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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241613EnglishN2014July12General SciencesSTUDY OF ANTIMICROBIAL ACTIVITY OF NANO SILVER (NS) IN TISSUE CULTURE MEDIA
English0105Ibrahim Bala SalisuEnglish Aminu Shehu AbubakarEnglish Madhu SharmaEnglish Ramesh N. PudakeEnglishPlant tissue culture is a basic and fundamental component of plant biotechnology and progress in various fields of biotechnology greatly depends on the improvement of this technique. Nowadays, nanomaterials especially Nano silver (NS) are frequently being used as an antimicrobial agent in different fields of sciences including in vitro propagation of plants. Microbial contamination is one of the most serious problems in plant tissue culture and various techniques are being employed to reduce it. This study was carried out to assay the anti-microbial activities of green synthesized silver nanoparticles in the tissue culture growth mediaIn order to assay the efficacy of NS in controlling microbial contamination in the tissue culture; we first synthesized the AgNPs from the leaf extract of Lemon grass (Cymbopogon citratus). The synthesized AgNPswere characterized by UV-vis spectroscopy (UV-vis), and transmission electron microscopy (TEM). After wards, we used various rate of silver nano particles in MS media (5, 10, 20, 25, 40 ml L-1) and the sterilized explants from C. citratuswere cultured on MS medium and evaluatedafter a week interval upto the 4th week of treatment. Adding nano silver at the rate of 40 ml L-1 to growth media was fully effective to control the bacterial infection when evaluated after four weeks of culturing. The finding of this study indicates that NS has a good potential in eliminating of the bacterial contaminants in plant tissue culture.
EnglishAntimicrobial activity, Nano Silver, Biosynthesis,Cymbopogon citratus, Tissue CultureINTRODUCTION
Nanotechnology is one of the most power full areas of research in contemporary materials science. Nanoparticles entirely display novel or better properties on basis of some important unique features such as size, distribution and morphology. Recent applications of nanoparticles and nanomaterials are emerging rapidly. Nano crystalline silver particles have found large applications in high sensitivity bio molecular detection, diagnostics, therapeutics, microelectronics, catalysis, and also as antimicrobials (Jain et al. 2009). The use of Nano silver is rapidly increasing in consumer products due to its synthesis simplicity and can be easily produced on a large scale.The potential of silver as a medicine or traditional anti-microbial agent particularly bacteria was not realized until nineteenth century. Since then, the antimicrobial activity of silver has been studied and more extensively used than any other inorganic antibacterial agent. Silver nanoparticles (NPs) are found to be toxic to bacteria, and are presently used in various devices likemedical devices, washing machines etc. to inhibit microbial growth (Li et al. 2008) The toxicity of Silver is due to its ability to attack a wide range of biological processes in microorganisms leading to the disruption cell membrane structure and collapse of plasma membrane potential which depletes the intra cellular ATP thereby ensuring the cell death. Small amount in micro molar (1 to 10 μM) of silver ions can efficiently inhibit bacterial growth in water. However at higher doses silver can be harmful to mammals, freshwater and marine organisms, and such micro molar amount of silver is non-toxic humans. Hence, silver has been used extensively for the development of many biological and pharmaceutical processes, products, and appliances such as coating materials for medical devices, orthopedic or dental graft materials, and topical aids for wound treatment, water sanitization, textile products, and even washing machines (Jo et. al. 2009). The use of silver nano particles as antimicrobial agents has become more common due to the technological advancement, whichresulted into an economical production. The potential of silver as antimicrobial agent is extensively used in plant diseases control as well as the management of various plant pathogens in a relatively safer way as compared to synthetic fungicides (Jo et. al. 2009). Currently different strategies such as the use of antibiotics have been developed to eliminate microbial contamination during in vitro propagation. However, studies have shown that antibiotics are frequently toxic to plants and may otherwise delay or even inhibit the growth of plant tissues (Abdi et. al. 2008). For example, Streptomycin and chloramphenicol are inhibitors of protein synthesis; while nucleic acid synthesis is inhibited by quinolone and rifampicin, and penicillin inhibits cell-wall membrane synthesis (Kohanski et. al. 2010). Due to the continuous used of antibiotics; bacteria are developing resistance and becoming insensitive. The use of silver nanoparticlescan be considered as good alternative (Rai et. al. 2012), as at low concentration it possesses antimicrobial activity (Safavi et. al. 2011). The use of green synthesized nanoparticle in various fields is receiving attention from many researchers because of their ecofriendly nature Deepak et al. 2011). The present study was conducted to assay the anti-microbial activities of green synthesized silver nanoparticles in plant growth media.Lemon grass was selected for its richness in plant phytochemicals such as flavonoids, alkaloids, saponins, alcohol, ketones, aldehydes, steroids, terpenes, phenols (Asaolu et. al. 2009; Shah et. al. 2011; Sofowora et al.1982) which serve as reducing agent in reducing Ag+ to nanosilver.
MATERIAL AND METHODS
Preparation of plant extract Fresh leaves of Cymbopogon citratus were collected from the field and washed thoroughly with sterile distilled waterbeforechopped into small pieces. Afterwards 10 g of clean chopped leaves were taken into a flask with 100ml sterile double distilled water and boiled for 5 minute. The extract was decanted and then filtered using Whatman filter paper and used as reducing agent during the green synthesis of AgNP. Preparation of silver nanoparticles 1mM aqueous solution of silver nitrate (AgNO3) was prepared and used for the synthesis of silver nanoparticles. 10 ml of Cymbopogon citratus extract was taken and added into 90 ml of aqueous solution of 1 mM Silver nitrate and incubated overnight at room temperature in the dark. Brownish yellow solution was formed, indicating the successful formation of silver nanoparticles. UV-visible spectrum analysis Equal amount of sample aliquot and distilled water(1ml each) were mixed in a 10 mm-opticalpath-length quartz cuvettes, and the UV-vis spectrum analysis of the reaction mixture was carried out to detect the reduction of pure Ag+ ions. The concentration of AgNPs produced was measured using a Systronics UV double beam spectrophotometer, at a resolution of 1 nm, between 200 and 800 nm (Figure 1).
Transmission electron microscopy (TEM) analysis
TEM analysis was used to get the micrograph image of the green synthesized AgNPs (Figure 2). Modification of plant tissue culture media by nanomaterial Different amounts of nano silver were added to tissue culture media. Five different levels of NS (5, 10, 20, 25 and 40 ml/L) were added into the Murashige and Skoog (MS) medium (Murashige and Skoog, 1962). The nanoparticles were added after autoclaving and afterwards thesterilized explants (nodal segment) from C. citrates were inoculatedonto the medium. A completely randomized design was used with each treatment was replicated six times. The cultures were monitored, observations were made and records were takenup to four weeks (1, 2, 3 and 4) after inoculation.The percentages of inoculated media that showed a growth or sign of microbial growth were estimated.
RESULTS AND DISCUSSION
The detailed study on extracellular biosynthesis of AgNP using the leaf extract of C. citratus extract was carried out with the anti- bacterial effects in tissue culture medium. Results of this study (Table 1) showed that addition of Nano-Silver to tissue culture media significantly reduce bacterial contamination compared with the control. The use of the 40mlL-1 1mM concentration of the AgNps in the MS medium eliminated bacterial contamination (0.0%). Increasing the amount of the nanoparticles in the media from 10ml to 20 ml significantly decreased the rate of bacterial contamination from 66.70 % to 33.30% and subsequently to 16.30% when 25ml was added. Total elimination of fungal contamination was however not achieved even at the highest rate of the AgNPs used (40 ml/L), but use of AgNPs showed a decreased fungal growth ascompared to control. 40ml/L significantly reduced the rate of fungal contamination from (83.3% to 33.3%). Similar finding was also reportedin previous studies where a 100mg/Lof AgNPs in plant tissue culture controlled bacterial growth (Safavi et. al. 2011). It is evident from this study that, higher concentration AgNPs is required to effectively controlling fungal growth. This is also in line with what had been reported in previous studies, likeaconcentration of 200 mg L-1 AgNPs successfully controlled bacterial and fungal contamination without any harmful effects on regeneration of the lemon grass explants (Fakhrfeshani et. al. 2012). It has also been reported that NS can be an efficient tool for removing contaminants from plant tissues, only if the right dose and exposure time are to be used (Mahna et. al. 2013). Nevertheless, NS has not yet become a universal decontamination agent, and our finding will help in future research in finding the effective way of controlling microbial contamination in plant tissue culture.
CONCLUSION
The use of NS in tissue culture media as a substitute of antibiotics to control microbial contaminations is becoming an interesting area of study. In this research the antimicrobial activity of nano silver was studied, and our results confirm its ability to reduce the microbial growth in the MS media and can allowed the explants to grow successfully when appropriate concentration is used. These results will be helpful in the refinement of protocol for use of NS particles in in vitro multiplication of various plants.
ACKNOWLEDGMENTS
The authors would like to thanks Mrs. Geetika Sahni, Assistant Professor, Lovely professional University, Phagwara for providing the necessary support for successful completionof this experiment. Authors also acknowledged the authors, journals and publishers whose articles were cited in this work.
Englishhttp://ijcrr.com/abstract.php?article_id=819http://ijcrr.com/article_html.php?did=8191. Abdi G, Salehi H, Khosh-Khui M. Nano silver: A novel nanomaterial for removal of bacterial contaminants in valerian (Valeriana officinalis L.) tissue culture. Acta Physiol Plant 2008; 30: 709-714.
2. Asaolu MF, Oyeyemi OA, Olanlokun JO. Chemical compositions,phytochemical constituents and in vitro biological activity of various extracts ofCymbopogon citratus, P.J. Ntr, 2009; 8(12): 1920-1922.
3. Deepak V, Kalishwaralal K, Pandian SRK, Gurunathan S. An insight into the bacterial biogenesis of silver nanoparticles, industrial production and scale-up In Rai, M., Duran, N. (Eds), Metal nanoparticles in microbiology 2011; pp 17-35. http://www.springer.com/978- 3-642-18311-9
4. Fakhrfeshani M, Bagheri A, Sharifi A. Disinfecting effects of nano-silver fluids in Gerbera (Gerbera jamesonii) capitulum tissue culture. J. Biol. Environ Sci2012; 6: 121-127. http://dx.doi.org/10.4172/2157-7439.1000161
5. Jain D, Kumar H, Daima S, Kachhwaha S, Kothari L. Synthesis of Plant-mediated silver nanoparticles using papaya fruit extract and evaluation of their antimicrobial activities. A. Digest Journal of Nanomaterials and Biostructures 2009; 4: 557 – 563.
6. Jo YK, Kim BH, Jung G. Antifungal activity of silver ions and nanoparticles on phytopathogenic fungi. Plant Disease 2009; 93:1037-1043.
7. Kohanski MA, Dwyer DJ, Collins JJ. How antibiotics kill bacteria: from targets to networks. Nat Rev Microbiol 2010; 8(6): 423- 435.
8. Li Q,Mahendra SH, Lyon DY, Brunet L, Liga MV, Li D. Alvarez PJJ. Antimicrobial Nanomaterial for water disinfection and microbial control: Potential applications and Implications. J Inter water research 2008; 42.
9. Mahna N, Vahed SZ, KhaniS. (2013). Plant in vitro culture goes nano: Nano silver-mediated decontamination of ex vitro explants: J Nanomed Nanotech., 4:2.http://dx.doi.org/10.4172/2157- 7439.1000161.
10. Murashige T, Skoog F. A revised medium for rapid growth and bioassays with tobacco Tissue cultures. Physiol Plant 1962; 5:473-97.
11. Rai MK, Deshmukh SD, Ingle AP, Gade AK. Silver nanoparticles: the powerful nanoweapon against multidrug-resistant bacteria. J Appl Microbiol 2012; 112(5): 841- 52.
12. Safavi K, Esfahanizadeh M, Mortazaeinezahad DH, Dastjerd H. The study of Nano-Silver (NS) antimicrobial activity and evaluation of using NS in tissue culture media. Inter Conference on Life Sci and Tech, IPBCEE 2011.
13. Shah G, Shri R, Panchal V, Sharma N, Singh B. Scientific basis for the therapeutic useof Cymbopogon citratus. J Adv Pharm Technol Res 2011; 2(1), 3–8.
14. SofoworaEA, OlaniyiAA, Oguntimehin BO. Pyhtochemical Investigation of some Nigerian Plants used against fevers. Planta Med 1982; 28: 186-189.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241613EnglishN2014July12General SciencesDETERMINANTS OF SUSTAINABLE VEGETABLE FARMING AMONG SMALLHOLDER FARMERS IN BOGOR REGENCY
English0614Wahid UllahEnglish Sri MulatsihEnglish SaharaEnglish Syaiful AnwarEnglishThe agricultural sector plays a significant role in the Indonesian economy and local’s livelihood. One of the major stakeholders in agriculture is the smallholder farm sector. Large number of these smallholder farmers (SHF) produces vegetables for commercial and subsistence purposes but they have limited access to agriculture resources including labor, technology and other inputs. The purpose of this study is to identify socio-economic characteristics, agricultural farming practices and environmental variables influencing smallholder’s sustainable vegetable production in the villages of Situdaun and Cinangneng located in the sub-district of Tinjolaya, Bogor regency, West Jawa. The study uses descriptive and ordinal logistic regression analysis. Drawing on a sample of 96 households, the study shows that sustainable production of vegetables is mainly affected by the low quality of agriculture inputs, excessive rainfalls and lack of financial resources. The findings in the paper reveal that, based on the output from logistic regression; crop rotation, agriculture training, member of a farmer’s group and land size are the significant variables influencing SHF production. Crop rotation and agriculture training are dominant variables that positively influenced SHF. Member of a farmer’s group and land size negatively influenced SHF vegetable production. The study also established that by providing institutional requirement such as infrastructure improvement, subsidized fertilizers, pesticides, seeds, soft loans and other necessary services for vegetable farming to ensure constant and sustainable production. Given the dominance of smallholder sector in the economy, the effective utilization of these resources will hinge on the implementation of a set of policies that would allow smallholders to seek greater specialization and improve their produce.
Englishsmallholder farmers, sustainable vegetable production, socio-economic,agricultural and environmental constraints, logit analysisINTRODUCTION
Indonesia has a large smallholder agriculture sector as in many other developing countries in Asia and the pacific. Agriculture contributes the Indonesian national economy, accounting for 15% of gross national product (Statistic Agency, 2012). Contribution of agriculture sector to exports was 4% in 2012. Smallholder farmers in Indonesia are involved in a variety of economic activities, as part of complex livelihood strategies (IFAD, 2010; Altieri, et. al. 2012). Smallholder farmers in Indonesia generally practice mixed-cropping systems, cultivating both annual and perennial crops to produce rice, vegetables, fruits and other staples (Roshetko et. al. 2012). Many smallholders face challenges related to crop production. These include lack of access to sufficient and productive land for expansion, sufficient water, modern irrigation system, mechanization, cheaper and good quality inputs, transport logistics and market information (Hazell, 2011; Sahara, 2012; Wickramasinghe, 2012, Thapa, et. al. 2011). Because of these conditions they are unable to take advantage of the opportunities offered by markets and it is also a reason that although they feed the world but their own households are amongst the poorest of the poor. Smallholder farmers choose crops that grow faster and require less investment (Gabre-Madhin,2009). In this regard vegetables are one of the best choices to grow but it needs best management and care to store and sell it. This study will steam the need for awareness among smallholder farmers towards sustainable agriculture with a focus on identifying the possible solution(s) for the constraints (socio-economic, agricultural and environmental) affecting small holder farmers’ production and possible suggestions through which they can further improve their yield sustainability. Justification of the Study Indonesia has a 246 million total population of which nearly 17 million are smallholders, most of which are often vulnerable to external shocks emerging from weather and access to other agricultural inputs (labor, technology, finance, fertilizers, pesticides and best management practices etc.), which keeps them in perpetual poverty. The contribution of smallholder farmers into Indonesian economy is fairly good which needs to be improved by providing the basic needs to the smallholder farmers to assure sustainable use of land. They cannot be ignored because of their huge number and contribution to agricultural. Research Objectives The overall research objective of the study is to identify the characteristics of smallholder agriculture practices related to sustainability, what constraints they are facing and how to cope with those hurdles in order to assure sustainable production from their lands? The specific research objectives are as follows; 1. To identify agricultural sustainability related farming practices of vegetable growing smallholder farmers 2. To identify factors (social, economic, and environmental) that influence smallholder’s vegetable production
RESEARCH METHODOLOGY
Study Area and Sample Size Selection The survey was conducted in two sample villages namely Situdaun and Cinangneng located in subdistrict Tinjolaya of Bogor Regency. A sample household survey technique was selected to accomplish the study and was carried out in JulyAugust 2013. Villages were chosen purposively and respondents were randomly selected according to their potential for vegetable production. A total of 96 households were selected in two sample villages for interview (Figure 1; Appendix 2). Data Analysis Data was analyzed in two sections i.e. descriptive data analysis and logistic regression analysis. From the survey, descriptive statistics on demographic information including age, gender, and marital status, size of the household and landholding sizes of the smallholder farmers is provided. Using farmers and farm characteristics, an ordinal logistic regression model was estimated to determine the dependency of yield on crop rotation, pesticide use, fertilizer use, agricultural training, member of a farmer’s group, access to market information, age of the household, gender, education, size of the household, time spent in agriculture and land holding size. Both dependent and independent variables were assigned specific codes (Table 1).
