor: facts and figures. Oral Onclogy 1998; 35:125-131.
7. Philipsen HP, Reichart PA, Zhang KH, Nikai H, Yu QX. Adenomatoid odontogenic tumor: biologic profile based on 499 cases. J Oral PatholMed1991; 20(4):149–58.
8. Rick GM. Adenomatoid Odontogenic Tumor. Oral Maxillofac Surg Clin North Am 2004;16: 333-54.
9. Regezi JA, Kerr DA, Courtney RM. Odontogenic tumors: analysis of 706 cases. J Oral Surg1978; 36(10):771–78.
10. Lee JK, Lee KB, Hwang BN. Adenomatoid odontogenic tumor: a case report. J Oral Maxillofac Surg2000; 58(10):1161–64.
11. Kramer IRH, Pindborg JJ, Shear M. WHO International histological classification of tumours. Histological typing of odontogenic tumors. 2nd ed. Berlin: Springer Vering; 1992.
12. Saku T, Okabe H, Shimokawa H. Immunohistochemical demonstration of enamel proteins in odontogenic tumors. J Oral Pathol Med 1992; 21(3):113–19.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241620EnglishN2014October20HealthcareCONCEPT AND MANAGEMENT OF WAJAUL- MAFASIL (ARTHRITIS) IN GRECO ARABIC MEDICINE -AN OVERVIEW
English4147Mirza Ghufran BaigEnglish Mohd. Aleemuddin QuamriEnglish Javed Ali SEnglish Shaikh ImtiyazEnglish Mohammad SheerazEnglish Zaheer AhmedEnglishArthritis is one of the commonest joint disorder affecting millions of people worldwide with an estimated 15% (40 million) of Americans had some form of arthritis in 1995 and by the year 2020, an estimated 59.4 million will be affected. In India it affects 15% (180 million) people. Ancient Unani scholars have elaborately described inflammation and pain of joints under the caption of Waja ul Mafasil and managed with multidimensional approach, in contrast with the present day management of disease mainly with non-steroidal anti-inflammatory drugs (NSAIDs) which will be having large number of adverse effects. This review article highlight the salient features describing arthritis with reference to Waja ul Mafasil for empathizing disease condition as enunciated by Unani scholars to provide a better alternative in terms of cost effective managements and side effects.
EnglishWaja ul Mafasil, Arthritis, Joints pain, Unani medicineINTRODUCTION
Waja ul Mafasil is an Arabic term, where Waja literally means ‘pain’ and Mafasil means ‘joints’. It is a painful or inflammatory condition affecting joints, its surrounding muscle and ligaments1 and may involve any joint viz; knee, hips, wrists, hands etc2,3,4 with accumulation of mawade fuzooni (vitiated matter) in the joints as the causative factor liable for pain and inflammation.5, 6 As per Unani literature in human body all bones are inter-related and inter-connected to form joints; articular surfaces of some joints are cartilaginous and possess some intervening spaces, 7,8 which helps them to perform different kinds of movements. These spaces are filled with rutubat (fluid) i.e., rutubate tajawif (synovial / interstitial fluid), which act as a lubricant and keep the joint surface consistently moist, so as to prevent from friction.5, 8While the articular surfaces of some joints are non-cartilaginous where consideration of this function is not necessary, a joint is created between two bones without any appendages or intervening space.5, 7, 8 Abu Sahal Masihi categorized all joints of the human body broadly into two types: Mafsal: Movable joints Lahaam: Immovable joints Ibn Sina, categorized the joints based on the articulation into three types: Chaneeda mafsal salas (Diarthrosis): Freely movable joints Mafsal usregair mossiq (Amphiarthosis): Slightly movable Usre gair mumdissiq (Synarthrosis): Immovable7, 8
Asbaab (Etiology)
Ibn Sina categorized the etiology of Waja ul Mafasil in to two types3, 4, 6, 10 Asbabe fa’ilah (primary causes) 2) Asbabe munfa’ilah (secondary causes) while another eminent Unani scholar Ismail Jurjani in his treatise “Zakhirae khuwarezam Shahi” classified as “Asbabe asli” and “Asbabe a’rzi.” 5 (figure 1)
1. Asbabe fa’ilah
These are the primary causes responsible for the initiation of Waja ul Mafasil such as Sue mizaj (Maltemperament) and Mawade fasidah (vitiated humours/morbid).11 Sue mizaj (altered temperament)3 Alteration in the mizaj may be general (entire body) local (particular organ). Different types of kaefiyat act in different ways such as Hararat as a multahib (inflammatory), Burudat as a mubarrid (refrigerant) and munjamid (consolidant), yabusat as a muyabbis (dessicant) and munqabiz (astringent). These alteration aggravate when Ratoobate gharibiya (abnormal fluids) are also involved.3,11
Mawade fasidah (vitiated humours)
The vitiated matter will be Dame khalis (pure sanguine), Dame balghami (phlegmatic sanguine), Dame safravi (bilious sanguine), Dame saudavi (melecholic sanguine), Balghame khalis (pure phlegmatic), Suddae Balghame kham (obstruent of raw phlegma), Mirrahe khalis (pure bilious), Balgham and Mirrah ka murahkkab (phlegmatic bilious), Midda (pus), Riyah (flatulent). It is often due to Balgham (phlegma) then Balghame kham (raw phlegm), than Dam (sanguine), then safra (bile) and rarely due to Sauda (black bile) 3,11
2. Asbabe munfa’ilah
They include weakness of joint,2,6 improper digestion13, sedentary life style,2 lack of exercise 13, excessive coitus2,13, use of alcohol and intoxicating agents2,13, sudden withdrawal or discontinuing the habit of Istifragh like fasd, is’haal, excessive coitus,2 exercise or coitus just after foods 2, horse riding 2 In zakhirae khuwarezam Shahi, Asbab are classified as Asbabe asli and Asbabe a’rzi. 5 Three factors are included in Asbabe Asli; movements, heat production, weak digestive power or excretion of joints while Asbabe A`rzi are mentioned under the context of asbabe munfaila5 . Figure 1: Flowchart depicting etiology of Waja ul Mafasil
Mahiyate marz (Pathogenesis)
Joints get easily affected with various morbid matters, for the following reasons
• Wide joint space as compared to other organs of body. 1,5
• Hypersensitivity due to nerve innervations.1,2
• Barid yabis Mizaj (cold and dry temperament) of joints.5
• Zaeef hararat (Feeble heat) of joint.1
• Improper resolution of morbid matter (tahlil of mawad) in joint cavity.1
• Due to upright and dependent position of the organ as it lies in relation to the other organs.1,3,10
• Joints are covered with ligaments, tendons and muscles, hence the accumulated morbid matter are not easily removed through skin pores.1
• Weak quwate hazema wa dafea` (digestive and excretory powers).1,5
Accumulation of mawade fuzooni (vitiated matter) in joints will produce pain and inflammation. Following factors are responsible for the collection of mawade fasidah within the joint spaces; 5Weakness of joints increases susceptibility to accumulation of mawad. 6 When vigorous physical movements occur, it stimulate the mawad (matter)I and produce heat in the joint cavity, which has the property of absorbing and attracting fluids or mawad (matter). During the movements the morbid matters which are stagnated in the interstitial spaces starts migrating and gets collected in the joint cavity, since it has adequate space to receive. Besides this the temperament of the contents of joint like bone, cartilage, tendons and ligaments is sard wa khushk (cold and dry),1 due to this prime reason the joint fails to perform its digestion. Thus the morbid matter collected in the joint spaces is not eliminated properly, which gradually affects the joints8 (figure 2).
Classification of Waja ul Mafasil according to Mizaj
Akbar Arzani has classified Waja ul Mafasil into:6
• Non inflammatory due sue mizaj sada
• Inflammatory due to sue mizaj maddi
Waja ul Mafasil Sada (Due to simple altered temperament)
In this condition there is no morbid material involved, there is alteration in kaefiyat only. it may be divided into three types. 3,4,6,11
• Haar multahib (inflammatory)
• Barid munjamid (consolidant)
• Yabis munqabiz (astringent)
Waja-ul-Mafasil Maddi (Due to altered temperament with humoural involvement) 3,4,6,11,12
In Waja ul Mafasil Maddi there is accumulation of morbid maWaja-ul-Mafasil Maddi (Due to altered temperament with humoural involvement) 3,4,6,11,12tters or humour inside the joint cavity. It may be further divided into following types.
• Waja ul Mafasil Balghami (phlegmatic)
• Waja ul Mafasil Damavi (sanguineous)
• Waja ul Mafasil Safravi (bilious)
• Waja ul Mafasil Saudavi (melancholic)
• Waja ul Mafasil Reehi (Due to excessive flatulent matter)
• Waja ul Mafasil Murakkab (Involvement of compound/mixed humors)
Classification based on involvement of joint Wajaul Mafasil is a general term used either for painful joints of body or specially hands and feet but it can affect wrist, elbow, hip, ankle and knee.11 Specific name of its various types based on the involvement of joints are • Irqunnasa (sciatica) 1,2,3,4,5,6,10,11,13,14,15,16,17 • Niqris (gout)1,2,3,4,5,6,10,11,13,14,15,16 • Waja ur rakba (knee joint pain) :,3,4,11,17, • Waja uz zahr (low Back pain) 3,4,10,11,17 • Waja ul warik (hip joint pain) 3,4,6,10,11,16,17 • Wala ul khasera (buttock pain) 1 • Wajs us saqain (calf pain) 11 • Waja ul aqib ( heel pain) 11 Zakariya Razi considered Waja ul Mafasil, Niqras and IrqunNisa, as a disease of the same genus.17 Ali ibn Abbas Majoosi and other Unani scholars believe that Waja ul mafasil can also occur in intervertebral, temporomandibular and joints of auditory ossicles. 11,12, Alamaat (Clinical Features) Waja ul Mafasil Balghami (Phlegmatic) • Commonest form of Waja ul Mafasil. 1,6,17, • The onset of symptoms and sign are gradual3 . • Area of affected joint is swollen, soft, whitish and cold on touch1,3,12, • Pain and throbbing is nominal1,3,12 • Swelling is soft and cold with deep pain and tenderness marked1 • Aggravated by exposure of cold2,3,12 • Relieved by exposure of heat over affected part1,3,12 • Generalized and localized symptoms of dominance of phlegm (Ghalbae Balgham) will be present3, 12 • History of using diet or drugs causing abnormal genesis of phlegm is positive1
Waja ul Mafasil Damavi (Sanguineous)
• It is second commonest form of Waja ul Mafasil. 1,6
• Onset is comparatively sudden, symptoms and signs are sever.3
• The swelling is more marked with severity of pain1,2,3,6,12
• Pain is throbbing in nature. 1,3,6,12
• Marked redness of skin over the joint. 1,2,3,6,12
• Warmth over affected joint. 2,3,6,12
• Aggravated by exposure of heat 2, 3
• Relieved by exposure of cold application over affected part or venesection.2,3,6,12
• Generalized and localized symptoms of dominance of sanguine (Ghalbae Khoon) will be present. ,2,3,6,12 Waja ul Mafasil Safravi (Bilious) • Rare variety of Waja ul Mafasil. 1,6, • In this type, onset is sudden.3 • There is slight yellow discoloration or there may also be red tinge to yellow discoloration of skin over the joints. 1,2,3,6, • The swelling is less marked, with warmthness 1,2,3,6, and throbbing pain is relatively more in comparison to Waja ul Mafasil damvi over the joints.3,12,17 • Aggravated by exposure of heat.2,3,19 • Relieved by exposure of cold application over affected part.1,2,3,6,12,17 • Generalized and localized symptoms of dominance of Bile (Ghalbae safra) will be present.3,12
Waja ul Mafasil Saudavi (Melancholic)
• Rarest variety of Waja ul Mafasil. 1,6
• Area of affected joint is cold and dry on touch 1,2,3,6,12
• There is dryness of the skin around the joints. 1,2,3,12
• The pain is mild, swelling is moderate but hard on touch. 1,3,6,12
• Aggravated by exposure of cold.
• Relieved by exposure of heat application over affected part. ,3,6,12
• Generalized and localized symptoms of dominance of black bile (Ghalbae Sauda) will be present.3,6
Waja ul Mafasil Murakkab (Involvement of compound/mixed humours)
Though every single humour is responsible for causing Waja ul Mafasil but mixed humours can also cause the disease. Among them mixture of Balgham and Safra, sauda and safra is quite common but Balgham and Sauda is rarest.1,6,11,17Mixture of ghaleez balgham and tez Safra is worst variety of Waja ul Mafasil. Hence safra causes throbbing pain and balgham is responsible for chronicity /prolong duration12
Waja ul Mafasil Rehi (Pneumatic)
It is a rare type of Waja ul Mafasil,where pain is mild, absence of heaviness, shifting in nature, with sever distension due to Riyah6,11
Tahajjure Mafasil (Degenerative Arthritis)
When patient suffer with Waja ul Mafasil for longer duration, due to the freezing of ghaleez barid madda.11,17 inside the joint will leads to stiffening of the joint. In the initial stage of (waram) inflammation, use of either barid and mukhaddir zimad or mudir (diuretic) and qawi mushil (strong purgative) without munjiz can causes tahajjur in the joint.11 Sometimes it restrict the movement of affected joint.11
Tashkhees (Diagnosis)
The diagnosis of Waja ul Mafasil due to Sue mizaj sada or maddi. 10,11can be made through following points
• Presence or absence of swelling, inflammation, heaviness with pain in or over the joint,
• Color change over affected joint,
• Onset of pain either sudden or gradual, if onset is gradual, without heaviness, inflammation or swelling and no change in skin colour of affected joint, then it is considered to be due to sue mizaj sada, but Waja ul Mafasil is rarely found in sue mizaj sada.
• Change in tactile sensation, pulse, urine and other Unani diagnostic parameter are helpful in knowing the nature of sue mizaj.
• If pain is mild, absence of heaviness, shifting in nature, with severe distension, indicates due to Riyah
• Presence of marked swelling or inflammation, color changes, sudden onset of disease, or pain with heaviness is to be consider due to khilti madda10,11
General principles of Treatment 7,18
The treatment of Waja ul Mafasil in Unani system of medicine is carried out by using one of three modes or with combination viz. 1. Ilaj bit Tadbeer wa Ilaj bit taghzia (Regimenal therapy and Dietotherapy) 2. Ilaj bid Dawa (pharmacotherapy) 3. Ilaj bil Yad (surgical therapy)
Usoole Ilaj (Line of Management)
Waja ul Mafasil in initial stage can be treated easily but if it persists for a longer period it becomes difficult to treat. 11 If it is due to Sue mizaj sada, it can be treated with taadile mizaj (alteration of temperament) such as if pain is due to Sue mizaj haar (Excess of heat) then for Taadile mizaj (alteration of temperament) cold applications is useful for restoration of health, in the same way in case of Sue mizaj barid (Excessive cold) hot applications is useful.10,11 • Removal of causes • In Zamanae Ibteda (early stage) Qabezat (Astringent) and Radeat (Repellent) in Zamanae Tazayyud (Progressive Stage) less Qabezat and Radeat than Mohallilat (anti-inflammatory) and in Inteha (Peak Stage) Mohallilat and Munzijat (concoctives) and in Zamanae Inhetat (late/Declinig stage) Mohallilat and Murakhkhiyat (local relaxant) should be used. • Tanqiyae mawad (evacuation of vitiated or morbid matter) 11 • In case of balghami and saudavi variety, first use munzijaat (concoctives) for making humours suitable for excretion then use Mus’hilaat (Purgatives) for its evacuation followed by mubarridat (refrigerant) for normalizing the excess heat produced by Mus’hilat.
