Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241615EnglishN2014August10Evaluation of results of Open Reduction and Internal Fixation with Dynamic Condylar Screw in management of fracture distal third femur
English0105Ramavtar SainiEnglish Rakesh Kumar MishraEnglish Anamika VyasEnglishIntroduction: Fractures of distal third femur may present difficulties in their treatment and require careful management to obtain good cosmetic and functional results. In recent years greater advances have been made in understanding the technique of internal fixation. Over the time different type of implants angle blade plate, rush rod, enders nail have been used for the fixation of these fractures. These devices are technically demanding and none of them can provide interfragmentary compression across intercondylar fracture surface. However it is documented that dynamic condylar screw can solve these problems with added advantages of early functional rehabilitation of knee, stable internal fixation and maintenance of joint congruity.
Aim: The study was conducted to evaluate the results of dynamic condylar screw in management of fracture distal third femur in adults, at the same time comparing the results with other studies. Materials and Methods: The study was conducted on 30 patients of fractures of distal third femur treated by open reduction
and internal fixation with dynamic condylar screw with a post operative follow up of one year. Releavant parameters like time of union, range of movements at knee and complication associated with these fractures treated with dynamic condylar screw were recorded. Schatzker and Lambert criteria were used to grade the result.
Results: Out of 30 patients, 26 (87%) were male and 4 (13%) were female. The cause of injury was road traffic accident in 27 (90%) cases. Average time of union was 15 weeks. In 21 patients (i.e. 70%) the range of movement of knee was 110° on above.
Two patients (7%) had non union. There were 4 patients (13%) with knee stiffness and two (7%) with limb shorting up to 1.5cm.
Infection was also noted in 2 patients (7%). The surgical outcome was excellent in 12 patients (40%), good in 9 patients (30%), fair in 5 patient (17%) and poor in 4 patient (13%).
Conclusion : The dynamic condylar screw is an easy, technically less demanding and effective method for treatment of fracture distal third femur.
EnglishFracture, Femur, Dynamic Condylar Screw (DCS), managementINTRODUCTION
The incidence of distal femoral fractures is 4-7% of all femur fractures.1,2 There is a bimodal distribution of fractures based on age and gender. Most high energy distal femur fractures occur in males of younger age, while most low energy fractures occur in elderly osteoporotic women. The most common high energy mechanism of injury is a road traffic accident and the most common low energy mechanism is fall at home. Fractures of distal femur are difficult to treat because of unstable fracture pattern and comminution. These fractures are in proximity to the knee joint contributing to functional rehabilitation of knee difficult. Till 1960, these fractures used to be treated non-operatively (Traction & Cast bracing) because of lack of adequate internal fixation devices. With development of improved internal fixation devices by AO group in 1970, a new era began in which operative methods proved their significance in management of distal femoral fractures. Thus the trend changed towards operative management of distal femoral fractures in 1980s.3-7 While treating any fracture the goal of operative management is to restore the limb function. Anatomical articular reduction, stable fixation, gentle tissue handling and early mobilization are some key factors to achieve this goal. The limiting factors are osteoporosis, small distal fragment and amount of soft tissue damage. Open reduction and internal fixation has been advocated using various implants including Angle blade plate, Zickle device, Rush rod, Enders nail, but these devices are technically demanding and none of them can provide inter fragmentary compression with good purchase in osteopenic bone. No implant can stabilize every fracture type, but the device chosen must provide fixation rigid enough for early mobilization for best result. Dynamic Condylar Screw (DCS) is a better implant to achieve the goals of operative management of distal femoral fractures. The advantage of DCS over others are the leg screw supplies not only interfragmentary compression across the intercondylar surfaces but also better purchase in osteopenic bone. The stability provided by this device allow early aggressive restoration of knee motion and muscle power.8,9,10 DCS shares many of the features of a compression hip screw. Since most of the orthopaedic surgeons are already familiar with use of a compression hip screw in the management of hip fractures, the instrumentation is easily mastered. It was against the above back drop that the present study was conducted to evaluate the results of Dynamic Condylar Screw (DCS) in fractures of distal third femur in adults.
Materials and Methods
The present study was conducted at Department of Orthopaedics, of a tertiary care hospital with a one year follow up post operatively. The study group consisted of 30 cases of fractures of distal third femur in age group of 18 years and above of either sex, treated with Open Reduction Internal Fixation (ORIF) with Dynamic Condylar Screw (DCS). Despite that the operative management was a part of patients treatment protocol, informed consent was taken after explaining the procedure to the patients in local language. Beside, permission was obtained from Institutional Ethics Committee for approval of the study. Fractures were classified according to the AO system (Muller et al)11 and consisted of 10 type A (3A1 ,3A2 ,4A3 ) and 20 type C (7C1 , 7C2 ,2C3 )fractures. Patients with lower diaphyseal fractures of femur, pathological fractures, active infection anywhere in body and medically unfit patients were excluded from the study. After admission all patients were evaluated as per trauma management protocol and initial resuscitation if required was performed. Detailed history about mechanism and type of injury was obtained. Thorough physical examination of the patients was performed. Local examination of injury including nature of fracture, status, whether closed or compound, deformity, condition of proximal and distal joints and associated injuries was performed. As a part of management of open fractures, initial irrigation, debridement, intravenous antibiotic, proximal tibial pin traction and delayed wound closure was done. Radiological examination of fractured site obtaining AP and lateral views with joint above and below the fracture was performed. From the initial radiographs, the fractures were classified according to AO system (Muller et al).11 All patients received prophylactic antibiotic (IVceftriaxon) and the same antibiotic was given intravenously for three days post operatively, followed by oral form and analgesics as per ward protocol (i.e. till stitch removal on 14th day). All patients were operated under general/ spinal anaesthesia and DCS was inserted as per standard protocol. In all patients passive range of motion exercises of knee joint were started on 3rd post operative day followed by active range of knee movements at 14th day after removal of stitches. Patients were instructed to only toe touch weight bearing for first six weeks. During this period patients were advised to wear hinge knee brace and to do knee bending, quadriceps and hamstrings exercises at home. Partial weight bearing was permitted after reviewing x-ray at six weeks.
After discharge from the hospital, these patients were called for follow up at forth, sixth, twelfth week and then monthly for six month and every three months till one year post operatively. Check x-rays were taken in immediate post operative period and on follow up visits. Any complication if encountered was recorded. During follow up visits clinical and radiological union was assessed. On clinical examination if fracture site was stable and pain free, clinical union was considered satisfactory. Radiological union was considered satisfactory when plain x-ray showed bone trabeculae or cortical bone crossing the fracture site. Full weight bearing was permitted only when signs of radiological union were present. All the patients had their final assessment at one year. Assessment of results was done with the criteria laid down by Schatzker and Lambert (1979)6 for Supracondylar fractures, as given below.
Result
In the present study fractures were more common in age group 18-40yrs and males (87%) out numbered females (Table 1). 22 patients had fractures on right side and 8 patients on left side. 21 fractures were closed and nine were open fractures. In 27 cases (90%) the mode of injury was road traffic accidents, remaining 3(10%) sustained injuries due to domestic fall. 13 cases (43%) were with associated injuries. The range of movement was more than 110° in 21 cases i.e. (70%) (Table 2). 22cases (73%) achieved union between 12-16 weeks (Table 3). The average time taken for union in all cases was 15 weeks. The most common complication was knee stiffness (13%), followed by loss of length (< 1.2 cm) (10%) (Table 4). To assess the outcome of treatment criteria laid down by Schatzker and Lambert et.al 19796 were used (Table-5). Excellent to good results were obtained in 21cases (70%).
Discussion
Fractures of distal femur are always regarded with great concern because of their proximity to knee joint. These fractures demand expertise and sound judgement on the part of surgeon.12 Non operative methods of treatment have been used traditionally for these injuries, using tibial traction. As a consequence of non operative management, confinement to bed for prolonged periods resulted in complications in the form of mal-union, shortening and stiffness of knee joint.13 Dissatisfied with the results of traditional methods of treatment orthopaedic surgeons started looking for newer ways of treatment. Over the time, with the introduction of various implants (fixation devices) along with surgical principals for fixation techniques as outlined by AO/ASIF group the results of operative management for fracture distal third femur has improved significantly. Operative treatment attains restoration of limb length, rotation and axial alignment, stable fixation, and early motion14. Multiple surgical treatment options exist for fractures of distal third femur but controversy remain regarding the optimum fixation device.6,15,16 Selection of appropriate implant is determined on the basis of the fracture pattern, the condition of soft tissues ,the need of the patient, and the preference of the surgeon.
Various accepted methods of treatment have their pros and cons and all the problems associated with management of distal femur fracture cannot be solved by a single method of treatment. The DCS is an effective method of treating supracondylar & intracondylar fractures of femur with a wide range of advantages.17, 18. In our study the fractures were more common in age group 18-40 years. As these are the most active and productive years of life, people in this age group are involved in outdoor activities and therefore more prone to road traffic accidents and other injuries. Males (87%) outnumbered females (13%) in our study. This is because of male dominated society with less active participation of females in day to day activities especially outside the house in our region. Road traffic accidents (RTA) were responsible for most of the cases (90%). Similar finding was also reported by marya et al.19Advances in mechanization, acceleration of travel, increase in number of high velocity automobile vehicles, over populated cities are few reasons for increased RTA. In present study 13 (43%) patients had associated injuries. This is because RTA was the major cause of fractures in which there are more chance of associated injuries. None of the patients were operated in first 24 hours because of non availability of implant in emergency, financial issues and heavy work load in orthopaedic unit. According to Schatzker and Lambert criteria, results were graded as excellent in 12 (40%) patients, good in 9 (30%), fair in 5 (17%), and poor in 4 (13%) patients. Christodoulou et al.20 reported excellent results in 19 (51%), good in 11 (30%), moderate in 4 (11%) and poor in 3 (8%) in total 37 patients. M. Ayaz et al.21 reported excellent results in 18 (60%), good in 6 (20%), fair in 5 (17%) and poor in 1 (3%) in total 30 patients. In a total of 35 patients Ali I et al22 reported excellent results in 20 (57.14%), good in 6 (17.14%), moderate in 3 (8.07%) and poor in 6 (17.14%) patients. Preponderance of comminuted (type c) fractures in the study group, improper fixation due to complexity of comminution, delay in surgery, poor compliance of patients for post operative physiotherapy were few culprits for poor result. Average time of union in our study was 15 weeks. Few other studies reported the average time of union ranging between 12-20 week17, 18, 20, 22, 23. This variation reported might be due to differences in post operative mobilization protocol and criteria for union. In 22 patients (77%) complete weight bearing was allowed between 12-16 weeks, in 6 cases between 17-20 weeks. Sherwing et al18 showed better result by early weight bearing in third week of operation. Present study did not follow this protocol, complete weight bearing was permitted only after radiological union. 2 cases (7%) of non union were observed in our study which were treated by autologous bone grafts without exchange of implants. Fu et al23 and christodoulou et al.20 reported 7% and 6% non union rate. The rate of infection in our study was 7% (2 cases).Both the cases were open fractures managed by debridement and antibiotics. The reported rate of infection is 0-8%, in other studies.17,18,20-24 There were 3 cases of limb shortening (10%) up to 1.5cm. The shortening was intentional, in order to get stable fixation in comminuted fractures. Although much attention was given to the range of knee movements in the follow up period still knee stiffness (less than 90° of flexion of knee joint) was observed in 4 cases (13%). Two of these patients were having degenerative changes due to osteoarthritis and were reluctant to do exercises due to pain and rest two did not follow instructions regarding knee exercises and were lost to follow up for first three months. The overall union rate was 93% which is comparable with other studies.17,20,21,23
Conclusion
From the present study it was concluded that Dynamic condylar screw is an easy, technically less demanding method of treatment of supracondylar and intracondylar fracture of femur in adults if followed by controlled rehabilitation programme. The problems encountered in the study also focuses on importance of thorough preoperative planning, meticulous attention to intra operative details such as careful handling of soft tissue, anatomical reduction of articular surfaces and bone grafting where needed and correct application of stable internal fixation.
Acknowledgement
We are grateful to Prof. Dr. R.N.Laddha, for his guidance, expertise and valuable suggestions throughout the study. Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors /publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. 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=787http://ijcrr.com/article_html.php?did=7871. Arneson TJ, Melton LJ, Lewallen DG, et al. Epidemiology of diaphyseal and distal femoral fractures in Rochester, Minnesota, 1965-1984. Clin Orthop Relat Res 1988; 234:188-194.
2. Martinet O, Cordey J, Harder Y, Maier A, Buhler M, Barraud GE. The epidemiology of fractures of the distal femur. Injury. 2000;31(suppl 3):C62-C63.
3. Giles JB, Delee JC, Heekman JD. Supracondylar-intercondylar fracture of the femur treated with a supracondylar plate and leg screw. JBJS 1982;64-A:868.
4. Healy WI, Brooker AF. Distal femur fractures: comparison of open and close methods of treatment. Clin Orthop 1983;174:166-71.
5. Mize BD, Bnchol RW, Gorgen DP. Surgical treatment of displaced communicated fractures of the distal end of the femur. JBJS 1982;64-A:871-9.
6. Schatzker J, Lambert DC. Supracondylar fracture of the femur. Clin Orthop 1979;138:77-83.
7. Zickle RE, Fietti VG, Lawsing TF. A new intramedullary fixation device for the distal third of the femur. Clin orthop 1997;125:185- 91.
8. Muller ME, Allgower M, Schneider R, et al. Mannual of internal fixation New York: Springer-Verlag, 1979
9. Sanders R, Regazzoni P, Ruedi TP: Treatment of supracondylar intercondylar fractures of the femur using the dynamic condylar screw. J Orthop Trauma 1989;3:214-222.
10. Harder Y, Martinert O, Barraud GE, et al: The mechanics of internal fixation of fractures of the distal femur:a comparision of the condylar screw (CS) with the condylar plate (CP), Injury 30:A31, 1999
11. Muller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classification of fractures of long bones. Berlin, etc: SpringerVerlag, 1990.
12. Johnson KD, Hicken G. Distal femoral fractures. Orthop Clin North Am 1987;18:115-32.
13. Kregor PJ. Distal femur fractures with complex articular involvement: management by articular exposure and submuscular fixation. Orthop Clin North Am 2002;33:153-75.
14. Mc Laren AC, Blokker CP. Locked intramedullary fixation for metaphyseal malunion and nonunion. Clip Orthop 1991;265:253- 60.
15. Insal JN. Fracture of distal femur. In Insal JN Ed, surgery of the knee. Churchil Livingstone New York, Edinburg, London, Malburne 1984;413-48.
16. Olerud S. Operative treatment of supracondylar fracture of the femur. J bone Joint Surg [Am] 1972;54-A:1015-32.
17. Huang HT, Huang PJ, Su JY, Lin SY. Indirct reduction bridge plating of supracondylar frature of the femur. Injury 2003;34:135-40.
18. Schewring DJ, Meggit BF. Fracture of the distal femur treated with the AO Dynamic Condylar Screw. J Bone Joint Surg [Br] 1992;74:122-5.
19. Marya KM. Critical evaluation of management of fracture shaft of femur by Brooker-Willis nails. J Bone Joint Surg [Am ]2003;85:2093-6.
20. Christodoulou A, Terzidis I, Ploumis A, Metsovitis S, Koukoulidis A, Toptsis C. Supracondylar femoral fractures in elderly patients treated with the dynamic condylar screw and the retrograde intramedullary nail: a comparative study of the two methods. Arc Orthop Trauma Surg 2005;125:73-9.
21. Khan AM, Shafique M, Sahibzada AS, Sultan S. Management of type-A supracondylar fractures of femur with dynamic condylar screw. J Med Sci 2006;14:44-7.
22. Ali I, Shahabuddin. Surgical outcome of supracondylar and intercondylar fractures femur in adults treated with dynamic condylar screw. JPMI2011,vol.25,no.1:49-55.
23. Fu HD, Ching Y, Wei-ming C, Yao OF, Wood C, Tianxiong C, et al. Dynamic condylar screw for fracture of the distal femur. J. Orthop Surg Taiwan 1996;3:237-42.
24. Sudheer U, Sreejith TG, Marthya A, Gopinath P, Raveendran MK. A prospective study on the functional outcome following open reduction and internal fixation in supracondylar, intercondylar fracture femur. J Orthop 2007;4:30.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241615EnglishN2014August10High-Output External Duodenal Fistula Treated Conservatively With Feeding Jejunostomy - A Case Report
English0609N.S. KannanEnglish Jayakarthik Y.English M. PalaniappanEnglish K.L. JanakiEnglishHigh-Output External Duodenal Fistula (EDF) is a challenging condition to treat. It is associated with significant morbidity and mortality. Sepsis, malnutrition, and electrolyte abnormality due to high out put fistulae is the classical triad of complications of External Duodenal Fistula. We are presenting a case of high-output external duodenal fistula following duodenal perforation closure treated conservatively with feeding jejunostomy designed with forethought at the time of duodenal perforation closure itself to hasten the recovery at lesser cost with less morbidity and no mortality
EnglishHigh-Output External Duodenal Fistula (EDF), Conservative Treatment, Feeding JejunostomyINTRODUCTION
High-Output External Duodenal Fistula (EDF) is a challenging condition to treat. It is associated with significant morbidity and mortality. Sepsis, malnutrition, and electrolyte abnormality due to high out put fistulae is the classical triad of complications of External Duodenal Fistula. To reduce the severity of malnutrition, and electrolyte abnormality and to hasten the recovery at lesser cost with less morbidity and no mortality, it is suggested that all patients of duodenal perforation in whom highoutput external duodenal fistula is expected, be provided with feeding jejunostomy. We are presenting a case of High-Output External Duodenal Fistula following duodenal perforation closure treated conservatively with feeding jejunostomy designed with forethought at the time of duodenal perforation closure itself.