RESULTS AND DISCUSSION
Socio-economic Profile of Smallholder Farmers In this study information on socio-economic profile (Table 2) of the smallholder farmers were collected. Indicators used for percentage analyses of those indicators were age, gender, education level, marital status and size of the household. Out of total 96 smallholder farmers that were interviewed 13.54 % were in the age category of 20-29 years old, 22.91% in 30-39, 26.04% in 40- 49, while 37.5% smallholder in the 50 and above age category. Out of the total sample; 22.91% respondents were female and 77.09% were male. The traditional gender imbalance dominated by males associated with farming was present in smallholders growing vegetables. In terms of education, the findings showed that of the stallholders, 10.41% had 0-2 years of education, followed by 75.0% with 3-5 years of education and 14.59% had 6 or above years of education. The survey also investigated that 96.87% smallholders were married and 3.13% unmarried. For household size, 45.83% smallholders were in 1-3 people’s category, 48.95% in 4-7 following by 5.22% in 8 or more people living in one household category. The survey discovered that 34.37% smallholder were involved in farming (both agriculture and horticulture) for less than 10 years, 26.04% of the sampled respondents were involved in farming between 11-20 years, followed by16.67% of them between 21-30 years and 22.92 in the age category of 31 or above. Landholding Sizes of the Smallholders The landholding size in the study area is less than average farm size in Indonesia as reported in the agricultural census of 2003 and 2013. According to the census, farm considered as small farms are about 0.79 ha (Statistic Agency, 2003; Sahara, 2012). The findings reveal that of out of the total smallholders interviewed, 14.58% have the land size of less than 1000m.square, 68.75% have land size between 1000-5000m.square, 15.62% have more than 5000m.square while 1.04% respondents did not know his agricultural land size. The average holding size of the farmers in the survey area was 4466.15m^2 or (+ 0.45ha). Environmental Characteristics of Smallholder Farmer’s Agriculture Practices The study (Table 3) also comprises of farming practices vegetable growing smallholders do related to agricultural sustainability which is one of the main concerns of smallholder farming. From the survey, it was observed that 87.5% farmers were satisfied with the quality of their vegetables while 12.5% were not because of its bad taste and reduced size problems as a major problem. The smallholders believed those problems could be controlled by disease control and its vector. Out of total farmers interviewed, 95.83% sampled respondents were using pesticides to control diseases following by 4.17% that were not using any kind of pesticides. Crop rotation is considered to one of the important technique of modern sustainable agriculture because it gives soil time to use its nutrients in a sustainable manner. In our sampled farmers 84.37 respondents were rotating crops each time they wanted to do agriculture while 15.63% were growing the same kind of vegetables without rotating it to another crop type. In terms of soil analysis it was very interesting to know that none of the sampled smallholders have ever analyzed their soil in order to know its suitability for the desired vegetable crop. It was also believed that smallholders are normally exposed to seasonal shocks like droughts, floods and heavy rainfalls which destroy their vegetables and other crops (Wickramasinghe, 2012). Results showed that 44.79% smallholders had never experienced any drought, flood or heavy rainfalls, 37.5% had experienced disturbance from excessive rainfalls, 11.45% from floods and 6.25% from droughts. According to 99.06% respondents’ organic agriculture needs more labor to take care of vegetables and soil quality. It also needs more energy and labor and always diminishes total production because of their weak management skills. In this regard, they prefer inorganic agriculture because it needs less energy, money and labor compare to organic agriculture Ordinal Logistic Regression Model Explanation The logistic regression analysis (Table 4) was used to estimate the extent to which socio-economic or demographic characteristics influence smallholders yield. The estimated factor scores were then used in an ordinary logistic regression analysis along with selected socio-economic agricultural factors, such as crop rotation, pesticide usage, fertilizer usage, agricultural training, member of a farmer’s group, access to market information, age, gender, education level, size of household, time spent in agriculture and land size. The estimated Logit model was statistically significant with a likelihood ratio test probability of P-Value = 0.236, overall percentage of right prediction was 69.6%, Chi-Square was -97.307, degrees of freedom were 12 which indicates joint significance of all coefficient estimates. The estimated coefficients are tested by using standard errors, t-ratios and P-values. A positive sign on the statistically significant parameter estimates of one variable indicates the likelihood of the response increasing, holding other variables constant, and vice versa. The model output reveals that out of twelve variables seven positively and five negatively influenced the dependent variable. However two out of twelve variables were statistically significant on 90% confidence interval and influencing the production of smallholders. Both these variables were negative namely: member of farmer’s group and land size were ordered properly and influencing the dependent variable negatively which was unexpected. Thus, the smallholder characteristics in the ordered model for equation are relevant in explaining the importance of yield towards participation in supermarkets. The results indicated that, the farmers’ characteristics play an important role when explaining the importance of education level for their participation in supermarkets. Many studies in the literature reveal that crop rotation led to increase in productivity and soil fertility, resulting in high crop production in the long term (Bajracharya, 2002; Karki, 2006; Raut, et. al. 2011). It was assumed that smallholders who practice crop rotation will have higher yield. The results expectedly showed positive response. Smallholders rotating their crops were more likely to increase yield. This value was significant on 77% confidence interval. Trained smallholders with knowledge of agriculture were assumed to be having increased yield from their lands. The logistic regression model showed significant and an expected result. Farmers working in groups had easy access to inputs because of the resource sharing among the groups. The result was significant but unexpected. Farmers groups were only active to attract aid (agricultural inputs) from government. The aid is usually divided equally among all the members of group but they work on their individual lands. Access to market information or any other social media was another variable used in the model. It was expected that smallholders having access to social media will be more aware of the market situation i.e. prices of agricultural inputs, good quality fertilizers, pesticides and other agriculture related news. The results showed unexpected results meaning that access to market information have no significance over yield. It was expected that smallholders having large land will have increased yield but results showed negative response. Smaller lands were easy to manage for them based on their economically marginalized condition. It also needs labor, money, time and energy. Lack of finance was the main constraint that smallholders were facing. Pesticide and fertilizers use, gender, age, education level, time spent in agriculture and size of the household unexpectedly showed insignificant and unexpected results. Table 4 also presents the estimate odds ratios. The odd rations are calculated by the binary Logit coefficients (probability = [odd/1-odd]) and it means that smallholders practicing crop rotation which is significant at 0.202 willingness level have 2.23 times more yield than those who do not do crop rotation. Agricultural training was significant at 0.211 willingness level and trained farmers have more 2.58 times more yield than untrained smallholders. Results of logistic regression model indicate a negative response for working in farmer’s groups. Estimated coefficient for member of a farmer’s group is negative and 0.24 less likely meaning that smallholders working individually on their lands have 0.24 times more yield than those working in groups. Respondents who indicated no access to market information have 0.60 times higher yield than those who can access market information. The response land size negatively influences the probability of smallholders having higher yields i.e. 0.68 less likely. Land size is also significant but coefficient value is negative. According to the result smallholders with fewer land sizes are more likely to have higher yield and vice versa because lack of access to good quality inputs including seeds, fertilizers, pesticides, modern technology and other financial resources to manage large lands. In order to assess how well the model fits the data, Goodness of fitness test statistic was developed and a chi-square test from observed and expected frequencies was computed. As shown in Table 4, the model has P value of 0.236, which confirms that the fit of model is good.
CONCLUSION AND RECOMMENDATIONS
This Study has provided information on smallholder’s farming practices related to sustainability in Bogor Regency of Indonesia. Information has also been provided on the requirements of smallholders to produce vegetables sustainably. The results suggest that most farmers view increase in production favorably. Smallholders strongly identify the small sizes of their lands and lack of purchasing power to buy good quality agricultural inputs for farming as the main area of interest. They demanded inputs from government including trainings, soft loans, good quality fertilizers, pesticides, and seeds. Smallholders emphasized on lack of support from both public and private sector. The results also indicates that small farms need to raise their productivity through access to better technologies, good quality agricultural inputs, improvement in infrastructure facilities, external shocks emerging from weather and improved management practices, while at the same time achieving more environmentally sustainable patterns of production. There is urgent need for the kinds of sustainable intensification that significantly raise farming produce. This will require the best of modern science, the best of indigenous knowledge and ecological literacy. This kind of knowledge intensive farming requires new approaches to research and extension, as well as an enabling policy environment. The both public and private sector has little incentive to invest in this kind of for small farms, and the public sector has to play a bigger role to keep the farmers in the equation.
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=820http://ijcrr.com/article_html.php?did=8201. [IFAD] International Fund for Agricultural Development. 2010. Smallholder Farmers can be Part of the Solution. International Fund for Agricultural Development.
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3. Bajracharya, RM. 2002. Fertility and productivity parameters for soil from five midhill districts of central Nepal. In: Proceedings of international seminar on Mountains, Royal Nepal Academy of Science and Technology, Kathmandu, Nepal
4. Gabre-Madhin, ME. 2009. A market for all farmers: Market institutions and smallholder participation. Agriculture for Development, Center for Effective Global Action, UC Berkeley
5. Hazell, P. 2011. Five big questions about five hundred million small farms. Rome: International Fund for Agricultural Development.
6. http://www.uncapsa.org/LIBRARYJournal_de tail.asp?VJournalKey=886
7. Karki, KB. 2006. Impact of cropping intensification on nutritional balance in Nepalese soils, In: Proceedings of International Seminar on Environment and Social Impacts of Agricultural Intensification in Himalayan Watersheds. Kathmandu, Nepal.
8. Nkamleu, GB. & Adesina, AA. 2000. Determinants of chemical input use in periurban lowland systems: Bivariate Probit Analysis in Cameroon. Agricultural Systems, 63(2): pp. 111-121.
9. Raut, N, Sitaula, BK., Vatn, A, &Paudel, GS. 2011. Determinants of Adoption and Extent of Agricultural Intensification in the Central Mid-hills of Nepal. Journal of Sustainable Development, 4(4).
10. Roshetko, JM, Kurniawan, I.& Budidarsono, S. 2012. 17. Smallholder Cultivation of katuk (Sauropusandrogynous) and kucai (Allium odorum): Challenges in Sustaining Commercial Production and Market Linkage.
11. Sahara, 2012. The transformations of modern food retailers in Indonesia: opportunities and challenges for smallholder farmers [dissertation]. Adelaide: School of Agriculture, Food and Wine, Faculty of Sciences, the University of Adelaide.
12. Statistic Agency of Indonesia, 2012. Overview of Indonesian Agriculture Sector. http://www.gbgindonesia.com/en/agriculture/s ector_overview.php.
13. Statistic Agency of Indonesia. 2004. Agricultural Censuses. Indonesian Statistic Agency, Jakarta
14. Thapa, G. & Gaiha, R. 2011. Smallholder farming in Asia and the Pacific: Challenges and opportunities. IFAD conference on New Directions for Smallholder Agriculture, pp. 24-25.
15. Tiwari, KR. Sitaula, BK., Nyborg, IL. & Paudel, GS. 2008a. Determinants of farmers’ adoption of improved soil conservation technology in a Middle Mountain Watershed of Central Nepal. Environmental Management, 42(2): 210-222.
16. Wickramasinghe, U. 2012. Towards Promoting the Participation of Smallholders in Agricultural Markets in Papua New Guinea. Vol. 29(3). Palawija newsletter.
17. Wijaya, KS. Budidarsono & Roshetko, JM. 2007. Socio-economic Baseline Studies. Agroforestry and Sustainable Vegetables Production in Southeast Asian Watershed: Case Study of Nanggung Sub-District, Bogor, Indonesia. Research Report. The WorldAgroforestry Centre (ICRAF), Southeast Asia Program Office, Bogor, Indonesia.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241613EnglishN2014July12HealthcareA STUDY OF SHORT TERM PULMONARY REHABILITATION ON EXERCISE CAPACITY, FORCED VITAL CAPACITY AND QUALITY OF LIFE IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE
English1523Christian Preeti S.EnglishBackground: Chronic Obstructive Pulmonary Disease (COPD) is a progressive disease characterized by airflow limitation / obstruction that is either not reversible or only partially reversible. Pulmonary rehabilitation is an accepted non-pharmacological intervention for individuals with COPD. But there is ‘no consensus’ regarding the most favorable duration of pulmonary rehabilitation for patients with COPD. Objective: To determine the effects of a short term Pulmonary Rehabilitation programme on exercise capacity, forced vital capacity and Quality of life in chronic obstructive pulmonary disease. Methods: 30 mild-moderate COPD patients, who fulfill inclusion and exclusion criteria, were given conventional physical therapy and aerobic training for 5 days per week and continued for 4 weeks. 6 min walk distance; Forced vital capacity (FVC) and chronic respiratory questionnaire (CRQs) were taken at baseline before and after completion of rehabilitation program as outcome measures. Results: Results show statistically significant difference in 6 min walk distance (6 MWD), Dyspnea, Fatigue (pEnglishChronic Obstructive Pulmonary Disease, Pulmonary Rehabilitation, Chronic Respiratory Disease Questionnaire, Forced Vital Capacity, 6 Minute Walk Test.INTRODUCTION
According to World Health Organization Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible. COPD is currently the fourth leading cause of death worldwide.1-5 the problem is seen mostly among older adults, the true age-specific prevalence will be much higher, especially in countries where cigarette smoking is common. India can be projected as a classical example with reference to the rising burden of chronic respiratory diseases accounting for 7% of all death.6 Presumably the inflammation caused by cigarette smoking interacts with other host or environmental factors to produce excess decline in lung function that results in COPD. It is believed that inhaled noxious particles and gases results in lung inflammation, induce tissue destruction, and impair defense mechanisms that serve to limit or repair this damage. 5.
Since COPD includes irreversible obstruction and progressively decreased pulmonary function but Stopping exposure to these agents, even when significant airflow limitation is present, may result in some improvement in lung function and slow or even halt progression of the disease.5 None of the existing medication for COPD has been shown to modify the long-term decline in lung function. Therefore, pharmacotherapy for COPD is used only to decrease symptoms and complications. According to the Global initiative for chronic Obstructive Lung Disease recommendations, pulmonary rehabilitation is one of the main non?pharmacological treatment modalities. The rehabilitation program is provided by a multi-disciplinary team and typically consists of exercise, disease specific education, nutritional, psychological and social support.9, 10 There is strong evidence that pulmonary rehabilitation (PR) reduces symptoms, increases exercise tolerance and improves health-related quality of life in patients with COPD.11Updated clinical practice guidelines from the American College of Chest Physicians (2007) state that there is ‘no consensus’ regarding the most favorable duration of pulmonary rehabilitation for patients with COPD. However, the guidelines recommend programs of longer than 12 weeks in duration to better promote maintenance of benefits over time, but longer program must be weighed against the issues of hectic work schedule, adherence to the program and the potential for higher program costs.13It may encourage the irregularities in the treatment program, there have been a number of studies evaluating the effectiveness of short-term courses of pulmonary rehabilitation.7, 8, 9 With regard to cost and program duration, the study by Clini et al15 demonstrated that a short, intensive inpatient PR program, with up to 12 sessions held 5 days per week, led to comparable gains in exercise tolerance at a lower cost, compared to a longer outpatient program (exercise three times per week for ~8 weeks). Certainly, more research is required to determine the optimal duration of pulmonary rehabilitation for promotion of long-term exercise adherence and consequently, maintenance of outcomes. Hence there is a purpose and background for conducting the study.
MATERIALS AND METHODOLOGY
Study Design: Single group, pre test post test design Sample Design: Consecutive sampling Sample Size: 30 Patients Study Setting: Out Patient Department of Physiotherapy College Study Duration: 1 year (Dec 2011-Nov 2012)
Selection Criteria 12, 15, 17 Inclusion Criteria ? Mild to moderate COPD patients ? Those who can complete the 6 min walk test ? Age – 35 to 55 years ? Both male and female ? Patient who were willing to participate in the study Exclusion Criteria ? COPD with other cardiovascular disease ? COPD associated with other pulmonary disease ? COPD with musculoskeletal problems that would inhibit exercise ? COPD with neurological condition ? COPD patients with other systemic disorders. ? Current smokers ? Patients who had undergone any surgery in last one year ? Patients who had attended pulmonary rehabilitation within last 2 years
DATA COLLECTION PROCEDURE TOOLS
Cardiopulmonary assessment kit, Pen and Pencil, Evaluation form and CRQs sheet,Chairs with arm rests,Bathroom weighing scale,Stopwatch,10 meter Walkway,Treadmill,Disposable mouth piece for PFT and Nose clips,Schiller PC based spirometer
OUTCOME MEASURES
6 minute walk distance (6MWD) 12, 16 Forced vital capacity (FVC) 12, 14 Chronic Respiratory Disease Questionnaire (CRQ) 12, 14, 20
PROCEDURE
Consent to carry out the study was granted by the ethical committee and then baseline data including age, gender, BMI, admission diagnosis, PFT values, and chronic respiratory questionnaire were noted of those who fulfilled selection criteria.Informed consent was taken from patients before starting training. Standard care, as advised by the concerned physician, was strictly implemented throughout the intervention. Patients attended five days weekly with each session lasting for 45 minute / day for 4 weeks. Treatment was given in form of pursed lip breathing, thoracic mobility exercises for upper chest and side flexors of chest and treadmill walking for four weeks. Treadmill walking was started with warm up for 5 min and then after conditioning program was carried out for maximum 20 minutes. Treadmill walking speed was decided by calculating 80% of 6 minute walk test average speed. [6MWT average speed = (6MWT distance x 10) ÷ 1000 km / hr].21, 22, 24, 26, 27Conditioning program was followed by 5 minutes of cool down period. The session was terminated if patient complains about Fatigue, Headache, Confusion, Nausea, Severe dyspnea, Giddiness, Leg cramps or claudication.25, 26Out of 34 patients 4 have discontinued due to intolerance or some personal reasons. Results were compared and analyzed statistically for remaining 30 patients.