Ilaj (Management)
Nuskha Munjiz Balgham: Maviz munaqqa (Vitis Vinefera) 9 number, Badiyan (Foeniculum vulgure) 5gm, Aslussus (glycyrrhiza glabera) 7gm, Parshiyawshan (Adiantum cappilus) 7gm, Injeer zarda (Ficus carica) 2 number Or; Bekhe Badiyan (Foeniculum vulgare)7gm, Bekhe kibr (Capparis Spinosa) 7gm, Bekhe kirafs (Apium Graviolanse) 7gm, Bekhe Izkhar (Andropogon Schoenthus) 7gm, Socked in the water over night and next morning Prepare Decoction And use with Gulqand 20gm. Nuskha Munjiz Saud: Badranjboya (Mellisa officinalis)7gm, Aftimoon (Cuscuta reflexa) 7gm, Bisfaij (Polypodium vulgure) 5gm, Aslussus (glycyrrhiza glabera) 7gm,Gaozaban (Borage officinalis) 7gm, Bekhe kibr (Capparis spinosa) 7gm, Badiyan (Foeniculum vulgure) 7gm, Inabussalub (Solanum nigrum) 7gm, Suranjan (Cholchicum luteum) 5 gm 11 Socked in the water over night and next morning prepare decoction and use with Gulqand 20gm or turanjabeen (Alhaji Pseudoalhaji) 20gm. Mus’hilaat Balgham: Sana Makki (Cassia Aungustifolia), Turbud (Ipomea turpthum), Zanjabil (Zingiber Offici-nalis),, Khayarishamber (Cassia Fistula) 11 Shame hanzal (Citullus Cholocynthis), Suranjan (Cholchicum Luteum), Bozidan (Pyrethrum indicum), Hajre Armani (armanian stone) , Habul Neel(Ipomoea nil)1 Mus’hilaat Sauda: Matbookhe Aftimoon 6 or Aftimoon (Cuscuta reflexa) ,Turbud (Ipomea turpthum), Kharbaq siyah (Helloborus niger), Halelah Kabli (Terminalia chebula). Mubarridat: Shire Tukhme kahu (Lactuka sativa), Shirae Tukhme kaddu (Cucurbita maxima), Shirae Tukhme Kasni (Chicorium intybus), Shirae Tukhme Khyarain (Cucumis sativus), 11 The reason for administering the Nuskhae Tabrid is to reduce heat and agitation of Khilte Dam, Safra or Mushilat. Fasad and Moaddelate Dam: In case of predominance of khilte dam, Fasd (venesection) and moadelate dam (alterative) should be use1,6 Mus’hilaat safra: In case of Predominance of Safra use of munzijat is not mandatory only mus’hilat can be use directly if disease is not of longer duration. such as Matbookhe Halelah 1,6,11 Matbookhe Halelah: Poste Halelae Kabli (Terminelia chebula), Shahetra (Fumeria officinalis), Tukhme Kasoos (Cuscuta reflexa), Tukhme Kasni (Chicorium intybus), Poste Bekhe Badiyan (Foeniculum vulgare), Aalu Bukhara (Prunus domestica), Unnab( Zizyphus sativus ) along With Maghze Amaltas (Cassia fistula)19 While managing the Waja ul Mafasil Murakkab Which is caused due to admixture of different humours (akhlaat) due importance should be given in the selection of drugs having multiple effects on different humours; however it should always be kept in the mind to rectify the predominant humour with specific Munzij followed by Mushil. Musakkine Alm (analgesics) to reduce pain. e.g. Afyun (papaver somniferum), Zafran (Crocus sativus), Bekhe Luffa (Atropa belladona), Suranjan (Cholchicum luteum)1 Abe kahu (Lactuca sativa)6 can be used as a zimad (paste)11 Use of Raadeaat (repellent) in initial stages of warm. e.g Sandale Safaid (Santulum Album), Sandale Surkh (Ptero carpus santilimus), foofal (Areca catechu), Aqaqiya (Acacia) prepare zimad with Sirka (Vinegar) and Aabe kishneez (Coriandrum sativum) 11Gule surkh (Rosa damascus)6 Use of Muhallile Awraam (anti inflammatory drugs) in the last stage of warm. e.g. Khitmi (Althoea officinalis), Baboona (Anthimis nobilis), Nakhoona (Trigonella uncata) in the form of zimad 1 Mullayinat wa Murakhiyate Auram:. Arade Hulba (Trigonella foenum), Tukhme Katan (Linum usitatissimum), Muqil (Commiphora mukul), Jao’sheer (Ferula galbaniflua), each 7gm and Tukhme Arand (Ricinnis communis) 7 number, prepare paste with Roghane zaitoon (oil of Oleum europium), Roghane Gao (oil of Bos taurus) and Charbie Buz (fat Of Capra aegagrus hircus) 1,6 Muhallil Wa Mullayinate Auram: use in combination in case of Tahajjur Mafasil: Arade krisna (Pisum sativum), Turmus (Lupinus albus ), Ushq (Dorema ammoniacum), Anjadaan (Ferula foetida), Arade baqla (Vicia feba), as a zimad along with Sikanjabeen 10 Use of Kasire Riyah (carminative) drugs in case of Waja ul Mafasil Rehi. e.g. Sa’tar (Zataria multiflora), Anisoon (Pimpinella anisam), Tukhme kasoos (Cuscuta reflexa), Zira siyah (Carum cavri), Badiyan (Foeniculum vulgure)11 Local application of drugs in the form of Zimad (paste), Tikor (fomentation) and Roghan (oil) etc, are recommended during the course of treatment to relieve pain and reduce the inflammation.
Murakkab Advia (Compound Drugs)
Majune Azraqi11,20,21 Majune Ushba1,11,19, Majune Suranjan 1,11,19,20,21, Majune Chobchini19, Majune flasifa19,21 Majune Jograj Goggul20, Habbe Azaraqi 1,19,20,21 Habbe Suranjan 1,19,20,21, Habbe Asgand ,19,20,21, Habbe Gule Aak 1,20,21,22,23,Habbe Hindi19 Habbe Mafasil19 Ilaj bit tadbeer (Regimenal Therapy) Dalk (Massage) It is a type of Riyazat (Manipulation method) resolve and liquefies vitiated matter, produces slight heat and strengthen ligaments and muscle 24 It is also helpful in evacuation of viscous and adhered matter accumulated inside the joints24, and relieves pain, 25,26 produces heat which removes barudat and rehi mawad 24,25,diverts morbid matter,24 reduces swelling, 25,26 excretes fuzlaat specially of last grade of digestion (hazme Akheer)27 Dalk layyin Kaseer (Gentle and prolog massage) Specially dalk layyin kaseer (gentle and prolong massage) is more beneficial for such painful conditions, because dalke layyin make organ soft and relaxes the muscle 25,27 According to Ibn rushd it opens the pores which is helpful in excretion of mawad . 27 While Dalke kaseer is helpful for tehlil mawad which is part and parcel in the causation of Waja ul Mafasil24,25 Roghaniyat (Oils) used for Waja ul Mafasil Roghane Baboona20,21Roghane Dhatura11,21 Roghane Surkh19,21 Roghane Suranjan19,21 Roghane Gule Aak1,20,21 Roghane Malkangni21 Roghane Hifte Barg20, Roghane Kuchla1,20 Roghane Hina19Roghane Zanjabil19 Roghane Shibit19Roghane Qust1
Hijama
Hijama (Cupping) is one of the oldest and popular therapeutic regimen in Unani system of medicine indicated in different forms/ types of Waja ul Mafasil such as gout, sciatica, knee pain28 It is beneficial for Waja ul Mafasil because it is used for Tanqiya and Imalae mawad (diversion and evacuation of morbid matter) from affected part3,4,26,28,29,30,31,32,33 it relives pain,26, 28 ,29 ,31, 32, 33 resolves inflammation, 28 ,29 ,31, 32, 33 flatulence, 26 produces localized heat by increasing local blood circulation 26,28 Jalinoos believed that hijama is beneficial in resolving Ghaleez Khilt 14
Fasd (Venesection/ Phlebotomy)
Fasd is one of the classical methods of treatment in Unani system of medicine for cleansing, evacuation and diversion of surplus and morbid humours from the body, which helps in relieving inflammatory congestion and pain in Waja ul Mafasil, such as sciatica and lumbago. This objective will be achieved through fasd of specified veins of the body part7 . Irsale Alaq (Leech Therapy) Leech or hirudotherapy is one of the most important and widely practiced method of regimenal therapy used for local evacuation of morbid humours very effectively with use of medicinal leeches to treat various ailment including Waja ul Mafasil. 18, 34
DISCUSSION
Waja ul Mafasil has been discussed by ancient Unani scholars in detail as to its etiology, types, clinical features and management.1,2,5,6,11,12,29 The concept of Unani medicine when applied in this scientific era has promising hope. Several studies had suggested the beneficial use of single and compound Unani formulations in arthritis.3,4,28,31,32,33 The efficacy of classical Unani regimenal procedures such as Irsale Alaq (leeching),34 Hijama (Cupping) 3,4,28,31,32,33 Dalk (Massage),25 in the management of different types of Waja ul Mafasil also show a ray of hope for the mitigation of patients suffering from this chronic disease.
CONCLUSION
The profound literary survey pertaining to Waja ul Mafasil as to its concept, detailed classification, iology and multidimensional approach in the management testifies to the fact that this age old disease was meticulously managed by Unani scholars successfully in spite of the limitations prevailed over at that time. This has been documented in the classical literature of Unani medicine. Of late scientific studies with different Unani formulations are being carried out by different research institutions to validate these claims. The scintillating point of this approach is through drug less regimental therapies viz; Irsale alaq ,Fasd , Hijama, Dalk which seems to be a boon for intervention of disease condition in terms of easy to perform, cost effective and at the same time devoid of adverse effects. Hence the objective of this review would be fully accomplished if it reaches a larger section of medical domain and ultimately benefit the humanity.
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 particularly assistance rendered by staff of Central library of National institute of Unani medicine, Bangalore in providing the necessary classical literature
Englishhttp://ijcrr.com/abstract.php?article_id=734http://ijcrr.com/article_html.php?did=7341. Ahmed K. Tarjuma Sharahe Asbabma’ahashiya Sharif Khan wa Mamoolate Matab. Vol.3. New Delhi: CCRUM, Ministry of Health and Family Welfare, Govt. of India; 2010.p. 397- 414.
2. Ali Ibn Abbas Majoosi .Kamilus Sanah. Vol.1. (Urdu translation by Kantoori GH) New Delhi: Idara Kitabus Shifa; 2010.p. 543-46.
3. Nayab M. Clinical Study on Effect of Hijamat (Cupping Therapy) In the Management of Waja ul Mafasil. Dissertation: Bangalore: RGUHS; 2007. p.7-14
4. Nayab M, Anwar M, Quamri M A. Clinical study on Waja ul Mafasil and Evaluation of efficacy of Hijamat Bila Shurt in the treatment. Indian journal of Unani Medicine.2011. Oct; 10 (4): 697-701
5. Ismail Jurjani. Zakheera Khawarzam Shahi. (Urdu translation by Khan HH). Vol.2. Part. 6th. New Delhi: Idara Kitabus Shifa; 2010.p. 637-40.
6. Akbar Arzani. Tibe Akbar. (Urdu Translation by Mohammad Husain). Deoband: Faisal Publications; YNM.p. 617- 28.
7. Ibn Sina. Al Qanoon fit Tib (English translation and published by). Vol.1 & 2. New Delhi: Jamia Hamdard; 1995.p. 38-40, 168,169. 318,350,364
8. Ali M.Evaluation Of Efficacy Of Hulba( Trigonella foenum graecum Linn.) In Rhematoid Arthritis. Dissertation: Bangalore: Rajiv Gandhi University of Health Sciences; 2012.p.9,17-19
9. Abu Sehel Masihi. Kitab al Miat fit Tib. (Urdu translation by CCRUM). Vol.1. New Delhi: Ministry of Health and Family Welfare, Govt. of India; 2008.p. 57-60.
10. Ibn Sina. Al Qanoon fit Tib. (Urdu translation by Kantoori GH). Vol.3. Part 2. New Delhi: Idara kitabus Shifa; YNM.p. 1119-21,1129.
11. Mohammad Azam Khan. Akseer Azam (Al Akseer). New Delhi: Idara kitabus Shifa; 2011.p. 832-852.
12. Ibn Hubal. Kitabul Mukhtarat fit Tib. (Urdu translation by CCRUM). Vol.2. Part 4. New Delhi: Ministry of Health and Family Welfare, Govt. of India; 2007.p. 79-83
13. Zakariya Razi .Kitabul Mansoori, Urdu Translation by CCRUM, New Delhi: Ministry of Health and Family Welfare Govt. of India; 1991.p. 313,318
14. Abul Mamsoor ul Hassan Quamri. Ghana Mana Ma Tarjuma Minhajul Ilaj.New Dehli: CCRUM; 2008.p. 339,341
15. Sabit bin Qurrah. Tarjumae Zakheera Sabit Qurrah (Urdu translation by Syed Ayub Ali). AMU: Litho Colour Printers Aligarh; 1987.p. 313-332.
16. Rabban Tabri. Firdousul Hikmat. New Dehli: Idarae Kitabus shifa; 2010.p.191-192
17. Zakariya Razi. Al Hawi fit Tib. (Urdu Translation by CCRUM) Vol.X1. New Delhi: Ministry of Health and Family Welfare, Govt. of India; 2004. p. 75-79, 89.
18. O.C. Grunner. The Canon of Medicine of Avicenna. London: First Book, Luzac & Co., 1930. p.353, 513–514.
19. Mohammad Kabiruddin. Al-Quarabadeen. 3rd Ed.New Dehli: CCRUM; 2006.p. 183-186,466-468,1210-1215
20. Mohammad Kabiruddin. Bayaze Kabeer. New Dehli: Idarae Kitabus shifa; 2010.p. 30, 37, 50, 57, 88, 94, 176, 177, 179, 80, 89-93.
21. Qarabadeene Majidi. New Delhi: All India Tibbi Conference Ajanta offset & publication; 1996.p. 68, 69,85, 92, 149,155-158, 164-165, 346, 276, 378.