Case report
A 70-year-old male presented to the casualty with a history of abdominal pain, obstipation, fever and vomiting for three days. Pain was sudden in onset, over epigastrium to begin with and progressed to involve the entire abdomen. Vomiting was containing food particles, spontaneous, non projectile, non-bilious and non-blood stained. Fever was low grade with no chills and rigors. He was a known alcoholic for the last 30 years. No previous history of surgeries. On examination, he was having tachypnea and tachycardia with normal blood pressure. Per abdomen examination revealed mild distention, diffuse tenderness with rigidity. Plain X ray abdomen erect revealed massive air fluid levels under both domes of diaphragm suggestive of hollow viscus perforation (Figure 1). Routine blood investigations revealed total WBC count of 1000 cells/cumm with hemoglobin levels of 7g%, hypoalbuminemia and mild jaundice. Ultrasound abdomen revealed mild ascites. He was given two units of whole blood and taken up for emergency laparotomy under epidural anesthesia On laparotomy through mid midline incision approximately one litre of bilious peritoneal fluid was sucked out and found to have a large duodenal perforation of size 2.5 x 2 cm in the anterior aspect of first part of duodenum (Figure 2). The perforation was closed with interrupted through and through sutures using 1-0 vicryl reinforced with live omental patch. Since a high output external duodenal fistula was anticipated in view of the old age, large perforation, severe anemia, hypoalbuminemia, low total WBC counts, a feeding jejunostomy was designed in the same sitting after perforation closure to ensure early enteral nutrition. Closed tube drains two in number one in each flank were placed, to drain sub-hepatic and pelvic collection (Figure 3). Peritoneal toileting done with three liters of normal saline. Then laparotomy wound was closed in layers. Immediate post operative period was managed with routine orders including antibiotics, intravenous fluids, blood transfusions and other supportive measures. Jejunostomy feeding using commercial enteral feeding products was initiated on day six after delayed return of bowel sounds. On the fourth post operative day, bile staining was noted in the dressing for the right sub hepatic drain which gradually increased in quantity in the next few days resulting in a high output external duodenal fistula. Right drain was removed on day twelve and a colostomy bag was placed to collect the output which was quantified and fed through feeding to replenish the lost electrolytes and protein. Total parenteral nutrition (TPN) was avoided and supportive intravenous fluid with electrolytes correction was done through central venous line. Intravenous octriotide was also used to reduce the biliary and pancreatic secretions. Meanwhile, patient developed surgical site infection and partial dehiscence which was treated with appropriate antibiotics based on culture and sensitivity report and subsequent secondary suturing. With this conservative line of management the high output external duodenal fistula slowly got converted into low output fistula and finally spontaneous closure was achieved within forty days of post operative period. The patient was discharged from hospital on forty fifth post operative day after proper weaning out from jejunostomy feed to oral feeding with usual advice for a case of emergency duodenal ulcer perforation closure. Discussion High-output external duodenal fistula (EDF) remains a challenging condition to treat. Prakash K et al1 in their study from South India have also derived similar inferences: Entero Cutaneous Fistula (ECF) is a difficult condition managed in the surgical wards and is associated with significant morbidity and mortality. Sepsis, malnutrition, and electrolyte abnormality due to high out put fistulae is the classical triad of complications of Enterocutaneous fistula. The reported mortality rates in these patients are 32-33%2,3. Sitges-Serra A et al3 in their study proved that parenteral nutrition has substantially improved the prognosis of fistulous patients by increasing the rate of spontaneous closure and improving the nutritional status of patients needing repeated operations. Despite advances in metabolic and nutritional care, morbidity and mortality from both prolonged parenteral nutrition and surgical intervention in the treatment of external duodenal fistulae are high2,3,4,5,6,7,8,9,10. Wlliam et al2 , in their retrospective case note review of patients managed on a specialised unit, thirteen of 388 admissions, 3.4% had an external duodenal fistula. Management was by eradication of abdominal and systemic sepsis and maintenance of nutritional status by the administration of total parenteral nutrition. The majority of fistulas followed surgery for peptic ulcer disease. Eight of 13 fistulas closed spontaneously. Their conclusion was, enterocutaneous fistulae arising from the stomach and duodenum are associated with significantly greater morbidity and mortality as the surrounding tissues are exposed to large volumes of enzyme rich secretions and such high-output external duodenal fistula may be successfully managed in a specialised unit. Alivizatos et al11 in their study have concluded that as an adjunct treatment to total parenteral nutrition, octreotide reduces rapidly the fistula output without significant influence in the spontaneous closure rate. A mean reduction of 50% of fistula output was noted in all the patients who received octreotide, within 24 hours of its administration. Spontaneous closure was achieved in 13 patients of the octreotide group (mean closure time: 15.3 days, range: 6-35) and in 12 patients treated only with total parenteral nutrition (mean closure time: 13.9 days, range: 7-25); this difference was not significant (P = 0.5). Also, the fistula closure rate was not influenced by the anatomic site, the high or low output, and the age of the patient. Currently, most authors recommend a trial of conservative management before surgical therapy is attempted; accurate fluid and electrolyte replacement and prevention of malnutrition are combined with attempts to reduce the drainage of intestinal contents by nasogastric intestinal intubation12,13,14,15,16,17,18.
Definitive surgical closure of the fistula should only be performed when the patient is apyrexial and in good nutritional status, and if the fistula effluent shows no signs of decreasing in volume after 4-6 weeks of nutritional support19. Provision of appropriate nutritional support and prompt control of sepsis has been associated with a low mortality rate and high rate of spontaneous fistula closure20. Verma et al21 in their study of 31 patients with external duodenal fistula, none could afford TPN for optimum time. All patients received hospital-based enteral nutrition through nasojejunal tube, besides supportive medical treatment and/or surgery. External Duodenal Fistula can be satisfactorily managed without Total Parenteral Nutrition. Successful placement of enteral feeding line, supportive treatment and delayed surgery can achieve survival in 85% of patients. Minimum intervention is recommended when early surgery is performed in peritonitis or to establish enteral feeding line. Chapman et al22 emphasized the importance of adequate nutrition in the care of these patients and outlined a set of priorities for treatment. Fistula closure was more than twice as likely (89% versus 37%) in a group of patients that received over 1600 calories a day compared with those that did not. A follow-up report by Sheldon et al23 documented the success of this treatment regimen, noting that most patients could be given adequate nutrition by standard methods such as tube and enterostomy feedings. Nutritional needs can be met in several ways other than through Total Parenteral Nutrition by feeding of commercially available liquid diets by a tube passed beyond the fistula or through surgically created enterostomies has been used most widely as reported by Bowlin et al24, and Webster et al25. Reber et al6 in their study inferred that Total Parenteral Nutrition is fairly of high cost and frequently leading to catheter related septicaemia and thrombo embolism. Total Parenteral Nutrition per se had no impact on fistula mortality, and that maintenance of adequate nutrition using more conventional methods was equally as effective. Large fluid and electrolyte losses often persist in patients with a proximal intestinal (e.g., gastric, duodenal, proximal jejunal) fistula even when the patient is fasting and receiving Total Parenteral Nutrition.
Conclusion
In all cases of duodenal perforation potentially prone to develop high-output external duodenal fistula it is better to spare just five more minutes to provide feeding jejunostomy at the time of perforation closure itself, to ensure cost effective conservative management with the aim to hasten fistula closure, reduce morbidity and avoid mortality.
Aknowledgement
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=788http://ijcrr.com/article_html.php?did=7881. Prakash K, Nanda K. Maroju, and Vikram K. Enterocutaneous Fistulae: Etiology, Treatment, and Outcome – A Study from South India. Saudi J Gastroenterol., 2011 Nov-Dec; 17(6): 391–395
2. Williams NMA, Scott NA, Irving MH. Successful management of external duodenal fistula in a specialised unit. Am. J. Surg., 1997;173:240-1
3. Rossi JA, Sollenberger LL, Rege RV. External duodenal fistula causes, complications and treatment. Arch Surg., 1986; 121:908- 12
4. Sitges-Serra A, Jaurrieta E, Sitges-Crues A. Management of post operative enterocutaneous fistulas: the role of parenteral nutrition and surgery. Br J Surg., 1982;69:147-50.
5. Edmunds LH, Jr, Williams GM, Welch CE. External fistulas arising from the gastro-intestinal tract. Ann Surg,. 1960;152:445–71.
6. West MA. Conservative and operative management of gastrointestinal fistulae in the critically ill patient. Curr Opin Crit Care., 2000;6:143–7.
7. Makhdoom ZA, Komar MJ, Still CD. Nutrition and enterocutaneous fistulas. J Clin Gastroenterol., 2000;31:195–204.
8. McIntyre PB, Ritchie JK, Hawley PR, Bartram CI, Lennard-Jones JE. Management of enterocutaneous fistulas: A review of 132 cases. Br J Surg., 1984;71:293–6.
9. Visschers RG, Olde SW, Winkens B, Soeters PB, Gemert WG. Treatment strategies in 135 consecutive patients with enterocutaneous fistulas. World J Surg., 2008;32:445–53.
10. Martinez JL, Luque-de-Leon E, Mier J, Blanco-Benavides R, Robledo F. Systematic management of postoperative enterocutaneous fistulas: Factors related to outcomes. World J Surg., 2008;32:436–43.
11. Alivizatos V, Felekis D, Zorbalas A. Evaluation of the effectiveness of octreotide in the conservative treatment of postoperative enterocutaneous fistulas. Hepatogastroenterology., 2002;49:1010–1012
12. Fischer JE. The management of high out-put intestinal fistulas. Adv Surg., 1975;9: 139-176
13. Reber HA, Roberts C, Way LW, Dunphy JE. Management of external gastrointestinal fistulas. Ann Surg., 1978;188(4) : 460-467
14. Blackett RL, Hill GL. Postoperative external small bowel fistulas: a study of a consecutive series of patients treated with intravenous hyperalimentation. Br J Surg., 1978;65: 775-778
15. Soeter PB, Ebeid AM, Fischer JE. Review of 404 patients with gastrointestinal fistulas. Ann Surg., 1979;1 90:189-202
16. SandIer JT, Deitel M. Management of duodenal fistulas. Can J Surg., 1981 24:124-1 26
17. Gardner AMN. The use of a modified Miller-Abbott tube in the treatment of duodenal fistula. Br J Surg., 1951 Jul;39(153):65–70.
18. Levy E, Frileux P, Cugnenc PH, Honiger J, Ollivier JM, Parc R. Highoutput external fistulae of the small bowel: Management with continuous enteral nutrition. Br J Surg., 1989;76:676–9.
19. Haffejee AA. Surgical management of high output enterocutaneous fistulae: A 24-year experience. Curr Opin Clin Nutr Metab Care., 2004;7:309–16.
20. Garden OJ, Dykes EH, Carter DC. Surgical and nutritional management of postoperative duodenal fistulas. Dig Dis Sci., 1988 Jan;33(1):30-5.
21. Verma GR, Kaman L, Singh G, Singh R, Behera A, Bose SM. External duodenal fistula following closure of duodenal perforation. Indian J Gastroenterol., 2006;25:16–19.
22. Chapman, R., Foran, R. and Dunphy, J. E.: Management of Intestinal Fistulas. Am. J. Surg., 108:157, 1964.
23. Sheldon, G. F., Gardiner, B. N., Way, L. W. and Dunphy, J. E.: Management of Gastrointestinal Fistulas. Surg. Gynecol. Obstet., 133:385, 1971.
24. Bowlin, J. W., Hardy, J. D. and Conn, J. H.: External Alimentary Fistulas: Analysis of Seventy-nine Cases, with Notes on Management. Am. J. Surg., 193:6, 1962.
25. Webster, M. W. and Carey, L. C.: Fistulae of the Intestinal Tract. Current Problems in Surgery, Vol. XIII, Year Book Medical Publishers, June, 1976.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241615EnglishN2014August10Immune mechanisms involved in malaria: A review
English1014Anil PawarEnglishDespite extensive research, malaria is still very rampant and unrestrained. The complexity of Plasmodium parasite’s life cycle,its intracellular nature, and its ability to evade the innate and adaptive immune responses make our efforts incompetent. Understanding the induction pathways of immune responses during malaria infection is crucial for the development of an effective vaccine. Present review explains the various aspects of immune mechanisms involved in fortification against malaria infection.
EnglishPlasmodium, innate, acquired, immunity, malariaINTRODUCTION
Malaria is one of the most prevalent and devastating of all human parasitic diseases, and is closely associated with socioeconomic burden in many temperate and most tropical countries. As a result of a massive scale-up in malaria control programs by the World Health Organizations (WHO) as part of the Millennium Development Goals, the estimated incidence of malaria globally has reduced by 17% and malaria-specific mortality rates by 26% between 2000 and 20101 . Although this represents some progress in reducing the disease burden, malaria still remains a major global health threat and continues to cause high morbidity and mortality, especially in subSaharan Africa, where almost 600 million people are at risk2 . Together, the Congo, India and Nigeria account for 40% of estimated malaria cases, and the Congo and Nigeria account for over 40% of the estimated total of malaria deaths globally in 20103 . Malaria is caused by a protozoan parasite of genus Plasmodium and is transmitted by female Anopheles mosquitoes. There are five species that infect humans, namely, Plasmodium falciparum, Plasmodium vivax, Plasmodium malariae, Plasmodium ovale and Plasmodium knowlesi. P. falciparum is the causative agent of 90% of infections and is the target of the vaccine trials of the different initiatives and programs. Immunity to malaria has a major role in controlling disease and pathogenesis. For malaria, partial antiparasite immunity develops only after several years of endemic exposure. Evidences suggest that this inefficient induction of immunity is partly a result of antigenic polymorphism, poor immunogenicity of individual antigens, the ability of the parasite to interfere with the development of immune responses and to cause apoptosis of effector and memory B and T cells, and the interaction of maternal and neonatal immunity4. Studies of the immune responses of naive animals to malaria parasites indicate that the host response varies depending on the strain of parasite and genetic background of the host5,6,7. Both innate as well as adaptive immune responses play an important role in parasite suppression.
INNATE IMMUNITY
In both human infections as well as experimental malaria models, survival appears to be critically linked to the ability of the host to control blood-stage parasite replication within the first 7–14 days of infection8 . It is noteworthy that the parasite-specific antibodies and cellular responses are basically absent during the acute stage of infection; innate immune mechanisms seem to be vital in controlling early parasite replication and decreasing the risk of advancement to severe and fatal disease. Interferon gamma (IFN-γ) is a macrophage-activating factor involved in the innate immune response to malaria. It is mainly produced by CD4+ and CD8+ T lymphocytes in a specific immune response and by natural killer (NK) cells in a non-specific response. Early production of IFN-γ is critical since it directly mediates anti-parasitic effects and hence helps to limit progression from mild malaria to severe and life-threatening complications. Augmented release of IFN-γ stimulates monocytes/macrophage and γδ-T cells to secrete tumor necrosis factor-alpha (TNF-α), which can further promote anti-plasmodial properties through formation of toxic free radicals, such as nitric oxide9 . Interleukin (IL)-6 and IL1-β, like TNF-α, are other inflammatory cytokines that also play a role in limiting parasite replication but are involved in induction of fever and acute phase response10. The ability to balance effectively the anti-parasitic and immunopathogenic effects of these cytokines is a hallmark of clinical immunity to malaria. As a central component of the innate immune response, complement plays a critical role in neutralizing invading parasites; however, excessive activation of this system has the potential to mediate disease pathogenesis11. Clearance of infected erythrocytes by monocytes/macrophages is important for control of infection and in limiting excessive inflammation induced by the rupture of infected cells. Blocking complement deposition has been shown to prevent nearly 80–95% of phagocytosis of erythrocytes harboring immature (ring-stage) parasites in vitro12. Macrophages contribute in the control of the infection through both antibody-dependent and -independent phagocytosis, and secretion of soluble factors directly or indirectly toxic to the parasite, such as IL-1, TNF-α, granulocytes-macrophage colony stimulating factor (GM-CSF), reactive nitrogen and oxygen radicals13. CD36, a member of the class B family of scavenger receptors, was primarily expressed on dermal microvascular endothelium that supported adhesion of most natural isolates of P. falciparum malaria. It has been demonstrated that it performs dual function in mediating phagocytosis as well as produces cytokine responses to malaria, and helps in innate host defence to P. chabaudi chabaudi AS (PCCAS) malaria in vivo. Phagocytosis of microbial pathogens is linked to innate sensing and cytokine response mediated via cooperation between pattern recognition receptors such as scavenger receptors and toll-like receptors (TLRs)14. Production of IL-12 from activated macrophages is also crucial to early activation of γδ-T cells, resulting in additional production of IFN-γ15. γδ-T cells represent the interface between innate and adaptive immune response and together with NK cells, contribute to a rapid resolution of clinical malaria. Though, the innate effector mechanisms that actually regulate the blood stage parasitemia during acute infection are not fully understood.
ACQUIRED IMMUNITY
The acquired immunity to malaria involves activation of both humoral as well as cellular immune responses8,16. Dendritic cells (DCs) are supposed to play a crucial role, both as highly efficient presenters of antigen to helper T cells and in determining the balance of cell-mediated immunity and antibody-mediated immunity by steering the T cell population towards a Th1 or Th2 response17,18. The influence of environment, genetic background and nutritional status cannot be ruled out to explain the disparity of specific immunity.
Natural acquired immunity Contrasting to many acute viral diseases that produce life-long resistance to reinfection, Plasmodium provokes immunity only after several years of continuous exposure, during which recurring infections and illness occur. Robert Koch first reported a scientific basis for naturally acquired protection against malaria. By cross-sectional studies of stained blood films, Koch inferred that protection against malaria was acquired only after heavy and uninterrupted exposure to the parasite. But it is not clear that as to how this protection comes about, and there is only little knowledge on the key determinants of protection19. Natural immunity against malaria develops only gradually over many years of repeated and multiple infections in endemic areas20,21. The identification of immune correlates of protection among the abundant non-protective host responses remains a research priority. While evasion and modulation of the host immune response clearly occurs throughout the Plasmodium life cycle, immune mechanisms to control blood-stage parasites are acquired and maintained by individuals living in malaria endemic areas, allowing parasite densities to be kept below the threshold for the induction of acute disease and providing protection against severe malaria pathology22.
In human host, it appears that natural immunity is acquired only to blood stages. Conversely, naturally acquired immunity to pre-erythrocytic stages is not believed to occur and this is likely due to the small infectious load, the immunotolerant state of the liver as well as host impairment of the liver-stage infection in individuals with blood stage disease23. Once established, anti-malarial immunity appears to be a ‘regional phenomenon’, as seen in labor migrants or refugees, who lose protection against re-infection when moving to geographically separate places24. The concept of ‘P. falciparum diversity’ postulates a rationale for the detected slow acquisition of natural immunity.