STATISTICAL ANALYSIS
Mean and standard deviation were computed as measure of central tendency and measure of dispersion respectively. The intra group pre and post comparison of 6MWD and FVC were done by paired t- Test and intra group pre and post comparison of CRQs was done by Wilcoxon signed rank test. Differences were considered as significant at P< 0.05.
RESULTS AND INTERPRETATION
The rehabilitation group includes 30 patients. Patient’s characteristics are shown in Table 1. The mean and standard deviation before and after treatment was analyzed by using Paired t-test for values of 6MWD and FVC presented in Table 2 and Table 3 respectively.The mean and standard deviation of CRQs before and after treatment was analyzed by using Wilcoxon signed rank test presented in Table 4. Results show statistically significant difference in 6 min walk distance, Dyspnea, Fatigue (pEnglishhttp://ijcrr.com/abstract.php?article_id=821http://ijcrr.com/article_html.php?did=8211. American Thoracic Society. Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease. Am J RespirCrit Care Med 1995; 152:77-121.
2. British Thoracic Society. Guidelines for the management of chronic obstructive pulmonary disease. Thorax 1997; 52: 1-28.
3. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis management and prevention of chronic obstructive lung disease. NIH Publication2001;2701:1-100.
4. Siafakas NM, Vermeire P, Pride NB. Optimal assessment and management of chronic obstructive pulmonary disease (COPD). The European RespiratorForce. EurRespir J 1995; 8: 1398-1420.
5. Guidelines for Management of Chronic Obstructive Pulmonary Disease (COPD) in India: A Guide for Physicians.Indian J Chest Dis Allied Sci 2004; 46: 137-153.
6. K.J.R. Murthy, J.G. Sastry. Economic burden of chronic obstructive pulmonary disease. Burden of Disease in India 2012;234-275.
7. Votto J, Bowen J, Scalise P. Short stay comprehensive inpatient pulmonary rehabilitation for advanced chronic obstructive pulmonary disease. Arch Phys Med Rehabil 1996; 77:1115-1118.
8. Von Leupoldt A, Hahn E, Taube K, Schubert Heukeshoven S, Magnussen H, Dahme B.Effects of 3-week outpatients pulmonary rehabilitation on exercise capacity, dyspnea, and quality of life in COPD. Lung 2008; 186(6):387-91.
9. Skumlien S, Skogedal EA, Bjortuft O. Four weeks intensive rehabilitation generates significant health effects in COPD patients. Chronic Respiratory Disease 2007; 2:5-13.
10. Elpern EH, Stevens D, Kesten S. Variability in performance of timed walk tests in pulmonary rehabilitation programs. Chest 2000; 118: 98–105.
11. Carolyn L. Rochester, MD. Exercise training in chronic obstructive pulmonary disease. Journal of Rehabilitation Research and Development 2003; 40(5):5980.
12. Nobuaki Miyahara,Ryosuke EDA,hiroyasutakeyama,Naomi kunichika,michihikomoriyama,keisukeaoe et al.Effect of short term pulmonary rehabilitation on exercise capacity and quality of life in participant with chronic obstructive pulmonary disease.Acta Med Okayama 2000;54(4):179-184
13. Pitta F, Troosters T, Probst VS. Are patients with COPD more active after pulmonary rehabilitation? Chest 2008; 134(2): 273-280
14. EinarHaave, Michael E Hyland, HaraldEngvik. Improvements in exercise capacity during a 4-weeks pulmonary rehabilitation program for COPD patients do not correspond with improvements in selfreported health status or quality of life. International Journal of COPD 2007;2(3): 355–359
15. Brenda O’Neill, Anne Marie,McKevitt, Sara Rafferty, Judy M Bradley,Doreen Johnston et al. A Comparison of Twice- Versus OnceWeekly Supervision during Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Disease. Chest 2002; 121:1085- 1091.
16. Hatem FS Al Ameri. Six minute walk test in respiratory diseases: A university hospital experience.Thoracic medicine 10.4103/1817- 1737.25865.
17. R H Green, S J Singh, J Williams, M D L Morgan. A randomised controlled trial of four weeks versus seven weeks of pulmonary rehabilitation in chronic obstructive pulmonary disease. Thorax 2001; 56:143– 145.
18. DonraweeLeelarungrayub. Chest Mobilization Techniques for Improving Ventilation and Gas Exchange in Chronic Lung Disease. Chronic Obstructive Pulmonary Disease. Current Concepts and Practice 2000; 13:410-411.
19. Fuchs-Climent D, Le Gallais D, Varray A, Desplan J, Cadopi M, Préfaut C.Quality of life and exercise tolerance in chronic obstructive pulmonary disease: effects of a short and intensive inparticipant rehabilitation program. Am J Phys Med Rehabil. 1999; 78(4):330-5.
20. Gordon H Guyatt, Leslie B Berman, Marie Townsend. A measure of quality of life for clinical trials in chronic lung disease. Thorax 1987; 42:773-778.
21. Aeholland, knapman, DjBrazzale, Cj Hill, I Glaspole, N Goh, et al. Exercise prescription from 6-minute walk test achieves the suggested training intensity in interstitial lung disease. Austin Health, VIC 3084.
22. J.Alison. The validity of field walking tests in prescribing lower limb exercise intensity in clinical rehabilitation for people with chronic obstructive pulmonary disease. Australian New Zealand clinical trial registry 2012; 12609000439246.
23. Guyatt, G.H., L.B. Berman, M. Townsend. Long-term outcome after respiratory rehabilitation. CMAJ 1987; 137:1089-1095.
24. Zainuldin R,mackoy MG,Alison JA. Prescription of walking exercise intensity from the incremental shuttle walk test in people with chronic obstructive pulmonary disease.Am J Phys Med Rehabil 2012; 91:00- 00.
25. David C. Nieman. Fitness and Sports Medicine- A Health Related Approach. Mayfield Publishing Company 1995.
26. CorlnyKisner, Lynn Allen Colby. Therapeutics Exercise: Foundation and Techniques. 4th Ed. New Delhi: Jaypee Brothers, Medical Publishers 2002; 150-165.
27. The Australian Lung Foundation and Australian Physiotherapy Association.August 2009.
28. Troosters T, Gosselink R, Decramer M. Short- and long-term effects of outpatient rehabilitations in patients with chronic obstructive pulmonary disease: a randomized trial. Am J Med 2000; 109:207-212.
29. Russell S. Richardson. Skeletal muscle dysfunction vs muscle disuse in patients with COPD.J App Physio 1999;86:1751-1752.
30. Christine Cadena. COPD: Rehab Therapy Improves Lactic Acid and Improves Exercise and Mobility. An Overview of the Impact of Therapy2007; 45-58.
31. Carter R, Nicotra B, Clark L. Exercise conditioning in the rehabilitation of patients with chronic obstructive pulmonary disease. Arch Phys Med Rehabil 1988; 69: 118-122.
32. Ries AL,Kaplan RM, Limberg TM, Lela M. Prewitt. Effects of pulmonary rehabilitation on physiologic and psychosocial outcomes in patients with chronic obstructive pulmonary disease. Ann Intern Med 1995; 122:823-832.
ABBREVIATIONS USED: COPD :
Chronic Obstructive Pulmonary Disease CRQ: Chronic Respiratory Disease Questionnaire FEV1:Forced Expiratory Volume in One Second FVC:Forced Vital Capacity PR:Pulmonary Rehabilitation 6MWD:6 Minute Walk Distance
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241613EnglishN2014July12HealthcareEFFECT OF ENDOTRACHEAL TUBE CUFF INFLATION AND HEAD POSITION ON THE SUCCESS OF BLIND NASOTRACHEAL INTUBATION
English2430Shubhada R. DeshmukhEnglish Charuta P. GadkariEnglish Gunjan M. BadwaikEnglish Anjali R. BhureEnglishObjectives: The study was conducted to assess the effect of endotracheal tube cuff inflation and position of the head on the success of blind nasal intubation. Method: In a hospital based cross-sectional study, 52 ASA Iand II patients were included. After induction of general anaesthesia, blind nasotracheal (BNTI) intubation was tried with patients on spontaneous ventilation in following sequence of head position and state of endotracheal tube cuff – Head on bed+cuff deflated (HBCD); Head on bed+cuff inflated (HBCI); Head on pillow+cuff deflated (HPCD); Head on pillow+cuff inflated (HPCI). Once intubation was successful in any one of these positions, the remaining positions were not tried. If blind nasal intubation failed, laryngoscopy was done and patient intubated. Results: Out of 52 patients, 1 of the 4 positions was successful for blind nasotracheal intubation in 47 cases (90.38%). BNTI was successful in 3(6.38%), 17(34.69%), 1(3.13%), 25(83.87%) in HBCD, HBCI, HPCD and HPCI positions respectively. The remaining 5 cases (9.62%) required laryngoscopy for intubation. Success of BNTI was significantly more with the tracheal tube cuff inflated whether head was on table (z score 3.265, P=0.0015) or head was on pillow (z score 4.89, P=0.000006). BNTI was also more successful with the head on pillow as compared to head on bed (z score 2.73, pEnglishBlind nasal intubation, cuff inflation, head position.INTRODUCTION
Nasotracheal intubation is an effective and potentially life saving approach to the difficult airway. Magill and Rowbotham developed and practiced the technique of “blind” nasal intubation and coined the term. [1] Blind nasotracheal intubation (BNTI ) was widely used in patients in whom orotracheal intubation was not possible e.g, patients of trismus. Recently, agents such as sevoflurane and propofol that allow depression of laryngeal reflexes and intubation with rapid recovery, as well as equipment such as the intubating fibreoptic laryngoscope, have resulted in the BNTI technique becoming rarely used in current practice. Flexible Fibreoptic assisted intubation has become the first choice when orotracheal intubation is difficult or impossible. But BNTI during spontaneous ventilation may still be useful when a Flexible Fibreoptic Laryngoscope is not available at all or not in the required size. Apart from this situation, flexible fibreoptic laryngoscopy is not possible when there is bleeding or secretions in the airway. [2] If it can be done easily, BNTI can remain a dependable technique in the armamentarium in the scenario of the difficult airway. Temporary inflation of the endotracheal tube cuff in the oropharynx has been shown to improve the success rates of BNTI. [3,4,5,6] The position of the head for BNTI was classically described as “sniffing the morning air” position, but studies have also shown that BNTI in neutral position of the head (no pillow under the occiput) has more success rate.[5] Craniofacial structure differences among ethnic populations are known. [7] Hence we conducted this hospital based cross-sectional study to evaluate the effect of tracheal tube cuff inflation and head position on the success of BNTI in our population with the hypothesis that neutral position of head and inflation of endotracheal tube cuff would aid BNTI.
MATERIAL AND METHOD
The study was conducted in our institute after approval by the Institutional Ethics Committee. A written informed consent was taken from the patients. Fifty two patients of either sex belonging to ASA I and II posted for surgery under general anaesthesia in a period of 12 months and consenting to participate in the study were included in the study. Inclusion and Exclusion Criteria – Patients in the age group of 18 to 60 years, belonging to American Society of Anaesthesiologists (ASA) status I and II, and posted for elective surgery were included in the study. Patients having coagulopathy and those on anticoagulants or antiplatelet agents, patients complaining of nasal obstruction, patients having nasal polpys or any other mass in nasal cavity on anterior rhinoscopic examination and patients with history of basal skull fractures were excluded from the study. All patients had an anterior rhinoscopy done prior to anaesthesia to rule out any nasal pathology. The more patent (i.e, open and unobstructed) nostril was determined by asking the patient to breathe through one nostril at a time with the mouth closed and feeling the blast of air during exhalation. The more patent nostril was then used for intubation. In cases where both nostrils were equally patent, the right nostril was chosen. The Mallampatti class of the patient was noted. The routine monitors like cardiac monitor, non-invasive blood pressure monitor and pulse oximeter were attached to the patient. Intravenous (IV) line was established. The nostrils were decongested with xylometazoline drops and then lubricated with 2% lignocaine jelly. The patient was placed supine on the Operation Theatre table without a pillow under his or her head (neutral position). All intubations were done by either author 1 or 3. The patient was premedicated with Midazolam 30 mcg/kg, 1.5 mcg/kg Fentanyl and 20 mcg/kg glycopyrrolate intravenously. General anaesthesia was then induced with intravenous Propofol 1% given slowly till loss of eyelash reflex. The anaesthesia was deepened with O2 + Isoflurane using Bain’s circuit with the patient breathing spontaneouly. Isoflurane was started at 0.6% and increased after every 2 breaths till a concentration of 2.5% was reached. When the patient was judged to be in adequate depth of anaesthesia by the muscle tone and the pattern of respiration, a polyvinyl chloride (PVC) ivory cuffed nasal tube (Internal Diameter 6 or 6.5 mm for female patient and 7 or 7.5 mm for male patient) was inserted in the nostril and gently advanced until there was a loss of resistance indicating that the tube had entered the oropharynx. At this time the proximal end of the endotracheal tube was connected to the Bain’s circuit, the other nostril was occluded and the mouth was kept closed by a finger below the chin of the patient. The movement of the rebreathing bag was then used as a guide to judge correct alignment of the tip of the tube and the glottis of the patient. Anaesthesia was maintained with O2 + Isoflurane via Bain’s circuit. If the bag movements decreased and the respiration became abdominal, the depth of anaesthesia was judged to be excessively deep and Isoflurane was decreased till the bag was moving adequately again. The sequence of head position and cuff inflation used in the patient was - 1) Head on table, endotracheal tube cuff deflated: HBCD. 2) Head on table, endotracheal tube cuff inflated with 15 ml of air: HBCI. 3) Head raised on pillow of 10 cms thickness, cuff deflated: HPCD. 4) Head raised on same pillow and cuff inflated with 15 ml of air: HPCI. This was done in the following manner. After the tube reached the oropharynx, it was advanced slowly. Proper alignment of the tip of the tube with the glottic opening resulted in good movement of the rebreathing bag. If on advancement of the tube, the bag movement stopped, the tube was withdrawn to the oropharynnx, cuff inflated with 15 ml of air and the tube was readvanced, again observing the bag movement. If bag movement stopped again, the cuff was deflated, tube withdrawn in the oropharynx, a pillow put under the patient’s occiput and the above procedure done again, first with cuff deflated and then with cuff inflated with 15 ml of air. In those patients who were intubated with cuff deflated, successful intubation was indicated by the bag movements continuing to be good or even improved when the tube was inserted to a depth of 27-28 cms. In those cases which we could intubate with cuff inflated, a resistance was felt as the tube was advanced when the cuff met the vocal cords while the bag movement continued to be good. The cuff was deflated when this occurred and the tube advanced further. A good bag movement with the tube inserted to 27-28 cms was taken to be a successful intubation. The confirmation of intubation was done by capnography. If the tube was palpated on either side of the larynx, the tube was withdrawn in the oropharynx, external laryngeal manipulation was done or the head was tilted on the same side and the tube readvanced. Two attempts of intubation were made in each position. If the patient could not be intubated in any of the conditions mentioned above, direct laryngoscopy was done and oral intubation done under vision. When the intubation was successful in any one position, the remaining positions of the head and the cuff were not tried. After extubation, the complications if any, were noted. Sore throat or irritation in the throat was taken to be present if the patient said so on being asked in the Post Anaesthesia Care Unit. Epistaxis was defined as bleeding from the nasal cavity that required some intervention to stop it. So only the presence of blood stained secretions during oral or nasal suction was not considered to be epistaxis. The “z” score between the intubations with cuff deflated and inflated with head on bed i.e HBCD and HBCI; with head on pillow i.e HPCD and HPCI; intubations with head on bed (HBCD+HBCI) and head on pillow (HPCD+HPCI) was calculated by proportion test using the software Epi.info version 3.4.3; level of significance α = 0.05.