22. National Formulary of Unani Medicine. Part- III, 1sted. New Delhi: Ministry of Health and Family Welfare Govt of India; 2001.p. 15
23. Mohammed Said. Hamdard Pharmacopoeia of Eastern Medicine. 2nded (Reprint) Delhi: Sri Satguru Publications; 1997. p.150
24. Burhan Uuddin Nafees. kulliyate Nafeesi, Part-II. Translated by Hkm. Kabeer Uddin, New Dehli: Idarae Kitabusshifa; YNM. p. 622-626
25. Shaikh Ejaz. Study 0f Efficacy of Dalak (Massage) in the Treatment of Osteoarthritis (with and without Roghan-eSurkh) Indian journal of Unani Medicine. 2011. 6 (2): 33- 40
26. Ibn Sina. Kulliyate Qanoon. Urdu Translated by Mohammad Kabeer Uddin. New Dehli: Ejaz Publishing house; 2006.p.347-349
27. Ibn Rushd. Kitabal Kulliyat (Urdu Translation by CCRUM). 2nded. New Delhi: Ministry of Health and Family Welfare, Govt. of India; 1987.p.346 .
28. Nighat A, Shakir J, Abdul H, Jamal A, Bilal A. Clinical efficacy of Hijamat (Cupping) in Waja ul Mafasil Muzmin (arthriris). Indian journal of Traditional Knowledge. 2005. 4 (4): 412-415
29. Akbar Arzani. Meezanut Tib. Dehli: Daftarululoom; 1940. p.147-148
30. Ibn ul Qaf Masihi. Kitab Umda fil Jarahat. Hyderabad: Doeratul moarif usmaniya university;1935.p.15-35
31. Nayab M, Ansari M A, Anwar M, Yaseen A, Effect of Hijamat Bila Shart in the Management of Waja uz Zohar - A Clinical Study. Hippocratic journal of Unani Medicine. 2011.vol.6 : 79-86
32. Zarnigar, Riyaz A. Clinical efficacy of Al Hijama (Cupping) in Waja ul Mafasil Muzmin (Osteo arthriris). Indian journal of Traditional Knowledge.2011. 10 (2):327-329
33. Akhtar J, Siddiqui MK. Utility of Cupping Therapy Hijamat in Unani medicine Indian journal of Traditional Knowledge.2008 .7 (4): 572-74.
34. Zaidi SMA, Jamil SS, Sultana A, ZamanF, Fuzail M. “Safety and efficacy of leech therapy for Symptomatic knee osteoarthritis using Indian medicinal leech.” Indian journal of Traditional Knowledge. 2009. 8 (3):437-442.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241620EnglishN2014October20HealthcarePOSTOPERATIVE NAUSEA AND VOMITING: A REVIEW
English4854Dhruva SharmaEnglish Neha SharmaEnglish Ajitesh Kumar MishraEnglish Preksha SharmaEnglish Neelima SharmaEnglish Pooja SharmaEnglishPostoperative Nausea and Vomiting (PONV) was termed “the big little problem” nearly a quarter century ago in an editorial (Kapur et al, 1991). The past decade has witnessed the introduction of several significant innovations to combat PONV, particularly the introduction of serotonin antagonists and the use of combinations of drugs for analgesia and control of PONV. But it still remains as big a problem as before because newer choices and confusions over standardization added side by side. PONV remains a significant problem in modern anesthetic practice also because of adverse consequences such as delayed recovery, unexpected hospital admission, delaqayed return to work of ambulatory patients, pulmonary aspiration, wound dehiscence, and dehydration PONV is controlled by the emetic, or vomiting centre, in the brain. Stimuli are also sent from the cerebral cortex and chemoreceptor trigger zone (CTZ), which is situated in the brainstem. PONV is generally influenced by multiple factors that are related to patient, surgery and anesthesia and which requires release of 5-hydroxytryptamine (5- HT) in a cascade of neuronal events involving both the central nervous system and the gastrointestinal tract. The 5-HT subtype 3 receptor (5-HT3) participates selectively in the emetic response. Patients might become extremely distressed, which in turn can cause them anxiety about undergoing further surgery. PONV also has cost implications in terms of nursing time, delayed recovery, hospital resources and possible re-operation costs. In the present scenario, though we have better understanding and knowledge about the pathophysiology of nausea and vomiting and use of more stable and effective anti-emetics, the postoperative nausea and vomiting (PONV) continues to be the most disturbing complication following surgery and anesthesia.
EnglishPostoperative Nausea and Vomiting (PONV), 5-HydroxytryptamineINTRODUCTION
POSTOPERATIVE NAUSEA AND VOMITING
Postoperative Nausea and Vomiting (PONV) was termed “the big little problem” nearly a quarter century ago in an editorial (Kapur et al, 1991) [1]. The past decade has witnessed the introduction of several significant innovations to combat PONV, particularly the introduction of serotonin antagonists and the use of combinations of drugs for analgesia and control of PONV.[2] But it still remains as big a problem as before because newer choices and confusions over standardization added side by side.[2] PONV remains a significant problem in modern anesthetic practice also because of adverse consequences such as delayed recovery, unexpected hospital admission, delayed return to work of ambulatory patients, pulmonary aspiration, wound dehiscence, and dehydration .[3]
NAUSEA, VOMITING, AND RETCHING
Nausea, vomiting, and retching are distinct concepts. However, terms to describe them often are used interchangeably, which may result in imprecise assessment, measurement, and education. [4] Nausea By definition nausea is “the feeling of a need to vomit”.[5] Nausea is a non-observable phenomenon of an unpleasant sensation experienced in the back of the throat and the epigastrium that may or may not culminate in vomiting; it is synonymously described as feeling “sick at stomach”.[6] In short, nausea is an unpleasant sensation that commonly precedes vomiting. It is usually determined through self-report but also may have some objective elements, depending on intensity. A visual analogue scale for nausea is also prescribed (Boogaerts et al, 2000) analogous to that widely used for pain measurement.[7] Rectching While nausea is an unpleasant sensation of the urge to vomit; retching involves spasmodic contractions of respiratory muscles without the expulsion of gastric content. Thus retching is the attempt to vomit without bringing anything up. As retching is gastric and esophageal movement of vomiting without expulsion of vomitus, it is described by such terms as “gagging,” “dry heaves,” and “attempting to vomit without results’’.[4]
Vomiting
The final act of vomiting is a reflex – actually an important defense mechanism for the expulsion of toxins. Thus vomiting is the forceful expulsion of the contents of the stomach through the oral or even nasal cavity. Thus vomiting involves the contraction of the abdominal muscles resulting in an expulsion of the stomach contents from the mouth .[8] Both the occurrence and the frequency of vomiting may be objectively measured. [9] The Rhodes index of nausea, vomiting, and retching (RINVR) is a method of quantifying nausea and vomiting objectively in patients who receive anti-cancer therapy.[10]
The neuroanatomical site which controls nausea and vomiting is basically an ill-defined region called the “vomiting center” which is situated within the lateral reticular formation in the brainstem. [18] It receives afferent inputs from higher cortical centers, the cerebellum, the vestibular apparatus, and vagal and glossopharyngeal nerves.[9]Further interactions occur with the nucleus tractus solitarius and the CTZ which is located in the floor of the fourth ventricle. The CTZ is outside the blood-brain barrier and in contact with cerebrospinal fluid (CSF). The CTZ enables substances in the blood and CSF to interact. [9][18] Not only direct stimulation of the CTZ induce PONV but immunochemical studies of these anatomical sites shows that these areas contain histamine, serotonin, cholinergic, neurokinin-1, and D2 dopamine receptors which results in vomiting. [9][18] The “vomiting reflex” is precipitated by different stimulation from the glossopharyngeal, hypoglossal, and vagal nerves reaching the vomiting center.[9][18] Efferent signals are directed to the glossopharyngeal, hypoglossal, trigeminal, accessory, and spinal segmental nerves. There is a coordinated contraction of abdominal muscle against a closed glottis, which raises intra-abdominal and intrathoracic pressures.[9][18] The pyloric sphincter contracts and the esophageal sphincter relaxes, and there is active antiperistalsis within the esophagus, which forcibly expels the gastric contents. This is associated with marked vagal and sympathetic activity leading to sweating, pallor, and bradycardia.[9][18] PONV is generally influenced by multiple factors that are related to patient, surgery and anesthesia and which requires release of 5-hydroxytryptamine (5- HT) in a cascade of neuronal events involving both the central nervous system and the gastrointestinal tract. The 5-HT subtype 3 receptor (5-HT3 ) participates selectively in the emetic response.[19] Otherwise too, seeing multiple mechanism and receptors physio-pathologically involved in PONV, a combination of antiemetics may be necessary – esp in the high risk groups and/ or refractory cases.[20]
PHARMACOLOGICAL FACTORS INFLUENCING
PONV Pre-medications are administered to provide sedation, anxiolysis, analgesia, reduces secretions and cardiovascular responses during induction. Sevoflurane, transdermal scopolamine and benzodiazipines are preferred to avoid PONV.[21][22][23] Many of the drugs used in anesthesia and pain control (esp opioids) cause PONV because chemoreceptors in the CTZ monitor substances in the blood and cerebrospinal fluid. The use of opioids for pain relief stimulates the vomiting centre via the CTZ. [14] They also decrease gut motility causing distension. Opioids can increase the sensitivity of the middle ear to movement which can cause nausea in some people. This explains their association with travel sickness.[14] Paracetamol alone is a sufficient pain killer in tonsillectomy and thereby also helps in reduction of anxiety and associated PONV .[24] Even reversal of skeletal muscle relaxants like curares may need neostigmine and being an anticholinesterase, it increases acetylcholine level sufficient to induce PONV. [26] Inhaled anesthetic agents, such as nitrous oxide, increase the risk of PONV. Nitrous oxide causes gut distension and pressure on the middle ear, which can both contribute to PONV.[14][26] Twenty four of twenty seven studies show a greater incidence of emesis associated with nitrous oxide than with alternative anesthetics.[27] Preoperative clonidine has also been preferred over midazolam as a sedative premedication as it is better effective against PONV, specially in children.[28] Glycopyrrolate intravenously before spinal anesthesia in caesarean section effectively controls the PONV.[29] Gabapentin, an anticonvulsant used in pains like tic doloreaux has also been proposed for PONV under similar justification of pain modification.[30] And this anticholinergic benefit considered with antiadrenergic benefit of clonidine supports the idea that reactionary (and homeostatically compensatory) hyperactivity of parasympathetic system which follows ‘sympathetic
INCIDENCE OF PONV
The depicted bar diagram in figure-1 shows a general prevalence of PONV as per surgery type and in surgery overall. [11][12] Yet, among other surgeries, some procedures like tonsillectomies, strabismus surgery, laparoscopic cholecystectomies are associated with higher incidence of PONV[13], may be due to inherent increased chances of procedural errors.
MECHANISM OF PONV
PONV is controlled by the emetic, or vomiting centre, in the brain. Stimuli are also sent from the cerebral cortex and chemoreceptor trigger zone (CTZ), which is situated in the brainstem (Jolley, 2001). The vomiting centre receives messages via the nervous system from different sources, including the pharynx, gastrointestinal tract, eye, vestibular apparatus in the ear, respiratory and circulatory systems, testicles and pain receptors. [14] Primary control of nausea and vomiting arises from the “central pattern generator for vomiting,” located in the medulla oblongata. There are five primary afferent pathways involved in stimulating vomiting (Kakuta et al, 2011): 1. the chemoreceptor triggering zone (CTZ) 2. the vagal mucosal pathway in the gastrointestinal system, 3. neuronal pathways from the vestibular system, 4. reflex afferent pathways from the cerebral cortex, and 5. midbrain afferents. Stimulation of one of these afferent pathways can activate the sensation of vomiting via cholinergic (muscarinic), dopaminergic, histaminergic, or serotonergic receptors .[15] The vomiting centre can also be stimulated by disturbance of the gut or oropharynx, movement, pain, hypoxaemia and hypotension. Because many different factors contribute to PONV, it can be difficult to prevent and treat.[14] The schematic diagram depicted in Figure-2 [16] shows the main targets of induction/ inhibition of PONV. Better explanation on the receptor level is explained in Figure-3.[17]
hyperactivity of sympathetic system during surgery’ may be a mechanism of PONV. Some of the older intravenous induction agents such as thiopentone are associated with PONV, whereas propofol has a lower incidence of PONV.[31][32] Because of the short duration of action, it is known that propofol does not show enough anti-emetic effect for PONV and in late post operative period (by now, even emetogenic effect of inhalant anesthetics might have vanished) it doesn’t differ significantly from inhalational anesthesia.[31]
NON-PHARMACOLOGICAL FACTORS INFLUENCING PONV
Differences exist in risk factors of postoperative nausea vs vomiting. The authors reported that female gender, non-smoking status, and general anesthesia increase both PONV; whereas a history of migraine and the type of surgery tend to influence nausea only .[33] And that’s why there remain many contradictory reports concerning contribution of a given factor influencing the post surgical emetic responses when patients are categorized by a carpet approach of PONV (in adults) or POV (in children).[33] 1. Age – Usually children have a higher incidence than adults but the lowest incidence occurs in infants (5%). Children aged > 3 years have an average vomiting incidence of 40%—almost twice as frequent as the rate in adults .[34] 20% of cases are seen in preschool children with a peak incidence in school going children (34-50 %).[8][35] Sex differences in risk of vomiting are not seen in children before puberty.[34]The incidence of PONV reaches a peak between 5 and 9 years of age .[36] 2. Sex – Females are more prone to PONV (Rowley et al, 1982). and women are three times more likely than men to experience PONV .[12][37] Hawthorne et al (1995) has suggested that the predictive value of female gender diminish following menopause, when the risk to each sex becomes equal. [38] The incidence of postoperative nausea and vomiting in women undergoing laparoscopy is found to be aggravated during menstruation.[39][40] Interestingly, droperidol was later shown to be ineffective in men while benefitting females irrespective of the phase of menstrual cycle – earlier studies failed to exhibit it because of sex limited (women only) use or smaller sample size .[41] Type of surgical procedure – The type of surgery performed also has an influence on the incidence of PONV and it is independent of other factors .[8] Gynecological and abdominal surgeries are more prone to PONV.[12] Later, surgery type as a factor is denied through systematic meta-analysis.[42]Rather high risk patient [42] or intraoperative hypotension has also been implicated in PONV.[34] Pneumoperitoneum induced by laparoscopy can stimulate vagal response and induce release of various emetogenic substances such as 5-hydroxytryptamine and acetylcholine and hence increase nausea and vomiting.[43] General anesthesia increases the risk of PONV 11?fold compared to regional anesthesia.[34] It is reported that the incidence of PONV is higher in laparoscopy procedures compared with laparotomy procedures.[44] Thus laparoscopic surgeries in females are most risky concerning PONV.[8] Surgical factors also include the effects of intraperitoneal CO2 insufflation on residual stretching and irritation of the peritoneum.[45] The patients undergoing ophthalmologic surgery that involves extensive manipulation of extra-ocular muscles are even more prone to develop post-operative nausea and vomiting because of the oculo-emetic reflex.[46] Excessive nausea and vomiting may interfere with post-operative care. They lead to increase in the intra-ocular pressure (IOP), which in turn may cause ocular morbidity.[46] In addition, vitreoretinal (VR) surgery often requires intra-operative administration of air, airgas or silicon oil into the vitreous cavity for prevention of post-operative tamponade.[46] These patients need to be nursed in prone position. Presence of PONV does not allow the patients to be in prone position. In such cases, ketoprofen with centrally and peripherally mediated analgesic activity can safely replace opioids as pain killer[46] In adults, many of the short-duration ophthalmologic surgeries are undertaken under regional anesthesia obviating the need of opioids as pain killer which could further aggravate PONV.[46] As regional anesthesia is not feasible in children and young adults, ketoprofen can be chosen. It has liposomal membrane stabilizing action and antibradykinin activity and inhibitory effects on leukotriene synthesis. Thus ketoprofen acts rapidly, producing analgesia within 10 minutes from an intravenous bolus dose.[46] 3. Duration of surgery- PONV increases with duration of surgery and anesthesia because of greater accumulation of emetogenic anesthetic agents .[8] [47] 5. Previous history of PONV- Greater complications has been seen in patients with previous history of motion sickness and PONV.[48]
Either due to previous experience of PONV or because of general fears about a hospital admission, apprehension can increase the likelihood of PONV occurring. This might be because of conditioning or learned responses.[14] 6. Gastric distension- Increased incidences of PONV have been seen in patients with gastric distension. The use of N2 O during laparoscopic procedures has been considered to be an important problem because of its propensity to produce bowel distension during the surgery and to increase the incidence of PONV.[49] Emergency, in which patient is operated without “empty bowel since the night before”), can also be a factor for PONV.[14] 7. Smoking status – non-smokers are more prone to PONV – it might be due to gradual desensitization of CTZ due to continued smoking which initially and universally induces nausea and vomiting .[41] 8. Other than drugs being used before, during or after anesthesia and surgery, an important confounding factors can be obesity (lipid soluble drugs may get deposited in the adipose tissue and continue longer to causes this ADR) .[14] But some studies deny the role of body mass index in PONV .[2] 9. Postoperative pain. It is very important to manage postoperative pain as it can prolong PONV by increasing gastric emptying time .[22]At the same time, prevention of PONV in surgical patients gets similar priority to that of alleviating postoperative pain .[3] Patient controlled analgesia (PCA) is a common measure against post operative pain but PCA is not without side effects and pain relief with opioids is achieved at the expense of PONV, which is a commonly reported symptom.[50]
IMPACT OF PONV
Problems associated with vomiting are loss of fluid and electrolytes, exhaustion, soreness and patient distress . [14] The negative impact of PONV on patient’s physical, metabolic and psychological condition not only delays discharge from or cause re-admission to hospital but also decreases the confidence level in future surgery and anesthesia .[5] S. Chatterjee et al 2011 documented that an episode of vomiting prolongs postanesthetic care unit (PACU) stay by about 25 minutes and even patients were willing to pay at their own expense, for a completely effective antiemetic.[18]
It is estimated that approximately 0.2% of all patients may experience intractable PONV leading to increased medical costs.[18] Vomiting also increases the risk of esophageal perforation, and bleeding. The increased abdominal pressure during emesis may cause tension on suture lines resulting in incisional hernia.[41] As well as medical complications, nausea and vomiting can have psychological effects on patients, such as discomfort and distress; shame and embarrassment; exhaustion; dissatisfaction with the outcome of the operation; and fear of further surgery .[14] Research has shown that nausea and vomiting are feared far more in comparison to post-operative pain, and PONV is ranked as a major concern by the most surgical patients .[41] Each episode of emesis delays discharge from the recovery room nearly by 20 minutes .[34] Patients might become extremely distressed, which in turn can cause them anxiety about undergoing further surgery. PONV also has cost implications in terms of nursing time, delayed recovery, hospital resources and possible re-operation costs .[14]
CONCLUSION
In the present scenario, though we have better understanding and knowledge about the pathophysiology of nausea and vomiting and use of more stable and effective anti-emetics, the postoperative nausea and vomiting (PONV) continues to be the most disturbing complication following surgery and anaesthesia.