Immunity in infants Infants seem to be relatively protected from malaria infection and its consequences for initial six months of their life. When infants become susceptible, their infection tends to be of low parasite density, asymptomatic and is cleared within a month25. Simister (1988)26 reported that in humans, systematic transfer of maternal antibodies of IgG isotype occurs across the placenta. P. falciparum specific IgG1 and IgG3 are more reliably transferred from mother to child as compared to IgG2 and IgG427. It is crucial to know about the period during which infants lose their maternally derived antibodies to malaria and instigate to acquire naturally their own immune responses against parasite antigens, so that malaria vaccines may be best administered. Duah et al. (2010)28 investigated the rates of decline and acquisition of serum antibody isotypes IgG1, IgG2, IgG3, IgG4, IgM and IgA to P. falciparum antigens; apical membrane antigen (AMA1), merozoite surface proteins (MSP1-19, MSP2 and MSP3) in a birth cohort of 53 children living in an urban area in the Gambia, followed over the first 3 years of life (sampled at birth, 4, 9, 18 and 36 months). Antigen-specific maternally transferred antibody isotypes of all immunoglobulin G (IgG) subclasses were detected at birth and were almost totally depleted by the age of 4 months. Attainment of specific antibody isotypes to the antigens began with IgM, followed by IgG1 and IgA. Against the MSP2 antigen, IgG1 responses were observed in the children, in contrast with the maternally derived antibodies to this antigen that were mostly IgG3. This confirms that IgG subclass responses to MSP2 are strongly dependent on age or previous malaria experience, polarized towards IgG1 early in life and to IgG3 in older exposed individuals28. STAGE-SPECIFIC ACQUIRED IMMUNITY Acquired immunity against the Plasmodium parasite is complex and stage-specific. By convention, immune responses in malaria are dichotomized into pre-erythrocytic responses (directed against sporozoites and liver-stage parasites) and erythrocytic responses (directed against merozoites and intra-erythrocytic parasites). Pre-erythrocytic stage immunity After their inoculation into the skin, some sporozoites get associate with Dendritic cells (DCs) in the draining lymph nodes. These cells present sporozoite antigens to naive T cells, and hence T cells get activated. Activated T cells enter the circulation and traffic to the liver, help in obliteration of the infected hepatocytes that display antigen-MHC complexes on their surface, reducing liverstage parasite load29. Pre-erythrocytic immunity generally consists of cellular responses against infected hepatocytes, which inhibit intracellular parasite development through the induction of reactive nitrogen intermediates. Various antigens, specific to the liver stage, have been identified and it has been suggested that these antigens, along with those brought in with the invading sporozoites, are rapidly processed by the host cell and presented on the surface of infected hepatocytes in combination with MHC class I 30. This presentation leads to recognition by cytotoxic T lymphocytes (CTLs) and killing of the infected cell, or stimulation of NK and CD4+ T cells to produce IFN-γ. This can trigger a cascade of immune reactions and ultimately can lead to the death of intracellular parasite30,31. The CTLs may be directly cytolytic against malaria-infected hepatocytes by releasing perforin and granzyme or by binding to apoptosis-inducing receptors on the infected cells32.
Plasmodium sporozoites suppress the respiratory burst and antigen presentation of Kupffer cells, which are regarded as the portal of invasion into hepatocytes. It is not known whether immune modulation of Kupffer cells can affect the liver stage. In a study, it was observed that sporozoites inoculated into wistar rats could be detected in the liver, spleen, and lungs; however, most of the sporozoites were arrested in the liver. Sporozoites were captured by Kupffer cells lined with endothelial cells in the liver sinusoid before hepatocyte invasion. Pre-treatment with TLR3 agonist poly (I:C) and TLR2 agonist BCG primarily activated the Kupffer cells, inhibiting the sporozoite development into the exoerythrocytic form, whereas, Kupffer cell antagonists dexamethasone and cyclophosphamide promoted development of the liver stage. Present data implies that sporozoite development into its exo-erythrocytic form may be associated with Kupffer cell functional status. Immune modulation of Kupffer cells could be a promising strategy to prevent Plasmodium infection33.
Erythrocytic stage immunity Merozoites that survive to the pre-erythocytic stage are responsible for the modification of infected red blood cells in terms of parasite proteins expressed on the cell surface and the concomitant immune response to the Plasmodium parasite, resulting in the clinical manifestations of malaria34. The pathogenic manifestations during a malaria crisis are due to proinflammatory cytokines released by T cells and macrophages in response to malaria parasites and their products, including glycosylphosphatidyl-inositol (GPI) moieties35, malaria pigment36 and Plasmodium-derived nitric oxide synthase (NOS)-inducing factor37.
Humoral responses against extracellular merozoites and intraerythrocytic parasites have traditionally been considered the most important component of blood-stage immunity. An antibody binding to the surface of the merozoite, and to proteins that are externalised from the apical complex of organelles involved in erythrocyte recognition and invasion, seems to have an important role in immunity to asexual blood stages. This antibody could neutralize parasites or lead to Fc dependent mechanisms of parasite killing by macrophages38. T cell responses against pRBC remain less well understood, partly because erythrocytes lack MHC class I or class II presentation capacity. Nevertheless, cellular responses against pRBC have been suggested to contribute to protection in humans in the absence of antibodies39,40. Finally, monocyte/macrophage-mediated responses, in particular phagocytosis and antibody-dependent cellular inhibition (ADCI) also form an important component of bloodstage immunity41. Immunity to blood-stage Plasmodium parasites is critically dependent on the type 1 cytokine IFN-γ and requires coordinate and timely innate and adaptive immune responses involving dendritic cells (DC), NK cells, CD4+ T helper cells, and B cells8,41. Moreover, a balance between pro-inflammatory and anti-inflammatory responses is essential to limit the development of life-threatening immune-mediated pathology such as CM and SMA. Although a better understanding of the mechanisms involved in protective immunity and immunopathology is emerging, still the understanding of regulatory mechanisms required to maintain the balance between beneficial and deleterious responses during blood-stage malaria infection remains limited42. IMMUNE EVASION BY PLASMODIUM Despite the presence of various immune mechanisms, the parasite is adept at evading immunity by a variety of mechanisms, which help its survival in the host. Possible mechanisms of interference in the activation of T cells and B cells, and the generation of immunological memory by the parasite have been described by many workers21,43. The parasite modulates the immune mechanism either by interfering with presentation or processing and cause apoptosis of T cells and other effector cells or mutates the sequence of epitopes critical for B or T cell recognition44. Furthermore, because malaria is a chronic infection, it is possible that B and T cell exhaustion may contribute to the suboptimal host immunity that is inadequate to control the parasite. Data from a longitudinal study in Mali has shown that exhausted B cells comprise 20-60% of that circulating B cell pool as compared with 1–2% of the B cell pool in people from non-endemic areas45. Understanding the immunological and molecular mechanisms of the crosstalk between the host and parasite is a pre-requisite for the rational discovery and development of a safe, affordable, and protective anti-malaria vaccine46. CONCLUSIONS Immunity contributes an essential role in controlling the disease, but partial immunity develops only after several years of endemic exposure. Innate immunity, involving complement system, macrophages and various cytokines, is vital in controlling early infection. The adaptive immunity is complex and stage-specific, and includes activation of both humoral as well as cellular immune responses. Plasmodium evades the immune mechanisms by interfering the activation of B and T cells, and the generation of immunological memory. Overall, a better understanding of the immunopathology and immunoregulatory pathways involved both in experimental malaria models as well as in individuals is essential for the development of an effective vaccine so that this fatal disease can be controlled.
ACKNOWLEDGEMENTS
Author is thankful to University Grants Commission (UGC), New Delhi for providing financial assistance to him in the form of Research Fellowship in Science for Meritorious students (RFSMS) under UGC-CAS programme. At the same time, he acknowledges all the scholars, whose articles are cited for preparation of this manuscript.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241615EnglishN2014August10INQUIRY-BASED LEARNING APPROACHES: THE BEST PRACTICE FOR BASIC SCIENCE TEACHERS
English1519Ayodele Mathew OlagokeEnglish Olatunbosun Segun MobolajiEnglish Daramola Mercy AEnglishThis paper provides information obtained from Junior Secondary School teachers on their orientation towards the use of inquirybased approach for teaching Basic Science in Ekiti State, Nigeria. The population of the study comprises all the Basic Science teachers in the State. A sample of one hundred and eighty (180) teachers was selected from the three (3) senatorial districts of the State using multi-stage sampling technique. A fifteen-item scaled response questionnaire was used as an instrument. The items addressed teachers’ related beliefs, orientation and difficulties in implementing IBL in Basic Science classrooms. The fourscale, adopted likert-scale questionnaire was distributed by the researchers to the participants in their schools. The instrument was validated by experts in the fields of language, science education and evaluation while the reliability coefficient of 0.74 was obtained for the questionnaire. Data collected were analyzed using the mean score and standard deviation of each statement while the only hypothesis formulated was tested using t-test statistics at 0.05 level of significance. The result showed that many teachers had no knowledge of IBL as reflected in their responses, but they have a strong belief that IBL has the potential to overcome learning problems of students in Basic Science. The study also revealed that teachers suffer from lack of resources, unequipped laboratory, too large class size and lack of time allocation in the school time-table for implementing IBL. The study also revealed that the opinion of male and female teachers in the use of IBL did not differ significantly. It was recommended that practicing science teachers should endeavor to employ IBL in their teaching because of its great benefits to students as it allows
them to reflect on their own ideas in an effort to build their knowledge, understanding and interpretation of ideas.
EnglishInquiry-based learning, basic science teachers, junior secondary school and teachers’ orientationINTRODUCTION
Inquiry-based learning (IBL) approaches have been gaining significant influence among the science educators. It is an approach to teaching and learning that places students’ questions, ideas and observations at the centre of the learning experience. Inquiry-based learning ranges from a rather structured and guided activity, particularly at lower levels where the teacher may pose the questions and give guidance in how to solve the problem, through an independent research. IBL draws on constructivist ideas of learning in which learners construct new ideas or concepts based upon their experiences and prior knowledge (Kanselaar, 2002). Similarly, IBL is a student centered approach that encourages participants to draw on prior knowledge and experience in exploring their inquiries (Kahn and O’Rourke, 2005). In IBL, the student is responsible for constructing his/ her own meaning and understanding from the learning activities. According to Scardamailia (2002), educators play an active role throughout the process by establishing a culture where ideas are respectfully challenged, tested, redefined and viewed as improvable, moving children from a position of wondering to a position of enacted understanding and further questioning. For students to be able to engage actively in the inquiry process, they need specific skills. These are:
(i) identify causal relationships;
(ii) describe the reasoning process;
(iii) use data as evidence and;
(iv) evaluate. (Scardamailia, 2002)
Being aware of these skills, students have the opportunity to develop in self-directed inquiry, develop and diagnose problems, formulate hypothesis, identify variables, collect data, document their work and finally, interpret and communicate the results (Wu and Hsied, 2006).
Research has shown that there are three types of IBL, structured, guided and open inquiry-based learning (National Research Council, 2000), and the usage depend on the specific needs in the science classroom. Inquiry spans from more student-centered types of inquiry to more teacher-centered types. Understanding the different aspects of inquiry can help educators vary the types of teaching and learning experiences to better meet the needs of all science students. Studies on IBL revealed that teachers have responsibility of finding creative ways to introduce students to ideas and to subject matter that is of interest to them and offers “inquiry potential” or promise in terms of opportunities for students to engage in sustained inquiry of their own (Scardamalia, 2002). Another role of teachers is to provide the most valuable questions that lead to other questions and provide germs for future investigations (Lucas, Broderick, Lehrer, and Bohanan, 2005). However, there are times when inquiry begins not with a question or problem, but with a shared experience. Teachers are to support students’ engagement in inquiry and engage them in constructing meaningful understandings. The kind of support needed by the students strongly depends on the type of problem at hand and on the experience students have already got with IBL. It is worth nothing that, teachers have to provide the precise support to facilitate student learning. According to De Garcia (2013), the following practices are crucial to the teachers:
(i) anticipate student responses to challenging mathematical tasks;
(ii) monitor and support students’ work on and engagement with the tasks;
(iii) select particular students to present their mathematical work;
(iv) the student responses that will be displayed in specific order; and
(v) different students’ responses and connect the responses to key ideas.
Teacher questioning skills have a great influence on IBL culture and on students learning. Teachers have the ability to encourage their students to put forward their ideas, explore and discuss their point of view while using dialogic, critical and thought-provoking questions and giving students time to think and answer (Chin, 2007). Teacher as a key factor in a classroom must possess certain attitudes and skills to encourage student success in the inquiry-based classroom. According to Colburn (2000), teacher must support inquiry-based instruction; he must believe in the value of students having some element of control over what they will do and how they will behave. Hence, inquiry-based learning shifted the role of teacher as a source of knowledge to a facilitator of learning, made the students more responsible and selfdirected in the learning process. Spronken-Smith, Angelo, O’Steen, and Robertson (2007) provide a review of the potential benefits for teaching personnel that use an IBL approach. They cite a strengthening of teaching-research links, the rewarding aspect of seeing students being so engaged and gaining improved understanding and skills. Another benefit for teachers is the increased interaction with students and the induction into a wider community or practice of IBL practitioners (Slatta, 2004). Like students, teachers can have difficulties adjusting to the approach and IBL can be challenging and involve emotional turmoil (Spronken-Smith et al., 2007). Evidence from researches have shown that IBL is generally more effective than traditional teaching for achieving a variety of student learning outcomes such as academic achievement, student perceptions, process skills, analytic abilities, critical thinking and creativity (Prince and Felder, 2006). For example, Berg, Bergendahl, and Lundberg (2003) compared the learning outcomes of an open-inquiry and an expository version of a first year chemistry laboratory experiment. Data on student experiences of the two approaches were gained from interviews, questions during the experiment and students’ self-evaluations. The key findings of this study were that students taking the open-inquiry experiment version had more positive outcomes including a deeper understanding, higher degree of reflection, the achievement of higher order learning and more motivation. In a similar study, Justice, Rice, Warry and Laurie (2007) used five years of data to examine whether taking a first year IBL course made a difference in students’ learning and performance. In a comparative study between students taking an IBL course and those who did not, and, taking into consideration factors such as age, gender, high-school grade point averages etc., they found that students who took the inquiry course had statistically significant positive gains in passing grades, achieving honours and remaining in the university. Despite the benefits of IBL, there were divergence views on the use of IBL, for instance, Justice et al. (2003) show that students perceived an increased workload in IBL courses while Plowright and Watkins (2004) noted student difficulties in coping with group dynamics. The most valuable way by which teachers can effectively assist their students to appreciate science values and applications is to engage them in constructing meaningful understandings using inquiry-based approaches.
Statement of the problem
The deplorable state of the secondary school education in Nigeria with recorded poor performance in science examinations have called for an urgent attention of the stake holders in education. This poor performance in science examinations may be attributed to inappropriate teaching method and approaches used by science teachers and lack of teaching resources among other factors. Considering the fact, that acquisition of scientific skills is a requirement for technological development of any nation, there is need to improve students’ sciencebased knowledge and enthusiasm to learn the subject. For Nigeria to actualize her goal of industrialization by the year 2020, it is imperative to apply a more pragmatic approach to teaching of science using IBL model that would improve science-based knowledge of students. It is on this note that this study is out to examine how practicing science teachers applied IBL in Basic Science classrooms in Ekiti State Junior Secondary Schools with the aim of making science enjoyable and interesting to students. From the above problems, one general question was raised to guide the study: What are the feelings of teachers to the use of inquirybased learning approach for teaching basic Science in the Junior Secondary Schools.
Research Question
Is there any difference in the opinion of male and female teachers in the use of inquiry-based learning approach for teaching basic science in the Junior Secondary Schools.
Research Hypothesis
There is no significant difference in the opinion of male and female teachers in the use of inquiry-based learning approach for teaching basic science in the Junior Secondary Schools.
Methodology
The study adopted a descriptive research of the survey design. It is a survey because it involved drawing appropriate information from the existing situation and the beliefs of teachers in relation to the use of inquirybased learning approach. The population of the study comprises all Basic Science Teachers in public secondary schools in Ekiti State. There are 184 secondary schools in Ekiti State with a population of 2,050 science teachers (Source: Research and Statistics Department, Ekiti State Ministry of Education, Ado). The sample for the study was drawn from the three senatorial districts of the State using multi-stage sampling technique. At the first stage, simple random sampling technique was used to select 20 public Junior Secondary Schools each from the three senatorial districts of the State. The second stage was the selection of 3 Basic Science teachers from each school, making a total of 60 teachers from each senatorial district. The last stage was a stratified random selection of 100 male teachers and 80 female teachers. In all, a total of 180 teachers were used for the study. In collecting the data, a fifteen-item scaled response questionnaire adapted from the IBL literature (OECD/ PISA, 2009 and PRIMAS, 2007-2013) baseline survey were used as an instrument. The OECD/PISA and PRIMAS items were developed based on a multi-faceted understanding of IBL, which were not only the process of inquiry but also the classroom atmosphere and the rule of the teachers. The statement addressed teachers’ related beliefs, orientation and difficulties in implementing IBL in Basic Science classrooms. The questionnaire was distributed by the researchers to the participants in their schools. Each item was scored according to the rule by assigning a number for each point of the scale: Strongly Agree (4), Agree (3), Disagree (2) and Strongly Disagree (1). In order to ensure the reliability of the instrument, the researcher carried out a trial test for the instrument using 30 non participating teachers from 10 schools in Ondo State, Nigeria. The instrument was employed once and the scores from the single administration of the instrument was subjected to Alpha Cronbach reliability estimate and the value obtained for the questionnaire was 0.74 which was considered high enough for this study according to Alonge (2004). The face, content and construct validity of the instrument was ascertained by experts in the fields of language and science education and evaluation for proper scrutiny. The data collected from the respondents were analyzed using the mean score of each item and t-test statistics at 0.05 Alpha levels.
Results and Discussion
The general question raised was subjected to descriptive analysis using mean scores and standard deviation of the items as follows: Question 1: What are the feelings of teachers to the use of inquiry-based learning approach for teaching Basic Science in the Junior Secondary Schools? In addressing this question, the mean score and standard deviation of each item regarding the teachers’ responses was calculated and interpreted as follows: 1.00-2.49 = Rejected and 2.50-4.00 = Accepted. The data collected from the teachers were organized and discussed as follows:
Table 1 showed the mean of the items regarding teachers’ orientation towards IBL technique. It could be seen that teachers opinion on the knowledge of IBL was not accepted which indicated that many teachers had no knowledge of IBL as reflected in their response to item 1 while responses were positive to all other items. The moderate mean score of 2.86 in item 4 was an attestation to the fact that teachers’ lack good knowledge and principles guiding the use of IBL.