RESULTS
Out of 52 patients, one of the four positions was successful for blind nasotracheal intubation in 47 cases, i.e, a success rate of 90.38%. Only 5 cases (9.62%) required laryngoscopy for intubation. Among the successful BNTIs, the results were as follows (Tables 1 and 2). All 52 patients were first given a trial of BNTI with head on bed and cuff deflated (HBCD) position but in only 3 patients (6.38%) BNTI was successful in this position. In the remaining 49 patients, in 17 patients the BNTI was successful in the head on bed and cuff inflated (HBCI) position, i.e, 34.69% cases. In the remaining 32 patients, in only 1 patient BNTI was achieved in the head on pillow and cuff deflated position (HPCD), i.e, a success rate of 3.13%. In the now remaining 31 patients in the study, 26 could be intubated in the head on pillow and cuff inflated (HPCI) position, i.e, success rate was 83.87%. The remaining 5 cases (9.62%) required laryngoscopy for intubation. The z score by proportion test between HBCD and HBCI was 3.265 (p=0.0015, highly significant); between HPCD and HPCI was 4.89 (p=0.000006, highly significant); and between the two positions of head: on bed (HBCD+HBCI) and on pillow (HPCD+HPCD) was 2.73 (p=0.006, highly significant). Out of the 52 patients in this study, 27 patients were in modified Mallampati grade I; in 26 of these BNTI was successful, 1 patient required direct laryngoscopy for intubation. Out of 19 patients in modified Mallampati grade II, 13 could be intubated blindly but in 4 patients, BNTI was unsuccessful and direct laryngoscopy was required for intubation. There was 1 patient each in Modified mallampati grades III and IV and both could be intubated blindly with this technique. [Table 3] Complications seen postoperatively were as shown in the table [Table 4]. DISCUSSION Magill and Rowbotham pioneered blind nasal intubation. [1] Blind nasotracheal intubation is a technique learnt only by practice. Any maneuver that aids BNTI making it easier is therefore welcome. In the traditional method of doing BNTI, tube advancement after introducing the endotracheal tube in the nasopharynx is guided by the changes in the breath sounds at the proximal end of the tube and palpation of the larynx. Cessation of breath sounds indicates that the tip of the tube is not in alignment with the glottic opening. The tube is then withdrawn until the breath sounds are heard, head and neck position is adjusted and the tracheal tube is readvanced. Inflation of the endotracheal tube cuff to facilitate BNTI was first described by Gorback in 1987. [8] Previous studies have demonstrated that endotracheal tube cuff inflation in the oropharynx increases the success rate of BNTI. [3,4,5,6] In the presence of normal pharyngeal anatomy, inflation of the ETT cuff in the pharynx is assumed to center the tip of the tube with respect to the lateral wall of the pharynx. [9] Cuff inflation also would lift the endotracheal tube off the posterior pharyngeal wall and thus direct it towards the glottis. Magill described the position for blind nasal intubation thus: “The optimum position of the patient’s head for blind nasal intubation is simply that of a man sniffing the morning air. The head is in normal relation to the cervical vertebrae except for slight extension at the occiput-atlas junction. In this position the course of the airway from nose to the glottis is maximally open and a suitably curved rubber tube will follow that course naturally and enter the glottis in many cases. Of course, in the recumbent position a pillow under the occiput is usually necessary for this purpose”.[10] BNTI is also reported to be facilitated by neutral head position apart from endotracheal tube cuff inflation in spontaneously breathing patients. [5] In our study, we have assessed the effect of endotracheal tube cuff inflation as well as the position of the head on the success of BNTI. We have carried out the procedure on anaesthetized patients breathing spontaneously. Spontaneous ventilation confers the advantages of a widely opened larynx during inhalation. A good depth of anaesthesia was a precaution taken to prevent laryngospasm. The polyvinyl chloride ivory nasal tube was used to minimize the trauma caused. Of the PVC tubes available, this tube is most malleable for the nasal passage and yet retains the overall curve that is required for ease of laryngeal intubation. [11] After anaesthetizing the patient and after inserting the tube upto the oropharynx, we connected the tube to the Bain’s circuit. The movement of the rebreathing bag was good if the tube tip and the glottis were in alignment and decreased if the alignment was lost. Also, providing Oxygen and Isoflurane through the circuit helped us to maintain the oxygenation and the depth of anaesthesia. As per our protocol, the order of the positions in which BNTI was tried was HBCD, HBCI, HPCD and HPCI. Once intubation was achieved in any one position, the rest of the positions were not tried in order to prevent repeated unnecessary movement of the tube with respect to the laryngeal apparatus and hence the possibility of further irritation or trauma to the airway. Due to our protocol, among the successful BNTIs with endotracheal tube cuff inflated, all patients had been given a trial of intubation first with the endotracheal tube cuff deflated in that position of head (on bed or on pillow) in which they were intubated. To compare the effect of the inflation of endotracheal tube cuff on the success of BNTI, we compared the success rates of BNTI with the cuff inflated and those with cuff deflated in both the head positions. The rate of successful BNTI is 3/52 (6.38%) with cuff deflated (HBCD) and 17/49 (34.69%) with cuff inflated ( HBCI )with head on bed. [Table 1] The z score between these two is 3.265, p=0.0015 which is highly significant. With head on pillow, the success rate was 1/32 (3.13%) with cuff deflated (HPCD) and 26/31 (83.87%) with cuff inflated (HPCI). [Table 1] When these were compared the z score is 4.89, p=0.000006 which is also highly significant. This difference shows that tracheal tube cuff inflation increased the success of BNTI in any given position of the head . This could be as inflation of the cuff aligned the tube tip with the glottic opening. These results are in accordance to the previous studies. [3,4,5,6] To compare the effect of the head position (on bed versus raised with pillow under the occiput), we compared the total successful intubations on bed (with cuff inflated as well as with cuff deflated) with the total successful intubations with head raised on pillow (with cuff inflated as well as with cuff deflated) . 20/52 (HBCD+HBCI) i.e, 38.46% patients could be intubated with their head on bed and 27/32 (HPCD+HPCI) i.e, 84.38% with their head on pillow. [Table 2] The z score when these are compared was 2.73, P=0.006, highly significant. Thus the success of BNTI was more when the head was raised on a pillow as compared to when the head was on bed (neutral position). In this regard our results are not in accordance with the results of previous studies. [5] In our study, amongst the complications that we encountered [Table 4] most common was sore throat in the Post Anaesthesia Care Unit (PACU). Out of 52 patients, 21 (40.38%) patients had soreness or irritation of the throat when asked specifically in the PACU. These patients were treated with saline nebulization. A study on the comparison of glidescope videolaryngoscopy with direct laryngoscopy for nasotracheal intubation has found an incidence of moderate to severe sore throat in 34% patients. [12] One patient had epistaxis after extubation which was easily controlled by pinching the nostril for 2 minutes. One patient had stridor after extubation. Direct laryngoscopy revealed a blob of some transparent viscid material, probably the lignocaine jelly, near the cords. It was suctioned out and the stridor got relieved immediately. The failure rate of BNTI was 5/52 i.e, 9.62 %. We did not use any intubation aid and use of some aid like trachlite could have increased our success rate. Though patients of difficult intubation were not particularly included in this study the technique of endotracheal tube cuff inflation to aid blind nasotracheal intubation has been reported to be successful in patients anticipated to have difficult intubation like patients with limited mouth opening [3] and immobilized cervical spine in cases of cervical spine injury [4]. With respect to modified Mallampati score, the sample size in grade III and IV (Table 3) is too small to correlate the grade with success or failure of the technique of cuff inflation in aiding blind nasotracheal intubation. However it may be mentioned here that the Mallampati Classification was proposed as a clinical sign to predict difficult tracheal intubation on direct laryngoscopy.[13] Blind nasal intubation does not involve direct laryngoscopy. Our study has certain limitations. There was no randomization and this could have introduced some bias. Also, every patient did not undergo BNTI in all the four positions studied. When a patient was intubated in a particular position, the remaining positions of the head and the cuff were not tried. Hence the possibility that a patient could have been intubated in some later position also cannot be negated. However, all the 31 out of 52 patients in whom BNTI was successful with the head on pillow and with endotracheal tube cuff inflated had failed to be intubated in other three positions. Further study on the efficacy of endotracheal tube cuff inflation in aiding blind nasal intubation in anticipated cases of difficult intubation would provide more authenticity to this technique.
CONCLUSION
We conclude that endotracheal tube cuff inflation with the head raised on pillow is efficacious in achieving blind nasotracheal intubation in our population probably as in this position the endotracheal tube is in good alignment with the glottis opening.
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 the 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=822http://ijcrr.com/article_html.php?did=8221. Gold MI, Buechel DR. A Method of Blind Nasal Intubation in a Conscious Patient. Anesth Analg. 1960;39:257-63.
2. Nofal O. Awake light aided blind nasal intubation: prototype device. Br J A. 2010;104:254-7.
3. Van Elstraete AC, Pennet JH, Gajraj NM, Victory RA. Tracheal Tube Cuff Inflation as an aid to Blind Nasotracheal Intubation. Anaesthesia 2003;58:249-56.
4. Van Elstraete AC, Mamie JC, Mehdoui H. Nasotracheal intubation in patients with immobilized cervical spine: A comparison of tracheal tube cuff inflation and Fibreoptic Bronchoscopy. Anesth Analg. 1998;87:400-2.
5. Chung YT, Sheng Sun M, ShanWu H. Blind nasotracheal intubation is facilitated by neutral head position and endotracheal tube cuff inflation in spontaneously breathing patients. Can J Anaesth. 2003;50(5):511-3.
6. Casals-Caus P, Mayoral-Rojals V, Canales M A, Ruiz-Tamarit V, Casals-Castells A, Cochs-Cristià J. Inflation of the endotracheal tube cuff as an aid for blind nasotracheal intubation in patients with predicted difficult laryngoscopy. Revista Espanola De Anestesiologia Y Reanimacion .1997; 44(8): 302-4
7. Lam B, Ip MSM, Tench E, Ryan CF. Craniofacial profile in Asian and white subjects with obstructive sleep apnoea. Thorax 2005;60:504–510.
8. Gorback MS. Inflation of endotracheal tube cuff as an aid to blind nasotracheal intubation. Anesth Analg. 1987;66(9):917
9. Van Elstraete AC, Remy A. Difficult intubation: nasotracheal tube cuff inflation as an aid to difficult intubation. Ann Fr Anesth Reanim. 1994;13(6):873-5
10. Magill IW. Blind nasal intubation. Anaesthesia 1975;30:476-9
11. Hall CEJ, Shutt LE. Nasotracheal intubation for head and neck surgery. Anaesthesia 2003;58:249-56
12. Jones PM, Armstong KP, Armstrong PM, Cherry RA, Harle CC,Hoogstra J, Turkstra T. A comparison of Glidescope®videolaryngoscopy to direct laryngoscopy for nasotracheal intubation. Anesth Analg. 2008;107(1):144-8
13. Mallampati SR, Gatt SP, GuginoLD, Desai SP, Waraksa B, Freiberger D, Liu PL. A clinical sign to predict difficult intubation: a prospective study. Can Anaesth Soc J.1985;32 (1):429-34.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241613EnglishN2014July12HealthcareCURRENT TRENDS IN ECLAMPSIA AT TERTIARY CARE HOSPITAL
English3137Deliwala K. J.English Patel R. V.English Shah P. T.English Thaker R. V.English Patel S. L.EnglishAims and Objectives: (1) To evaluate the incidence of eclampsia (2) To study material and perinatal outcome in eclamptic patients and its management. Methodology: Prospective study was done between July 2007 to June 2012. A total of 308 patients with eclampsia were included in the study. Results: The incidence of eclampsia is about 1.31 %. Majority of patients were primipara and between 21-25 years of age group. 97.1% of patients showed good response to MgSO4 therapy. 53.9 % patients had vaginal delivery while 46.1 % patients had LSCS. Conclusion: Eclampsia is not a totally preventable disease but its incidence can be decreased by proper antenatal care, early diagnosis of Pregnancy Induced Hypertension (PIH) and its proper management.
EnglishINTRODUCTION
Eclampsia is defined as new onset of grandmal seizure activity and/or coma during pregnancy, labour or postpartum in a woman with signs or symptoms of preeclampsia, more than 50% occur in third trimester.1 It is one of the leading cause of maternal and perinatal mortality as well as morbidity throughout the world.2,3 Every year more than 50,000 deaths occurred due to eclampsia, most of which occurs in developing countries.4 Recent series reports antepartum eclampsia in 38-53% and postpartum eclampsia in 11-44%.1 Primigravidas are at higher risk of developing eclampsia and that antepartum convulsions are more dangerous than those beginning after delivery.5,6 Incidence of eclampsia is said to be declined, still is a major problem for maternal mortality associated with increased risk of abruptio placenta, disseminated intravascular coagulation (DIC), acute renal failure (ARF), cerebral hemorrhage. It also reduces uteroplacental perfusion, places the foetus at high risk for intra uterine growth retardation (IUGR), preterm birth, and perinatal mortality.6 The main pathology might be generalized vasoconstriction and the endothelial dysfunction and signs and symptoms appear in late mid trimester or in the advanced stage of disease. Mainstay of management in case of eclampsia is early delivery, to improve the prognosis in terms of reducing maternal and perinatal morbidity and mortality. The current study was done to determine the clinical presentation and management of eclampsia, maternal complications and foetal outcome who presented in our institution during the year July 2007 to June 2012.
AIMS AND OBJECTIVES
To evaluate the incidence of eclampsia in terms of age, parity, socio economic status and gestational age.
To study mode of delivery, complications, management of eclampsia and perinatal outcome.
To recognise various factors influencing the prognosis of maternal and foetal outcome.
MATERIAL AND METHODS
Prospective study was conducted at the department of obstetrics and gynaecology in one of the tertiary care teaching hospital. 308 cases of eclampsia patients were taken randomly to study the clinical manifestations, mode of delivery, management and its complications. On admission, assessment of each women was done on an individual basis depending on the severity of condition and the gestational age. Once the patients were stabilized with anti-hypertensive and MgSO4 therapy and detailed history was elicited. Induction of delivery was generally done after 3-4 hours from the last fit. If cervix favourable, induction done with Inj. Oxytocin i.v. infusion drip. If unfavourable, cervix ripened with prostaglandin gel. In case of failed induction cesarean section was done under general anaesthesia.
RESULTS
In our study, 308 patients of eclampsia were analysed between the period of July 2007 to June 2012. The incidence of eclampsia is 1.31% in our study.During the present study it is noted that about 80% of patients were emergency while 20% were registered patients. Highest incidence of eclampsia (55.2 %) was seen in the age group of21-25 years (Table Iand Chart I). In our study, almost 74 % of patients were primigravida. About 64.9 % patients had antepartum eclampsia, 15.9 % patients had intrapartum eclampsia while 19.2 % patients had postpartum eclampsia (Table IIand Chart II). Highest incidence of eclampsia was seen between 28-36 weeks of gestation(Table IIIand Chart III) which requires some screening test for prediction of PIH.In our study 88% of patients were having diastolic BP ≥100, 10% of patients had no oedema, 57.8% had +1 oedema and 50% had massive proteinuria. Out of 308 patients, 299 patients (97.1%) showed a good response to MgSO4 therapy (PRITCHARD regime). Only 9 patients (2.9%) required other anti convulsant therapy. Among those 9 patients, 3 had status epilepticus, 3 had two convulsions after MgSO4 therapy and 3 were known case of epilepsy. In patients with atypical eclampsia or prolonged coma, other diagnosis should be considered in women with onset of convulsion more than 48 hours postpartum or in women with focal neurological deficits. In present series, 53.9% of patients had vaginal delivery and 46.1% had cesarean delivery (Table IV). Out of total 308 babies, 9 were stillborn. In 50 live preterm births, 18 babies were expired due to low birth weight and birth asphyxia. Out of 179 live full term babies 9 were expired – 3 due to meconium aspiration and 6 due to birth asphyxia (Table V and VI, and Chart IV). In our study, maternal complication rate was 24.4% while maternal mortality rate was 5% (Table VIIand VIII and Chart V and VI).