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=735http://ijcrr.com/article_html.php?did=7351. Kapur PA. The big ‘little problem’. Anesth Analg 1991;73: 243 –245.
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3. Swaika Sarbari, Anirban Pal, Surojit Chatterjee. Ondansetron, ramosetron, or palonosetron: Which is a better choice of antiemetic to prevent postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy? Anesthesia assays and researchers 2011;5( 2): 182-186.
4. Verna A. Rhodes EdS, Dr. Roxanne W. McDaniel . Nausea, Vomiting, and Retching: Complex Problems in Palliative Care.CA Cancer J Clin 2001;51(4):232–248.
5. Prunty, Leesa M. “An Outpatient Approach to Nausea and Vomiting.” US Pharm38, no. 12 (2013): 24-28.
6. Rhodes, Verna A., and Roxanne W. McDaniel. “Nausea, vomiting, and retching: complex problems in palliative care.” CA: A Cancer Journal for Clinicians 51, no. 4 (2001): 232-248.
7. Boogaerts JG, Vanacker E, Seidel L, et al: Assessment of postoperative nausea using a visual analogue scale. Acta Anaesthesiol Scand 2000; 44:470 – 474.
8. Watcha MF, White PF. Postoperative nausea and vomiting: its etiology, treatment and prevention. Anesthesiology. 1992;77:162–84.
9. Islam S, Jain PN. Post-operative nausea and vomiting (PONV): a review article. Indian J Anaesth 2004; 48 : 253- 8.
10. Kim TH, Choi BM, Chin JH, Lee MS, Kim DH, Noh GJ. The reliability and validity of the Rhodes index of nausea, vomiting and retching in postoperative nausea and vomiting. Korean J Anesthesiol 2007; 52: S59-65.
11. Ernst E (1994) The Economics of Quality Care. Postoperative Nausea and Vomiting. Cookham, Direct Publication Solutions.
12. Rowbotham D (1995) Recognising risk factors. Nursing Times. 91, 28, 44-46.
13. Mihara, T., K. Tojo, and T. Goto. “Re-evaluation of the effectiveness of ramosetron in preventing post-operative nausea and vomiting: a meta-analysis without Fujii et al.’s RCTs: ESAPC1-2.” European Journal of Anaesthesiology (EJA) 30 (2013): 1-1.
14. Jolley, Sue. “Managing post-operative nausea and vomiting.” Nursing Standard 15, no. 40 (2001): 47-52.
15. Kakuta, Nami, Yasuo M. Tsutsumi, Yousuke T. Horikawa, Hiroaki Kawano, Michiko Kinoshita, Katsuya Tanaka, and Shuzo Oshita. “Neurokinin-1 receptor antagonism, aprepitant, effectively diminishes post-operative nausea and vomiting while increasing analgesic tolerance in laparoscopic gynecological procedures.” J Med Invest 58, no. 3-4 (2011): 246-51.
16. Kenny G, Rowbotham D (Eds) (1992) Postoperative Nausea and Vomiting. London, Synergy Medical Education.
17. tkenhead AR, Rowbotham DJ, Smith G. Textbook in Anaesthesia, 5 Edition. London: Churchill Livingstone Elsevier; 2007
18. Chatterjee, S., A. Rudra, and S. Sengupta. “Current concepts in the management of postoperative nausea and vomiting.” Anesthesiology research and practice 2011 (2011).
19. Baisakhi Laha, Avijit Hazra, S Mallick. Evaluation of antiemetic effect of intravenous palonosetron versus intravenous ondansetron in laparoscopic cholecystectomy: A randomized controlled trial.Ind J Pharmacol 2013; 45(1 ): 24-29.
20. Habib, Ashraf S., and Tong J. Gan. “Evidence-based management of postoperative nausea and vomiting: a review.” Canadian Journal of Anesthesia51, no. 4 (2004): 326-341.
21. Horimoto Y, Tomie H, Hanzawa K.Scopolamine patch reduces postoperative emesis in paediatric patients following strabismus surgery. Can J Anaesth 1991;38:441-4.
22. Rose JB, Watcha MF. Postoperative nausea and vomiting in paediatric patients. Br J Anaesth 1999; 83: 104–17
23. Splinter WM, Rhine EJ, Roberts DJ. Vomiting after strabismus surgery in children: ondansetron vs propofol. Can J Anaesth 1997; 44: 825–9
24. Sen, B., S. Dogru, Nursen Koltka, and M. Gura. “The effect of intra-operative paracetamol on post operative pain, nausea and vomit in children who underwent adenotonsillectomy.” Göztepe T?p Dergisi 27, no. 1 (2012): 16-21.
25. Rother, Catriona. “Post-Operative Nausea & Vomiting-Use of Anti-Emetic Agents in Anaesthesia.” Scottish Universities Medical Journal 1, no. 1 (2012).
26. Hovorka J, Korttila K, Erkola O.The experience of the person ventilating the lung does influence postoperative nausea and vomiting.Acta Anaesthesiol Scand.1990;34:203-5.
27. Hartung J.Twenty four of twenty seven studies show a greater incidence of emesis associated with nitrous oxide than with alternative anaesthetics.Anaesth Analg 1996;83:114-16.
28. Javaherfroosh, F., M. Raza Pipelzadeh, and M. Namazi. “Clonidine reduces post operative nausea and vomiting in laparoscopic gynecological surgery.” Pak J Med Sci 25, no. Part I (2009): 782-5.
29. Biswas, B. N., A. Rudra, S. K. Das, S. Nath, and S. C. Biswas. “A comparative study of glycopyrrolate, dexamethasone and metoclopramide in control of post-operative nausea and vomiting after spinal anaesthesia for caesarean delivery.” Indian J Anaesth 47 (2003): 198-200.
30. Soroush, Ahmadreza, Hosein Masoomi, Zhamak Khorgami, Seyed MojtabaMarashi, and Roza Mofid. “Effect of prophylactic gabapentin on post operative nausea and vomiting after laparoscopic cholecystectomy: a randomized controlled trial.” Journal of Minimally Invasive Surgical Sciences 2012, no. 1, Winter (2012): 17-20.
31. Shinn, Helen Ki, Mi Hyeon Lee, Sin Yeong Moon, Sung-Il Hwang, Choon Soo Lee, Hyun Kyoung Lim, and Jang-Ho Song. “Post-operative nausea and vomiting after gynecologic laparoscopic surgery: comparison between propofol and sevoflurane.” Korean journal of anesthesiology 60, no. 1 (2011): 36-40.
32. Tate S, Cook H (1996) Postoperative nausea and vomiting 1: physiology and aetiology. British Journal of Theatre Nursing. 5, 16, 962-966.
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34. Gan TJ, Meyer T, Apfel CC, Chung F, Davis PJ, Eubanks S, Kovac A, Philip BK, Sessler DI, Temo J, Tramer MR, Watcha M. Consensus Guidelines for Managing Postoperative Nausea and Vomiting. Anesthesia and Analgesia, 2003; 97:62– 71.
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36. Sossai R, Johr M, Kistler W, et al. Postoperative vomiting in children. A persisting unsolved problem. Eur J Pediatr Surg 1993; 3:206–208.
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39. Chauhan, Gaurav, Deepika Madan, Kapil Gupta, Chandni Kashyap, Prashant Maan, and Pavan Nayar. “Effect of intraoperative intravenous crystalloid infusion on post-operative nausea and vomiting after diagnostic gynaecological laparoscopy: Comparison of 30 ml/kg and 10 ml/kg and to report the effect of the menstrual cycle on the incidence of...” Anesthesia: Essays & Researches 7, no. 1 (2013).
40. Matchock RL, Levine ME, Gianaros P J, Stern, RM. Susceptibility to Nausea and Motion Sickness as a Function of the Menstrual Cycle. Womens Health Issues. 2008; 328-335
41. Apfel CC, Korttila K, Abdalla M, Kerger H, Turan A, Vedder I et al. A Factorial Trial of Six Interventions for the Prevention of Postoperative Nausea and Vomiting. The New England Journal of Medicine. 2004, June 350(24): 2441-2451
42. Apfel CC, Laara E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology 1999; 91: 693–700
43. Yotsui T. Clonidine premedication prevents sympathetic hyperactivity but does not prevent hypothalamo-pituitaryadrenocortical responses in patients undergoing laparoscopic cholecystectomy. Anesthesia J 2001;15(2):78-82.
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45. Fujii Y, Saitoh Y, Tanaka H, Toyooka H: Prevention of PONV with granisetron, droperidol or metoclopramide in patients with post-operative emesis. Can J Anaesth 1998;45: 153 – 156
46. Subramaniam, R., B. Ghai, M. Khetarpal, and M. S. Subramanyam. “A comparison of intravenous ketoprofen versus pethidine on peri-operative analgesia and post-operative nausea and vomiting in paediatric vitreoretinal surgery.” Journal of postgraduate medicine 49, no. 2 (2003): 123.
47. Rowley MP, Brown TCK. Postoperative vomiting in children. Anaesth Intensive Care 1982;10:309-13.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241620EnglishN-0001November30HealthcareSTUDY OF VARIATIONS IN THE BRANCHING PATTERN OF BRACHIAL ARTERY
English5560Preeti SonjeEnglish Neelesh KanaskarEnglish Vasanti AroleEnglish Sapna ShevadeEnglish Preeti AwariEnglish VatsalaswamyEnglishAs the arterial variations are very common, variations in the branching pattern of Brachial artery were studied at D.Y.Patil Medical College, Pune. 50 upper limbs were studied for the variations of Brachial artery. Different types of variations were found. The high origin of Radial artery in 2% of cases, high origin of ulnar artery in 4 % of cases was found. Other type of variation was also seen. These variations are important in different diagnostic as well as surgical procedures. Embryological basis of these variations has also been discussed.
EnglishBrachial artery, Profunda brachii artery, Radial artery, Ulnar arteryINTRODUCTION
Aim of this study is to study different variations in the branching pattern of brachial artery, which are clinically as well as diagnostically important. 50 upper limbs, embalmed in the formalin, were procured from the department of Anatomy of D. Y. Patil Medical college Pune. Brachial artery is a continuation of Axillary artery at the lower border of teres major muscle. It is the main artery of the upper limb which divides in the cubital fossa into its terminal branches, Radial and Ulnar arteries. Sometimes the Radial artery instead of arising in the cubital fossa, arises at higher level in the upper limb and it is called as high origin of Radial artery which was found in 2% cases unilaterally. Similarly ulnar artery may arise at higher level from the brachial artery which is called as high origin of Ulnar artery. This type of variation was seen in 4% cases, unilaterally. Axillary artery normally gives one branch from the first part i.e. Superior thoracic artery, two branches from the second part i.e. Thoracoacromial and Lateral thoracic arteries and three branches from the third part i.e. Sub scapular , Anterior circumflex humeral and Posterior circumflex humeral arteries . In the present study in 2% cases there was double Posterior circumflex humeral artery one was arising from the third part of Axillary artery and the other was arising from Brachial artery.