Table 2 showed the teachers’ hands-on-activities with students. From the mean of the score, it was apparent that the responses about the teachers’ hand-on-activities were all accepted with the exception that students were denied of designing experiments and draw out conclusions on the experiments conducted by them. This aspect of teaching is important in achieving the goal of basic science teaching.
Table 3 showed the difficulties encountered by teachers in implementing IBL with students. It was clear that teachers suffer from lack of resources in schools, unequipped laboratory, too large class size and lack of time allocation in the school time-table for implementing IBL.
Testing of Hypothesis
Ho1: There is no significant difference in the opinion of male and female teachers in the use of inquiry-based learning approach for teaching basic science in the Junior Secondary Schools.
From table 4, the result showed that at p < 0.05, t–calculated value was 1.13, df was 178, and t–table value was 1.96. It could be seen that the t-calculated value was less than the t-table value at 0.05 Alpha levels; this implies that there was no significant difference in the opinion of male and female teachers in the use of inquiry-based learning approach for teaching basic science at the Junior Secondary Schools in Ekiti State, Nigeria. Hence, the hypothesis which states that there is no significant difference in the opinion of male and female teachers in the use of inquiry-based learning approach for teaching basic science Schools is upheld.
Conclusion and Recommendations
The study reported that there are major problems confronting the successful implementation of IBL which have to be taken seriously by the major stakeholders in education if the objectives of teaching basic science is to be realized. The study observed that many teachers had no knowledge of IBL as reflected in their responses, but they have a strong belief that IBL has the potential to overcome learning problems of students in basic science. To spread the benefit of IBL, it would be useful to seek the assistance of teachers that have already had initial understanding of IBL and have an open mind towards developing their teaching technique and practices. Those teachers then could help to spread the implementation of IBL. From the study, there was no significant difference in the opinions of male and female teachers in the use of inquiry-based learning approach in teaching Basic Science. This finding showed that both male and female teachers had that same view in the use of inquiry-based learning approach. It is recommended that practicing teachers should endeavor to employ IBL in their teaching because of its great benefit to students as it allows them to reflect on their own ideas in an effort to build their knowledge, understanding and interpretation of the matter at hand.
Englishhttp://ijcrr.com/abstract.php?article_id=790http://ijcrr.com/article_html.php?did=7901. Alonge, M. F. (2004). Measurement and Evaluation in Education and Psychology (Second Edition). Adedayo Printing Nig. Ltd. Ado Ekiti.
2. Berg, C. A., Bergendahl, V.C.B. and B. K. S. Lundberg (2003). Benefitting from an Open-Ended Experiment? A Comparison of Attitudes to, and Outcomes of, an Expository Versus an OpenInquiry Version of the same Experiment. International Journal of Science Education 25, 351-372.
3. Chin, C. (2007). Teacher Questioning in Science Classrooms: Approaches that Stimulate Productive Thinking. Journal of Research in Science Teaching, 44 (6), 815-843.
4. Colburn, A. (2000). An Inquiry Primer. Science Scope.
5. De Garcia, L. A. (2013). How to Get Students Talking! Generating Math Talk that Supports Math Learning”, Math Solutions, http:// www.mathsolutions.com/documents/How to Get Students Talking. PDF, downloaded in May 2013.
6. Ekiti State Ministry of Education (2013). Research and Statistic Department. Ado Ekiti.
7. Justice, C., Rice, J., Warry, W., and Laurie, I. (2007). Taking Inquiry Makes a Difference - A Comparative Analysis of Student Learning. Journal on Excellence in College Teaching (in press).
8. Kahn, P. and O’Rourke, K. (2005). Understanding Enquiry-Based Learning (EBL) In Barrett, T., Mac Labhrainn, I. and Fallon, H. (Eds.), Handbook of Enquiry and Problem-Based Leaarning: Irish Case Studies and International Perspectives. Galway: Centre for Excellence in Learning and Teaching, National University of Ireland.
9. Kanselaar, G. (2002). Constructivism and Socio-Constructivism. [Online] Retrieved
10 April 2012 from: http://edu.fss.uu.nl/medewerkers/gk/files/Constructivismgk. pdf 10. Lucas, D., Broderick, N., Lehrer, R., and Bohanan, R. (2005). Making the Grounds of Scientific Inquiry Visible in the Classroom. Science Scope, 29 (3), 39–42.
11. National Research Council. 2000. Inquiry and the National Science Education Standards. Washington, D.C.: National Academy Press.
12. OECD. (2009). Technical Report- PISA 2006.
13. Plowright, D. and M. Watkins (2004). There are no Problems to be solved, only Inquiries to be made, in Social Work Education. Innovations in Education and Teaching International 41, 185- 206.
14. PRIMAS (2007-2013). Promoting Inquiry in Mathematics and Science Education Across Europe. Primas Survey Report on InquiryBased Learning in Europe. European Union Seventh Framework Programme FP7/2007-2013.
15. Prince, M. J. and R. M. Felder (2006). Inductive Teaching and Learning Methods: Definitions, Comparisons, and Research Bases. Journal of Engineering Education 95, 123-138
16. Scardamalia, M. (2002). Collective Cognitive Responsibility for the Advancement of Knowledge. In B. Smith (Ed.), Liberal Education in a knowledge Society. 67–98. Chicago, IL: Open Court.
17. Slatta, R. W. (2004). Enhancing Inquiry-Guided Learning with Technology in History Courses.
18. Spronken-Smith, R., Angelo, T., Matthews, H., O’Steen, B. and Robertson, J. (2007). How Effective is Inquiry-Based Learning in Linking Teaching and Research? Paper Prepared for An International Colloquium on International Policies and Practices for Academic Enquiry, Marwell, Winchester, UK, 19-21 April, 2007. Retrieved June 1 2007 from: http://portal
19. Wu, H. K., and Hsie, C. E. (2006). Developing Sixth Graders’ Inquiry Skills to Construct Explanations in Inquiry-based Learning Environments. International Journal of Science Education, 28 (11), 1289-1313.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241615EnglishN2014August10MECKEL-GRUBER SYNDROME - A RARE CONGENITAL ANOMALY
English2023Volga HarikrishnanEnglish Meenakshisundaram KEnglish Aruna GnanakuruparanEnglishAim: This study is aimed to stress the importance of prenatal tests and fetal autopsy after abortion to confirm the syndrome and counseling for abortion and evaluation of recurrence risk in the future pregnancies. Case report: A 25 year old female, G3P1L1A1 admitted for termination of pregnancy due to multiple anomalies which was revealed by ultrasound examination. Termination of pregnancy followed by foetal autopsy was carried out. A definitive diagnosis of
Meckel-Gruber syndrome was made out by morphological examination and histopathological examination.
Discussion: Meckel-Gruber syndrome is a rare autosomal recessive disorder, characterized by occipital myeloencephalocele, bilateral renal cystic dysplasia, hepatic ductal proliferation, fibrosis and cysts, and polydactyly. But the characteristic clinical triad consists of occipital encephalocele, polycystic kidneys and postaxial polydactyl. Locus heterogeneity is a feature of Meckelgruber syndrome. Conclusion: Meckel-gruber syndrome is a rare and lethal congenital anomaly.
EnglishMeckel-gruber syndrome, fetal autopsy, polycystic kidney disease, polydactylyINTRODUCTION
Meckel-gruber syndrome (MGS) is a rare autosomal recessive disorder. It is a lethal congenital anomaly characterized by presence of occipital meningocele, bilateral dysplastic kidneys and polydactyly. We report a rare case of Meckel-gruber syndrome aborted at 32 weeks of gestation for which fetal autopsy was done.
CASE HISTORY
25 year old female, G3P1L1A1 admitted for termination of pregnancy due to multiple anomalies. She was booked outside for present pregnancy. Ultrasound examination: Occipital meningocele, bilateral dysplastic kidneys, hypoplastic lungs, marked oligoamnios and polydactyly. Patient expelled dead born female foetus
AUTOPSY FINDINGS
32 weeks female fetus with crown rump length of 33cm, chest circumference of 22cm. Polydactyly (Six digits) noted in all four limbs (Figure 1 and 2).
Segment of umbilical cord measured 10cm in length and showed two arteries and one vein. Head circumference measured 45 cm and it showed features of meningocele (Figure 3). No cleft lip or cleft palate present. Two incisor teeth were identified in the oral cavity. Body opened by midline incision from symphisis menti to symphisis pubis passing left to umbilicus. On opening of thoracic and abdominal cavity the disposition of organs were normal. Thorax, Heart and major blood vessels, thymus, Gastro intestinal tract, liver, spleen and genital system were found to be normal. Lungs were grossly hypoplastic. Adrenals showed haemorrhage. Right kidney weighed about 20gm and left kidney was 15gm. External surfaces showed lobulation. Cut surface of both kidneys showed cystic areas of size 0.5cm (Figure 4). Sections were taken from appropriate sites.
MICROSCOPIC FEATURES
Section taken from meningocele showed meninges with congested vessels. No brain substance seen. Microscopically sections from both kidney showed primitive glomeruli and primitive tubules with dilated tubules lined by flattened cells and surrounded by immature mesenchyme. No cartilaginous elements seen. (Figure 5, 6)
DISCUSSION
Meckel-gruber syndrome (MGS) is otherwise called as Dysencephalia splanchnocystica (1). It was first described byJohann Friedrick Meckel and it is a rare autosomal recessive lethal disorder. The incidence worldwide has been reported as 1:13,250 to 1:140,000(2). Finnish and Gujarati Indians show an increased incidence of this condition. (3)
Meckel-gruber syndrome is characterized by occipital myeloencephalocele, bilateral renal cystic dysplasia, hepatic ductal proliferation, fibrosis and cysts, and polydactyly (4).But the characteristic clinical triad consists of occipital encephalocele, polycystic kidneys and postaxial polydactyly. At least two of these features are essential for the diagnosis. Microcephaly, cleft palate and ambiguous genitalia may also be present in Meckel-gruber syndrome. (5) Meckel-gruber syndrome can be diagnosed prenatally by ultrasound findings at 11 to 14 weeks of gestational age. Alfa fetoprotein can also be measured in the maternal serum but it is not elevated when the encephalocele contain a closed sac (6). It can occur following artificial insemination like in vitro fertilization. Celentano et al reported a case of MGS diagnosed at 17 weeks in a pregnancy obtained with intracytoplasmic sperm injection (ICSI) (7). Three genes (MKS1, MKS2 and MKS3) have been identified. MKS1 located on chromosome 17q, MKS2 is on chromosome 11q and MKS3 is on chromomsome 8q or 13 q. Locus heterogeneity is a feature of Meckel-gruber syndrome since the presence of phenotype variability (8).
CONCLUSION
We present this rare and interesting case of Meckel-gruber syndrome. In our case there was no consanguinity, presented with meningocele, bilateral cystic renal dysplasia and polydactyly of all four limbs. Although improved prenatal testing like ultrasound, serum alfa fetoprotein estimation and karyotyping has increased, the detection of Meckel-gruber syndrome, morphological confirmation by fetal autopsy remains valuable diagnostic tool. In pregnancy complicated by this syndrome, counselling for abortion and evaluation of recurrence risk in the future pregnancies are important.
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=791http://ijcrr.com/article_html.php?did=7911. Naveen N.S , Vishal K. and Vinay. MECKEL-GRUBER SYNDROME - A CASE REPORT. Nitte University Journal of Health Science, Vol. 3, No.1, March 2013, ISSN 2249-7110.
2. Prasanna shetty, Nandakishore ,Shankargouda Patil et al. Meckel-Gruber syndrome.The journal of Contemporary Dental Practice.Sep-Oct 2012;13(5):713-715.
3. Jha T, Bardhan J, Das B et al. Meckel-Gruber syndrome: a rare clinical entity. J Indian Med Assoc. 2010 Sep;108(9):611-2.
4. Chen CP. Meckel syndrome: genetics, perinatal findings, and differential diagnosis. Taiwan J Obstet Gynecol. 2007 Mar;46(1):9- 14.
5. Yu CJ, Chen CP, Jeng CJ, Yang YC. Early prenatal diagnosis of Meckel syndrome--a case report. Zhonghua Yi Xue Za Zhi (Taipei). 1990 Jul;46(1):53-6.
6. C Panduranga, Ranjit Kangle, Rajshree Badami et al. Meckel-Gruber syndrome: Report of two cases. J Neurosci Rural Pract. 2012 Jan-Apr; 3(1): 56–59.
7. Celentano C, Prefumo F, Liberati M et al. Prenatal diagnosis of Meckel-Gruber syndrome in a pregnancy obtained with ICSI. J Assist Reprod Genet. 2006 Jun; 23(6):281-3. Epub 2006 Jun 21.
8. Dahiya N, Vijay S, Prabhakar S et al. Antenatal Ultrasound diagnosis of Meckel-Gruber syndrome. Indian J Radiol Imaging [serial online] 2001 [cited 2013 Nov 1]; 11:199-201.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241615EnglishN2014August10ONLINE BROADCAST COUNSEL THROUGH WORD-CLOUD GATHERING
English2427G. RohithEnglish M. Suma DivyaEnglish G. AnjaneyuluEnglish A. Usha RaniEnglish P. N. Vara LakshmiEnglishA framework for recommending online videos operates by constructing user profiles as an aggregate of tag clouds and generating recommendations according to similar viewing patterns. For this the techniques used by us are the Online Video Recommendation which recommends the users according to his patterns and the data is suggested by the help of the protocols Tag- Cloud Cosine and Tag Cloud Similarity ranking. The exclusive feature of paper is it recommends offering the user an option that the user can only pay the amount for the resources which they had used by this feature users are given more advantage.
EnglishOnline Video Recommendation, Tag-Cloud Cosine, Tag Cloud Similarity rankingINTRODUCTION
A wide deployment of Internet Protocol Television (IPTV), In Internet User Created Contents (UCC), and Online Digital Video (ODV) enabled the rapid increase of online Video and programs which can be selected by consumers. This was not expected when we consider the conventional Video technologies and policies. Due to these paradigm changes, thousand of video and programs are now available to consumers. In the existing limited content providers existed, such as licensed broadcasting companies and a small number of video and satellite broadcasting operators. Thus the number of movie and programs were limited. It has become difficult and time consuming to find an interesting movie video and program via the remote control or channel guide map. To refine the channel selecting processes and to satisfy the consumer’s requirements, we propose the Online Video Recommendation (ODV) system under a cloud computing environment. The proposed ODV system analyzes and uses the viewing pattern of consumers to personalize the program recommendations, and to efficiently use computing resources. A proposed framework for recommending online videos operates by constructing user profiles as an aggregate of tag clouds and generating recommendations according to similar viewing patterns. The proposed personalization method collects and analyzes the viewing patterns, such as : the target user’s viewing pattern for contents, statistical information for the overall user’s viewing patterns, a user’s private profile or preference information through the analysis of a user’s computing environment, a communication service, and implemented in personal computer .
A REVIEW
a. Video Suggestion and Discovery for YouTube: International World Wide Web Since the launch of the YouTube for offering the online video services from 2005 it is estimated around 45000 people are visiting the YouTube and this popularity has created an up down trend to the organization to maintain the data and currently there is no any satisfactory mechanism to label videos with the majority of their content. To exacerbate the difficulty, the tags that exist on YouTube videos are generally quite small; they only capture a small sample of the content. b. The influence of online product recommendations on consumers’ online choices: From Retailer’s the capacity to offer consumers a flexible and personalized relationship is probably one of the most important. It allows them to provide more information and reduces the time consuming task but there are no accurate methods to find the exact product that helps the user to find what he wants as even though there are many recommendation systems available but they aren’t seems to be most promising among the certain consumers. c. Informed Recommender Agent: Conference on Web Intelligence and Intelligent Agent Technology Consumer reviews, opinions and shared experiences in the use of a product form a powerful Source of information about consumer preferences that can be used for making recommendations Product review forums and discussion groups are popular ways for consumers to exchange their experiences with a product. There is growing evidence that such forums inform and influence. d. Recommendation Systems in other streams: There are many streams in the engineering and each group definitely uses an recommendation system to produce the best and accurate results according to the output and while coming to the Mechanical Engineering the technique or recommendation system used by them to produce best results is Non Destructive Testing which helps the designers to produce the best results without the damage of the materials and the use of recommendation systems has been popular from many years in all the streams and they are used effectively and it is gaining a good popularity in the stream of computers in the present generation.
OVERVIEW OF DRAW BREATH SYSTEM
In the existing system the online Trading is being hosted on Stand Alone Server. This Causes bottleneck in the process of system implementation and it is very difficult to reuse algorithm module. Payment for combination of Physical Hosting and Hardware is demanded by the Web hosting Provider on monthly basis, increasing total cost and the lack of scalability in Dedicated Servers and inter-Server Adaptability becomes difficult all these problems lead to lack of Free Scripts and Install of additional features and many other problems are being raised they are threat to over cost and many other.
BRIEF DESCRIPTION ABOUT THE SYSTEM WE RECOMMEND
The main aspect and idea that we propose is described briefly by the help of an small diagram The above design of the recommended system explains the main idea of our system and these contains various program of studies.
1. Individuals Internet Terminals:
In the Individuals Internet Terminals here after the word is represented as “IIT”, user come to register or login the device and automatically user weblog history create for the target user. The User Behavior Monitor here after the word is represented as “UBM” continuously monitors a consumer’s behavior pattern and manages pattern information. The UBM retrieves weblog history information from devices such as a personal computer, mobile phone, and notebook. The UBM stores a consumer’s pattern information to the Private Computing Cloud here after the word is represented as “PCC”. Thus, a consumer’s information is independent of the device locations, and the consumer can be consistently supported over heterogeneous devices and locations.
2. Media Storage Cloud:
The Media storage Cloud here after the word is represented as “MSC” is a cloud computing based storage for media contents which are broadcast over hundreds of broadcasting channels. Content Vendors here after the word is represented as “CV” such as licensed broadcasting companies, small to medium operators, and content producers, store their own media contents on the media storage cloud. Service Agents here after the word is represented as “SAs” provide contents to consumers from the MSC, and generate statistical information, including a consumer’s preference for contents based on the consumer’s profile and analysis of their viewing history. MSC updates the user profiles at the Private Computing Cloud.