DISCUSSION
The hypertensive disorders of pregnancy (HDP) and particularly the pre eclampsia- eclampsia syndrome remain the leading cause of pregnancy related morbidity and mortality worldwide.7 Hypertensive disorders of pregnancy affect almost 7 % of all pregnancies and remain one of the leading causes of adverse maternal and neonatal outcomes, both in developed and developing world. Eclampsia is a major cause of maternal mortality along with hemorrhage and infection.8 This is second most common cause of maternal death during pregnancy.9The incidence of eclampsia is 1.31% in our study while Olakunleet al shows incidence of 1.61%.10The data from public hospitals show a high incidence of eclampsia because all complicated cases from smaller centers, even private clinics are shifted when a patient’s condition deteriorates.11 There is a better understanding of pathophysiology of eclampsia in recent years. It is now generally accepted that eclampsia is a multi-organ disorder unique to human pregnancy. There is generalized vasospasm affecting tissue perfusion in vital organs like brain, liver, kidney, etc. The cause of seizures is attributed to platelet thrombi, hypoxia due to local vasoconstriction or foci of haemorrhage in the cerebral cortex. It must be remembered that though eclampsia often follows severe pre-eclampsia, it can come like a bolt from the blue in a woman without preexisting preeclampsia.11 Eclampsia is more common in women who have not taken antenatal care. In India only 60 % of pregnant women receive antenatal care.11 Good antenatal care will help in prevention of PIH, early detection of PIH and to modify the severity of PIH by giving proper treatment in time. It was suggested that prophylactic use of aspirin, calcium, vitamin C and E may help in preventing PIH and thus may help in preventing eclamptic fit. Aspirin generated a lot of interest as a prophylaxis for PIH. However, recent studies show that its usefulness is to be confirmed by large multicentric trials prophylactic use of aspirin is controversial. Some studies have shown low serum levels of anti-oxidants in women with PIH. Anti-oxidants are known to reduce endothelial cell activation. Eclampsia is a disease specifically of teenage primigravida but highest incidence (55.2%) is seen in age group of 21-25 years in our study. This shift from, teenage to 21-25 years can be explained by late marriages in last few years.12 In our study, almost 74% patients were primigravida which supports the genetic theory of development of preeclampsia where alloimmunity between maternal and foetal tissues is the predisposing factor.13Reynolds suggested the possibility of a single gene likely to be responsible for pregnancy induced hypertension (PIH) which is usually responsible for eclampsia in many cases.14 Eclampsia can recur in future pregnancies in approximately 2% of eclamptics.In our study, about 65% of patients were antepartum. This is because developing countries still are struggling to cope with inadequate ANC, home deliveries and unsupervised deliveries.15In present series, 53.9% patients had vaginal delivery and 46.1 % had cesarean delivery. Umar et al (2007) showed 48.3 % had vaginal delivery and 51.7 % had cesarean delivery.16Vaginal delivery is a safe option resulting in low maternal mortality rates as long as foetal presentation and status are appropriate and labour progresses in an ordinary fashion.17Labour should be closely watched to detect emerging complications like eclampsia, cardiac failure, pulmonary oedema, respiratory failure, cerebrovascular accidents, eye complications, fetal complications like foetal distress/ and death. Neonatologist should be present at birth to look after the newborn. Maternal complication rate was 24.4 % in present series. Rate of complications depends upon number of convulsions, duration of convulsion, duration of admission between hospitalization and last fit, proper nursing care and least time for delivery. Maternal mortality rate was 5 % in our study while Chekari A et al (2008) showed maternal mortality rate of 6.7 %.18Analyzing the causes of death it was found that delayed hospitalization, early onset of eclampsia, low socio-economic status of woman and lack of essential obstetric care are fundamental determinants of maternal death.
CONCLUSION
Eclampsia is not a totally preventable disease but its incidences can be decreased by proper antenatal care, early diagnosis of PIH and pre-eclampsia and its proper management with selective termination to improve maternal and perinatal outcome. This study suggests that MgSO4 therapy is considered as the best therapy and is very effective in preventing and controlling convulsions. Termination of pregnancy is the primary treatment for eclampsia. Induction of labour with oxytocics and prostaglandins decreases the duration of labour. Cesarean section has definite place to improve feto-maternal prognosis. Incidence of complications in LSCS has become very low due to better operative techniques, proper anaesthesia and easy availability of blood components. If vaginal delivery fails following induction of labour cesarean section is preferred.
ACKNOWLEDGEMENT
We acknowledge the immense help received from the scholars whose articles are cited and included in references of our manuscript. We 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. We are also thankful to our seniors, colleagues and patients to help us in our study. Not only that we are also thankful to our family for their kind cooperation and support.
Englishhttp://ijcrr.com/abstract.php?article_id=823http://ijcrr.com/article_html.php?did=8231. Sibai BM. Diagnosis, prevention and management of eclampsia. ObstGynecol; 2005; Feb; 105 (2).
2. Dare FO, Eniola OA, Bariweni AC. Eclampsia revisited. Nig. J Med; 1998; 7; 168-171 cs.
3. Adetoro OO. The pattern of eclampsia at the university of Ilorin teaching hospital, Ilorin Nieria, International J of gynecology and Obstetrics; 31: 221-226.
4. Duley L Maternal Mortality associated with hypertensive disorders of pregnancy in Africa, Asia,Latin America and Caribbean. Br. J. ObstetGynecol 1992; 99: 547-553.
5. Percy CN In: Handbook of Obstetric Medicine Isis Medical Media oxford 1997.
6. Chelsey LC. A short history of eclampsia, ObstetGynecol 1974; 43: 599-602.
7. Acharya p, Damania K.R., Konar H., Misra S., Singh A., Thanawala U., et al.; Pregnancy induced hypertension; In Duftary S.; ECAB clinical update: Obstretricsand Gynecology; High-Risk Labour and Delivery; Haryana; Elsevier; 2011; 42-44.
8. PatilMithil M. et al – Role of Neuro imaging in patients with Atypical Eclampsia – The Journal of Obstetrics and Gynecology of India ( September – October 2012 ) 62 (5) : 526- 530.
9. D’Souza R., Bhide A.; Hypertensive disorders of pregnanacy; In: Thanawala U, Divakear H.; ECAB clinical update: Obstretricsand Gynecology; Medical disorders in pregnancy; New Delhi; Elsevier; 2009; 1-37.
10. Olakunle Kusemiju MBBS : The internet journal of third world medicine, 2008, Volume 6 number.
11. Bhatt R., Patel V., Patel C.; EclampsiaDiagnosis and management; In Mittal C., Mittal P., Emergencies in Obstetrics and Gynecology; Volume I, Second edition; Delhi; Peepee; 2012; 95-101.
12. Wang Y, Gu Y, Zhag Y et al. Evidence of endothelial dysfunction in pre-eclampsia. Decreased endothelial nitric oxide synthatase expression is associated with increased cell permeability in endothelial cells from preeclampsia. Am. J. Obstet. Gynecol, 2004; 190: 817.
13. Kanki T, Mihara F, Nakanoh. Diffusion weighted images and vasogenicoedema in pregnancy. ObsteGynecol. 1999; 93: 821-3.
14. Reynolds C., Mabie W. Hypertension studies in pregnancy; In Current Obst. Gynec. Decheney A.; Ninth Edition; Lange Medical Books, New York; 2000; 338.
15. Naidu K, Modly J. SPECT, CT scan, and TCD findings in eclampsia. Br. J. ObstetGynecol. 1997; 104 (10) : 1162-72.
16. J. Tukur B. A. Umar, R. Rabi U. Annals of African Medicine volume 6, No. 4; 2007: 164- 167.
17. Pritchard J. A. Cunningham FG, Pritchard SA the Parkland Memorial Hospital, protocol for treatment of eclampsia. Evaluation of 245 cases Am. J. Obstet. Gynecol 148: 951, 1984.
18. MigullM;Chekairi, A. Hypertension in pregnancy, 27(2), May 2008.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241613EnglishN2014July12HealthcareMORPHOMETRY OF THE FIRST SACRAL PEDICLE IN SOUTH INDIAN POPULATION
English3844Padmavathi Devi S. V.English T. RajiniEnglish Varsha MokhasiEnglishInstrumentation of the sacrum is increasing in importance in treatment of spinal disorders, sacro-iliac joint disturbances and sacral fractures. There is concern about injuries to pedicle cortex, nerve root, facet joint, iliac vein penetration and other vital structures by a misplaced or a misdirected pedicle screw. In this study Description of the Morphometry of the sacral pedicles of Indian samples has been done. 100 dry sacral vertebrae were used for the morphometric analysis of the first sacral pedicle (57 male and 43 female) using vernier calliper (0.1mm) and goniometer. The height of the first sacral pedicle in male was 19.30±1.6mm and in female was 18.46±1.8mm. The width of the first sacral pedicle was 24.06±2.4mm in male and 23.48±2.3mm in female. The anteromedial trajectory length in male was 46.88±3.2mm and in female was 43.35±3.7mm. The anterolateral trajectory length in male was 45.78±3.5mm and in female was 44.02±2.2mm. The medial trajectory angle in the male was 34.28±2.5mm and in female was 32.08±2.4mm. The lateral trajectory angle in the male was 28.33±3.4mm and in the female was 25.58±2.8mm. The results of this study will guide surgeons on the choice of the screws that are used for pedicle fixation and their direction of insertion. A detailed knowledge of the morphometric anatomy of the sacral pedicles will minimize surgical complications.
EnglishSacrum, Pedicle, Screw fixation, Sacral pedicleINTRODUCTION
Pedicle is the cylindrical and strong structure bridging the gap between the dorsal spinal elements and the vertebral body [1]. The nerve roots form the caudal relation to the pedicles as they pass through the inter-vertebral foramina. The nerve roots after passing through the intervertebral foramen are related closely to the lateral border of the immediately caudal pedicle. Due to proximity to the nerve roots, injury to the nerve roots may be possible during procedures involving the pedicle. Pedicle screw fixation involving bone screws to obtain spinal fixation was first described by Tourney in 1943 and King in 1944 and practiced by Boucher in 1959. Over the years pedicle screw fixation systems have proved to be biomechanically superior to segmental fixation. The screws are fixed using linkages which may be rods, plates, internal fixators or have coupling to permit some motion. They may also allow controlling of kyphotic or lordotic forces on the vertebra. They are indicated in spinal instability, post laminectomy spondylolysthesis, painful pseudoarthrosis, spinal stenosis, unstable fractures, stabilizing spinal osteotomies etc.[2] The advantage of the pedicle screw system is that they stabilize dorsal as well as ventral aspects of the spine as they traverse all the three columns of the vertebra.Also the rigidity of the system allows for inclusion of fewer motion segments in order to achieve stabilization. They can be carried out even after a traumatic disruption of the laminae, spinous processes and facets. The main disadvantage is the possibility of neural injury as a result of caudal or medial penetration of the pedicle cortex. Mechanical injury inflicted by a drill ,curette or an eccentrically placed screw or postoperative late screw cut out causing nerve root irritation leading to radiculopathy or cauda equine syndrome. Perforation of the anterior cortex may cause damage to lumbosacral plexus and aorta (at or above Lumbar 4) or iliac vessels. Osteoporosis may prevent adequate screw fixation. The implantation requires extensive tissue dissection to expose points of entry and provide lateral to medial orientation for the screw trajectory. There can be an added risk of infection due to use of many instruments, an image intensifier etc. Pedicle screw systems also involve surgical techniques that bear several potential problems and complications such as postoperative epidural hematoma, overcorrection, and loss of stabilization, pseudoarthrosis and implant prominence. Pedicle fracture may occur due to placing of too large a screw through a small pedicle or due to placing of a screw in an incorrect axis. This reduces the strength of the pedicle and also results in damage to the surrounding structures.[1] The pedicle screw should be ideally placed along the axis of the pedicle incorporating the largest available transverse and sagittal diameters. A thorough understanding of the Morphometry of the first sacral pedicle will help to prevent the damage caused as a result of a misplaced pedicle screw. The purpose of this study is to morphometrically analyse the first sacral pedicle in the Indian population in order to provide surgeons a better understanding of its anatomy so that related complications could be avoided.
MATERIALS AND METHODS
100 dry sacral vertebrae devoid of any visible pathological findings were taken from the Anatomy department of Vydehi Institute of Medical Sciences And Research Centre. Linear parameters were calculated using verniercallipers (0.1mm). Angular parameters were calculated using goniometer.
Linear parameters:
? Pedicle height: line joining a point at the superior most point of the upper margin first sacral foramina and point at the superior border of the sacrum immediately superior to it. ? Pedicle width: the distance between the point at the junction of the first sacral facet and the first sacral body and the point at the junction of the first sacral body and the ala. ? Anteromedial screw trajectory distance: the distance between the midpoint of the sacral promontory to the junction of the first sacral facet and the first sacral body ? Anterolateral screw trajectory distance: the distance between the lateral most tip of the ala of the sacrum to the junction of the first sacral facet and the first sacral body
Angular parameters:
? Anteromedial screw trajectory angle: angle between the line joining the first sacral facet angle to the junction of the body and the sacral promontory and the line joining the first sacral facet angle to the midpoint of the sacral promontory. ? Anterolateral screw trajectory angle: angle between the line joining the first sacral facet angle to the junction of the body and the sacral promontory and the line joining the lateral most tip of the ala of the sacrum to the first sacral facet angle[4]
STATISTICAL METHODS
A t-test for significant difference in means was done at 5% level of significance between the male and female parameters.
A significant difference in the Pedicle height ,Antero-lateral screw trajectory distance,Anteromedial screw trajectory distance,Antero-medial screw trajectory angle,Antero-lateral screw trajectory angle were found between the male and female sacral vertebra (p0.05).
DISCUSSION
Pedicle screw fixation is a procedure requiring extensive technical expertise and skill. Placing the screw beyond the dimensions of the pedicle, fracturing the pedicle or usage of screws of inadequate circumference, thread size or length has resulted in nerve damage. Any disproportion in the screw diameter or trajectory could hold potential threat to damage of surrounding anatomical structures. The first sacral pedicle has been defined differently in different studies and we find that the differences in measurements of the sacral pedicles can be explained by the differences in the definitions. In this study the distance of entry from a point just inferolateral to the first sacral facet to the midpoint of the sacral promontory was takes as the anteromedial screw trajectory distance and the same point to the lateral most tip of the ala of the sacrum was taken as anterolateral screw trajectory distance. The mean angles for anteromedial and anterolateral orientations were measured. Harrington and Dickenson suggest that sacral screw placements passing through the first sacral pedicle to the sacral promontory were the most secure and thus the anatomical measurement of the first sacral pedicle is of crucial importance.[3] Candan Arman et al. conducted a complete Morphometry of the sacral vertebra in the Turkish population using vernier calliper and goniometer. The results were tabulated in forms of linear and angular parameter. The pedicle height, width anteromedial screw trajectory lengths and angles and the anterolateral screw trajectory lengths and angles were defined similar to our study. However the pedicle height in our study was 4.26 mm more while the anteromedial screw trajectory length was 6.08mm less and the anterolateral screw trajectory length was 5.40mm less than their study. The differences in the measured values in this study and the study conducted by Candan et al. may be accounted for by the diet and socio-economic status of the different populations.[4] Okutan et.al defined the pedicle height between the superior border of the first sacral foramen and superior surface of body of first sacral.The width was between the anterior and posterior width of first sacral pedicle. The measurements were carried out on dry sacra of Turkish population. The pedicle length was the distance from entrance point(X- The tip of the first sacral facet) to promontory. The pedicle height in their study was found to be 5.47mm greater than the values of our study. In our study we have not done a side comparison as no significant differences were encountered between the left and right pedicular morphometric values.[5] Rongming et al. have provided a surgical anatomy of the sacrum. They divide the sacrum into 2 zones, the anatomical parameters of first sacral pedicle in each of the zones were measured and zone 2 was found to be wider and longer than zone 1; and suggest zone 2 is ideal for screw placement. They also suggest that instrumentation extending to second sacral vertebra may enhance the strength of sacral fixation.[7] Ebraheim et.al conducted CT guided anatomical study of the screw paths and lengths. 4 paths were chosen. Path 1 was from lateral border of the superior facet to the anterior cortex of the sacrum at 30 medial inclinations. Path 2 was from the midpoint between the medial and lateral borders of the superior facet to the anterior cortex of the sacral canal. Path 3 was from the medial border to the superior facet to the anterior cortex along the lateral cortex of the sacral canal. Path 4 was from lateral border of the superior facet to the most anterior cortex of the ala. The longest screw lengths were seen with path4. They concluded that the optimum medial screw paths for first sacral are paths 1 and 2. The median distance from the screws inserted this way to the lateral aspect of the sacral canal was 5 to 6mm. Mean length of anteromedial screw was 33 mm and anterolateral screw was 37mm. The current study does not incorporate CT findings.[8] Deepak and Najeeb have provided entry sites and trajectories for thoracic, lumbar and spinal pedicles. They have suggested that the size and angulation of pedicles varies throughout the spinal column. According to their study the transverse pedicle width is said to be narrower than the sagittal pedicle width except in the lower lumbar spine. Pedicles below 10 thoracic vertebra are greater than 7mm in transverse diameter and most below first lumbar are greater than 8mm. The transverse pedicle width increases from first lumbar to first sacral. Coronal angulation decreases along the spine until the lumbar region[1]. According to Mirkovic et.al, using a 30 angulation, the length of the screw was 38 while usage of 45 angulation, the mean length was 44mm[9] . XU et al. reported a mean first sacral pedicle medial angle was 39.4 degrees. Morse et al. using average angles for anteromedial and anterolateral first sacral screw placement defined risks to important structures and advice CT scan verification to determine safe angles to decrease the risk[10]. Peretti et al. notified that the oblique forward and inward degrees of first sacral are 15 and 30 respectively[11] . The current study holds significance as sacral screw fixation surgeries are less common in India. Although morphometric analysis of the sacral pedicle have been carried out many times, an analysis of the Morphometry in the south Indian population will make it simpler for the surgeons to choose the appropriate screw in surgeries performed on this population. The demerits of this study are that it has been carried out on dry sacral specimens and a variation in the in-situ value may be expected. It is also limited to the first sacral pedicle while studies suggest an extension of instrumentation to the second sacral vertebra provides better stability [6] .