MATERIALS AND METHODS
50 formalin fixed upper limbs were procured from the department of Anatomy, Dr D.Y.Patil Medical College Pune. Arm and forearm were dissected by taking incision given in Cunningham’s dissecting manual. After reflection of skin, fascia was cleaned to expose brachial artery and its branches. Incisions were extended both vertically and horizontally whenever necessary. Brachial artery was exposed. It was traced downwards in the upper limb, branching pattern of brachial artery was studied and the variations in its branching pattern were noted and photographed.
RESULT
Different types of variations in the branching pattern of brachial artery were found as follows.
• Presence of unilateral high origin of Radial artery was found in2% of cases.
• The Radial artery was arising from the Brachial artery just 4cms below the lower border of teres major muscle,winding around the median nerve from medial to lateral side to cross superficial to the Median nerve. The artery passed lateral to brachial artery and then was seen lying on the lateral side in the cubital fossa.(fig.1) and ( fig.2)
• The common interosseous artery was absent. The Anterior interosseous and posterior interosseous arteries were seen arising separately from the ulnar artery. Inferior ulnar collateral artery was seen arising from the ulnar artery. Superior ulnar collateral artery was arising from the brachial artery. Also both the structures , the median nerve and brachial artery were seen piercing the brachialis muscle.(fig3)
• High origin of ulnar artery was found in 4% of cases
• The Ulnar artery was arising from the Brachial artery in the arm about 10 cms distal to the lower border of teres major muscle .In both the cases the high origin of Ulnar artery was seen unilaterally. (fig.4) and (fig.5)
• The Common interosseous artery which is normally a branch of ulnar artery was seen arising from the Radial artery, while the Ulnar artery had the same course as that of normal ulnar artery in the forearm.(fig.6)
• In 2% of cases there was a common stem for the posterior circumflex humeral artery and Profunda brachii artery.
• Normally the posterior circumflex humeral artery is a branch of third part of axillary artery and the profunda brachii artery is a branch of brachial artery. In our study, there were two posterior circumflex humeral arteries. One posterior circumflex humeral artery was arising as a branch of third part of axillary artery as seen normally but it was very thin, while the other quite thick posterior circumflex humeral artery was arising from the brachial artery as a common trunk with profunda brachii artery. .(fig.7)
• The Superior ulnar collateral artery was seen arising from the Profunda brachii artery instead of arising from the brachial artery (fig.8). This variation was also unilateral.
DISCUSSION
Variations in the branching pattern of brachial artery have been reported by many workers. These variations are important from diagnostic and surgical point of views M. Rodri et al found Brachioradial artery which is defined as a radial artery with a high origin in 39 out of 192 cadavers. Presence of Brachioulnar artery in 13% of cases . This is defined as a high origin of the ulnar artery coexisting in the whole arterial pattern of the limb, with a brachial artery which branches into the radial and common interosseous trunk [1]. John Gourassas presented a case-report of a patient with a failed radial coronary angiography approach, due to the anomalous high origin of the radial artery from the brachial artery [2]. O Okaro et al reported bilateral high origin of radial artery from the Axillary artery [3]. JE Waghmare reported that radial artery was arising from 2nd part of axillary artery [4]. Konstantinos Natsis reported two cases of a uni-lateral high-origin of radial artery with different variations in each case in the course of the artery [5]. Dong Zhan described a brachioradial artery where the radial artery was seen originating from the upper one-third of the brachial artery and continuing distally asthe radial artery in the forearm[6]. Sharmila Bhanu demonstrated high origin and superficial course of Radial artery [7]. Harbans Singh reported an unusual case of bilaterally symmetrical higher bifurcation of brachial artery into radial and ulnar arteries with superficial course of radial artery in right forearm [8]. According to Swaroop. N et al a high origin of radial artery in the left upper limb with superficial course in arm and forearm was found in a male cadaver .The radial artery was originating from the medial side of the brachial artery in the proximal 1/3 rd of the arm. In the cubital fossa a communication was also seen between the radial artery and the Ulnar artery at the level of the neck of radius[9]. Gh. Noditi reported a case presented to the Diagnostic Imaging Centre with peripheral vascular disease of the upper right limb. Using MDCT angiography (64-slice MDCT system; SOMATOM Sensation, Siemens Medical Solutions, Forchheim, Germany) where the patient was found to have a superficial radial artery [10] Venkata Ramana Vollala presented a case of a high origin of the ulnar artery from the brachial artery which was observed during anatomical dissection of a right upper limb This superficial ulnar artery, after running over the bicipital aponeurosis in the cubital fossa was also having a superficial course to the flexor muscles in the forearm and terminated as the superficial palmar arch in the hand [11]. Dr. Sharadkumar Pralhad Sawant observed an unusual branch of the right brachial artery. The brachial artery terminated in the cubital fossa by dividing into radial and common interosseous arteries. The radial artery had normal course and branches. The common interosseous artery was deeper and gave anterior and posterior ulnar recurrent arteries, and then terminated by branching into anterior and posterior interosseous arteries. The unusual large branch from the right brachial artery was a variant of ulnar artery and was seen arising from the lateral side of the brachial artery [12].
Chauhan K et al demonstrated that the superior ulnar collateral artery was seen arising as common trunk with profunda brachii artery in 18 % cases [13]. Dr. Chandrika Teli demonstrated high division of brachial artery into radial and ulnar arteries in the upper third of arm. The posterior circumflex humeral artery, profunda brachii artery and superior ulnar collateral artery all arose from one common trunk in proximal part of brachial artery before its termination. Similar variation was found in the present study in one case [14]. Suat Keskin demonstrated the origin of the ulnar artery from the proximal part of brachial artery. The ulnar artery had a course through the arm and had its normal course in the forearm, forming the palmar arch. In addition, the brachial artery continued as the radial artery, which had a normal course. The common interosseous artery originated from radial artery instead of ulnar artery .This type of variation was also found in the present study in one case [15]. Embryological Explanation: Every anomaly in the peripheral vascular anatomy can be related to genesis as regression or persistence of one or other segment of the embryologic axial artery .The type of anomaly presented in this case is due to persistence of radial artery in the arm and failure of formation of communication between radial and axial arteries in cubital fossa The superficial course of radial artery in upper part of forearm can be explained on the basis of haemodynamic mechanism between deep and superficial arteries in the forearm. Normally due to deep haemodynamic predominance, superficial terminal branches of radial artery undergo developmental arrest and deep part persists as normal radial artery.The superficial radial artery in right upper limb as seen in this case appears to be due to chance variations in haemodynamic factors which leads to regression of deeper vessels and persistence of one of the superficial terminal branches of radial artery. The early limb bud receives blood via inter segmental arteries, which contribute to a primitive capillary plexus. At the tip of the limb bud there is a terminal plexus that is constantly renewed in a distal direction as the limb grows. Later one main vessel supplies the limb and the terminal plexus; it is termed the axis artery.This avascular region contains an extracellular matrix consisting largely of hyaluronic acid. Removal of this hyaluronic acid by hyaluronidase results in vascularization of the tissue since partial degradation products of hyaluronic acid are angiogenic. Thus ectodermal-mesenchymal interactions and extracellular matrix components are controlling the initial patterning of blood vessels within the limb. In the upper limb bud the axis artery is derived from the lateral branch of the seventh intersegmental artery (subclavian). It is pertinentto mention here thatthe normal vascular development including the patterning of the blood vesselsis influenced greatly by local hemodynamic factors. Altered hemodynamic environment may give rise to variant patterning of blood vessels [16]. The developmental reason for the superficial ulnar artery in the present case may be due to the ulnar artery establishing a connection with the axis artery in the arm.
CONCLUSION
Diagnostically these types of variations may disturb the evaluation of angiographic images. Knowledge of such variations has got clinical importance especially in the field of orthopedic, plastic and vascular surgeries [11]. Also knowledge of these different variations is important for the clinicians in day to day practice for measurement of blood pressure using sphygmomanometer cuff in the arm. The knowledge of such variation is important for the diagnostic, interventional and surgical procedures. It may cause misinterpretation of angiographic images. Accidental puncture of superficially placed arteries may occur while attempting venae puncture. Anomalous origin of the radial artery may cause the failure of the radial approach of the coronary angiography and in the reconstructive surgery of the upper limb. When the superficial brachial artery persists it is more vulnerable to the accidental injuries. The superficially located artery increases the risk of heavy bleeding in unexpected situations.
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 allthose articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=736http://ijcrr.com/article_html.php?did=7361. M. Rodriguez-niedenfuhr1, T.Vazquez 2, L. Nearn 3 , B. erreira1, I. Parkin 4 And J.R. Sanudo (2001) Variations of the arterial pattern in the upper limb revisited: a morphological and statistical study, with a review of the literature. J. Anat. 199, pp. 547–566.
2. J. Gourassas (2003) Anomalous Origin of Right Radial Artery as a Cause of Radial Approach Failure of Coronary Angiography J Cardiol 44: 226-229.
3. O Okaro , B.C. Jiburum (2003) Rare high origin of radial artery : a bilateral symmetrical case. The Nigerian journal of surgical research vol.5 no 1-2 jan.-Junes; page- 70-72.
4. JE Waghmare et al (2009) A high origin of radial artery with asymmetrical vasculature of upper limbs: a case report. Nepal Med Coll J; 11(4): 284-286.
5. Konstantinos Natsis et al (2009) Study of two cases of highorigin radial artery in humans. Eur J Anat, 13 (2): 97-103
6. Dong Zhan et al (2010) High Origin of Radial Arteries: A Report of Two Rare Cases The Scientific World Journal; 10, 1999–2002.
7. Sharmila Bhanu P, Devi Sankar K Susan P (2010) High origin and superficial course of radial artery Case Report .International Journal of Anatomical Variations 3: 162–164.
8. Harbans Singh, Neena Gupta, Bargotra RN, NP. Singh (2010) Higher Bifurcation of Brachial Artery with Superficial Course of Radial Artery in Forearm. JK SCIENCE Vol. 12 No.1, January-March ; page 39-40.
9. Swaroop. N et al (2011) The High Origin of Radial Artery and its Clinical Significance. Anatomica Karnataka, Vol-5, (2) Page 32-35
10. Gh. Noditi et al (2011) Superficial Radial Artery: case report using MDCT angiography.Journal of Experimental Medical & Surgical Research. Pag. 202 – 205.
11. Venkata Ramana Vollala, Raghu Jetti Simmi Soni(2011) High Origin of An Ulnar Artery –Development and Surgical Significance .Chang Gung Med J Vol. 34 No. 6 (Suppl)page 39-42.
12. Sharadkumar Pralhad Sawant , Dr. Shaguphta T. Shaikh , Dr. Rakhi M. More (2012) .Variant Origin and Course of Ulnar Artery. International Journal of Modern Engineering Research (IJMER) available at www.ijmer.com. Vol.2, Issue.6, Nov-Dec. pp-4102-4104.
13. Chauhan K, Udainia A, Bhatt C, Patil D, Patel V and Prajapati B (2013) Morphological study of variations in branching pattern of brachial artery. Internat ional Journal of Basic and Applied Medical Sciences. (Online)Available at http:// www.cibtech.org/jms.htm Vol. 3 (2) May-August, pp.10- 15.
14. Chandrika Teli , Dr. Nilesh N. Kate , Dr. Paarthipan N (2013) High division and variation in brachial artery branching pattern. IOSR Journal of Dental and Medical Sciences available at www.iosrjournals.org. Volume 3, Issue 6 (Jan.- Feb 2013)., PP 68-70
15. Suat Keskin, Zeynep Keskin, M Akif Teber (2013) Common interosseous artery arising from the radial artery and ulnar artery origin from proximal brachial artery -case Report. Eur J Gen Med; 10 (Suppl 1):36-38.
16. Keith L.Moore, T.V.N. Persaud.The developing human – Clinically oriented embryology.Elsevier publications, 2008, 8th edition page no 371-374.
Abbreviations:
BA- Brachial artery, CT- Common trunk, PCHA- Posterior circumflex humeral artery ,PBA- Profunda brachii artery, RN – Radial nerve, SUCA – Superior ulnar collateral artery, UN – Ulnar nerve.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241620EnglishN2014October20HealthcareCOMPARISON OF TREADMILL VERSUS CYCLE ERGOMETER TRAINING ON FUNCTIONAL EXERCISE CAPACITY IN NORMAL INDIVIDUALS
English6165Zahara K. PolenEnglish Snehal JoshiEnglishBackground : There is an increasing awareness among the people about fitness and health. The bicycle ergometer and treadmill are the commonest forms of indoor aerobic exercises. Motor driven treadmill exercise is similar to walking or jogging or running depending upon the speed of the treadmill. In case of bicycle ergometer the amount of exercise can be controlled voluntarily by pedaling the cycle with predefined resistance. Aim of Study: The study was aimed at finding out the effects of these commonly used machines in gyms and in cardiovascular rehabilitation and comparing these effects. Methodology: type of study – experimental type. • Subjects were randomly allotted into two groups of 10 each. One group underwent treadmill training and the second group underwent cycle ergometer training for 30min, 3days per week for four weeks. The intensity of training was within 60% to 70% of age matched target heart rate(5) which was monitored using pulse oximeter.(12) • Shuttle walk test was admistered pre and post training and the results were recorded. • Vo2 was calculated using the formula (0.0289 *distance)+17.46.(6) • Results were analysed using paired t test for intra group analysis and unpaired t test for inter group analysis. Results: According to the study conducted the increase in shuttle walk distance and Vo2 values post treadmill training and cycle ergometer training were found to be extremely significant. No significant difference was seen between the improvements in two groups.Conclusion: Our study concludes that, treadmill and bicycle ergometer are equally effective in improving functional exercise capacity.
EnglishFitness, Aerobic exercises, Shuttle walk test, Vo2 values, Heart rate, Treadmill, Cycle ergometerINTRODUCTION
Physical fitness is a state of well-being with low risk of premature health problems and energy to participate in a variety of physical activities. Physical fitness is classified into health related and skill related categories. Health related fitness is the ability to perform activities of daily living without undue fatigue. Its components are cardiorespiratory endurance, muscular strength and endurance, flexibility and body composition. (1) Physical fitness is generally achieved through correct nutrition, exercise, hygiene and rest. To stay healthy, it is important to engage in physical activity. The primary recommendations from the ACSM and AHA regarding guidelines for physical activity suggest that all healthy adults aged 18 to 65 need moderate-intensity aerobic physical activity for a minimum of 30 minutes five days per week, or vigorous activity for a minimum of 20 minutes three days per week.(2) Aerobic exercise is associated with low-intensity, repetitive exercise of large muscle groups performed over an extended period of time. Aerobic exercise depends primarily on the aerobic energy-generating process. Aerobic refers to the use of oxygen to adequately meet energy demands during exercise via aerobic metabolism. This mode of exercise primarily increases muscular and cardiopulmonary endurance. Aerobic exercises include walking, cycling, jogging, running, swimming, skating, and skiing. Indoor aerobic exercises include treadmill, stationary bicycle, elliptical trainer, stair climbing, etc. (3) The bicycle ergo meter and treadmill exercises are the commonest to perform as indoor aerobic exercises. The motor driven treadmill exercise can be similar to walking or jogging or running if the speed of the treadmill motor is changed accordingly .Bicycle ergometer is exercise is similar to cycling. The intensity of exercise can be changed by varying the amount of resistance. There is an increasing awareness among the people about fitness and health. Healthy adults are being encouraged to exercise regularly to fight the effects of aging and avoid health problems. There has been a significant increase in the number of people joining health clubs, gyms and other fitness centers. A study was conducted which found that Values of HRmax were significantly higher on treadmill than cycle ergometer for each testing session. The subjects had significantly higher relative VO2max on treadmill than cycle ergometer for each testing session. (9) In a study conducted, it was found that ground walk training increased endurance walking capacity more than cycle training and was similar to cycle training in improving peak walking capacity, peak and endurance cycle capacity and quality of life. (10) This study was attempted to see whether treadmill training and cycle ergometer training improves functional exercise capacity and which of the two machines has a better effect, since both these equipments have their own advantages and disadvantages. The change in functional exercise capacity was indicated by shuttle walk distance and Vo2 consumed pre and post training.