3 Private Computing Cloud:
The PCC monitors the target consumer’s personal profile. The PCC supports management, scheduling, security, pri- vacy control of the consumer profile, and the required resources. In the proposed system, each intelligent device individually transfers weblog history to the PCC. The Profile Manager here after the word is represented as “PM” then analyzes the combined weblog, and creates the consumer profile based on this weblog. The proposed PCC can identify the consumer’s preference in a short amount of time, and provide a recommended channel list at initial time. Tags can be aggregated in various ways to characterize an entity of User interest tag information is referred to as a tag cloud, which is usually displayed in alphabetical order and visually weighted by font size. The PCC is also independent of the device location, and can provide Consistent profile information according to the consumer for various devices.
4. Recommendation system:
A content-based recommendations system recommends the most likely matched item, then compares the recommendation list to a user’s previous input data or compared to preference items. A content-based recommendations system is based on information searching and generally uses a rating method which is used in the information searching. To measures for computing the user similarity, namely tag cloud-based cosine here after the word is represented as “TCC” and tag cloud similarity rank here after the word is represented as “TCSR”. The Profile Filtering Agent here after the word is represented as “PFA” creates a personalized channel profile based on the accumulated viewed content list by using a content based filtering.
5. Multimedia Broadcasting System:
The Multimedia Broadcasting System here after the word is represented as “MBS” provides broadcasting functionalities. An interface agent enables the consumer in the selecting and viewing of media content at the requested time, from the various channels via the large volume of available content through the set-top box, which includes the Personal Digital Recorder here after the word is represented as “PDR”. Additionally, all of the consumed channel list and history is accumulated at the setup box.
6. Utility Counter:
The Utility Counter hereafter the word is represented as “UC” is the one that is responsible for counting the consumer usage after the selection of the option Pay Peruse. After the termination of the UC window it shows the total count used by the consumer and costs the data according to the usage.
The Urged System:
As the existing systems are proposing methodologies of high time consuming and insufficient in the space management and the maintenance of these system become difficult day-by-day on both the financial and general ways and these problems are overcame by the design that we propose. The urged system mainly describes the Cloud based online trading platform possessing high flexibility, high reliability, low-level transparency, security features and the proposed tag cloud recommendation approaches, TCC and TCSR, outperformed the other recommenders and the methods that are used are To measures for computing the user similarity, namely tag cloud-based cosine (TCC) and tag cloud similarity rank (TCSR). The Profile Filtering Agent (PFA) creates a personalized channel profile based on the accumulated viewed content list by using a content based filtering.
Cloud Computing
In computer networking, cloud computing is computing that involves a large number of computers connected through a communication network such as the Internet, similar to utility computing. In science, cloud computing is a synonym for distributed computing over a network, and means the ability to run a program or application on many connected computers at the same time. A computing platform distributed in large-scale data center. Uses Virtualization technology to dynamically and transparently supply virtual Computing and storage resources. Reusability and extensibility of this framework component. In common usage, the term “the cloud” is essentially a metaphor for the Internet. Marketers have further popularized the phrase “in the cloud” to refer to software, platforms and infrastructure that are sold “as a service”, i.e. remotely through the Internet. Typically, the seller has actual energy-consuming servers which host products and services from a remote location, so end-users don’t have to; they can simply log on to the network without installing anything. The major models of cloud computing service are known as so In common usage, the term “the cloud” is essentially a metaphor for the Internet. Marketers have further popularized the phrase “in the cloud” to refer to software, platforms and infrastructure that are sold “as a service”, i.e. remotely through the Internet. Typically, the seller has actual energy-consuming servers which host products and services from a remote location, so end-users don’t have to; they can simply log on to the network without installing anything. The major models of cloud computing service are known as software as a service, platform as a service, and infrastructure as a service. These cloud services may be offered in a public, private or hybrid network.[3] Google, Amazon, Oracle Cloud, Salesforce, Zoho and Microsoft Azure are some well-known cloud vendors.
CONCLUSION
This paper presents techniques that are much more useful for generating the recommendations for the user profile by the help of the system. And the paper proposes the technique of cloud computing for the well organizing the database by tagging the user profiles. The experimental results suggest that the proposed approach is flexible and is able to generate acceptable segmentation results automatically by the use of the protocols such a Tag Cloud Cosine and Tag cloud Similarity ranking which are mainly hosted by the Online Video recommendation under the environment of Cloud Computing
Englishhttp://ijcrr.com/abstract.php?article_id=792http://ijcrr.com/article_html.php?did=7921. The TV-Anytime, “TV-Anytime Forum,” [Online]. Available: http://www.tv-anytime.org,2004.
2. P. Resnick and H. R. Varian, “Recommender systems,” communications of the ACM, vol. 40, no. 3, pp. 56-58, Mar. 1997.
3. Online].Available: http://en.wikipedia.org/wiki/Cloud_Computing.
4. Personalized DTV Program Recommendation System under a Cloud Computing Environment by SeungGwan Lee, Daeho Lee, and Sungwon Lee,Member, IEEE.
5. G. Adomavicius and A. Tuzhilin, “Toward the Next Generation of Recommender Systems: A Survey of the State-of-the-Art and Possible Extensions,” IEEE Trans. Knowledge and Data Eng., vol. 17, no. 6, 2005, pp. 734-749.
6. R. Kohavi, B. Becker, and D. Sommerfield, “Improving Simple Bayes,” Proc. European Conf. Machine Learning (ECML), Springer, 1997.
7. M. Dubinko et al., “Visualizing Tags Over Time,” ACM Trans. the Web, vol. 1, no. 2, 2007.
8. D. Yamamoto et al., “Video Scene Annotation Based on Web Social Activities,” IEEE Multimedia, vol. 15, no. 3, 2008, pp. 22-32.
9. J. Park, B-C. Choi, and K. Kim, “A Vector Space Approach to Tag Cloud Similarity Ranking,” Information Processing Letters, vol. 110, nos. 12-13, 2010, pp. 489-496. 10. S. Park, S. Kang, and Y. Kim, “A channel recommendation system in mobile environment,”IEEE Trans. Consum. Electron., vol. 52, no. 1, pp. 33-39, Feb. 2006.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241615EnglishN2014August10Ovarian leiomyoma- rare tumor with unusual presentations: Report of 2 cases with brief review of literature
English2832Swati SharmaEnglish Manna ValiathanEnglish Pratap KumarEnglishOvarian leiomyoma is a rare and incidentally detected neoplasm. It is usually reported in women of childbearing age. Clinically most patients are asymptomatic. Histopathologic examination is required to distinguish it from subserous leiomyomas and fibroma-thecoma group of ovarian tumors. We present 2 cases of ovarian leiomyoma along with brief review of literature. The first case of a 25 year old woman who presented with primary infertility and history of irregular menstruation and the second case of a 54 year old post menopausal lady with complaints of abdominal pain who was referred with the clinical impression of ovarian malignancy.
EnglishOvarian leiomyoma, infertility, fibromaINTRODUCTION
Ovarian leiomyoma was first described in the year 18621 . It is a rare benign tumor that accounts for 0.5 to 1% of all benign ovarian tumors2 . Origin of ovarian leiomyomas is not yet established with many possibilities described in the literature. It is found to be frequently associated with uterine leiomyomas3 .
Case report
Case I: A 25 yrs old female, came with the complaints of primary infertility. She was married for four years, gave history of regular sexual intercourse with no usage of any contraceptives. She also had history of irregular menstrual cycles. General physical examination was normal. Per vaginum left adnexal mass was noted. Transvaginal sonography showed left tubo-ovarian mass and pelvic inflammatory disease, with clinical suspicion of chocolate cyst. On diagnostic laparoscopy, left ovary was enlarged with lobulations and glistening surface. There were no adhesions. It was not possible to preserve a part of affected ovary as no healthy parenchyma could be identified. Left fallopian tube, right ovary and tube were normal. Left salpingo-oopherectomy was done and specimen was sent for histopathology. Grossly, multiple nodular grey white tissue bits together weighing 76 gms, largest tissue bit measured 7x 3x2.5 cms. Cut section showed grey white areas with whorling pattern along with degenerative changes. No normal ovarian parenchyma was noted (Figure 1). Microscopy showed a vague nodular neoplasm composed of intersecting fascicles of spindle shaped cells resembling smooth muscles, with oval and vesicular nuclei showing fine chromatin interspersed with collagen, blood vessels, stromal hyalinization and calcific deposits. No significant mitotic activity/ cellular pleomorphism/ necrosis noted. Ovarian parenchyma was preserved only at the periphery (Figure 2, 3, 4). On Masson’s trichrome stain fascicles of spindle shaped cells stained red in color confirming the muscle origin (Figure 5). Fallopian tube showed normal morphology. Based on histopathology and special stain diagnosis of ovarian leiomyoma was given.
Case II: A 54 year old female came with the complains of dull pain and distension in the lower abdomen for the last 4 years. There was no history of any discharge per vaginum and bowel/ bladder abnormalities. Work up done outside the hospital was suggestive of ovarian malignancy. Patient was referred to our hospital for further management. On examination, per abdomen a mass was felt in the subrapubic area with restrictive mobility. Per speculum, senile changes were noted. On per vaginum examination a mass was felt measuring approximately 10 cms across on the right side with restricted mobility. All hematological and biochemical investigations were within normal limits. Serum beta HCG, alpha fetoprotein, C.A 19.9, C.A 125 and carcinoembryonic antigen were normal. Transvaginal ultrasound revealed a solid pelvic mass measuring 11x9.2 cms with no doppler uptake. Ovaries were not visualized separately. On CT scan abdomen a well defined heterogeneously enhancing solid abdomino-pelvic lesion arising from the right adnexal region was seen with the possibility of ovarian malignancy. Patient underwent staging laparotomy, right ovariectomy, omentectomy and pelvic lymphadenectomy. On gross examination, specimen of ovary was weighing 365 gms and measuring 11x10x7.5 cms. Cut section showed a well circumscribed solid grey white mass measuring 7x7 cms with preserved ovarian parenchyma at the periphery (Figure 6). Histology showed tumor composed of fascicles of spindle shaped cells with plump nuclei and few with moderate pale cytoplasm, arranged in sheets and storiform pattern with interspersed foci of collagen deposition, areas of hyalinization and cystic degeneration. No significant mitotic activity/ cellular pleomorphism/ necrosis noted (Figure 7, 8). Masson’s trichrome stain confirmed the muscle origin (Figure 9). Immunohistochemistry done showed tumor cells positive for smooth muscle actin. Ki-67 index was less than 1% (Figure 10, 11). All the lymphnodes showed reactive changes. Based on histopathology, special stain and immunohistochemistry a diagnosis of ovarian leiomyoma was given.
Discussion
Ovarian leiomyoma is a rare benign tumor accounting for 0.5 to 1% of all benign ovarian tumors2 . About 80 cases have been reported in the literature worldwide till date4 . It generally occurs in premenopausal women aged between 20 to 65 years2,3. Only about 16% of cases are reported to occur after menopause5 . These tumors are usually unilateral, although a single case of bilateral ovarian leiomyoma in a 21-year-old woman has been documented in literature6 . Bilateral involvement is uncommon in women over 35 years of age2 . Origin of ovarian leiomyomas is not well established yet. The probable origin could be smooth muscle cells in the ovarian hilar blood vessels, cells in the ovarian ligament, smooth muscle cells or multipotential cells in the ovarian stroma, undifferentiated germ cells, or cortical smooth muscle metaplasia2 . And the described probable origin from smooth muscle metaplasia of endometriotic stroma, smooth muscle present in mature cystic teratomas, and smooth muscle in the walls of mucinous cystic tumor may also explain their concomitant occurrence in certain ovarian lesions2 . Uterine leiomyoma directly metastasizing to the ovary is another possible origin7 . Our first case was not associated with uterine leiomyoma. Hence this was a primary lesion and not a parasitized or a metastasized uterine neoplasm. However, in second case since the cause of hysterectomy was not known, hence the possibility of associated uterine leiomyoma cannot be ruled out. Most ovarian leiomyomas are asymptomatic and are found either during routine physical examination, incidentally at surgery or at autopsy. In symptomatic cases, clinical presentations like abdominal pain, palpable mass, hydronephrosis, hydrothorax, ascites and elevated CA-125 have been described2,3. The largest tumor, measuring 36x37x11cms and weighing 6855gms was reported in a 72-year-old nulliparous woman who presented with ascites and polymyositis8 . In our first case, patient presented with primary infertility. Ovarian leiomyomas are described as a potential cause of compromised fertility9 , but further studies are needed for substantiation. Second case presentation with abdominal pain and palpable mass mimicking ovarian malignancy has also been described and reported in literature5 . Ovarian leiomyomas are usually associated with uterine leiomyoma, probably suggesting an identical causative hormonal stimulant. They are identical to their uterine counterpart both grossly and on microscopy7 . Degenerative changes such as hyalinization, calcification, and cyst formation may be seen in ovarian leiomyomas3 as well and were noted in our cases. They are also described to be associated with certain other ovarian lesions like ovarian endometriosis and mucinous cystadenoma2,10-12. The correct diagnosis of ovarian leiomyomas requires recognition of its smooth-muscle origin. Differential diagnosis include tumors in the fibroma-thecoma group, tumors arising in the broad ligament and extending into the hilum of the ovary, myometrial fibromyomas becoming parasitic on the ovary and leiomyosarcomas. Ideally primary ovarian leiomyomas should be entirely within the ovary, with no similar lesions in the uterus or elsewhere1,3. Masson’s trichrome stain can be used to distinguish smooth muscle and fibrous components of the tumor7 . Immunohistochemistry (IHC) is confirmatory and used in doubtful cases as the cytoplasm of the spindle tumor cells stain positive for desmin and smooth muscle actin. Desmin shows diffuse positivity in leiomyomas, whereas fibromatous tumors are typically negative or only focally positive. Since smooth muscle actin is usually positive in both, hence not helpful in distinguishing the two. Thecoma tumor cells do not express smooth muscle actin and thus may be differentiated from leiomyomas which are strongly positive for this stain2,7. Primary leiomyosarcoma of the ovary is hypercellular with high mitotic activity (>10 mitotic figures per 10 high power fields), hence can be differentiated from its benign counterpart3 . Our cases showed fascicles of smooth muscle cells which was confirmed on Masson’s trichrome stain. Immunohistochemistry was done for the second case also confirmed the diagnosis.
Treatment of ovarian leiomyoma is surgical removal. These tumors are benign, hence least radical surgery should be preferred1,7. Conservative surgery with preservation of ovarian function and anatomy is considered to be the first treatment modality especially in patients of reproductive age4 .
Conclusion
Ovarian leiomyoma is a rare benign tumor with distinct histopathologic and immunohistochemical features. In our first case patient presented with primary infertility and the absence of a uterine counterpart of the lesion makes it primary ovarian origin. The origin of ovarian leiomyoma is still unresolved. Despite its rarity, it should be considered as a possible cause of infertility. Our second case mimicked ovarian malignancy in its presentation. Awareness of this entity can avoid unnecessary aggressive surgery. Immunohistochemistry may be required in its differentiation from other ovarian spindle cell tumors. Since, most of these tumors appear at reproductive age, ovary- preserving management is preferred.
Acknowlegement
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 of this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=793http://ijcrr.com/article_html.php?did=7931. Tsalacopoulos G, Tiltman AJ. Leiomyoma of the ovary- report of three cases. S Afr Med J 1981; 59:574
2. Tomas D, Lenicek T, Tuckar N, Puljiz Z, Ledinsky M, Kruslin B. Primary ovarian leiomyoma associated with endometriotic cyst presenting with symptoms of acute appendicitis: a case report. Diagnostic Pathology 2009; 4:25
3. Mathew M, Krolikowski A, Al-Haddabi I, Nirmala V. Primary ovarian leiomyoma. Saudi Med J 2005; 26 (2): 306-07
4. Kim MJ, Na ED, Lee YJ, Kim ML, Seong SJ, Kim JY. A case of ovarian leiomyoma treated with laparoscopic mass excision. Korean J Obstet Gynecol 2012;55(3):218-23
5. Kurai M, Shiozawa T, Noguchi H, Konishi I. Leiomyoma of the ovary presenting with Meigs’ syndrome. J Obstet Gynaecol Res 2005;31:257-62
6. Kandalaft PL, Esteban JM. Bilateral massive ovarian leiomyomata in a young woman: a case report with review of the literature. Mod Pathol 1992;5:586-89
7. Usta U, Karadag N,Turkmen E, Haltas H. Primary leiomyoma of the ovary. Trakya Univ Tip Fak Derg 2006;23(1):39-42
8. Van Winter JT, Stanhope CR. Giant ovarian leiomyoma associated with ascites and polymyositis. Obstet Gynecol 1992; 80: 560-63
9. Koo YJ, Cho YJ, Kim JY, Lee JE, Kim ML, Kim JM, Han HW, Joo KY. Ovarian leiomyoma as a potential cause of compromised fertility. Fertil Steril. 2011;95(3):1120
10. Fukunaga M: Smooth muscle metaplasia in ovarian endometriosis. Histopathology 2000; 36:348-52
11. Hameed A, Ying AJ, Keyhani-Rofagha S, Xie D, Copeland LJ: Ovarian mucinous cystadenoma associated with mural leiomyomatous nodule and massive ovarian edema. Gynecol Oncol 1997; 67:226-29
12. Nichols GE, Mills SE, Ulbright TM, Czernobilsky B, Roth LM: Spindle cell mural nodules in cystic ovarian mucinous tumors. A clinicopathologic and immunohistochemical study of five cases. Am J Surg Pathol 1991; 15:1055-62.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241615EnglishN2014August10PLYOMETRIC TRAINING: A REVIEW ARTICLE
English3337Namrata N. PatelEnglishPlyometric Training: This article presents a theoretical basis for plyometric training. It is thought of as missing link between weight training (strength) and athletic performance (power), with particular emphasis on the speed of activity. During this training eccentric contraction is followed by concentric contraction known as stretch shortening cycle. The initial part of paper presents introduction; historical background; neurophysiology and biomechanics; benefits of plyometric training. Final part of paper presents detail about application and progression of plyometric training and evidence for use of plyometric training. The author hopes to encourage physiotherapists to enhance their skills with elements of plyometric training.