CONCLUSION
Development in technology has lead to an increase in the instrumentation at the lumbo sacral level.The knowledge of the pedicular anatomy of the first sacral vertebra has crucial importance in the pedicular-corporeal screw placement.Screw placement will be safe if the screw has proper length and angulation.Larger angles(>34.28mm) may cause damage to the spinal nerves .Smaller angles(Englishhttp://ijcrr.com/abstract.php?article_id=824http://ijcrr.com/article_html.php?did=8241. Deepak Awasthi and Najeeb Thomas, Pedicle, cited at http://www.medschool.lsuhsc.edu/neurosurger y/nervecenter/tlscrew.html Accessed on 14.4.14.
2. Weinstein JN, RydevikBL, Rauschning W. Anatomic and technical considerations of pedicle screw fixation.Clin Orthop Relat Res. 1992 Nov;(284):34-46.
3. Harrington PR, Dickson JH. Spinal Instrumentation in the treatment of severe progressive spondylolistheses. Clin.Orthop,1976(117),157-163
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241613EnglishN2014July12HealthcareWHAT CAN WE MISS IN IDENTIFYING "MATERNAL NEAR MISS"EVENT?
English4550Niyati ParmarEnglish Ajay ParmarEnglish V. S. MazumdarEnglishBackground: The maternal mortality ratio (MMR), the most sensitive indicator for social inequalities, varies dramatically between developed and developing countries. With declining MMR, the need for the search of a new indicator has motivated investigators to study hospital obstetrical morbidity data especially the new concept of severe maternal morbidity called “Maternal Near Miss (MNM)” which was defined using WHO and / or Mantel et. al. criteria. Methodology: A hospital based cross sectional study was carried out at tertiary care regional referral hospital where selection of study participants was from the Obstetrics and Gynecology ward irrespective of the place of delivery to improve coverage. Data collection was done over a period of five months by one to one interview of patients after two days of admission to ensure survival after critical condition and then followed up till their discharge. Results: Out of 2238 admissions, 50 women with severe maternal morbidity were identified, of which, 46 women were classified according to WHO and / or Mantel et. al. criteria. While remaining 4 women (~10%) though treated as near miss, did not fit into either WHO or Mantel et. al. criteria and were analyzed separately. Conclusions: Study of factors leading to near miss events which would be factors related to maternal mortality also should be undertaken routinely to identify preventable ones and actions required for the same. Appropriate modifications to the WHO criteria, evolved and validated for local needs, are required as they currently underestimate near misses in India.
EnglishMaternal near miss, severe maternal morbidity, maternal mortality.INTRODUCTION
Health Indicators in India are significantly improving. Still maternal mortality and morbidity continue to remain a major public health problem. The maternal mortality ratio (MMR) is the most sensitive indicator for social inequalities. It is considered to be an indicator of economic development and of the quality of obstetrical care. No other health indicator varies so dramatically between developed and developing countries(1) . Maternal mortality is used as a sentinel event to assess the quality of a health care system(2) . Maternal Death Review (MDR) is an important strategy to improve the quality of obstetric care and reduce maternal mortality and morbidity (3) . Studies of negative outcomes have been highly successful in preventing their causes(2). But this strategy of prevention faces difficulties when the numbers of negative outcomes drop to low level. Due to improved health care the ratio has been declining steadily in developed countries(2) . MMR in India has shown an appreciable decline from 212/100,000 live births in the year 2009-10 to 178/100,000 live births as per report of Census India 2010-12 (4) . As there is constant decline in the number of maternal deaths, there is a need for the search of a new indicator. This search has motivated investigators to study hospital obstetrical morbidity data. This idea led to formation of new concept of severe maternal morbidity called “near miss”. The term „„near-miss?? describes a serious adverse event that only failed to occur by luck or by adequate management. This concept was recently defined by the World Health Organization (WHO) as „„a woman who, being close to death, survives a complication that occurred during pregnancy, delivery or up to 42 days after the end of her pregnancy?? (1) . Currently there is paucity of literature available regarding Maternal Near Miss (MNM), as not many studies have been carried out in India; it is a potential area of research. Therefore, a study was carried out to find such events at a tertiary care hospital of central Gujarat. Near Miss women were identified using WHO criteria(5) and Mantel G D et al(6) criteria. Near miss cases occur more often than maternal deaths and theirinquiry is much easier as women survived this condition. Such events start at periphery and end up at higher centre of care. In periphery and rural areas, there is a need to identify high risk women by midwives. When there is presentation of patients with such serious clinical problems, they must be trained to identify these critical conditions or they should be provided with a list of criteria by which they can identify them. With this objective in mind “near miss” cases were attempted to be identified.In the process, some cases were identified who otherwise did not fit into either criteria used for classifying „„near-miss?,? though they should have been classified as Near Miss as they had serious morbidities. The following cases, which though did not fit into the above criteria, were saved only because they were given rigorous and timely medical interventions, and this study presents some of them.
METHODOLOGY
A hospital based cross sectional study was carried out at Department of Obstetrics and Gynaecology at ShriSayajirao General Hospital (SSGH), Vadodara during May to September 2012.It is a tertiary care regional referral hospital having a case load of about 5000 deliveries per year. Selection of study participants was from the ward, irrespective of the place of delivery. Data collection were done by interview after 2 days of admission to ensure survival after critical condition and followed up till their discharge. All the interviews were conducted by the same investigator to avoid inter - observer variation. MNM was defined using WHO(5) and Mantel et al criteria(6). Since both differ in their components it was decided to use both. Over the period of data collection there were some cases which though did not fit into the inclusion criteria did present with clinically serious morbidities and were analyzed separately.
OBJECTIVE
To describe, cases of near miss women, who did not fit into either WHO(5) or Mantel et al criteria(6) defined for classifying “Maternal Near Miss”.
RESULTS AND DISCUSSION
During the entire study period, from May to September 2012, 2238 patients were admitted in Department of Obstetrics and Gynecology. During this time, 18 maternal deaths were reported giving maternal mortality ratio of 933/ 100000 live births for this hospital during the study period. All 2238 cases were followed up for their clinical, laboratory and/or management details to identify the criteria of maternal near miss event if present. 50 women with severe maternal morbidity / near miss were identified, of which, 46 women were classified according to WHO and Mantel et. al. criteria. While, the remaining women though treated as near miss, did not fit into either WHO or Mantel et al. criteria. The number of such women was 4 out of 50, almost 10% of suspected “near miss”. These important set of patients who were missed by both criteria were patients who ideally should have been classified in the category of “near miss” but did not fit into either of the criteria. Their clinical condition was serious enough to be considered as maternal near miss. A brief description of all these cases is as under: Case A A 22 year old primigravida with 31 weeks 6 days pregnancy presented with dry cough, breathlessness and pedal edema. Her blood pressure was 160/100 mm Hg. She had severe pedal and vulval edema. Respiratory system examination showed crepitations and bilateral deceased air entry in basal area. On further investigation she was found to be Rh negative. On ultrasonography (USG) examination Gross free fluid (++++) was present in abdomen. Moderate free fluid was found in left pleural cavity with underlying lung collapsed and mild free fluid was present in right pleural cavity with underlying lung collapsed. Significantly, she had taken 6 Antenatal visits at a private hospital and the last visit was before 25 days of admission to this hospital. At that time, she was diagnosed as having pregnancy induced hypertension (PIH) andUSG was also done. But other problems were not ruled out. After 12 days of admission she delivered a preterm still birth baby by normal delivery. Her total duration of stay at hospital was 17 days. Case B A 28 year old, 4th gravida woman, presented with severe abdominal pain, leaking and bleeding per vaginum. She was referred from one of the Community Health Centres (CHC) due to non availability of doctor at that time and that she needed urgent treatment. As she was in labour, initially assisted vaginal breech delivery was conducted, but it was followed by laparotomy for ruptured uterus due to scar dehiscence of previous caesarean section. She was given 2 PCV (Packed Cell Volume) and 1 RCC (Red Cell Concentrate). When her labour pain started she was alone and finally when it became severe her neighbor took her to hospital in 108 (Ambulance Service). Thetotal time taken between onset of labour pain and reaching 1st referral centre was 12 hours and reaching SSGH was almost 13 hours. This could have been one of the reasons for ruptured uterus. This patient would have died because of ruptured uterus causing haemorrhage, if she had not got timely tertiary care treatment and early transportation by 108. This was one the cases of “near miss”, which was missed by either criterion. Her age at the time of 1st pregnancy was 19 years. Case C A 25 year old woman, 4th gravida, labourer by occupation, presented with severe abdominal pain and bleeding per vaginum at 36 weeks of pregnancy. She came from one of the tribal villages after travelling almost 110 kilometers. Before coming to this hospital she was referred to 2 other hospitals. Within 1 hour onset of labour pain, she was taken to one government hospital in 108(Ambulance Service). The hospital staff waited for 2 hours for progression of labour and gave only pints and some injections. When they felt that labour was not progressing, they referred patient to SSG hospital for further management. Even then, she was taken to some private clinic in government ambulance taking almost 1 hour. The doctor at private clinic examined patient and looking at the severity of condition referred her to SSG hospital within 15 minutes. After another 1 hour of travelling, she was brought to SSGH in unconscious state where immediate laparotomy was done for ruptured uterus delivering still born baby of 3100 grams, which was followed by suturing of uterine rent. She was given blood transfusion in the form of 2 PCV and 1 RCC. She stayed in hospital for 10 days. She took 2 ANC during 3rd trimester at Anganwadi, but no ANC was taken during 1st or 2 nd trimester. On eliciting past history, during previous 3 deliveries she had delivered live babies by normal vaginal delivery which occurred at home. But 2 of them died at the age of 1 year and 1 died at the age of 2 years. So at presentation she did have any living child. Case D A 32 years old farmer, 5th Para, was referred to SSGH from a private hospital post laparotomy for further post-operative management. She was taken to a government hospital in 108 after 2 hours of onset of labour pain. The nurse waited for 12 hours and tried to conduct a normal delivery. During this time she received few injections and pints. Even after waiting for 12 hours when she did not deliver, she was referred to a higher centre in 108. When she was taken to another private clinic after travelling for almost one and half hours, emergency laparotomy was done for ruptured uterus with retroperitoneal hematoma with mild anemia. This whole procedure took almost 2 hours and when critical phase was over she was referred to SSGH for further postoperative management. Two units of blood were given at that private hospital and during transportation On elaborating above cases, Case A was identified as having severe pre-eclampsiawith Rh negativity, severe anasarca and severe vulval edema, with ascites with pleural effusion; still she was not classified by either the criteria as “near miss”. Case B and C were not identified by Mantel and WHO criteria as hysterectomy was not done for ruptured uterus and also, the threshold for severe haemorrhage is transfusion of five or more packed red blood cells. At SSG hospital they received 3 units of blood. In our set up threshold of 5 units may be too high. It may be more appropriate to set it at 1,500 ml (equivalent to three or more packs) or even lower. In both the cases, the women presented in severely morbid conditions, in unconscious state with ruptured uterus, but still did not fit into defined criteria of “near miss”. Case D did not fit into either criteria, but she may have died if she had not got timely treatment at the private hospital at Rajpipla, which is almost 100 km from SSGH, for ruptured uterus before coming to SSGH. When she reached SSGH her critical phase was over. From these incidents we can assume that many more such near miss cases may occur in remote rural areas than those who reach tertiary care centres. But either they would not be reported or may die by the time they would reach such tertiary care centres. Thus, it is necessary to evolve criteria by which such near miss events can be identified earlier at peripheral areas and be referred to higher centers without delay, but only after receiving primary treatment which is necessary for their survival. In the same case at 1st centre nursing staff wasted 12 hours for giving trial of labour. This passage of time with non-progression of labour resulted in rupture of uterus causing formation of retro peritoneal hematoma. As tertiary care centre was almost 130 kilometers away from 1st referral centre, passage of time during transportation may have led to occurrence of maternal death if she had not received treatment at 2nd referral centre.
CONCLUSIONS
Study of factors leading to near miss events which would be factors related to maternal mortality also should be undertaken routinely to identify preventable factors and actions for the same. Appropriate modifications to the WHO criteria, evolved and validated for local needs, are required as they underestimate near misses in India. These criteria can further be implemented by the peripheral health care system to enable early identification of such factors which may, in turn, help prevent some maternal deaths, because of more rapid reporting on maternal care events (because of the larger number of cases).
ETHICAL ISSUES
Before starting enrolment of the participants, necessary clearances and permissions were obtained from concerned authorities and Institutional Ethics committee for Human research (IECHR).
ACKNOWLEDGEMENT
We are highly obliged to all the study participants who enthusiastically participated in the study. We express our honest gratitude to all those who made this study possible including all doctors and hospital staff. We acknowledge immense help received from scholars whose articles are cited and included in references of this article. We are also grateful to authors / editors / publisher 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=825http://ijcrr.com/article_html.php?did=8251. Fátima Aparecida Lotufo, Mary Angela Parpinelli, Samira Maerrawi Haddad, Fernanda Garanhani Surita, Cecatti JG. Applying the new concept of maternal nearmiss in an intensive care unit. Clinics (Sao Paulo. 2012;67(3):6.
2. Wikipedia tfe. Maternal near miss. Available from: http://en.wikipedia.org/wiki/Maternal_near_m iss.
3. NRHM. Maternal death review. In: Department of Health and Family Welfare GoP, editor.JULY 2010.
4. Office of Registrar General I. A Presentation on Maternal Mortality Levels (2010-12). 20th December 2013.
5. Morse ML, Fonseca SC, Gottgtroy CL, Waldmann CS, E. G. Severe maternal morbidity and near misses in a regional reference hospital. Rev Bras Epidemiol. 2011;14(2):310-22.
6. Mantel GD, Buchmann E, Rees H, Pattinson RC. Severe acute maternal morbidity: a pilot study of a definition for a near-miss. BJOG: An International Journal of Obstetrics and Gynaecology. 1998;105(9):985-90.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241613EnglishN2014July12HealthcareCLINICAL STUDY OF MUTLAZIMA QABL HAIZ (PREMENSTRUAL SYNDROME) AND ITS MANAGEMENT WITH UNANI FORMULATION - A RANDOMIZED CONTROLLED TRIAL
English5157HafeezaEnglish Wasia NaveedEnglish Ismath ShameemEnglish K. TabassumEnglishBackground and Objectives: Mutlazima Qabl Haiz (Premenstrual Syndrome) is a group of menstruation related cyclical disorder manifested by emotional and physical symptoms in the second half of the menstrual cycle, which subsides after the beginning of menstruation. During the reproductive years, 80-90% of menstruating women experience symptoms like breast pain, bloating, acne, constipation, mood swings, irritability and depression that fore warns them of impending menstruation. The objective of the study was to evaluate the efficacy of Tukhme Sambhalu (Vitexagnuscastus) and Arq Pudina (Menthapiperita) in the management of Mutlazima Qabl Haiz. Methods: A single blind, randomized placebo controlled study was carried out in Gynaec OPD of the Institute?s Hospital, Bangalore. Patients were randomly allocated to test (n=30) and control (n=30) groups. Patients in the age group of 13-40 years with regular menstrual cycle were included in the study irrespective of marital status and parity. In test group, Tukhme Sambhalu1 gm and Arq Pudina 36 ml were administered orally twice daily, 10 days prior to menstruation in every cycle for 3 consecutive months. In control group placebo was given for the same duration. Severity of Premenstrual Syndrome was assessed by Premenstrual Tension Syndrome Scale and reduction in the Premenstrual Tension Syndrome Scale score was noted in each cycle. The data were analyzed using Analysis of variance - one way with Turkey Kramer Multiple pair comparison test and Premenstrual Tension Syndrome Scale scores of the two groups were compared by Chi Square test. Results: In test group, 70% patients were cured while 16.66% and 10% were relieved and partially relieved respectively, while 3.33% patients showed no response. In control group, the cured, relieved, and partially relieved patients were 23.33%, 23.33% and 20% respectively where as 33.33% patients showed no response. Significant reduction in the Premenstrual Tension Syndrome Scale scores was observed in test group than compared to control group (pEnglishPremenstrual Syndrome; Premenstrual Tension Syndrome Scale; Vitexagnuscastus; Menthapiperita.INTRODUCTION
Premenstrual Syndrome is the cyclic appearance of one or more of a large constellation of symptoms just prior to menstruation occurring to such a degree that life style or work is affected followed by a period of time entirely free of symptoms. 1 It is a functional disorder that affects the personal and emotional life of a woman irrespective of age, marital status and parity. The symptoms are variable that occur 7 10 days prior to menstruation, disrupts the life of a woman temporarily and subsides with the onset of menses to recur again in the next cycle. Approximately 40% of menstruating women experience luteal phase symptoms that are bothersome; for 25% these are annoying but do not impair functioning; for 10 15%, the symptoms are severe and report significant impairment of one or more areas of aily life. 2,3 Mutlazima Qabl Haiz is the term framed from the Arabic dictionary 4,5 in which syndrome is translated as „mutlazima’, pre stands for „qabl’ and menstrual is the word given for ‘haiz’. No such term was coined by ancient Unani Physicians but they had given a description on premenstrual features. The ancient physicians mentioned that, imtelayikaifiat exist in the premenstrual phase which leads to number of features. It is well studied that surge of akhlatmuharrika (hormones) are responsible for accumulation of body fluid in tissue spaces during premenstrual phase and this theory correlates with the concept given by IbnSina 6 and others. Premenstrual Syndrome may have an onset at any time during the reproductive years and once symptoms are established, they tend to remain fairly constant until menopause. It is a psychological and somatic disorder of unknown aetiology. The exact cause of PMS is not known, but it is thought to be related to changes in hormone levels related to the menstrual cycle 9. In 1931 Frank was credited with the first published description of the “Premenstrual Tension”. In 1953, Greene and Dalton called this conditionas “Premenstrual Syndrome” to allow the inclusion of both somatic and psychological complaints in the symptom complex 10 While there is no cure for PMS, the symptoms can be successfully managed with lifestyle changes, dietary modifications and supplements, hormone treatment and medications 11 . It has been reported that herbal medicine is useful in relieving the symptoms of PMS 12, 13. In addition clinical trials demonstrated that women taking chaste berry tree had significant improvements in irritability, depression, headaches, and breast tenderness. Theoretically, it may interact with hormones or drugs that affect the pituitary gland 14 . The main objective of the study was to evaluate the efficacy and safety of Tukhme Sambhalu and ArqPudina scientifically in the management of Mutlazima Qabl Haiz
MATERIALS AND METHODS
Study design: A placebo controlled randomized single blind study was undertaken in the Dept of Ilmul Qabalatwa Amraze Niswan, National Institute of Unani Medicine, Hospital, Bangalore. Study was completed within the duration of one and half year. Study was started after obtaining the ethical clearance from the Institutional Ethical Committee Participants: Patients were randomly allocated to test (n=30) and control (n=30) groups. Randomization was done by lottery method. Written informed consent was obtained from each participant before entering into the study. Selection criteria: Patients in the age group of 13 40 years with regular menstrual cycle were included in the study irrespective of marital status and parity. Exclusion criteria were pregnant and lactating women, irregular menstrual cycles, organic pelvic pathology, major psychiatric disorders, hormonalcontraceptives, medication for PMS in last 2 months and systemic diseasesetc. Procedure of the study: In each included patients, biochemical test such as LFT (SGOT, SGPT, Alkaline phosphatase) and RFT (Blood Urea, Sr. Creatinine) were carried out along with specific investigations like Serum Progesterone and Serum Prolactin to evaluate the safety and efficacy of the research drug apart from routine investigations. Diagnostic criteria: Premenstrual Syndrome can be diagnosed if the patient reports at least one of the following psychological and somatic symptoms during the first five days before menses in each of the three prior menstrual cycles: Psychological symptoms like Depression, Angry outbursts, Irritability, Anxiety, Confusion, Social withdrawal etc Somatic symptoms like Breasttenderness, Abdominal bloating, Headache, Swelling of extremities etc These symptoms are relieved within 4 days of the onset of menses without recurrence until at least day 13 of cycle. The symptoms are present in the absence of any pharmacologic therapy, hormone ingestion, drug or alcohol use. The symptoms occur reproducibly during two cycles of prospective recording. The patient suffers from identifiable dysfunction in social or economic performance.