MATERIALS AND METHODOLOGY
The project was sent to Ethical committee for approval and clearance was obtained. Healthy subjects between 18 to 24 years of age were selected. PAR-Q was administered to the subjects. The subjects were informed about the project and written consent was obtained. Study Type: Experimental Type. Inclusion Criteria: Healthy individuals of age group 18 to 24 years. Exclusion Criteria: Person with 1. Normal individual training in a gym or exercising regularly 2. A known Cardiac and Respiratory disorder 3. Any systemic Illness at the time of training and 4. Lower limb orthopaedic problems Materials used: Treadmill, bicycle ergometer, pulse oximeters to monitor heart rate during exercise, 10m track for shuttle walk test, shuttle walk test, audio CD, CD player, calculator, book and a pen.
METHODOLOGY
• Shuttle walk test was administered to each healthy subject and results were recorded.
• Subjects were randomly allotted into two groups. One group underwent treadmill training and the second group underwent cycle ergometer training for 30min, 3days per week for four weeks. The intensity of training was within 60% to 70% of age matched target heart rate(5) which was monitored using pulse oximeter.(12)
• At the end of four weeks, subjects were reassessed using shuttle walk test and the results were recorded.
• Vo2 was calculated using the formula (0.0289 *distance)+17.46.(6)
• The Shuttle Walk Test (SWT) is a submaximal, standardized, incremental walking test that measures functional capacity by exercising an individual to a symptom limited maximal performance.
This incremental exercise test requires patients to walk at increasing speeds back and forth a 10-m course. (6)
STATISTICAL TESTS
Results were analysed using paired t test for intra group analysis (i.e for pre and post effect of each) and unpaired t test for inter group analysis (i.e for pre and post effect of each).
RESULTS
On observational analysis it was seen that there was a significant increase in exercise capacity brought about by treadmill training protocol and cycle ergometer training indicated by the increase in shuttle walk test distance and Vo2 values post training protocol. There was no significant difference between the improvements in exercise capacity in treadmill as compared to bicycle ergometer.
DISCUSSION
The increase in shuttle walk distance and Vo2 values post training protocol on treadmill as well as cycle ergometer is due to the adaptations in skeletal muscle and bone, metabolic changes and cardiovascular adaptations that take place in the body following aerobic exercise and training. (7) Skeletal muscle adapts to endurance training chiefly through a small increase in the cross-sectional area of slow-twitch fibers, because aerobic activity primarily recruits these fibers. Endurance training also increases number of capillaries in skeletal muscle, thereby allowing a greater capacity of blood flow in the exercised muscle. (7) Significant metabolic adaptations occur in skeletal muscle in response to endurance training. Both the size and number of mitochondria increase substantially as does the activity of oxidative enzymes. Myoglobin content in the muscle is also augmented. Such adaptations combined with increase in capillary and muscle blood flow in the trained muscle, greatly enhance the oxidative capacity of endurance trained muscle. (7) After training, stroke volume is increased at rest, during submaximal exercise, and during maximal exercise; conversely, post training heart rate is decreased at rest and during submaximal exercise and is usually unchanged at maximal rates of work. The increase in stroke volume appears to be the dominant change and explains most of the changes observed in cardiac output. Arterial blood pressure at rest, blood pressure during submaximal exercise, and peak blood pressure all show a slight decline as a result of endurance training. (7) Body response to exercise depends on the type of exercise. Cardiovascular changes again depend on the type of exercise and severity of exercises. Cardiovascular responses differ in bicycle ergometer exercise and treadmill exercise as the method of exercise differs. Studies have shown that increase in heart rate was more in treadmill exercise compared to bicycle ergometer exercise. Systolic blood pressure increases more in treadmill exercise compared to bicycle ergometer exercise due to more sympathetic activation. (8) The study conducted also shows no significant difference between improvements in between the two groups that is treadmill and bicycle trained individuals. This is due to the fact that both types of exercises primarily focus on large muscles of the lower limb. Responses in the exercised muscle produce an effect on central circulation and leg blood flow. In both cases similar muscular and cardiovascular adaptations are produced responsible for the increase in shuttle walk distance and increased V02 value in both groups. Hence treadmill and bicycle ergometer can be interchangeably used for training.
CONCLUSION
The study shows that there is an extremely significant increase in exercise capacity brought about by treadmill training protocol indicated by the increase in shuttle walk test distance and Vo2 values post training protocol. The increase in exercise capacity post cycle ergometer training protocol was very significant as indicated by the increase in shuttle walk distance and Vo2 values. There was no significant difference between the improvements in exercise capacity in treadmill as compared to bicycle ergometer. Thus, it is concluded that, treadmill and bicycle ergometer are equally effective in improving functional exercise capacity.
CLINICAL IMPLICATION:
Since both treadmill and cycle ergometer are equally effective in improving functional exercise capacity, they can be used interchangeably or as per convenience. Treadmill can be used by younger individuals as it brings about higher energy expenditure as compared to bicycle. (11) Also walking is a familiar movement pattern as opposed to cycling. Since treadmill walking or running is in the weight bearing position it puts more stress on the joints especially the knees and may not be suitable in individuals with arthritis or injuries. Also it involves exercising on an unstable surface and can be hazardous for individuals with poor balance. Bicycle ergometer is a non weight bearing exercise and can be used in older individuals. Also it is a stable exercise. The increase in heart rate is also comparatively lesser than treadmill hence it is better for patients with cardiac conditions. However, it has a lower energy and caloric expenditure as compared to treadmill. (11) The advantages of Bicycle ergometer are that is more economic, occupies less space compared to treadmill and does not require electricity to run whereas treadmill does require electricity(8)
ACKNOWLEDGEMENT:
Authors would like to express their gratitude to the Principal and the staff of D.E.Society’s Brijlal Jindal College of Physiotherapy, Pune for their constant support and encouragement and for letting me use the college OPD and the college equipments. They are also thankful to the subjects of this study for their valuable participation. The authors of this study also acknowledge the great help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors/ editors/ publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Authors are grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=737http://ijcrr.com/article_html.php?did=7371. Dr Wener Hoeger, Sharon Hoeger Principles and labs for fitness and wellness, 12th edition.
2. American College of Sports Medicine ACSM’s Guidelines for Exercise Testing and Prescription 8th edition.
3. Carolyn Kisner, Lynn-Allen Colby Therapeutic exercise 5th edition, pages 165, 232-240.
4. Vanessa Noonan, Elizabeth Dean Submaximal Exercise Testing: Clinical Application & Interpretation Physical Therapy Journal, Vol 80, August 2000, pages 782-807.
5. W.D. McArdle, F.I. Katch and V.L. Katch Exercise Physiology 6th edition, Chap. 21.
6. Patricia J. Ohtake Field tests for aerobic capacity for children and older adults Cardiopulmonary Physical Therapy Journal, Vol 6 June 2005, pages 3-11.
7. Center for Disease control and Prevention CDC Physiological responses and long term adaptation to exercise Physical activity and health, chap. 3.
8. Dr R. Kisan, Dr S. Kisan, Dr Anitha, Dr Chandrakala Treadmill and bicycle ergometer exercise: cardiovascular response comparison Global Journal of Medical Research, Vol 12 June 2012, pages 23-25.
9. Fabien Basset, Marcel Boulay Treadmill and Cycle ergometer tests are interchangeable to monitor triathletes annual training Journal of Sports Science and Medicine (2003) 2, pages 110-116.
10. Leung, R.W.M. , Alison, J.A., McKeough, Z.J., Peters, M.J Ground walk training improves functional exercise capacity more than cycle training in people with chronic obstructive pulmonary disease (COPD): A randomized trial Journal of physiotherapy, Vol. 56 June 2010, pages 105-112
11. Anne Zeni, Martin Hoffman, Philip Clifford Energy Expenditure with Indoor Exercise Machines Journal of American Medical Association Vol 275, May1996, pages 1424-1427
12. Y. Iyriboz,S. Powers, J. Morrow, D. Ayers and G. Landry Accuracy of pulse oximeters in estimating heart rate at rest and during exercise Br J Sports Med 1991, pages 162-164
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241620EnglishN2014October20HealthcareBILATERAL RENAL ARTERY VARIATIONS - EMBRYOLOGICAL SIGNIFICANCE AND CLINICAL IMPLICATIONS
English6669Sujatha ManupatiEnglish Subhadra Devi VelichetyEnglish LalithaKumari M.K.English Sofia PeddityEnglishBackground: With increased incidence of kidney transplantation and related surgical procedures anatomical knowledge of renal artery variations is gaining importance. Normally a single renal artery supplies each kidney. Accessory renal vessels are the commonly seen renovascular variations. Materials and Methods: During routine dissection for 1st year undergraduate medical students in the Department of Anatomy S.V.Medical College, Tirupati, renal artery variations were observed in 24 formalin fixed cadavers (16 male & 8 female).The renal artery variations were identified and photographs were taken. Results: In the present study renal artery variations were observed in 03 cadavers (12.5%). Bilateral accessory renal vessels were observed in two cadavers (8.4%) and bilateral single renal artery with pre-hilar branching and double ureter is seen in one cadaver (4.1%). Conclusion: knowledge on renal artery variations are necessary during renal transplantations, urological procedures and for angiographic interventions.
EnglishRenal transplantation, Bilateral variations, Embryological significance.INTRODUCTION
Kidneys are the vital organs in the human body. They receive blood supply through renal arteries arising from the lateral sides of abdominal aorta below the origin of superior mesenteric artery. Near the hilum of kidney each renal artery divides in to anterior and posterior branches, which in turn divide in to number of segmental branches supplying different segments of kidney. Accessory renal vessels constitute the most common, clinically important vascular variant seen in one- third of population. Development of kidney is very complex, as it develops from the pronephros, mesonephros and metenephros. The pronephros and mesonephros regress but the arterial network to those segments may remain and lead to supernumerary renal arteries. In 70% of cases there is a single renal artery supplying each kidney and multiple renal arteries are unilateral in 30%of patients and bilateral in 10% of patients [1]. One or two accessory renal vessels are commonly seen, and are more common on left side. The knowledge of these variations in the renal arteries is important for urologists, radiologists and surgeons.
MATERIALS AND METHODS
A total of 24 formalin fixed cadavers used for routine 1st year medical students dissection in the Department of Anatomy, S.V.Medical college, Tirupati were observed for renal artery variations during the period of three years(2010 to 2013). Among the 24 cadavers 16 were male and 08 were female. During dissection of the abdomen Kidneys and surrounding structures were observed carefully for renal artery variations. The observed variations were carefully photographed and the findings were recorded.
RESULTS
In the present study out of 24 cadavers 03 cadavers presented renal artery variations. Bilateral accessory renal arteries were observed in three male cadavers (12.5%). In one cadaver the two renal arteries were arising directly from the abdominal aorta on both sides (Fig.1).In another case triple renal arteries on right side and double renal arteries on left side were noted with right testicular artery arising from the inferior renal artery on right side (Fig.2). In another cadaver one single renal artery was present on each side which further divided in to two branches and supplying the kidneys with bilateral double ureters (Fig.3).
DISCUSSION:
Knowledge of renal vascular variations is an essential prerequisite for diagnostic, endovascular and operative procedures in the abdomen. Any artery arising from abdominal aorta in addition to the main renal artery should be named as ‘accessory’ and those arising from a source other than the aorta should be called ‘aberrant’(2). Most of the abnormalities in the renal arteries are due to the various positions occupied by kidneys during their developmental ascent from pelvis to lumbar region (3). The metanephros is the functional kidney and to begin with it is located in the sacral region and it gradually ascends to upper lumbar region during 6th to 9th week of development. During its ascent its blood supply shifts from branches of internal iliac to common iliac artery and finally to the abdominal aorta. Origin of renal arteries from different sources and their frequent variations can be explained by the development of 20-30 segmental mesonephric arteries in the fetal life (4). Failure of degeneration of these primitive lower vessels in ectopic caudal kidney results in origin of more than one accessory and polar renal artery. Renal arteries are end arteries. If an accessory artery is ligated or damaged, the part of kidney supplied by that artery will be ischemic. Thus the embryology of renal vessels and its development is essential to understand variations and anomalies in renal arteries. Accessory renal vessels originate just above or below to the main renal artery. The accessory renal vessels may be 2-4 in number. Variation in the number of accessory vessels is due to the persistence of lateral splanchnic arteries (5). Normally, double renal arteries may coexist with other neurovascular variations, such as double renal vein, double ureter and persistence of foetal renal lobulations on the same or opposite side (6).But in the present study we observe accessory renal arteries with double ureter in one cadaver (fig.3)with abnormal origin of testicular artery from inferior right renal artery which is different from that reported in literature. Bilateral prehilar multiple branching of renal arteries, three right renal arteries with origin of right testicular artery from the inferior right renal artery and bilateral variant testicular arteries arising from the accessory reanal arteries were reported in literature (7,8,9). A 20% incidence of accessory renal arteries with a 15% unilateral and 5% bilateral was reported in literature (10).In the present study wereport12.5% (3/24 cases) incidence of accessory renal arteries that were bilateral. Hussein Muktyaz et al (11) based on their observations in 56 cases reported 39.2 % (22cases) incidence of renal arterial variations of which unilateral variations were observed in 10 cases (17.8%) and bilateral in 12 cases (21.4%). According to Irena Vilhova et al (12) the renal artery anomalies can be classified as follows
1. Triple renal arteries arising from the Aorta with different diameters entering the kidney through the hilum.
2. Double renal arteries originating from the Aorta with similar diameter entering through the hilum of the kidney.
3. Accessory renal arteries arising from the Aorta with the diameter of segmental arteries supplying one segment only, entering the kidney through the upper pole or lower pole or the hilum.
4. Perforating renal arteries arising from the Aorta or one of its major branches, diameter being subsegmental supplying one segment and entering the kidney outside the hilum.