EnglishPlyometric training, Stretch shortening drillsINTRODUCTION
Plyometric is a type of exercise which utilizes the stretchshortening cycle of musculotendinous tissue. Eccentric stretching is followed by concentric shortening of the same muscles. Often involves rebound activities. 1Plyometric training also called stretch shortening drills or stretch strengthening drills or reactive neuromuscular training. 2, 3 Plyometric is thought of as missing link between weight training (strength) and athletic performance (power), with particular emphasis on the speed of activity. 4 It is a form of training designed to develop explosive power for athletics. Running, walking and hopping are typical examples in human locomotion of how external forces (e.g. gravity) lengthen the muscle. In this lengthening phase the muscle is acting eccentrically then a concentric (shortening) action follows. The true definition of eccentric action indicates that the muscles must be active during stretch. This combination of eccentric and concentric actions forms a natural type of muscle function called the stretch-shortening cycle (SSC). The period of time between the stretch and shortening cycles is known as the amortization phase. Amortization phase is kept very brief by a rapid reversal of movements to capitalize on the increased tension in the muscle.5
HISTORY
The word “plyometrics” has roots in the Greek word “pleythyein” which means to increase or augment. Though eastern countries used plyometric techniques in the 60s, but it came to the attention of the west during the 1970s.4 The leading researcher of plyometric training was a Russian scientist named Yuri Verkhoshansky. Dr. Verkhoshansky developed a system of exercises called “Jump Training” that used repetitive jumping in order to increase the speed and explosiveness of Russian track and field athletes. He published the results of his studies on this new form of training in 1964. Two years later he entered into scientific research. In his research, the use falling weight’s kinetic energy to increase the strength effort was adapted further for upper body explosive movements. He named this discovery the “shock method”.6 The term plyometric was first used in 1975 by an American track and field coach named Fred Wilt after he performed an extensive study of Dr. Verkoshansky’s training methods. Fred derived the word from the Latin words “pilo” and “metrics”. Pilo means more and metrics means to measure. By about 1980 had become a valuable tool in major athletic programs. In the early 1990s, George Davies and Kevin wilk introduced plyometrics into rehabilitation. 6
NEUROPHYSIOLOGY AND BIOMECHANICS OF PLYOMETRICS
Plyometrics is also known as reactive neuromuscular training. Loaded eccentric contraction is thought to prepare the contractile element of muscle for a concentric contraction by stimulation and activation of monosynaptic stretch reflex. If eccentric contraction occurs more rapidly, more likely it is that the stretch reflex will be activated.7 Plyometric training is thought to utilize the serialelastic properties of soft tissues and stretch reflex of neuromuscular unit. When muscle is stretched; mechanical energy is absorbed by the muscle. This energy can be dissipated as a heat or it can be stored within muscle as elastic energy. This storage of elastic energy in the musculotendinous tissues contributes to the increased force produced in the subsequent concentric contraction phase and increased efficiency of movement. This phenomenon can be visualized as the action of a spring.8 Stiffer musculotendinous unit may result in an increased rate of concentric contraction and a more rapid transmission of forces to the working limbs.9 Increased musculotendinous stiffness is more important than the ability to store more elastic energy in terms of enhancing stretchshortening cycle SSC performance in activities such as sprinting.10
BENEFITS OF PLYOMETRICS
Plyometric training (PT) is a method of choice when aiming to improve vertical jump ability and leg muscle speed-strength and power.11 Ground reaction time is decreased with plyometric training helps to improved reaction time and agility.12 Hamstring to quadriceps peak torque strength ratio increases. After plyometric training, peak landing forces from a volleyball block jump and knee adduction and abduction moments (medially and laterally directed torques) decreases. Multiple regression analysis revealed that knee adduction and abduction moments are significant predictors of peak landing forces. Female athletes demonstrated lower landing forces than male athletes and lower adduction and abduction moments after training. This training may have a significant effect on knee stabilization and prevention of serious knee injury among female athletes.13,14,15 In season training is more effective than preseason in Anterior cruciate ligament (ACL) injury prevention.16 Plyometric activities may facilitate neural adaptations that enhance proprioception, kinesthesia, and muscle performance characteristics.17 Plyometric jump training continued over a longer period of time during adolescent growth may increase peak bone mass.18
APPLICATION AND PROGRESSION OF PLYOMETRICS
1) Equipment
Plyometric can be performed indoors or outdoors. Flooring or playing surface is probably the most important equipment needed for plyometric training. Jumping on concrete or asphalt can lead to knee, ankle, and hip problems; as such these surfaces should be avoided. The landing surface should be able to absorb some of the shock of landing. Gymnastic or wrestling mats are good indoor surfaces as ar2) Pre training consideratione the sprung wood floors found in many aerobics studios. Outdoors, plyometrics are done on the grass or sand. 19 Footwear should provide good cushion and also sturdy support. A standard cross training shoe is best suited for lower extremity plyometrics for support and shock absorption. Equipments like; Solid boxes 6 to 24 inches or more in height can be used. Plastic cones, hurdles, slide board, plyometric/weighted balls, elastic band, trampoline are very useful for both upper and lower extremity plyometric.4
2) Pre training consideration
Plyometrics are a very high intensity form of training, placing substantial stress on the bones, joints, and connective tissue. While plyometrics can enhance an athlete’s speed, power, and performance, it also places them at a greater risk of injury than less intense training methods. Prior to starting a program there are several variables to consider so the training sessions are performed in a safe and effective manner. A person should have an adequate base of muscle strength and endurance as well as flexibility of the muscles to be exercised. Criteria to begin plyometric training usually include an 80% to 85% level of strength and 90% to 95% ROM.7 Power squat test is a good closed chain exercise to determine whether a patient has an adequate strength base for lower extremity plyometrics. It is performed with 60% of athlete’s body weight. Squat repetitions are done in 5seconds, and the depth should be knee flexion close to 900 for each repetition. 5 Although static stretching is important in the performance of plyometrics, some ballistic stretching is warranted. An individual must be able to perform a 30 seconds one leg stance with eye open and closed for proprioception and single leg half squat for strength.20 For shock and high intensity lower extremity plyometrics, it is recommended that healthy athletes have enough leg and hip strength to be able to perform a squat with 1.5 to 2.5 times the athlete’s body weight. For high intensity upper extremity plyometrics, it has been suggested that an athlete be able to perform five clap push-ups in row. 5
Although static stretching is important in the performance of plyometrics, some ballistic stretching is warranted.4 sufficient warm up is required before engaging to plyometric training.21 3) Load The training with light-load (30% of 1 RM) jump squats results in increased movement velocity, Peak force, peak velocity capabilities than high load (80% of 1 RM).22 However, no extra benefits were found to be gained from doing plyometrics with added weight.23
4) Speed
Drills should be performed rapidly but safely. The rate of stretch of the contracting muscle is more important than the length of the stretch. If a jumping activity is performed, for example, progression of the plyometrics activity should centre on reducing the time on the ground between each jump.20
5) Frequency
Plyometrics should not be performed more than two to three times per week unless you are alternating days of upper and lower body plyometric drills. Off-season plyometric routines are performed twice per week. In season, one session per week is appropriate for most sports. Track and field athletes may perform two to three time per week.4
6) Intensity
The intensity of plyometric drills is typically classified as low, medium, or high. When high-intensity levels are reached by the athlete, volume should decrease. The intensity of plyometric drills for the lower extremities has been related to foot contacts, direction of jump, speed, jump height and body weight.4 Volume is typically expressed as the number of foot contacts, throws of the medicine ball or distance jumped. Volume of 10 weeks duration and more than 20 sessions using high intensity programs (> 50 jumps per session) seems to maximize the probability of obtaining significantly greater improvements in performance.23 Adolescent athletes should perform low-impact plyometric training once-weekly to increase lower-body power resulting in increased Vertical Jump and kicking distance.2 9) Rest and recovery The work to rest ratio should be 1:5 to 1:10 to be certain that the intensity and proper execution of movement are preserved. It is suggested that 1 to 5 minutes of rest is needed between plyometric exercises, depending upon the intensity and volume of the workout. Recovery time between sessions is recommended 48-72 hours.25 10) Safety consideration Following points are considered for prevention of knee injuries: “Stick” the landing, holding the landing for 5 seconds, land softly and quietly, keep the shoulders over knees when landing, and avoid hyper extension during all activities. 4 11) Progression4 Low to high intensity Two legged jumps to one legged jumps Raising box jump and heights Increasing resistance of elastic band Increase weight of medicine ball Increasing number of hurdles
DISCUSSION
Philo u. Saunders et al in 2013 performed study on “Effects of knee injury primary prevention programs on anterior cruciate ligament injury rates in female athletes in different sports: A systematic review”. They concluded that three training programs in soccer and one in handball led to reduced ACL injury incidence. In basketball no effective training intervention is found. In season training is more effective than preseason in ACL injury prevention. A combination of strength training, plyometrics, balance training, technique monitoring with feedback, produced the most favourable results.16 Goran Markovic et al in 2007 had done a meta-analytical review on “Does plyometric training improve vertical jump height?” The result of the study showed that Plyometric training provides both statistically significant and practically relevant improvement in vertical jump height. It also suggest that the effects of PT are likely to be higher in slow stretch-shortening cycle (SSC) vertical jumps (countermovement jumps and countermovement jumps with arm swing) rather than in either concentric (Squat Jump) or fast SSC jumps (drop jumps).11 Saunders et al in 2006 performed a study on “Short-term plyometric training improves Running economy in highly trained middle and long distance runners”. Short-term plyometric training showed no significant difference in cardio respiratory measures or VO2max in plyometric group. But result showed improvement in Running economy, with likely mechanisms residing in the muscle, or alternatively by improving running mechanics.26 Johnson et al had done a Systematic Review on “Plyometric Training Programs for Young Children”. The current evidence suggests that a twice a week program for 8-10 weeks beginning at 50-60 jumps a session and increasing exercise load weekly results in the largest changes in running and jumping performance. An alternative program for children who do not have the capability or tolerance for a twice a week program would be a low-intensity program for a longer duration. The research suggests that plyometric training is safe for children when parents provide consent, children agree to participate, and safety guidelines are built into the intervention.27 CONCLUSION Plyometric Training can be safely introduced to improve vertical jump ability, speed-strength and power and reduce chances of sports specific injury. ACKNOWLEDGEMENT I acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. I am 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. I want to thank all editorial committee members of IJCRR.
Englishhttp://ijcrr.com/abstract.php?article_id=794http://ijcrr.com/article_html.php?did=7941. Dictionary of Sport and Exercise Science and Medicine by Churchill Livingstone © 2008 Elsevier.
2. Kisner Wilk, KE, et al. Stretch-shortening drills for the upper extremities: theory and clinical application. J Orthop Sports Phys Ther 1993; 17:225-239.
3. Voight, ML. stretch strengthening: an introduction to plyometrics. Orthop Phys Ther Clinic North Am 1992; 1:243-252.
4. Andrews, Kevin E. Wilk.ch 11.physical rehabilitation of injured athletes.3rd edition.265.
5. Paavo v komi. Stretch-shortening cycle: a powerful model to study normal and fatigued muscle, journal of biomechanics 2000; 33(10):1197–1206.
6. Natalia v erkhoshansky. Shock method and plyometrics: updates and an in-depth examination. CVASPS 2012.
7. Chu DA, Cordier DJ. Plyometrics in rehabilitation. In Ellenbecker, TS(ed). Knee ligament Rehabilitation. New York: Chrchill-Livingtone; 2000; 321.
8. Cavagna GA. Storage and utilization of elastic energy in skeletal muscle. Exerc Sport Sci Rev 1977; 5:89-129.
9. Wilson GJ, Murphy AJ, and Pryor Jf. Musculotendinous stiffness: Its relationship to eccentric, isometric, and concentric performance. J Appl Physiol 1994 Jun; 76(6):2714-2719.
10. Benn C, Forman K, Mathewson D, et al. Effects of serial stretch loading on stretch work and stretch shorthen cycle performance in knee musculature. J Orthop Sorts Phys Ther; 27:412-422.
11. Goran Markovic. Does plyometric training improve vertical jump height A meta-analytical review.Br J Sports Med 2007; 41:349- 355.
12. Michael G. Miller, Jeremy J. Herniman, Mark D. Ricard, Christopher C. Cheatham, and Timothy J. Michael.The Effects of a 6-Week Plyometric Training Program on Agility. J Sports Sci Med Sep 2006; 5(3): 459–465.
13. Timothy E. Hewett, Amanda L. Stroupe, Thomas A. Nance, ATC, Frank R. Noyes. Plyometric Training in Female Athletes Decreased Impact Forces and Increased Hamstring Torques. Am J Sports Med December 1996; 24:765-773.
14. Nicole J. Chimera, Kathleen A. Swanik, C. Buz Swanik and Stephen J. Straub. Effects of Plyometric Training on Muscle-Activation Strategies and Performance in Female Athletes.J Athl Train Jan-Mar 2004; 39(1): 24–31.
15. Patrick Sadoghi, Arvind von Keudell and Patrick Vavken. Effectiveness of Anterior Cruciate Ligament Injury Prevention Training Programs. J Bone Joint Surg Am 2012; 94:1-8.
16. Michael Michaelidis, George A. Koumantakis. Effects of knee injury primary prevention programs on anterior cruciate ligament injury rates in female athletes in different sports: A systematic review. Physical Therapy in Sport 2013 December 19.
17. Kathleen A Swanik, Scott M Lephart, C Buz Swanik, Susan P Lephart, David AS, Freddie H Fu. The effects of shoulder plyometric training on proprioception and selected muscle performance characteristics. Journal of Shoulder and Elbow Surgery November–December 2002; 11(6) 579–586.
18. Witzke KA, Snow c M. Effects of plyometric jump training on bone mass in adolescent girls.Medicine and science in sports and exercise 2000; 32(6):1051-1057.
19. Ed McNeely, MS, NSCA’s Performance Training Journal/ www. nsca-lift.org/perform; 6(5):20.
20. Voight M, Tippett S. Plyometric exercise in rehabilitation. In Prentice, WE, Voight ML S(eds) Techniques in Musculoskeletal Rehabilitation.New York: McGraw-Hill; 2001:167–178.
21. Costill DA, and Wilmore JH. Physiology of sport and exercise. Champaign,IL,humankinetics 1994.
22. Mcbride, Jeffrey M, Triplett-Mcbride Traviset, et al. The Effect of Heavy- Vs. Light-Load Jump Squats on the Development of Strength, Power, and Speed. Journal of Strength and Conditioning Research February 2002.
23. Saez Saez de Villarreal, E Kellis, E Kraemer WJ and Izquierdo M. Determining variables of plyometric training for improving vertical jump height performance: a meta-analysis. J Strength Cond Res 2009; 23(2): 495-506.
24. Rubley MD, Haase AC, Holcomb WR, Girouard TJ and Tandy RD. The effect of plyometric training on power and kicking distance in female adolescent soccer players. J Strength Cond Res 2011; 25(1): 129-134.
25. Chu DA and Cordier DJ. Plyometrics-specific applications in orthopedics. Orthopedic Physical Therapy Home Study course 98-A, Strength and Conditioning Applications in Orthopedics. Orthopedic session, APTA, INC., LACrosse, WI.
26. Philo U Saunders, Richard D Telford, David B Pyne, Esa M Peltola, Ross B Cunningham, Chris J Gore and John A Hawley. “Shortterm plyometric training improves Running economy in highly trained middle and long distance runners”. Journal of Strength and Conditioning Research 2006; 20(4): 947–954.
27. Johnson BA, Salzberg CL, Stevenson, David AA. Systematic Review: Plyometric Training Programs for Young Children. Journal of Strength and Conditioning Research September 2011; 25 (9):2623-2633.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241615EnglishN2014August10Role of Post-mortem in deciding cause of death
English3840Chandrashekhar BhuyyarEnglish Prerna GuptaEnglish Dharmaraya IngaleEnglish Anand B MugadlimathEnglish Tyagaraju M. R.English Rekha HiremathEnglishLigature marks are those marks made by an item of cord, rope, silk or some such material that has been used for the purposes of strangulation. The appearance at autopsy naturally depends on the nature and texture of the ligature. When there is a pronounced pattern, such as a weave of a cord, or the plaiting of a thong, the same pattern may be imprinted in to the skin1. Articles used as ligature may include rope, dhoti, saree, chunni, turban, bed sheet, cord of paijamas or dressing gowns, belts, brace, neck tie and towel etc2. Sometimes it is very difficult to find out whether ligature mark is antemortem or post mortem.
EnglishLigature mark, pattern, strangulationINTRODUCTION
Suicide by hanging is one of the most common ways to end life. To kill any conscious person by hanging is very difficult that in an adult male. Ligature or manual strangulation is the one of the common method to kill any one. Here we are presenting a very interesting case report in which how proper examination changed the direction of investigation and administration of justice.
Case report
• A body of 35 years old male, was found floating naked in a lake, 10 km away from City.
• Police traced the body as of an Engineer, who lost his job 3 months ago.
• A missing complaint was lodged by relatives two days ago.
P.M Examination
• Inquest – appears suicide by drowning please give the exact cause of death.
• Body of adult male, moderately built and nourished, E/o tongue bite.
• Postmortem lividity on front of the body, Fixed.
• Rigor mortis – Generalized and well-marked
• S/o immersion seen -
EXTERNAL EXAMINATION
1. Ligature Mark- A reddish coloured ligature mark around neck, at the level of thyroid cartilage, horizontally placed, more prominent on left anterolateral aspect of neck & running upwards towards right mastoid, deficient posteriorly, measuring 32cm x 1.2cm.