INTERVENTION
Test Group: Research drug comprised of Tukhme Sambhalu VitexAgnusCastus 15 and Arq Pudina (Menthapiperita 15which possesses antispasmodic, analgesic and diuretic properties. Preparation, Administration & Dosage The seeds of Tukhm Sambhaluwere cleaned, finely powdered, sieved and filled in 500 mg capsules & administered orally in a dose of two capsules per day. Arq Pudina was purchased from the market (prepared as per the formula of Bayazekabir 13 ) and administered orally in a dose of 36mltwice daily. Control Group:Wheat flour was filled in same colourcapsules as that of research drug and given with plain water containing few drops of ArqBadiyan for change of flavour as placebo. Duration of treatment:In both the groups, drugs were given 10days prior to menstruation for 3 consecutive cycles. Assessment cum follow up: Patients were followed for three consecutive cycles during treatment and one cycle after treatment. During this period, improvement in PMTS score was assessed. Patients were also enquired for any adverse effect of drug during the trial. Repeat LFT, RFT, Serum Progesterone and Serum Prolactin was carried out after completion of treatment to evaluate the effect of drug. Parameters for Evaluation of Efficacy of Research Drug Subjective Parameters Breast tenderness, muscle cramps, nausea, anorexia, abdominal bloating, headache, depression, irritability, loss of concentration, sleep disturbances, altered libido, peripheral oedema etc. Objective Parameters: Premenstrual Tension Syndrome Scale (PMTS) 16, 17, 18 Serum Progesterone and Serum Prolactin PMTS scoring: The scale ranges from 0 to 36. “0” is given for no features and “36” are given for full features of the Syndrome. For statistical purpose, the scale was divided into 5 categories as follows: Severity of PMS o Normal (0 7) o Trivial (8 14) o Mild (15 21) o Moderate (22 28) o Severe (>28) Serum Progesterone and Serum Prolactin: The pre and post treatment basal levels of Sr. Progesterone and Sr. Prolactin were measured on nd day of menstrual cycle preferably in fasting condition. Sr. Progesterone: 0.20 1.50ng/ml 19 Sr. Prolactin: 2 29 ng/mL 20 Analysis of result: Results were analyzed on the basis of 4 categories:
Cured: When symptoms abolished completely and severity of PMTS score reduced to normal. Relieved: When PMTS score reduced from severe to mild. Partially relieved: When PMTS score reduced from severe to moderate or moderate to mild. No response: when PMTS score remains in the same category during the trial. Statistical Analysis: Effect of research drug on Serum Progesterone and Serum Prolactin was assessed by ANOVA one way with Dunn?s Multiple Comparison test. Effect of research drug on PMTS scoring was assessed by ANOVA one way with Turkey Kramer Multiple Comparison Test. Over all response of the research drug was assessed by χ² (chi square) test.
RESULTS AND DISCUSSION
A placebo controlled randomized single blind study was carried out in the Dept. of IlmulQabalatWaAmrazeNiswan, NIUM, Hospital, Bangalore. The study was managed by Tukhme Sambhalu and Arq Pudina and its effect was assessed by using Premenstrual Tension Syndrome Scale (PMTS). In this studypatients between the age group of 13 40 years were included and the highest incidence of PMS was observed in the age group Englishhttp://ijcrr.com/abstract.php?article_id=826http://ijcrr.com/article_html.php?did=8261. Chanana C, Rehman SM. Premenstrual syndrome. Obs Gynae Today 2006; 9 (8): 452 4.
2. Johnson SR. Premenstrual Syndrome, Premenstrual Dysphoric Disorder and Beyond: A Clinical Primer for Practitioners. ObstetGynaecol 2004; 104 (4):845 59.
3. Sternfeld B, Swindle R, Chawla A, Long S, Kennedy S. Severity of Premenstrual Symptoms in a Health Maintenance Organization Population. ObstetGynaecol 2002;99:1014 24.
4. www.languagesource.com/acatolog/Arabic_Tr anslation_Software_Arabic_Al_Wafi.html. cited on27.11.06
5. Anonymous. The Unified Medical Dictionary. Eng Ara Fren.3 rd ed. Switzerland: Council of Arab ministers of health; 1983:642.
6. IbnSina. Al QanoonFilTib. Vol II. (Urdu Translation by Kantori GH). New Delhi: IdaraeKitabusShifa; 1981: 331.
7. Kapur A. Use of Evening Primrose Oil in Premenstrual Syndrome. ObstetGynaecol 2001; 6 (11):690 695.
8. Kessel B. Premenstrual Syndrome: Advances in Diagnosis and Treatment. ObstetGynaecol of North America 2000;27(3): 625 639.
9. http://www.webmd.Com/women/pharmacist 11/herbal treatments for pms. Cited on06/12/2013.
10. Copeland LJ, Jarrell JF, McGregor JA. Textbook of Gynaecology. Philadelphia: WB Saunders Company; 1993: 403 413.
11. http://www.betterhealth.vic.gov.au/bhcv2/bhc articles.nsf/pages/premenstrual_syndrome. Cited on 04.12.2013.
12. Zulkifle MD. Physiochemical Basis of Temperament. Thesis submitted to the Department of Kulliyat, AKTC, U. P: Aligarh, AMU; 1993.
13. Kabeeruddin. BayazeKabir. VolII. Hyderabad:Hikmat Book Depot;1921:96.
14. http://altmedicine.about.com/cs/womenshealth /a/PMS.htm. Cited on 07.12.2013.
15. Kabeeruddin M. MaghzanulMufradat. New Delhi: Aejaz Publication; YNM: 170, 171, 358, 359.
16. Critchlow DG, Bond AJ, Wingrove J. Mood Disorder: History and Personality Assessment in Premenstrual Dysphoric Disorder. J clinPsychiatry 2001; 66(9): 688 93.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241613EnglishN2014July12HealthcareSTUDY OF VISUAL OUTCOME AND POSTOPERATIVE COMPLICATIONS IN SCLERAL FIXATED POSTERIOR CHAMBER INTRAOCULAR LENS IMPLANTATION
English5863Sangeetha T.English Narendra P. DattiEnglishPurpose: To assess the visual outcome and complications in patients after scleral fixated posterior chamber intraocular lens implantation. Materials and methods: This hospital based prospective study was conducted at R.L. Jalappa Hospital and Research Centre, Tamaka, Kolarbetween November 2011 and May 2013. Study included 50 patients fulfilling inclusion criteria. All cases were worked up according to the protocol.Andall patients underwent mandatory anterior vitrectomy followed by Ab –externo scleral fixated posterior chamber intraocular lens implantation.10-0 Proline sutures were used for transscleral fixation of lens haptics. Patients were followed up at 1st day, 1st week, 1st month, 3rd month and 6th month. Postoperative evaluation included best corrected visual acuity, Slit lamp Biomicroscopy and Indirect ophthalmoscopic evaluation and Biomicroscopic assessment of macula. Results: Best corrected visual acuity improved in 28 (56%) patients in the range 6/6-6/12 while 18(36%) patients in the range 6/18-6/36. The most common complication observed were striaekeratopathy, iritis and secondary glaucoma; which subsided by two weeks with postoperative medications. Conclusion: Ab–Externo scleral fixated posterior chamber intraocular lens was found to have stable implantation and a true posterior chamber location in eyes having no capsular or zonular support with a low intra and post-operative risk profile. This technique also showed favourable postoperative visual outcome in aphakic eyes.
EnglishAphakia, absence of capsule support, intraocular lens, AC-IOL,PC-IOL, Iris fixation, sclera fixation, secondary intraocular lensimplantation.INTRODUCTION
Cataract surgery has become the most commonly performed intraocular procedure worldwide, with constantly improving outcomes. Planned extracapsular cataract extraction (ECCE) with posterior chamber intraocular lens (PC-IOL) implantation became more widespread1 and is the “Gold Standard” procedure for managing cataracts. Refinements in surgical techniqueshave givenway to newer techniqueslike manual small incision cataract surgery and phacoemulsification with, inthe-bagPC-IOL implantation which have become the procedure of choice in the management of cataracts.The essential pre-requisite for PCIOLimplantationis the presence of adequate capsulozonular support and ideally the IOL is placed in the capsular bag, which affords stable fixation at a position closest to the nodal point of the eye. However, in the absence of this support it becomes a great challenge for a surgeon, who is faced with manydecisions including when to implant the intraocular lens and which type of intraocular lens should be implanted leaving the patient aphakic. Secondary IOL implantation provides favorable visual outcome offering superior visual rehabilitation in comparison to aphakic spectacles or contact lens, as these lenses have many advantages over both of these techniques.They permit a betterelimination of perceptual problemsand reduceimage size disparity. Hence secondary implantation of intraocular lenses has become the standard procedure in the aphakic eyes. Placing an anterior chamber intraocular lens in aphakics have been discouraged as it carries a high risk of postoperative complications like corneal endothelial damage, pupillary block glaucoma, hyphema, uveitis and cystoid macular edema. Another method where the intraocular lens was sutured to the iris resulted in iris chafing, uveitis and pupillary constriction2 . To avoid these complications and still achieve a posteriorly placed lens position, scleral fixation of posterior chamber intraocular lens to the ciliary sulcus which lies about 1.0mm posterior to limbus3,4, are commonly used which have good visual outcome and less complications.
MATERIALS AND METHODS
A two year prospective study was carried out between November 2011 and May 2013 on 50 aphakic patientsfulfilling the selection criteria after informed consent. All patients were analyzed for visual outcome and intra operative and postoperative complications of Scleral fixated posterior chamber intraocular lens implantation in aphakic eyes using the Modified four point AbExterno scleral fixation technique. Patients with Corneal pathology (degenerations and dystrophies), pathology of retina, macula and optic nerve, chronic uveitis, traumatic cataracts andbleeding disorders were excluded from this study. The patients were divided into following groups according to the nature of procedure required: 1. Primary scleral fixation of IOL. (Patients who had capsular rupture during cataract surgery.Eg: Hyper mature cataracts, pseudoexfoliation, subluxated/dislocated lens) 2. Secondary scleral fixation of IOL. (Patients wanting secondary implantation in aphakic eyes) A complete ocular examination was carried out which included theBest corrected visual acuity with aphakic correction, slit lamp biomicroscopic examination for corneal clarity (endothelial status), presence of synechiae, phacodonesis or frank subluxation / dislocation of lens, pseudoexfoliation in pupillary margins. Dilated evaluation of fundus periphery and biomicroscopic evaluation of macula was done with a+90 D lens, Gonioscopy with Goldmann three mirror for any evidence of PAS, recession or neovascularisation, Applanation tonometry, Keratometery, A-scan and IOL power calculation was done by SRK –2 formula. All patients were given systemic antibiotics (Tab Ciprofloxacin 500mg). On the day of surgery pupils were dilated adequately with 0.8% tropicamideand 5% or 10% phenylephrineeye drops every 10 minutes along with Flurbiprofen eye drops, one hour before surgery. Informed consent was taken and all patients underwent mandatory anterior vitrectomy followed by Ab –externo four point scleral fixated PC-IOL implantation under peribulbar anaesthesia by all operating surgeons. Postoperatively all patients recieved a course of topical antibiotic and steroid eye drops hourly followed by a tapering dose for 6 weeks along with Flurbiprofen eye drops 0.03% TID for 4 weeks. Systemic antibiotics Tab Ciprofloxacin 500 mg was given for 5 days postoperatively. Postoperatively the patient was evaluated on 1st day, 1stweek, 1st, 3rdand 6th month. The total duration of followup was 6 months. At each postoperative visit, the patients were subjected to the following examinations:
1. Best corrected visual acuity for distant and near. 2. Slit lamp evaluation. 3. Indirect ophthalmoscopic evaluation and biomicroscopic assessment of macula was performed. A careful noteof IOL stability and centration, suture relatedcomplications, postoperative reaction and cystoidmacular oedema were made and the compiled pre andpostoperative data analysed. The results were comparedwith previously published studies.
RESULTS
The study included 2(4%) patients in age group Englishhttp://ijcrr.com/abstract.php?article_id=827http://ijcrr.com/article_html.php?did=8271. Apple D.J, Mamalis N, Loftfield K.et al. Complications of intraocular lenses. A historical and histopathological review. SurvOphthalmol, 1984; 29:1–54.
2. Evereklioglu C, H, Bekir NA,BorazanM,Zorlu F.Comparison of secondary implantation of flexible open loop anterior chamber and scleral fixated posterior chamber intraocular lenses. J Cataract Refract Surg. 2003; 29 (2):301-8.
3. Duffey R J, Holland, Agapitos P J, Lindstrom R L. Anatomic study of transcleral sutured intraocular lens implantation. Am J Opthalmol.1989; 108:300-9
4. Bergren R L. Four point fixation technique for suturing posterior chamber intraocular lens. Arch Ophthalmol.1994;12:1485-7
5. Bleckmann H, Kaczmarek U. Functional results of posterior chamber intraocular lens implantation with scleral fixation. J Cataract Refract surg. 1994;20:321-6
6. Rahman A, Bhutto I A, Bukhari S, Hassan M, NasirBhatti M. Visual outcome and complications in Ab-externo sclera fixation intraocular lens in aphakia. Pak J Ophthalmol 2011;(27):73-7
7. Zia UM, Wasif MK. Classification and Evaluation of Secondary Posterior Chamber IOL Implantation Scleral Fixation of IOL. Pak J Ophthalmol 2010, 26 (3): 148-153.
8. Chandrakanth K.S, Nirupama B. The functional results of posterior chamber intraocular lens with scleral-fixation: A one-year follow up analysis. 2007;19(4):386-90
9. Azizur R, Israr AB, Sadia B, Mazharul H et al. Visual outcome and complications in AbExterno Scleral Fixation IOL in Aphakia. Pak J Ophthalmol 2011; 27: 73-77.