In our study in one case double renal arteries (Fig.1) arising from the Aorta with 1 cm distance from each other with similar diameter entering through the hilum and upper pole of the kidney was observed corresponding to the 2nd variety described in literature (12). In other case (Fig.2) we observed a single renal artery arising as trunk which was further dividing in to two branches corresponding to 4th variant reported (12). One case in the present study (Fig.3) with bilateral double ureters represents 3rd variety reported in literature (12). Hemanth Kommuru et al (13), studied 182 kidneys. Among them 34 kidneys presented one additional artery and 18 kidneys showed two additional arteries. Extra artery was unilateral in 6 cadavers and bilateral in 20 cadavers. They also mentioned that in one of the cases the accessory renal artery was a branch of superior mesenteric artery. According to him bilateral accessory renal arteries are seen more in male cadavers and in our study also we observed in males only. Sarithaet.al.,(14), studied 25 cadavers and observed unilateral variations in one cadaver and bilateral in two cadavers. NeeleshKanaskar et al (15), reported a case ad-ditional renal arteries on the right side. Virendhrabudhiraja et al (16), studied 50 formalin fixed cadavers and reported prehilar branching in 11 cases, duplication of renal arteries in 8 cases (5 right & 3left) and superior polar arteries in 7 cases. Krunal Chauhan et al (17), studied 40 formalin fixed cadavers and observed renal artery anomalies in 20 cadavers (unilateral variations in 14 cadaver and bilateral in 6 cadavers).
CONCLUSION
Accessory renal arteries are end arteries. A good knowledge of the Anatomy and anomalies of renal vessels facilitates a safe approach to the kidney in trauma management and prevents damage of kidney in the surgeries. These variations are of utmost importance to the urologists, surgeons dealing with kidney transplantation and also for radiologists.
ACKNOWLEDGEMNTS
Authors would like to express their deep gratitude towards Professor and Head of Department of Anatomy Dr. Subhadra Devi Velichety.
Englishhttp://ijcrr.com/abstract.php?article_id=738http://ijcrr.com/article_html.php?did=7381. Standring S, Gray’s Anatomy, Basis of Clinical Practice. 40th Ed., Edinburgh, Churchill Livingstone. 2009; 1086-1089.
2. Graves FT. The aberrant renal artery. J. Anat 1956; 90:553- 58.
3. Satyapal KS, Haffejee AA, Singh B, Ramsaroop L et al. Ad- Satyapal KS, Haffejee AA, Singh B, Ramsaroop L et al. Additional renal arteries; incidence and morphometry. Surg Radio / Anat.2001; 23: 33-48.
4. Keith L Moore and Persaud TVN. The developing human. Saunders, an Imprint of Elsevier. 7th ed.293.
5. Hamilton WJ, Mossman HW. In Human Embryology; 4thed: McMillan Press, New York 1979; 392.
6. Surgical and Rad Anatomy, volume 26, number 6, pp.474- 479(6),December 2004.
7. Rao M, Bhat SM, Venkataramana V, Deepthinath R et al. Bi- Rao M, Bhat SM, Venkataramana V, Deepthinath R et al. Bilateral Prehilar Multiple branching of renal arteries. Kathmandu University Medical Journal. 2006; 4(3)15:345-48.
8. Nayak BS. Multiple Variations of the right renal vessels. Singapore Med J 2008; 49(6):e153.
9. Sylvia, SridharVarmaKakarlapudi,VenkataRamnaVollala,Bh agathkumar Potu et al. Cases Journal; 2009,2:114.
10. Dhar P, Lal K. Main and accessory reanl arteries A Morpho- Dhar P, Lal K. Main and accessory reanl arteries A Morphological study: Ital J Anat Embryo.2005; 110:102-110.
11. Hussein Muktyaz, HaqueMahboobul, Usman Nema, Has- Hussein Muktyaz, HaqueMahboobul, Usman Nema, Hassan Khalid et al. Bilateral Variation of Renal artery and Its Clinical Significance in North Indian Population. Innovative Journal of medical and health seience 3: 3may –june. (2013) 121-123.
12. Anson BJ, Kruth LE. Common variations in the renal blood supply. SurgGynecol Obstet.1955; 100:157-62.
13. HemmanthKommuru, Sreelekha D, Jothi S.S., RajeswaraRoaN,Sujatha N. Presence of Renal Artery Variation And Its Surgical Correlation. International Journal of Clinical and Medical Research, 2012; 3(5):176-79.
14. S.Saritha, Naga Jyothi, M. Praveen Kumar, G.Supriya. Ca- S.Saritha, Naga Jyothi, M. Praveen Kumar, G.Supriya. Cadaveric study of accessory renal arteries and its clinical correlation. International journal of Research in Medical Sciences. 2013; 1(1): 19-22.
15. Dr. Neelesh Kanaskar, Dr Vaishali Paranjape, Dr. Jyothi kulkarni, Sapna Shevade. Double accessory right renal arteries. Journal of Dental and Medical Sciences 2012; 1(5):17-20.
16. Budhiraja.V., Rastogi R., Asthana A.K Folia Morphol (war- Budhiraja.V., Rastogi R., Asthana A.K Folia Morphol (warsz), 2011;70(1),24-28.
17. Krunal Chauhan, Shweta J. Patel, Rashvaita K Patel, Mehta C.D and Maunil Desai. Variant origin of renal arteries and its clinical implication. jounal of surgery 2013;.2(2);7-12.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241620EnglishN2014October20HealthcareBODY DONATION AND EFFECT OF AWARENESS CAMPAIGNS IN MUMBAI REGION
English7073Sunil J. PundgeEnglish Pankaj WadekarEnglish Suresh GanganeEnglish Shabana BorateEnglishThe body donation is honorable and gracious act which helps society in many ways. The study of anatomy is important and done by dissection of human bodies. Anatomy is the subject which deals with structure of the human body. Anatomy is important basic subject for medical students, both Under Graduate (U.G.), Post Graduate (P.G.) and teaching faculties for conduction various workshops. Cadaveric dissection remains an important tool for learning anatomy. In Maharashtra the Anatomy Act was adopted as Bombay Anatomy Act 1949 which helps to obtain the bodies in medical institutions. It is said that, the demand for cadavers remains strong, and numerous ideas have been voiced to augment the supply. In Mumbai region various non-government organizations help in body donation by arranging various awareness camps. In this article the data of Grant Government Medical College is used to the effect of awareness camps on body donation. If we go through the data, it can be clearly said that due to awareness there is increase in numbers of body donation. In this article, the brief of history, the various anatomical acts, the tools to increase body donation, importance of body donation and some steps are suggested to create awareness in common people regarding body donation. The decision to donate one’s body for anatomical learning and research is one, which should not make hastily but should be based upon sound reasons and convictions.
EnglishBody donation, Cadaveric dissectionINTRODUCTION
Donation means something given for charity purpose to benefit a cause. According to Delmas (2001), donation is a clear will made by people free and informed. At Paris in 1953 a body donation center was created to obtain bodies for dissection. (1) Anatomy is the subject which deals with structure of the human body. Anatomy is important basic subject for medical students, both Under Graduate (U.G.), Post Graduate (P. G.) and teaching faculties. Aside from bodies being dissected in the anatomy classes, cadavers are also used for practicing surgical skills and developing new technique in various hands-on workshops. (2) Various courses which come under Maharashtra University of Health Sciences like Bachelor of Medicine Bachelor of Surgery (MBBS), Bachelor of Dental Surgery (BDS), Ayurved, Homeopathy, Unani, Physiotherapy and Occupational therapy in which thousands student take admission every year. They have to study Anatomy in first year. Dissection on human cadavers is best method of learning Anatomy, which remains principle teaching tool.
HISTORY
According to Indian mythology the first instance of Body Donation was that of Rishi Dadhichi. He donated his living body (during his life time) to Devraj Indra, for preparation of auspicious weapons out of his bones. These pious weapons defeated the enemy Daitya Vritasur. History of body donation can be traced long back in the ancient India, Shuhruta dissected human body in about 500 Before Christ (BC). In Europe the concept of human body dissection was started in 15th century where barbersurgeons used to demonstrate human structures at the professors command. Andreas Vesalius (1514-1564) was the first medical student to dissect human body and also continued as Professor. (3) In late 18th and early 19th centuries United State Medical Education was used bodies of slave and theft by grave robbers to meet demand. (3) In United Kingdome, the Murder Act 1752 permitted the use of corpses of executed criminals for dissection. However due to increased demand for cadavers for medical science, the Anatomy Act was passed in Massachusetts of America in 1831. In 1832 Anatomy Act was passed in United Kingdome (U.K.), which permitted the donation of the body of the deceased by his kin. (4)
Current Scenario in Mumbai
Body donation was started in 70s and gradually becomes popular. Pioneer work was done by ‘Shishu Vihar’ a social organization in Bhavnagar at Gujarat. They motivate people to donate blood during lifetime and bodies after death. In 1938 blood donation and eye donation in 1968 was started by this organization.
Non-governmental organizations (NGOs) helping in Body Donation at Mumbai
1. Manav Jyot, Khurana Bhavan, Mulund, Mumbai - 400 080.
2. Snehada, Tagorenagar, Vikroli, Mumbai - 400 083.
3. Dadhichi Mandal, Vishnunagar, Dombivli, Mumbai - 421202.
These organization gives forms to the people for body and eye donation with instructions to fill, collect from them and send them to the Medical Colleges where body donation committees has been formed. The college registers their name, sends them a form with instructions for action at the time of death and one identity card which helps them to bring body. Also the college issues a letter of thanks.
Anatomy Act
In India, the Anatomy Act was enacted in 1948 to provide unclaimed bodies of deceased persons to hospitals and medical and teaching institutions for the purpose of anatomical examination and dissection. It has been uniformly adopted in all its states. (5) In Maharashtra (old Bombay State) the Anatomy Act was adopted as Bombay Anatomy Act 1949. According to section 5(1) and (2) of this act, ‘Where a person under treatment in a hospital whether established by or vesting in, or maintained by the State Government or any local authority, dies in such hospital or a person in a prison and his body is unclaimed, the authorities in charge of such hospital or prison shall with the least practicable delay report the fact to the authorized officer and such officer shall then hand over the unclaimed body to the authorities in charge of an approved institution for any therapeutic purpose or for the purposes of medical education or research including anatomical examination and dissection’. The section 5(3) of the law states that ‘Where a person having no permanent place of residence in the area where his death has taken place dies in any public place in such area and his body is unclaimed, the authorized officer shall take possession of the body and shall hand it over to the authorities in charge of an approved institution for the purpose specified in sub-section (1). The act was further amended by the state legislative council in 2000 to permit donation before death of one’s body or any part thereof, after death by a person, to a hospital, and medical & teaching institution for therapeutic purpose, medical education and research. (6) Whereas the Punjab anatomy Act 1963 makes provision for supply of bodies of deceased person to hospitals medical teaching institutes for therapeutic purposes or of anatomical dissections, surgical operations and research work. (7) The Mysore Anatomy Act, 1957 later amended as Karnataka
Anatomy Act 1998 by Karnataka state defines ‘unclaimed body as the body of a person who dies in a hospital, prison or public place or a place to which members of the public have access, and which has not been claimed by any person interested within such time as may prescribed.’(7)
Who can donate the body?
Anyone 18 years of age or older can donate his or her body. If it were known that the deceased had wanted to make a bequeathal of their body, but never got around to filing the paperwork during their lifetime, the gift (donation) could be made by their relatives after their death (unregistered).
MATERIALS AND METHODS
Anatomy is very important subject for all medical and paramedical students. The bodies mainly used in the Grant Government Medical College, Mumbai are from body donation. The ratio of the students: cadaver in this college is 1:12. The data is collected from Grant Government Medical College Mumbai since 2003. The yearly registration and received bodies. Again it is divided in male and female bodies received.
OBSERVATIONS AND RESULTS
The body donation is important for medical education, the number of person who chose to donate body remains low because of lack of awareness. The present study is under taken to show the results of increase in numbers of body donation as results of increase in numbers of body donation awareness camps. If we compare the data of Grant medical college year wise there is increase in the number of persons who wanted to donate the body and numbers of received bodies.
DISCCUSIONS
Body donation is very legal and generous act. Supplying human cadavers is left to the responsibility of others, notably the anatomy course instructors or school administrators. Along the side medical education providers, a large number and wide range of other users are also trying to secure cadavers for their own needs. A good cadaver is one, not obese or evidently not diseased. (8) It is said that, the demand for cadavers remains strong, and numerous ideas have been voiced to augment the supply. As an illustration, there is an ongoing debate about the impact of using financial incentives for donors or their families to encourage anatomical donations. (9) The situation is equally affected in India, too. In a survey carried out by Shrikant A. Rokade et al in some of the medical colleges in Maharashtra (India), a gross insufficiency of cadavers was found in 90.90% of medical colleges. These include not only the colleges run by private managements but also those run by the state and central governments. 18.18% of the surveyed colleges did not receive a single cadaver by donation in last 5 years. In 63.63% of these colleges, the numbers of cadavers available were less than half of the requirement during 2006 to 2010. (10) There has been lot of resistance towards body donation. For the creation of awareness we need help of NGOs to organize the body donation camps. These camps are interactive and peoples should be answered thoroughly till they satisfied. The ‘holy’ dimension of the word ‘donation’ may be stressed during these campaigns. Some authors like Alashek et al (2009) suggested that the public educational campaigns should be coordinated with religious leadership. (11) Handbills written with body donation information also distributed in these camps. We can use other influential mediums like television, radio, newspapers. Give body donation information through Ganseh mandals / Navrathri mandals. Suggested steps to promote body donation Treat the body with utmost respected in front of the relatives by careful handling. Issue the body donation certificates to next of kin to express gratitude towards them for donating body. Provide assistance to relative in medical aid when they visit the hospital next time. Don’t delay them for completing the formalities. Don’t discourage them by saying there is no place to store body etc instead accept the body and keep it, the body may be transferred to any other college who needs. Provide proper and immediate storage facilities for preservation of the body some medical colleges tell the relatives to get body only during working hours and to preserve the body in private cold storages thereby causing financial burden to the relatives. We should give public recognition to the motivators who help in body donation.
CONCLUSION
The body donation is the ultimate gift to fulfill one’s life. It is charitable and altruistic for those who want to make use of their body even after death. These donors will help the medical students, teaching staff and practicing doctors for learning and research. Donation of the bodies after death should be encouraged and people should be motivated to make this a habit.
ACKNOWLEDGEMENT
The authors are grateful to Late Dr. P. C. Champaneri. 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=739http://ijcrr.com/article_html.php?did=7391. Delmas: Donation of bodies to science: Bull Acad Natl Med. 2001;185(5):849-56.
2. Bunprasert T. The new potential of surgical training: surgical training centre. Chula Med J 1998;42:413-5.
3. Rath G, Garg K. Inception of cadaver dissection and its relevance in present day scenario of medical education. Indian J Med Asso 2006;104(6):331-3.