2. Abrasions- brownish coloured abrasions on both wrists and on left knee.
There was no mention of these injuries in the inquest report given by police officer INTERNAL EXAMINATION No E/o injury to strap muscles of neck No E/o fracture of thyroid cartilage, hyoid bone or cricoid cartilage. No froth in respiratory tract. Stomach contained 100 ml of pale reddish fluid without any peculiar smell. Lungs- Lungs enlarged, voluminous. Reddish frothy fluid oozes from cut surfaces of lungs. When We Enquired Police On enquiry police submitted following photographs & narrated the story that the body was found floating approx. 40 feet away from bank of the lake, was pulled out from water with help of a local fisherman, by throwing a loop of cotton rope ( 1.5cm diameter), encircling around neck. Photograph no 2 – showing how the body was pulled out of water Material preserved Routine viscera preserved for chemical analysis.—report was Negative. Neck tissue from ligature mark and from control site for histopathological examination---- did not show any inflammatory reaction and hemorrhage. Discussion Ligature mark similar to the one observed in persons hanged alive can be produced if suspended within 2 hours or even longer period(?) after death. Besides, a similar mark may also be produced by dragging a body along the ground with cord passed around the neck soon after the death.3 Postmortem strangulation may be caused to bring a false charge of murder against one’s enemy. A dead body while being removed from water e.g. A well, cord may be tied around neck & limbs. And the marks caused by them may wrongly lead to diagnosis of strangulation death.4 Experiments of Casper who concluded that a mark of hanging where hanging took place during life can also be produced if the body is suspended within a couple of hours or even longer after death5 . Wounds may be found on the external examination of drowned persons such wounds may be produced before, at the time of, or after immersion. Before immersion they may be of accidental , suicidal or homicidal in nature. At the time of immersion they may be produced by the deceased striking hard objects such as rocks or stones6 . InDr. Modi’s experience, he had found that 21% out of dead bodies removed from water were such as were thrown in to well, pond, lake, canal or river after the deceased had been destroyed by wounds inflicted on the head or neck or by strangulation, suffocation and poisoning7 . When a dead body is found in water it is not safe to assume that the death was due to drowning, because the bodies of victims of murder and poisoning may be thrown into water to avoid detection of crime8 . Histopathology report The absence of tissue reaction, however would not exclude the antemortem origin for wound6 . This investigation would only be of value in case of hanging if the period of time that elapsed before death was sufficiently long for the tissue reaction to develop.
Conclusion
The ligature mark which was thought of being antemortem in nature, after detailed postmortem examination and circumstantial evidence was found to be postmortem artefact and hence the cause of death was given as “Asphyxia due to drowning”.
Acknowledgement
Authors 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 ofreviewers who have helped to bring quality of this manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=795http://ijcrr.com/article_html.php?did=7951. Knight B. Forensic Pathology, 1sted, London: Edward Arnold publishers ltd; 1991.p. 346.
2. Vij K. Textbook of forensic medicine and toxicology. 5th ed. Haryana: Elsevier publishers; 2011. p. 123-24.
3. MukhrjeeJ B,forensic medicine and toxicology,2nded, academic publishers,1981,p491.
4. Nandy A.. Principles of Forensic Medicine including Toxicology.2nd ed. Kolkata. New central book agency (P) ltd.2010.p.327-328.
5. Vij K. Textbook of forensic medicine and toxicology. 5th ed. Haryana: Elsevier publishers; 2011. p. 127.
6. Gorden I ,Shapiro H A,berson H D,forensic medicine a guide to principles 3rded.,Edinburgh, British library cataloguing in publication data, 1988 p-123.
7. Modi J P, medical jurisprudence and toxicology,23rded,Nagpur ,lexis nexisbutterworths wadhwa, 2009,p 607.
8. Guhuraj P V, Forensic medicine,2nd ed,Hyderabad, universities press private limited 2009, p188.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241615EnglishN2014August10STUDY OF VARIATIONS IN THE ORIGIN AND DISTANCE OF ORIGIN OF AXILLARY NERVE OF THE POSTERIOR CORD OF BRACHIAL PLEXUS
English4144Santosh M. BhosaleEnglish Nagaraj S. MallashettyEnglishBackground: Variations in the origin of axillary nerve from the posterior cord of brachial plexus and its distance of origin from mid clavicular point are important during surgical approaches to the axilla and upper arm, administration of anesthetic blocks, interpreting effects of nervous compressions and in repair of plexus injuries. The patterns of branching show population differences. Data from the South indian population is scarce. Objective: To describe the variations in the origin of the axillary nerve from the posterior cord of brachial plexus and its distance of origin from mid- clavicular point in the South Indian population. Materials and methods: Forty brachial plexuses from twenty formalin fixed cadavers were explored by gross dissection. Origin and order of branching of axillary nerve and its distance of origin from mid- clavicualr point was recorded. Representative photographs were then taken using a digital camera (Sony Cybershot R, W200, 7.2 Megapixels). Results: In forty specimens studied, 87.5% of axillary nerve originated from the posterior cord of brachial plexus and in 12.5% of specimens axillary nerve took origin from common trunk along with thoracodorsal or lower subscapular nerve or both. In 32.5% of the specimens axillary nerve had origin from posterior cord of brachial plexus at a distance of 4.6-5.0cm from mid-clavicular point.
EnglishPosterior cord, Axillary, common trunk, mid clavicular pointINTRODUCTION
The brachial plexus is a complex network of nerves which extends from the neck to the axilla and supplies motor, sensory and sympathetic fibres to the upper extremity. The brachial plexus is formed by platuing of ventral rami of the lower four cervical and the first thoracic nerves. The plexus extends from the inferior lateral portion of the neck downward and laterally over the first rib, posterior to the clavicle and enters the axilla. The brachial plexus is divided into supraclavicular part and infraclavicular part. The infraclavicular part consists of three cords-lateral, medial and posterior.The posterior cord runs posterior to the second part of the axillary artery behind the pectoralis minor muscle and gives off the following branches – upper subscapular nerve, thoracodorsal nerve, lower subscapular nerve, axillary nerve and then continues as a large terminal branch, the radial nerve. The axillary nerve is variable in its origin, course and supply to the muscles; its variations become important as it is involved fracture of surgical neck of humerus and quadrangular space syndrome. Descriptions of nerve variations are useful in clinical/surgical practice since an anatomical variation can be the cause of a nerve palsy syndrome due to a different relation of a nerve and a related muscle. Knowledge of variations in the branching pattern of axillary nerve from posterior cord of the brachial plexus is highly important in the surgical exploration of axilla, fracture of surgical neck of humerus , shoulder dislocation, and infraclavicular brachial plexus block. Anatomical variations in the origin of axillary nerve have been described by many authors, although these have not been extensively catalogued. These may be due to an unusual formation during the development of the trunks,
divisions, or cords and they usually occur at the junction or separation of the individual parts. For a surgeon, to know the variational patterns of the axillary nerve at his finger’s ends is essential in the light of not only the frequency with which the surgery is performed in the axilla and the surgical neck of the humerus and the rapid development of microsurgical techniques but also to give explanations when encountering an incomprehensible clinical sign. Thus knowledge of variations in the branching pattern of axillary nerve from the brachial plexus and its distance of origin from fixed point that is mid-clavicular point is important to anatomists, radiologists, surgeons and anaesthesiologists and has gained importance due to the wide use and reliance on computer imaging in diagnostic medicine. Literature on the variations in the origin of axillary nerve from the posterior cord of the brachial plexus and its distance of origin from mid-clavicular point among Indians is scanty and altogether lacking in South Indians. The present study describes the variations in the branching pattern of axillary nerve from the posterior cord of the brachial plexus observed in South Indian population. Materials and methods
SOURCE OF DATA:
The specimens for the study were obtained from the Department of Anatomy, S.S.I.M.S and R.C, Davangere, Karnataka. Requisite consent had been obtained from the Head of the Department to conduct the study.
SAMPLE SIZE:
The study was carried out on forty upper limbs of adult human cadavers of both sex and age group between 30- 60 years.
INCLUSION CRITERIA:
• All normal cadavers were included for the study.
EXCLUSION CRITERIA:
• Deformed or traumatized upper limbs were excluded from the study.
MATERIALS:
1. Dissection instruments
2. Measuring scale
3. Geometric radius
4. Sony cyber shot camera.
DISSECTION PROCEDURE
The cadaver was positioned in supine position with upper limb abducted at 90degrees.The incision made on the skin over lateral part of thoracic wall in the mid axillary line at the level of nipple which is carried up to the lateral wall of axilla at the junction of anterior 2/3 and posterior 1/3.The loose connective tissue, fat, and lymph nodes from the axilla were removed to expose its contents. The axillary artery and vein and the large nerves surrounding them were exposed. The smaller tributaries of the vein were removed in order to get a clear view of the nerves. The radial nerve was identified behind the artery. It was traced upwards and at the lower border of subscapularis, the axillary nerve was seen passing backwards with the posterior humeral circumflex artery. The pectoralis minor was cut across and the axillary vessels were followed to the outer border of the first rib. The anterior surface of subscapularis was exposed and the upper subscapular nerves entering it were identified. The upper and lower subscapular and thoracodorsal nerves were traced to their origin from the posterior cord of the brachial plexus. The distance of origin of axillary nerve from mid-clavicular point was noted and the origin of axillary nerve was studied. Representative photographs were taken using a Sony Cybershot R (DSC W50, 7.2 MP) digital camera
RESULTS
In the current study, the number of axillary nerves is same on both right and left side. Majority of the axillary nerve have origin from posterior cord in 87.5% of specimens (Fig.1).In 12.5% of specimens the nerve take origin from common trunk along with the thoracodorsal nerve (Fig.2) and with both lower subscapular nerve thoracodorsal nerve as common trunk (Fig.3). In 32.5% of specimens axillary nerve had origin at a distance of 4.6 – 5.0 cm, 30% of axillary nerve showed origin at a distance of 5.1 – 5.5 cm, 20% of axillary nerve took origin at a distance of 4.1 -4.5 cm, 10% at a distance of more than 6cm and 7.5% at a distance of 5.6 – 6.0 cm Table (1) and Graph (1).
DISCUSSION
Brachial plexus forms the innervations of the upper limb. During the early stages of development the upper limb buds lie opposite the lower five cervical and upper two thoracic segments. As soon as the limb buds form, the ventral primary rami of the spinal nerves penetrate into the mesenchyme of the limb bud.1 Atfirst each ventral ramus enters with isolated dorsal and ventral branches, but soon these branches unite to form large dorsal and ventral nerves for the extensor and flexor musculature of the upper extremity respectively. Immediately after the nerves enter the limb bud, they establish an intimate contact with the differentiating mesodermal condensations and the early contact between the nerve and muscle cells is a prerequisite for their complete functional differentiation.2 Several signalling molecules and transcription factors have been identified which induce the differentiation of the dorsal and ventral motor horn cells. Misexpression of any of these signalling molecules can lead to abnormalities in the formation and distribution of particular nerve.
In the current study among 40 specimens, axillary nerve has origin from posterior cord in 87.5% of specimens, from common trunk in 12.5% of specimens. In the present study, out of 40 specimens 32.5% of axillary nerve had origin at a distance of 4.6 – 5.0 cm, 30% at a distance of 5.1 – 5.5 cm, 20% at a distance of 4.1 -4.5 cm, 10% at a distance of more than 6cm and 7.5% at a distance of 5.6 – 6.0 cm. In a case reported by Bhat KMR and Girijavallabhan V the posterior cord was splitting into thick posterior and thin anterior roots, enclosing the subscapular artery near its origin. The two roots, after enclosing the subscapular artery were fused to continue as radial nerve. The upper subscapular nerve was arising from the main trunk of the posterior cord. Thoracodorsal nerve, lower subscapular nerve and the axillary nerve were originating from thick posterior root of the cord.4 No such variation was encountered in the present study. Priti Chaudhary et al observed in a study of 60 brachial plexus, the axillary nerve being normal in origin as one of the terminal branches of the posterior cord in 59 (98.33%); in one limb, (1.66%), it was found to originate from the posterior division of the upper trunk (root value-C5,6).5 Muthoka et al mentioned in their study of 75 posterior cords that the axillary nerve originated from the posterior Figure 3: Showing origin of axillary nerve from common trunk along with lower subscapular nerve and thoracodorsal nerve . PC- Posterior cord, USN- Upper subscapular nerve, TDN- Thoracodorsal nerve, LSN- Lower subscapular nerve, AN- Axillary nerve, RN- Radial nerve. cord in 97.3% cases while two (2.7%) cases had a supraclavicular origin.6 Variant origin of axillary nerve of such a kind was not observed in the present study.
Conclusion
Majority of axillary nerves in studied population display a wide range of variations in the origin and distance of origin. This knowledge is pertinent for clinicians, anesthetists while administering brachial plexus blocks and orthopaedic surgeons exploring axilla during surgery on the neck of humerus. Further study of variations in the diameter of axillary nerve along its course is recommended.
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 also thank the head of the department of anatomy Dr. A.V. Anagadi and Assistant professor Dr. Veeresh Itagi for their constant support and help during the study.
.
Englishhttp://ijcrr.com/abstract.php?article_id=796http://ijcrr.com/article_html.php?did=7961. Standring S. Gray’s anatomy. The Anatomical basis of clinical practice. 40th Ed., London: Elseveir Churchill Livingstone; 2008:821-822.
2. Saddler TW. Langman’s Medical Embryology. 10th ed. Philadelphia Lippincott Williams and Wilkins, 2006: 146-147.
3. Satyanarayana N, Vishwakarma N, Kumar GP, Guha R, Datta AK, Sunitha P. Variation in relation of cords of brachial plexus and their branches with axillary and brachial arteries - a case report; Nepal Med Coll J 2009; 11(1): 69-72.
4. Bhat K M R, Girijavallabhan V. Variation in the branching pattern of posterior cord of brachial plexus- A case report. Neuroanatomy 2008; 7: 10–11.
5. Chaudhary P, Singla R, Kalsey G, Arora K. Branching Pattern of the Posterior Cord of the Brachial Plexus: A Cadaveric Study. Journal of Clinical and Diagnostic Research August 2011; 5(4): 787-790.
6. Muthoka JM, Sinkeet SR, Shahbal SH, Matakwa LC, Ogeng’oJA. Variations in branching of the posterior cord of brachial plexus in a Kenyan population. Journal of Brachial Plexus and Peripheral Nerve Injury 2011; 6:1.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241615EnglishN2014August10IN-VITRO LEUCOAGGLUTINATION: A STUDY OF 11 CASES
English4548Kavita GuptaEnglish Deepak Nayak M.English Chethan ManoharEnglish Sushma V. BelurkarEnglishObjective: Cold agglutination of red blood cells and platelets are well recognized and extensively studied in literature. However aggregation of leukocytes in vitro is rare and may result in spuriously low leucocyte count. We present a case series of 11 patients with spurious leukopenia due to leucoagglutination in-vitro. Methods: A retrospective study was conducted at Clinical laboratory and Haematology division, Kasturba Hospital, compiling 11 cases which showed WBC clumping on the peripheral smear in the last 2 years. Results: The aetiologies ranged from immune mediated (4 cases), liver diseases (2 cases) and infections/drug induced (5 cases). The incubation of samples at 37° C for 30 minutes caused disaggregation of leucocytes; thus denoting the role of temperature dependent antibody.Conclusion: Leucoagglutination in-vitro can be linked to an immunological phenomenon, possibly due to a temperature-dependent
antibody
EnglishLeucoaggregates, EDTA (Ethylenediaminetetraacetic acid), antibody, leucocytesINTRODUCTION
The increasing application of automated analyzers for routine hematologic procedures has several advantages. Several of them are known for their unbeaten service excellence in terms of data reproducibility and accuracy. However possibility of spurious cannot be overseen. They may be due to the interaction of blood cells with components of serum such as antibodies, drugs and their derivatives or even something trivial as additives in reagents. Among these, platelet aggregation, neutrophil-platelet clumping (satellitosis), and aggregation of platelets, resulting in pseudothrombocytopenia or pseudoleukocytosis have been repeatedly described.1-3 In-vitro aggregation is a well-known laboratory phenomenon for platelets and erythrocytes due to EDTA (Ethylenediaminetetraacetic acid) and cold agglutinins respectively. But aggregation of neutrophils (also known as leuco-aggregation, neutrophil agglutination and leucocyte clumping) in peripheral smear is a very rare phenomenon and seldom described.4,5 We present a case series of 11 patients with spurious leukopenia due to leucoagglutination in-vitro. The objective of our study was to assess the clinico-pathological profile of leucoagglutination in-vitro and also to determine the potential usefulness of the Research Population Data (RPD) such as Mean Neutrophil Volume (MNV) in predicting this phenomenon. Only few case reports of leucoagglutination leading to spurious leukopenia have been published in literature. We believe it is not a very uncommon phenomenon but it is basically underrated or overlooked due to unawareness. This anomalous low WBC count can be clinically perplexing and lead to additional patient testing and unnecessary treatment, thus necessitating the recognition of this entity. A morphological evaluation along with new automated analyser parameters could possibly predict this phenomenon. MATERIALS AND METHODS A retrospective study conducted at Clinical laboratory and Haematology division, Kasturba Hospital, Manipal. A total of 11 cases of WBC clumping in the peripheral smear in the last two years (2011 – 2013); were included in the study. WBC counts in these cases were flagged by Beckman Coulter LH 750TM series analyzer as “uncorrected” WBC count and were lower than the normal reference range in most cases. Thus the corresponding peripheral smears before and after incubating (37°C for 30 minutes) the sample were also studied. The Volume conductivity scatter (VCS) parameters and research population data (RPD) were noted for all cases. A correlation with the clinical profile was done using the patient case files from medical records department. An Institutional ethical clearance was obtained for the study.
RESULTS
In our study the age ranged from 35-85 years with an equal sex predilection (table 1). The aetiologies ranged from immune mediated (4 cases), liver diseases (2 cases) and infections/drug induced (5 cases). 2 out of 11 cases showed serologic positivity for HIV. The WBC counts in all the 11 cases increased after incubating blood samples at 37° C for 30 minutes; suggesting that the WBC counts were spuriously low before incubation. So a peripheral smear examination was conducted for all the cases which showed neutrophil aggregates of 10- 20 neutrophils near the tail end of the smears (fig. 1a). These aggregates disappeared following incubation of samples at 37° C for 30 minutes (fig. 1b); thus denoting the role of temperature -dependent antibody. The Mean Neutrophil Volume (MNV) was increased in most of the cases with a mean of 161.5 fl (normal range of MNV is 138.2 to 147.8 fl).