4. Anatomy Act 1832. Available at http://en.wikipedia.org/ wiki/Anatomy _Act_1832. Accessed on 15 May 2011
5. Ajita R, Singh YI. Body donation and its relevance in anatomy learning- a review: JASI 2007; 56(1):44-7.
6. Bombay Act No. XI of 1949 (The Bombay Anatomy Act, 1949). Available at http://bombayhighcourt.nic.in/ libweb/acts/1949.11.pdf.
7. Ajita R, Singh YI. Body donation and its relevance in anatomy learning- a review.:JASI 2007; 56(1):44-7.
8. Agthong S., and V.Wiwanitkit, .Cadaver donation: A retrospective review at the King Chulalongkorn Memorial Hospital, Bangkok: The Southeast Asian Journal of Tropical Medicine and Public Health. 2002; 33:166-167.
9. Megan Clay and Walter Block “A Free Market for Human Organs.” Journal of Social, Political & Economic Studies. June 2002; 27(2):227-236.
10. Rokade SA, Bahetee BH. Body donation in India: a review. Int J Res Med Sci 2013;1(3):173-7.
11. Alashek W, Ehtuish E, Elhabashi A, Emberish W, Mishra A. Reasons for unwillingness of Libyans to donate organs after death. Lybian J Med 2009;4(3):110-3.
12. Patnaik, V.V.G.: Editorial J Anat Soc India.2002; 50(2):143- 144.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241620EnglishN2014October20HealthcareROLE OF MANTOUX TEST IN DETECTING TUBERCULOSIS IN TUBERCULOSIS SUSPECTS
English7476Supriya PandaEnglish S. SaraswathiEnglish K. Bhaskara RaoEnglish R. Sarath BabuEnglish D. Vijaya BharathiEnglish B. P. L. PremanandiniEnglishObjectives: To know the role of Mantoux test in detecting tuberculosis in tuberculosis suspects attending to MIMS General Hospital, Nellimarla, Vizianagaram.Methods: A total of 445 tuberculosis suspects between the age group 2 year to 70 year from rural area after taking written consent were included in the present study for a period of 1 year from April 2012 to March 2013.Inclusion criteria were smear negative & Chest X ray negative cases. Exclusion criteria were HIV infection & other immunosuppressive conditions. Mantoux test was done by injecting 0.1 ml of 5 TU PPD (Span) intradermally into the volar aspect of left forearm. The skin area free of lesions and away from veins was chosen. The injection was made by 1/4th to 1/2 inch 27 gauge needle and a tuberculin syringe so that an elevation of 6-10 mm was produced. Tests were read between 48-72 hrs after injection. The diameter of the indurations was measured transversely along the long axis of forearm.
Results: Out of 445 cases, 295 cases were positive (66.3%) having indurations of more than or equal to 10 mm. It was positive
in 88.23 % in children in 2-5 years age, 78% in females and 60% in males.
Conclusion: In the present study Mantoux test was positive in 66.3% of sputum smear & chest X ray negative tuberculosis
suspects in comparison to 30-40% in general population of India. So it has a role in detecting extra 26% of infection with M.
tuberculosis in this group.
EnglishMantoux test, Tuberculosis suspectsINTRODUCTION
Tuberculosis suspect means when a diagnosis of tuberculosis is being considered, whether or not treatment has been started, until the diagnostic procedures have been completed. The Tuberculin Skin Test is the only proven method for identifying M. tuberculosis infection. Although it is less than 100 % sensitive and specific, it gives a high positive predictive value in population with high prevalence of M. tuberculosis infection (1). It is less sensitive but more specific compared to gamma interferon assay (2). It is currently the only widely used method for identifying latent tuberculosis infection and tuberculosis in not clinically active cases.
AIM OF THE STUDY:
To know the role of Mantoux test in detecting tuberculosis in tuberculosis suspects attending to MIMS General Hospital, Nellimarla, Vizianagaram.
MATERIALS AND METHODS:
This is a retrospective study. Study group: A total of 445 tuberculosis suspects between the age group 2 year to 70 year from rural area after taking written consent. Study period: for a period of 1 year from April 2012 to March 2013. Inclusion criteria: smear negative & Chest X ray negative cases. Exclusion criteria: HIV infection & other immunosuppressive conditions. Mantoux test: It was done by injecting 0.1 ml of 5 TU PPD (Span) intradermally into the volar aspect of left forearm. The skin area free of lesions and away from veins was chosen. The injection was made by 1/4th to 1/2 inch 27 gauge needle and a tuberculin syringe so that an elevation of 6-10 mm was produced. Tests were read between 48-72 hrs after injection. The diameter of the indurations was measured transversely along the long axis of forearm. (1).
RESULTS
DMC data from April 2012 to March 2013--TB suspect screened were 1044 cases (which includes 144 cases of extra pulmonary tuberculosis). Out of them sputum smear positive were 80 cases and chest X ray positive were120 cases. We have done Mantoux test in 475 patients. Out of them 30 patients did not turn up & were excluded from the study. Out of 445 patients included in the present study, 224 cases were children between 2-13 years age, 221 cases were adults between 14-70 years age, 249 cases were outpatients and 196 cases were inpatients; and 290 cases were female and 155 cases were male. The Cut-off for Mantoux test was 10 mm indurations (1). Out of 445 cases, 295 cases were positive (66.3%) having indurations of more than or equal to 10 mm. It was positive in 88.23 % in children in 2-5 years age, 78% in females and 60% in males. We have observed 10-15 mm indurations in 84 cases, 16-20 mm indurations in 50 cases, 21-25 mm indurations in 126 cases and 26-30 mm indurations in 35 cases. We did not notice any vesicle formation. All 30 positive cases in 2-5 yrs age had indurations of more than15 mm.
DISCUSSION
Immunological basis of Tuberculin Reaction: It is a delayed type of hypersensitivity reaction. Sensitized T-lymphocytes are recruited to the site where they release lymphokines. Lymphokines induce indurations through local vasodilatation, edema, fibrin deposition and recruitment of other inflammatory cells to the area. Essential feature are-- 1. Its delayed course reaching a peak after 24 hrs. 2. Its indurate character. 3. Its occasional vesicle formation & necrosis which does not correlate with active disease. Reaction begins 5-6 hrs after injection, causes maximal indurations at 48-72 hrs and subsides over a period of time; positive reaction often persists for up to 1 week. In elderly, positive reaction may not peak until after 72 hrs. Immediate hypersensitivity reaction to tuberculin or its constituents may occur and disappears by 24 hrs. But if the reaction is severe retesting should not be done. Cut-off: • A cut point of ≥ 10 mm is suggested as positive for individuals having normal or mildly impaired immunity in BCG-vaccinated high prevalence population. (3) • A cut point of ≥ 5 mm is suggested as positive for persons who are immune suppressed • (HIV infection, drugs).
BCG vaccination:
• Post vaccination BCG induced tuberculin reactivity ranges from 0-19 mm indurations. In community based study there is no difference in prevalence of ≥10 mm indurations in BCG vaccinated and non vaccinated adolescents & young adults. Tuberculin test is not contraindicated and skin test results are used to support or exclude infection with M. tuberculosis. A positive tuberculin test after BCG vaccination does not predict its protective efficacy. (3,4).
In the present study:
The Mantoux test was positive in 66.3% of cases. In children 2-5 years of age, it was positive in 88.23 % of cases and all of them had indurations more than 15 mm. Reactions larger than 15 mm are unlikely to be due to previous BCG vaccination or exposure to environmental mycobacterium. (5).These children are at high risk for progression to active disease, with the potential for dissemination. (6).Although more number of females was screened, the test was positive in 60% of females compared to 78% in males. Inpatients had more positive reaction (79.6%) than outpatients (55.8%). There are various reports regarding tuberculin test results in individuals having tuberculosis. It has a reported false negative rate of 25% during the initial evaluation of persons with tuberculosis which appears to be due to poor nutrition, acute illness or immune suppression. (7, 8)
CONCLUSION
In the present study Mantoux test was positive in 66.3% of sputum smear & chest X ray negative tuberculosis suspects in comparison to 30-40% in general population of India. So it has a role in detecting extra 26% of infection with M. tuberculosis in this group. However further follow up to be done for these individuals and they should be evaluated and treated accordingly.
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=740http://ijcrr.com/article_html.php?did=7401. Nancy E. Dunlap, John Bass, Paula Fujiwara, Philip Hopewell, C Robert Horsburgh, Max Salfinger, Patricia M Simone. Diagnostic standards and classification of tuberculosis in adults and children. American J of Respiratory and Critical Care Medicine.2000; Vol. 161: p-1376-1395.
2. Sudha Pottumarthy, Arthur J Morris, Adrian C. Harrison and Virginia C. Wells. Evaluation of the Tuberculin Gamma Interferon Assay: Potential To Replace the Mantoux Skin Test. Journal of Clinical Microbiology: Oct. 1999; Vol. 37, No.10:p3229-3232.
3. Testing for Tuberculosis Infection and Disease. Chapter 3. Available at: http://www.cdc.gov/tb/education/corecurr/pdf/ chapter3.pdf.
4. The Role of BCG Vaccine in the Prevention and Control of Tuberculosis in the United States. Centers for Disease Control and Prevention (CDC), Mortality & Morbidity Weekly Report. April26,1996;Vol.45:No.RR-4. Available at:http://www.cdc.gov/mmwr/PDF/rr/rr4504. pdf
5. Surajit Nayak and Basanti Acharjya . Mantoux test and its interpretation. Indian Dermatology Online Journal. 2012 Jan-Apr; 3(1): 2–6. doi: 10.4103/2229-5178.93479 PMCID: PMC3481914.
6. Comstock, G. W., V. T. Livesay, and S. F. Woolpert. The prognosis of a positive tuberculin reaction in childhood and adolescence. American Journal of Epidemiology. 1974; Vol. 99, No 2: p131-138.
7. Holden, M., M. R. Dubin, and P. H. Diamond. Frequency of negative intermediate-strength tuberculin sensitivity in patients with active tuberculosis. N. Engl. J. Med. 1971; Vol.285:p1506–1509.
8. Tuberculosis Control in India. Directorate General of Health Services, Ministry of Health and Family Welfare, New Delhi; 2005. Available at: http://www.tbcindia.nic.in/pdfs
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241620EnglishN2014October11Healthcare
A Study of Association of Vitamin D Deficiency and Pelvic Organ Prolapse in Postmenopausal Women
English7779S AdarshEnglish K S SharadhaEnglish
Background: Vitamin D is essential for maintaining the integrity of the skeleton as well as proper functioning of the muscles. Postmenopausal women have a significantly increased risk of developing vitamin D deficiency and pelvic organ prolapse, which begs the question of whether or not these two conditions are connected. Aims and Objectives: To study the association of vitamin D deficiency and pelvic organ prolapse in postmenopausal women. Materials and Methods: This study was done in the Department of OBG along with the help of the Department of Orthopedics, Kamineni Institute of Medical Sciences, Andhra Pradesh. The study was done from Oct 2012 to Oct 2013. The recruitment of 60 women with POP and 60 controls took place over the course of two years in a row, during the sun-deprived winter months of November through April. Result: Our study revealed a significant association between vitamin D levels and POP in postmenopausal women. Conclusion: Highly significant relation between Vit D deficiency and prolapse was observed.
EnglishPelvic organ prolapse, POP-Q classifcation, Vitamin D, Postmenopause, Significance, Studyhttp://ijcrr.com/abstract.php?article_id=4704http://ijcrr.com/article_html.php?did=4704
1. Barber MD, Maher C. Epidemiology and outcome assessment of pelvic organ prolapse. Int Urogynecol J. 2013;24:1783–90.
2. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol. 1997;89:501–6
3. Epstein LB, Graham CA, Heit MH. Systemic and vaginal biomechanical properties of women with normal vaginal support and pelvic organ prolapse. Am J Obstet Gynecol. 2007;197(2):165. e1-6.
4. Bischof HA, Borchers M, Gudat F, et al. In situ detection of 1,25-dihydroxy vitamin D3 receptor in human skeletal muscle tissue. Histochem J. 2001;33:19–24.
5. Lips P, Binkley N, Pfeifer M, et al. Once-weekly dose of 8400IU vitamin D compared with placebo: efects on neuro-muscular function and tolerability in older adults with vitamin D insufficiency. Am J Clin Nutr. 2011;91:985–91.
6. Janssen HC, Samson MM, Verhaar HJ. Vitamin D defciency, muscle function and falls in elderly people. Am J Clin Nutr. 2002;75:611–5.
7. Badalian SS, Rosenbaum PF. Vitamin D and pelvic foor disorders in women. Obstet Gynecol. 2010;115:795–803.
8. Parker-Autry CY, Markland AD, Ballard AC, Downs-Gunn D, Richter HE. Vitamin D status in women with pelvic floor disorder symptoms. Int Urogynecol J. 2012;23:1699–705.
9. Holick MF. High prevalence of vitamin D inadequacy and implications for health. Mayo Clin Proc. 2006;81:353–73.
10. Lips P, Hosking D, Lippuner K, et al. The prevalence of vitamin D inadequacy amongst women with osteoporosis: an international epidemiological investigation. J Intern Med. 2006;260:245–54.
11. Souberbielle JC, Body JJ, Lappe JM, et al. Vitamin D and musculoskeletal health, cardiovascular disease, autoimmunity and cancer: recommendations for clinical practice. Autoimmun Rev. 2010;9:709–15.
12. Persu C, Chapple CR, Cauni V, Gutue S, Geavlete P. Pelvic Organ Prolapse Quantification System (POP-Q) – a new era in pelvic prolapse staging. J Med Life. 2011;4:75–81.
13. Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic foor dysfunction. Am J Obstet Gynecol. 1996;175(1):10–7.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241620EnglishN2014October11Healthcare
A Study of Skill Lab Training vs Clinical Practice of SeA Study of Skill Lab Training vs Clinical Practice of Seeing and doing to Learn Common Surgical Skillseing and doing to Learn Common Surgical Skills
English8082S AdarshEnglish K S SharadhaEnglish
Introduction: There is a lack of research on the long-term effectiveness of skills lab training, despite the fact that its benefits are widely acknowledged. As a result, we decided to conduct a prospective, randomized controlled trial to investigate whether or not students who were taught according to a “best practise” model (BPSL) performed one skill of different suturing in a simulated setting better than students who were taught with a traditional “see one, do one” teaching approach (TRAD), with a follow-up period of either three or six months. Aims and Objectives: To Study and understand Skill lab training Vs Clinical practice of seeing and doing to learn common surgical skills. Materials and Methods: This study was done in the Department of OBG along with the help of Department of Orthopedics, Kamineni Institute of Medical Sciences, Andhra Pradesh. The study was done from Oct 2012 to Oct 2013. Results: Significant difference seen between the two groups Conclusion: Skills lab teaching seems to be particularly helpful for the reproduction of easier skills.
EnglishSkill lab, Training, Clinical practice, Seeing and doing, Surgical, Skillhttp://ijcrr.com/abstract.php?article_id=4705http://ijcrr.com/article_html.php?did=4705
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