DISCUSSION
Leucoagglutination in-vitro is an elusive phenomenon. Most reports in literature are based on single case studies. This phenomenon has been linked to underlying malignancies, infections, hepatic disorders or autoimmune diseases.6 Interestingly, it has also been noted in apparently healthy subjects as well.7 One does come across these leucocyte aggregations in many smears ; albeit infrequently. But in most of the cases it is just a spreading or smearing artefact. It should be distinguished from true leucocyte aggregation wherein additionally, the total WBC count will also be spuriously low. The explanation for this spurious low WBC count being that the size of the clumps which is larger than upper threshold set for WBC detection. So we presume that if the clump is large it not counted at all and if the clump is small consisting of 2-3 neutrophils, it may be counted as a single event thus decreasing the total WBC count even if the counts appear normal on corresponding peripheral smears. In our study only aggregates of neutrophils were seen unlike many other studies where aggregates of lymphocytes, mature neutrophils around immature neutrophils and platelets around neutrophils were also seen.8 The number of cells in aggregates varied from 10 to 100 cells. The exact cause for this phenomenon is still not known. One of the proposed mechanisms incriminates the interaction of the anticoagulant EDTA with the leucocytes. Accordingly, EDTA unmasks antigens on the surface of WBCs, which creates the potential for any antibody in the serum to non-specifically bind and cross-link the leucocytes. In our study, EDTA was the anticoagulant used in all the samples. Secondly, it was noted that there was a reversal of clumping of the neutrophils after warming the sample to 37°C; suggesting that this reaction was also temperature-dependent.9-11 Was it the IgM antibodies then, which caused this phenomenon to manifest? The possible clues to this query may be in the medical condition of the patients. 4 cases had some underlying immune dysregulation, while 2 others had liver disorders. Still others had infectious aetiologies. These may explain the role of IgM antibodies, although the titre of antibodies was never assessed. Another interesting aspect of this phenomenon is that leucocyte agglutination is also a time-dependent phenomenon.12 The number and the size of the clumps depend on the time elapsed. In our laboratory, analysis of blood sample is conducted within 20 minutes of phlebotomy. Peripheral smear is prepared and reviewed within next 30 min. Mixture of both small and large clumps of neutrophils were seen. Repeat smear from the sample showed a marginal increase in the size of the neutrophil aggregates; possibly denoting the time dependent nature of the event.
The Coulter LH-750 VCS technology determines the 5-part WBC differential using 3 measurements - individual cell volume, high-frequency conductivity, and laserlight scatter. We depend a lot on VCS parameters in our routine reporting to look for reactive lymphocytes, left shift, etc. However, not many studies have been done to identify this rare phenomenon of leucoagglutination using VCS technology. We had made an attempt to use Mean neutrophil volume (MNV) to suspect the presence of leucoagglutination. In our study all 11 cases showed an increase MNV, with the mean being 161.5 fl (normal range of MNV is 138.2 to 147.8 fl).13 But the necessary disclaimer to this finding is that the same MNV can increase in acute infections, malaria as well as leukaemia’s. 14 Thus, with an appropriate clinical perspective, the MNV can potentially prove to be a useful clue in identifying this phenomenon.
CONCLUSION
Leucoagglutination in-vitro can be linked to an immunological phenomenon. The role of a temperature-dependent antibody cannot be ruled out. An increased MNV is a useful predictor in this regard. Hematopathologist should be aware of this spurious leukopenia to avoid unnecessary diagnostic tests and inappropriate treatment. Further studies are necessary to shed light on this elusive phenomenon.
Acknowledgements
I acknowledge the important contributions and guidance provided by the following members: Dr.Indira Shastry, Dr.Ayushi Agarwal, Dr. Dibakar Podder. Authors also acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed
Englishhttp://ijcrr.com/abstract.php?article_id=797http://ijcrr.com/article_html.php?did=7971. Hillyer CD, Knopf AN, Berkman EM. EDTA-dependent leucoagglutination. Am J Clin Pathol 1990; 94:458–461.
2. Lesesve JF, Haristoy X, Thouvenin M, Latger-Cannard V, Buisine J, Lecompte T. Pseudoleukopenia due to in vitro leukocyte agglutination polynuclear neutrophils: experience of a laboratory, review of the literature and future management. Ann Biol Clin (Paris)2000; 58:417–424.
3. Savage RA. Analytic inaccuracy resulting from hematology specimen characteristics. Three cases of clinically misleading artefacts affecting white blood cell and platelet counts. Am J Clin Pathol 1989;92:295–299.
4. Epstein HD, Kruskall MS. Spurious leukopenia due to in vitro granulocyte aggregation. Am J Clin Pathol 1988;89:652–655.
5. Guibaud S, Plumet-Leger A, Frobert Y. Transient neutrophil aggregation in a patient with infectious mononucleosis. Am J Clin Pathol 1983; 80:883–884.
6. Moraglio D, Banfi G, Arnelli A. Association of pseudothrombocytopenia and pseudoleukopenia: Evidence for different pathogenic mechanisms. Scand J Clin Lab Invest 1994;54:257–265.
7. Lombarts, A. J. P. F., de Kieviet W. Recognition and prevention of pseudothrombocytopenia and concomitant pseudoleukocytosis. Am J Clin Pathol 1988;89:634-639.
8. Claviez A, Horst HA, Santer R, Suttorp M. Neutrophil aggregates in a 13-year-old girl: a rare hematological phenomenon. Ann Hematol 2003; 82:251–253.
9. Glasser L. Pseudo-neutropenia secondary to leukoagglutination. Am J Hematol 2005;80:147.
10. Carr ME, Whitehead J, Carlson P, et al. Case report: Immunoglobulin M mediated, temperature-dependent neutrophil agglutination as a cause of pseudoneutropenia. Am J Med Sci. 1996;311:92–95.
11. Lesesve JF, Haristoy X, Lecompte T. EDTA-dependent leucoagglutination. Clin Lab Hematol 2002;24:67–69.
12. Savage, R. A. (1984) Pseudoleukocytosis due to EDTA induced platelet clumping. Am J Clin Pathol 1984; 81:317-322.
13. Beckman Coulter. Coulter LH750 system: Operation principles. Operator’s Guide. 2004:9.
14. Bagdasaryan R, Zhou Z, Tierno B, et al. Neutrophil VCS parameters are superior indicators for acute infection. Lab Hematol 2007;13:12–16.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241615EnglishN2014August10ISOLATED LEFT LUNG HYPOPLASIA IN AN ADULT- A CASE REPORT
English4952Vishnukanth GovindarajEnglish Manju REnglish Srinivas BanothEnglish Pratap UpadhayaEnglishCongenital anomalies of the lung occur due to various insults to the developing lung. Pulmonary hypoplasia is congenital
anomaly that can present either in isolation or with other anomalies. However they are not routinely considered in the differential diagnosis in adults. We present a case of isolated left lung hypoplasia in an adult who had no significant respiratory symptoms. We believe this case report would help in better understanding of this condition and help to create further interest in other similar conditions.
EnglishPulmonary hypoplasia, CT chest, Fiberoptic bronchoscopyINTRODUCTION
Pulmonary hypoplasia is a developmental abnormality of the lung characterized by a decrease in the number of alveoli, cells, and airways with resultant decrease in size and weight of the lungs. Though predominantly a disease of infancy and childhood, its presentation in adults is not uncommon. Pulmonary hypoplasia has associated other congenital anomalies like renal agenesis,diaphragmatic hernia. Post natal diagnosis of this condition usually requires imaging studies and bronchoscopy. We present a case of isolated left lung hypoplasia in an adult who had few respiratory symptoms. The diagnosis was confirmed with fiberoptic bronchoscopy and computed tomography studies.
CASE SCENARIO
An asymptomatic 35 year old agricultural laborer presented with complaints of occasional left sided chest pain on moderate to severe exertion. He had no other respiratory complaints. He was not a smoker and had no co morbid illness. . He was first male child of a second degree consanguineously married parents. He is married since last 10 years and has two male children. He was initially evaluated outside for possible cardiac disease. His ECG showed no evidence of myocardial ischemia and he was referred to our respiratory medicine department for further evaluation. Upon presentation the patient was stable and maintained normal saturation at room air. There was no pallor or clubbing. Respiratory system showed trachea deviated to the left, diminished movements on the left side and a mild drooping of left shoulder. The apex beat was palpable in the left sixth intercostal space in mid axillary line. Breath sounds were absent in the lower left chest. Hematological investigations were within normal limits. Echocardiography showed a mild Tricuspid regurgitation. Spirometry revealed a mixed airway pattern. Chest x ray (fig. no 1) showed tracheal and mediastinal shift to left with crowding of ribs on the left upper zone with a hyper inflated right lung. A possibility of left lung collapse was suspected and he was planned for computed tomography(CT) of the thorax and fiber optic bronchoscopy. CT Scan Thorax (fig 2) revealed marked asymmetry in thorax. The right lung was hypertrophied and was observed to extend to the left hemithorax through anterior recess. The left lung showed a compressed left main bronchus with only minimal residual lung tissue. No endo-bronchial lesion was observed. Bronchiectatic changes were seen in the left lung tissue. The mediastinum was shifted to left side. The pulmonary arteries were normal. A possibility of left lung hypoplasia was considered and a fiber optic bronchoscopy(FOB) was performed. Bronchoscopy showed a normal trachea, carina and right side bronchial tree. The left main bronchus was narrowed and slit like in appearance. On negotiating the left main bronchus, left lobar bronchi were seen but
Englishhttp://ijcrr.com/abstract.php?article_id=798http://ijcrr.com/article_html.php?did=7981. Boyden EA. Developmental anomalies of the lungs. Am J Surg 1955; 89: 79-89.
2. Kant S: Unilateral Pulmonary Hypoplasia. A case report. Lung India 2007; 24: 69-71.
3. DeFelice M, Silberschmidt D, DiLauro R, et al. TTF-1 phosphorylation is required for peripheral lung morphogenesis, perinatal survival, and tissue-specific gene expression. J Biol Chem. Sep 12 2003;278(37):35574-83.
4. Jay PY, Bielinska M, Erlich JM, et al. Impaired mesenchymal cell function in Gata4 mutant mice leads to diaphragmatic hernias and primary lung defects. Dev Biol. 2007 Jan 15;301(2):602-14.
5. Kling DE, Narra V, Islam S, et al. Decreased mitogen activated protein kinase activities in congenital diaphragmatic hernia-associated pulmonary hypoplasia. J Pediatr Surg. Oct 2001;36(10):1490-6.
6. Kendig and Chernick’s Disorders of the Respiratory Tract in Children. 8th edition. Elseiver publication.
7. Lindner W, Pohlandt F, Grab D, Flock F. acute respiratory failure and short-term outcome after premature rupture of the membranes and oligohydramnios before 20 weeks of gestation. J Pediatr 2002;140:177–82.
8. Kumar P, Burton BK. Congenital Malformations. Evidenced Based Management. Chicago: The McGraw Hill companies; 2008. Chapter 22, Pulmonary Hypoplasia; p.143.
9. Mata JM, Caceres J, Lucaya J. et al.: CT of congenital malformations of lung. Radio graphics. 1990; 10: 651.
10. Vergani P. Prenatal diagnosis of pulmonary hypoplasia. Curr Opin Obstet Gynecol. Mar 2012;24(2):89-94.
11. Obenauer S, Maestre LA. Fetal MRI of lung hypoplasia: imaging findings. Clin Imaging. Jan-Feb 2008;32(1):48-50..
12. Moore ADA, Godwin JD, Dietrich PA et al.: Swyer James Syndrome: CT findings in eight patients. Am. J. Roentgenol. 1992; 158: 1211.
13. Ghosh N, Das N, Nayak K Lung Hypoplasia Without Other Congenital Anomaly- A Rarely Encountered Entity : J Nepal Paediatr Soc 2013;33(2):138-140.
14. Terry Chin, Yazin Said, Natrajan, Abdulhamid I. Pulmonary hypoplasia. Available from:http://www.emedicine.com/ped/topic 2627.htm 15. Sundararajaperumal A, Vinodkumar V, Sundar V, Ranganathan D. Primary Pulmonary Hypoplasia in an adult. Pulmon 2008; 10 : 1 : 12 – 15.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241615EnglishN2014August10SURGICAL MANAGEMENT OF GINGIVAL ENLARGEMENT: A CASE SERIES
English5356Munaza shafiEnglish Nawal khanEnglish Prabhati GuptaEnglish Reyaz Ahmed MirEnglish Nasrina BashirEnglishIntroduction: Gingival enlargement is defined as an overgrowth or increase in size of gingiva. Gingival enlargement is associated with multiple factors including inflammation, medications, neoplasia, hormonal disturbances and heredity. A case of gingival enlargement should be treated in a step-wise manner, including consultation with the patient’s physician, substitution of the drug, nonsurgical therapy, surgical therapy (if needed), and supportive periodontal therapy after every 3 months. Case series: This case series presents diagnosis and management of amlodipine induced gingival hyperplasia and idiopathic gingival enlargement. Drug-induced gingival enlargement and idiopathic gingival enlargement was diagnosed and managed byscaling and root planing followed by gingivectomy with 6 months follow up Conclusion: Conventional gingivectomy with oral hygiene measures and regular followup is the treatment of choice for such
presentation.
EnglishDrug- induced enlargement, idiopathic gingival enlargement, gingivectomyINTRODUCTION
Gingival enlargement is defined as an abnormal growth of the gum tissue. It is associated with multiple factors including: inflammation, hormonal, drug use, neoplasm, genetic, systemic and idiopathic.(1,2,3) Gingival enlargement is one of the side effects associated with the administration of several drugs.(4) Currently, more than 20 drugs are associated with gingival enlargement. Drugs having side effect of gingival enlargement can be broadly divided into three categories: anticonvulsants, calcium channel blockers and immunosuppressant’s. Amlodipine-induced gingival enlargement is comparatively less prevalent among calcium channel blockers. Since pathogenesis of gingival enlargement is not well-understood, it is still a challenge for the periodontists to diagnose and manage the case effectively. Idiopathic gingival hyperplasia has been described in several case reports. The clinical presentation of the gingiva is pink, firm, fibrotic and nonhemorrhagic. Severity varies and may cover part/all of the crowns of the erupted teeth. General histological findings include normal overlying epithelium, rete pegs extending deep into underlying connective tissues with some areas of hyperplasia, proliferating dense fibrous CT with increased cellularity and coarse collagenous fiber bundles and hyperkeratosis and acanthosis with elongated papillae (5) The purpose of this paper is to present a case series of a patients with amlodipine induced gingival enlargement and idiopathic gingival hyperplasia and their management with 6 month follow up.
Case 1
A 47-year-old male was referred to the Department of Periodontics with complaints of gingival enlargement with foul odor, bleeding and fetid discharge from gums since 1 year. Gingival tissues were pale pink, enlarged, firm, and fibrotic .Generalized bleeding on probing was present. General examination revealed normal built. A diagnosis of generalized drug-induced gingival enlargement superimposed with periodontitis was made. With the consent of the patient and her physician, complete professional oral prophylaxis was performed, along with a prescription of a 0.2% chlorhexidine mouthwash (10 ml BID for 7 days). With the patient’s and physician’s
Conclusion
Successful treatment of drug induced gingival enlargement and idiopathic gingival enlargement depends on the proper identification of etiologic factors and improving oral hygiene status, esthetics, and function through elimination of local factors and surgical excision of the over growth.
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.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241615EnglishN2014August10VARIATION IN THE COURSE OF RIGHT RENAL ARTERY- A CADAVERIC STUDY
English5759Pradnya KulkarniEnglish Pradeep Pilajirao KulkarniEnglishObjectives: Recognize the common variations of renal vascular anatomy to avoid bleeding during transplantation and other surgeries related to kidney. Method: During dissection we found the variation in the course of right and left renal artery. On the right side renal artery was turning around the renal vein, coming anterior to the vein. While coming anteriorly it was giving segmental branches. Result: The organs which make extensive migrations during growth may either retain vessels from their original location (as in testis), or receive and incorporate new vessels of the region invaded (as in thyroid gland). Conclusion: Surgeon should know about blood vessels near kidney before doing any surgery related to kidney, especially in
transplantation surgery.
EnglishRenal vascular anatomy, transplantationINTRODUCTION
Knowledge of the number, size, course, and relationship of the renal arteries (of donor and recipient) are essential for the renal transplant. To avoid bleeding, knowledge of renal artery, its branches and their variations is important for any vascular reconstruction, endoscopic surgeries, treatment of abdominal aortic aneurism and treatment of renal artery stenosis and clinical evaluation of hypertension. In the present study, we highlight the abnormal course of renal artery.
Normal Renal Vascular Anatomy
In most individuals, each kidney is supplied by a single renal artery that originates from the abdominal aorta. The renal arteries typically arise from the aorta at the level of L2 below the origin of the superior mesenteric artery, with the renal vein being anterior to the renal artery. The renal arteries course anterior to the renal pelvis before they enter the medial aspect of the renal hilum. The right renal artery is longer (as abdominal aorta is slightly to the left of the midline) and usually arises slightly higher than the left.1 The main renal artery divides into segmental arteries near the renal hilum (Fig.1and 2). The first division is typically the posterior branch, which arises just before the renal hilum and passes posterior to the renal pelvis. The main renal artery then continues before dividing into four anterior branches at the renal hilum: the apical, upper, middle, and lower anterior segmental arteries. The apical and lower anterior segmental arteries supply the anterior and posterior surfaces of the upper and lower renal poles, respectively; the upper and middle segmental arteries supply the remainder of the anterior surface.
Embryology
1. The embryological explanation of these variations has been presented and discussed by Keibel F and Mall FP2 . In an 18 mm fetus, the developing mesonephros, metanephros, suprarenal glands and gonads are supplied by nine pairs of lateral mesonephric arteries arising from the dorsal aorta. Felix divided these arteries into three groups as follows: the 1st and 2nd arteries as the cranial group, the 3rd to 5th arteries as the middle group and 6th to 9th arteries as the caudal group.
Englishhttp://ijcrr.com/abstract.php?article_id=800http://ijcrr.com/article_html.php?did=8001. Grey’s Anatomy, 40th edition, section 8, chapter 62, page 1074
2. [KEIBEL F, MALL FP (eds), Manual of human embryology,Vol. 2, J.B. Lippincott, Philadelphia, 1912, 820–825]
3. Grey’s Anatomy, 40th edition, section 2, chapter 13, page 206- 207
4. (Human Embryology and Teratology by Ronan o’Rahilly and Fabiola Muller, 3rd edition, chapter 15, page 303-304).
5. (Essentials of Human Embryology by William J. Larsen, Chapter 8, page 131-132)
6. (Human Embryology and Teratology by Ronan o’Rahilly and Fabiola Muller, 3rd edition, chapter 15, page 308).
7. Bremer, J. L. (1915), the origin of the renal artery in mammals and its anomalies. Am. J. Anat., 18: 179–200. doi: 10.1002/ aja.1000180203)