10. Kanigowska K, Gralek M, Karczmarewicz B. [Transsclerally fixated intraocular artificial lenses in children-analysis of long-term postoperative complications]. KlinOczna.2007; 109:283-6.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241613EnglishN2014July12HealthcareHYPERTRIGLYCERIDEMIA IN CHRONIC KIDNEY DISEASE - A CLINICALLY RELEVANT STUDY
English6469Sanjay H. KalbandeEnglish Takkallapalli AnithaEnglishBackground: Cardiovascular disease is the major cause of mortality and morbidity in patients with chronic kidney disease [CKD] Hypertriglyceridemia may contribute to the progression of atherosclerosis and it is considered to be an independent risk factor for patients of chronic kidney disease. Aim: To study the effects of hypertriglyceridemia, especially in males and females suffering from chronic kidney disease, to comparative evaluation of serum triglyceride levels in patients of chronic kidney disease undergoing hamodialysis and patients on conservative therapy. Methodology: Our study included 100 patients of chronic kidney disease, of which 66 were males and 34 were females. Results: On decade wise grouping, we found maximum number of patients of chronic kidney disease between 51-60 years (42.8%) followed by 61-70 years (40%). The most common cause of chronic kidney disease was found to be type II diabetes mellitus (38%), followed by hypertension (32%) and hypertension 18%. The mean triglyceride levels in both males and females were less than 150 mg/dl in 40% of patients followed by borderline high in 32% and very high in 28% of chronic kidney disease patients. The mean serum triglycerides in patients on conservative therapy was 151.2±35.31 and in patients undergoing haemodialysis, the mean serum triglycerides was 205.8 ± 69.72. Conclusion: Our study shows that patients of chronic kidney disease have elevated serum triglycerides, in patients on Haemodialysis there is hypertriglyceridemia which could contribute to atherosclerosis and cardiovascular disease.
EnglishChronic kidney disease [CKD], Maintenance haemodialysis, [MHD] Serum triglycerides.INTRODUCTION
Chronic renal failure is the permanent and significant reduction in glomerular filtration rate, or chronic irreversible destruction of kidney tissue [1]. Cardiovascular disease is the leading cause of death in chronic kidney disease patients. Both traditional and non-traditional factors play a role in increased cardiovascular mortality. Among traditional risk factors, diabetes, hypertension and dyslipidemia are the leading causes. Anemia, inflammation, oxidative stress, disorders of calcium and phosphorus metabolism, arterial stiffness and malnutrition can be stated as nontraditional risk factors [2]. Chronic renal failure is often associated with dyslipoproteinemia, high levels of cholesterol and triglycerides, as well as decrease in the polyunsaturated fatty acids. Each of these abnormalities has been identified as an independent risk factor for atherosclerosis [3]. Hypertriglyceridemia is a common phenomenon in chronic renal failure and is associated with endothelial dysfunction. Plasma triglycerides, but not cholesterol, is increased in most patients with advanced renal failure. A high triglyceride concentration predicts coronary heart disease independently from other known factors [4]. Cardiovascular disease begins in the early stages of renal disease. Therefore it is imperative to screen all patients of chronic kidney disease for dyslipidemias and treat them intensively before they develop End stage renal disease.
MATERIALS AND METHODS
The present study was conducted in patients admitted to the department of nephrology, at the chalmeda Anand Rao Institute of Medical Sciences, Bommakal, Karimnagar during the period of 2012-2013. Inclusion Criteria:-Patients of chronic kidney disease, who have previous normal lipid profile. Diagnostic Criteria of chronic kidney disease: 1) Clinical sings and symptoms of Uremia 2) Patients with serum creatinine >1.5 mg/dl 3) Bilateral shrunken kidney / loss of cortico medullary differentiation on ultrasonography of abdomen. Exclusion Criteria:-patients of dyslipidemia due to other causes like hypothyroidism, ethanol, liver disease, known dyslipidemic diabetic patients, HIV patients, patients with genetic disorders were excluded from the study.
METHOD
Informed consent was obtained from all the 100 patients including 66 males and 34 females. All selected patients were subjected to detailed history and complete physical examination. The data collected was noted serially in a predesigned proforma. After 12 hours of fasting, blood samples of patients on conservative therapy as well as patients undergoing haemodialysis were collected and sent for serum triglyceride analysis.
OBSERVATIONS
The following criteria have been taken into consideration for interpretation of the results.
1) Age and sex of chronic kidney disease patients
2) Aetiology of chronic kidney disease
3) Evaluation of serum triglycerides in males and females
4) Treatment modalities of chronic kidney disease patients and estimation of their serum triglycerides.
RESULTS
In our study, 100 patients of chronic kidney disease were included of which 66 were males and 34 were females. On decade wise grouping we found maximum number of patients between 51- 60 years (42%) followed by 61-70 years (20%). The mean age of total number of patients was 51.26. The mean age for male patients was 49.60±16.43 and the mean age for female patients was 4.47±10.26 (table no.1). The most common cause of chronic kidney disease was found to be type II DM [38%] followed by hypertension [32%] (table no.2). The mean triglyceride levels in both males and females were less than 150mg/dl in 40% patients, followed by borderline high in 32% and very high in 28% of chronic kidney disease patients. Mean total triglyceride level was found to be 175.9±57.73. In males it is 170.2±47.85 and females it is 188.35±73.40 (table no.3) The mean serum triglyceride levels in patients undergoing haemodialysis was found to be higher i.e 205.8±69.72 than the patients on conservative therapy i.e 151.2±35.31
DISCUSSION
Patients with chronic kidney disease are at an increased risk of cardiovascular (CVD) disease and have higher prevalence of hyperlipidemia than the general population [5]. The risk of cardiovascular disease varies on the type of lipid abnormalities, the target population, the cause of renal disease and the degree of reduction on glomerular filtration rate [6]. The present study was conducted in 100 chronic kidney disease patients. The mean age of male patients was 49.60 and for females patients was 54.47 years. The overall male to female ratio was 1.94:1. Feast YG et. al. and smith SR [7] analysed age, sex and racial difference, and the incidence of renal disease in american population and found lowest incidence in children(10 years) and highest in the elderly (>40 years). In our study, the maximum numbers of patients is between 51-60 years and males are more commonly affected than females (table no.1). Wing Aj [8] studied causes of chronic kidney disease in different parts of the world and found that geographical variation occurs in different parts of the world. According to United States Renal Data System 1999, the most common cause of chronic kidney disease is Diabetes mellitus (33.2%), followed by hypertension (24%). In the present study, the leading cause of chronic kidney disease was diabetes mellitus (38%) followed by hypertension (32%) [table no.2]. Moreover, the concentration of triglycerides rises with increasing albumin excretion rate in parients with type 1 diabetes. In addition, there is increase in Low Density Lipoprotein mass and atherogenic small dense Low Density Lipoprotein particles, which correlates with the plasma triglyceride concentrations [9]. In the patients of diabetes and hypertension with chronic kidney disease, micro albuminuria is predictive of future proteinuria, progressive decline in renal function, accelerated atherosclerosis and increased cardiovascular mortality [10]. The hypertriglyceridemia is the most common plasma lipid abnormality in patients with renal failure and it is considered as an important risk factor for atherosclerotic vascular disease [11]. Shah et. al. [12] showed that significant hypertriglyceridemia does develop in a majority of chronic kidney disease patients. Anderson et. al. [13] suggested that when lipoprotein pattern in chronic kidney disease was analysed, hypertriglyceridemia was found in 43% of patients. In the present study 60% of patients presented with elevated serum triglycerides [table no.3]. Progressive renal failure, especially that associated with proteinuria, is accompanied by abnormalities of lipoprotein transport. Typically, the dyslipidemia is reflected predominantly in increased serum levels of triglycerides with high levels of very low density lipoprotein, apo B and pre-B high density lipoprotein, and low levels of high density lipoprotein and of apo A [14]. Impaired clearance of chylomicrons and very low density lipoprotein has emerged as the dominant factor for the increased serum triglyceride concentration. Lipoprotein lipase (LPL) is the rate limiting step in lipolysis of chylomicrons and very low density lipoprotein. Lipoprotein lipase binds to heparin sulfate proteoglycans on the cell surface of endothelium. In proteinuric renal diseases a down regulation of Lipoprotein lipase protein abundance and enzymatic activity was found [14]. Experimental data support the notion that triglyceride rich lipoproteins of lower densities are atherogenic and thrombogenic due to abnormal receptor mediated interactions with fibroblasts, macrophages and endothelial cells. It also has been suggested that the increased levels of Lipoprotein (a) in chronic kidney disease patients could represent a risk factor for atherogenesis in these patients. In their study, Cressman et. al. [15] have provided evidence that in haemodialysis patients, elevated Lipoprotein (a) is an independent risk factor for clinical events attributed to coronary artery disease. In our study, the serum triglycerides were found to be significantly higher in Haemodialysis patients as compared to the patients on conservative therapy. Similar hypertriglyceridemia was also observed in several other studies including the CHOICE study [12, 16] Furthermore, Hahn et al [17] have found that dialyzed patients with cardiovascular disease have a 50% increase in the triglyceride levels in comparison with unaffected individuals on dialysis. The recent K/DOQ guidelines on the management of dyslipidaemias suggest the following: 1) For those chronic kidney disease patients with triglycerides ≥200mg/dl and non-high density lipoprotein cholesterol ≥ 130mg/dl, the aim is to achieve non- high density lipoprotein cholesterol < 130 mg/dl. Initial treatment comprises lifestyle changes plus a low-dose statin which is increased as required [18]. 2) In patients with high fasting triglycerides ≥500mg-dl, the initial goal of treatment is to prevent acute pancreatitis. The target is to achieve triglyceride level < 500mg/dl and suggested treatment is with therapeutic lifestyle changes which includes diet, weight reduction, increased physical activity and abstinence from alcohol followed by a fibrate or niacin [18].
CONCLUSION
Patients of dyslipidemias will require lifestyle modification and lipid lowering therapy. All patients with hypertriglyceridemia considered as high risk should be screened and treated accordingly.
ACKNOWLEDGMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to author / 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=828http://ijcrr.com/article_html.php?did=8281. Dewardener, H.E, An outline of normal and abnormal function. In: The kidney 4th edition. Churchill Livingstone New York 1986;181- 235
2. Munter P, He J, Astor BC, Folsom AR, Coresh J. Traditional and non-traditional risk factors predict coronary heart disease:results from atherosclerosis risk in communities study J.Am. soc Nephrol.2005;16[2]:529-38
3. Assman G, Schulte H, Relation of high density lipoprotein cholesterol and triglycerides to incidence of atherosclerotic coronary artery disease (the PROCAM experience). Prospective cardiovascular Munster study. Am J cardio. 1992;70:733-737
4. Castelli;wp. The triglyceride issue: a view from fremingh am, Am Heart J 1986:112:432- 7.
5. Kasiske BL. Hyperlipidemia in patients with chronic renal disease. Am J kidney Dis. 1998;32:S142-S156
6. Weiner DE, Tighiouart H. stark PC, Amin MG, Macleod B, Griffith JL et al. kidney disease as a risk factor for recurrent cardiovascular disease and mortality Am J kidney Dis 2004; 44:198-206.
7. Feast TG and smith SR: Incidence of advance CRF and need for end stage renal replacement. BMJ / 1990;301,897-900
8. Wing AJ: Courses on end stage renal failure Oxford textbook of clinical nephrology. Oxford university press:1227-36:1992
9. Marrie M, Bouhanick B, Berrut G: Micro albuminuria. Curr opin nephrol Hypertens 3; 558-563, 1994
10. Hillege HL, Fidler V, Diercks GF, Van Gilst WH, dezeecw D, van veldhuisen DJ, Gans RO, Janssen WH, Grobbee DE, de Jong PE: Urinary albumin excretion predicts cardiovascular and non cardiovascular mortality in general population. Circulation, 2002; 106: 1777-1782
11. Green D, stone NJ, Krumlowsky A. Putative atherogenic factors in patients with chronic renal failure. Prog cardiovascular Dis. 1983; 26: 133-144 [pub Med]
12. Shah B, Nair S, Sirsat RA, Ashavaid TF, Nair KG, Dyslipidemia in patients with chronic renal failure and in renal transplant patients. J. Post grad Med. 1994;40[2];57-60
13. Anderson AJ : Lipoprotein pattern in chronic renal failure (moyo CLIN proc.1976 oct; 51910); 660-4)
14. Vaziri ND: Molecular mechanisms of lipid disorders in nephrotic syndrome. Kidney Int 63; 1964-1976, 2003
15. Cress man MD, Heyka RJ, Paganini EP, et al Lipoproterin(a) is an independent risk factor for cardio vascular disease in haemodialysis patients. Circulation 1992; 475-82
16. Longenecker JC, coresh J, Powe NR. Traditional cardiovascular disease risk factor on dialysis patients compared with the general population: The CHOICE study.J Am SOC Nephrol 2002; 13(1); 1918-27
17. Hahn R, Oette K, Mondorf H, Finke K, Sieberth HG. Analysis of cardiovascular risk factor in chronic haemodialysis patients with special attention to hyper lipoproteinemias. Atherosclerosis 1983;48: 279-88
18. K/DOQI clinical practice guidelines for management of dyslipidemias in patients with kidney disease. AM J kidney Dis2003;41(4 SUPPL):I-IV,S1-S91.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241613EnglishN2014July12TechnologyA SIMPLIFIED METHOD OF FAST TRACKING FMECA USING SMART SOFTWARE TOOL: A CASE STUDY
English7077Ahmed Tijjani DahiruEnglishMany approaches were modelled to achieve quality and reliability of manufactured goods and delivered services. Reliability Centred Maintenance RCM, Ishikawa Diagrams, Event Tree Analysis ETA, Fault Tree Analysis FTA, Failure Mode Effects and Criticality Analysis FMECA were few examples of risk mitigation and reliability enhancements. In this study FMECA as an appropriate tool for reliability modelling is justified based on prescriptions of modified Mil-Std-1629A enhanced by the opportunities of the newer standards such as BS-5760-5, IEC-60812, and SAE AIR-4845-93. This analysis use the electrical distribution network of Mallam Aminu Kano International Airport Nigeria as a case study, where the system is sub-divided into three major subsystems as 33kv substation, main control and standby units. The FMECA is performed at indenture level 3 where basic components and parts such as circuit breakers, transformers, generators, armoured cables, switch gears etc are located and failure modes being identified and analysed. For faster and easier implementation, software called ELECTRACE was developed and used for implementation as a result of the high prices at which commercial FMECA software are obtained. The developed ELECTRACE was used to implement FMECA by drawing out clear worksheets and plotting criticality matrix where failure modes are easily spotted and identified based on criticality rankings derived from classes of severity and frequencies of occurrence. Large number of failure modes in the case study was found to have concentrated within acceptable positions of low criticality ranks, with few falling within unacceptable positions of high criticality ranks. However, mitigating the few high criticality ranking failure modes exposes the lower criticality ranking failures as disturbing partly because of their high concentration. The developed ELECTRACE was very useful and effective in this analysis and is flexible enough to be applied for FMECA implementation in any electrical, electronic or mechanical systems operating in other sections of the airport such as navigational aids, airspace management, airways handling, meteorology, service stations and beyond.
EnglishReliability, FMECA, Electricity Distribution, Software, worksheets, criticality matrixINTRODUCTION
Failure Mode Effects and Criticality Analysis (FMECA) has been a traditional and very popular method of risk assessments been developed and deployed in operations of various industries such as defence, automotive, space missions, manufacturing, processes etc. for achieving reliability and operational costs reduction. The effectiveness of FMECA was probably the reason behind its adoption and implementation for decades. Part of its successes was the standards, Mil-Std-1629, BS-5460-5, SAE AIR-4845-93, IEC-60812 etc. prepared to guide through its implementations. Evolutions in technology that gives rise to a more complex systems was a serious challenge to FMECA implementation which necessitated the developments and use of different tools for tracking up with those periodic changes. Although other risk assessment and reduction techniques exist, Fish Bone (Ishikawa) Diagram, Fault Tree Analysis (FTA), Reliability Centred Maintenance (RCM) etc. FMECA remains relevant for its simplicity and comprehension. The long time it takes FMECA to be used as an effective tool for risk mitigation, however were met with series of challenges among which are the laborious and the bulk of paper work involved, which call for many hands and time to prepare. This trend may not be acceptable to rapid changes experienced within the technology world. Introduction of software in the wake of ICT revolutions to facilitate FMECAs was a welcomed development. It was seen widely to address issues of labour involved and provide means of quicker implementation. There was a number of software commercially available, XFMEA, FAULTREE, FAILMODE, QUICKMODE. In general terms, the software eases and speeds up the FMECA processes. This is justified mostly in large systems that are critical to the economy and safety of lives, such as the electrical power systems as an airport facility.
THE CASE STUDY
A FMECA was carried out on electrical distribution network of Mallam Aminu Kano International Airport (MAKIA), Nigeria’s Electrical Distribution Network [1]. The purpose was to highlight the frequency and severity implications of failures occurring in such a strategic section of the airport, looking at social, economic, security benefits derived. The large electrical distribution network’s data of the entire system when collected was classified into systems, sub-systems and modules to ensure the bottom-up approach of the systems’ analysis as illustrated in the hierarchical diagram shown in Fig. 1. The system’s hierarchical diagram is categorised vertically according to the functional sub-units and the components or parts, and horizontally according to the indenture levels 1, 2 and 3. With this every part or component can be easily reached, recorded and analysed. It is usual to find parts and components making up the distribution network to comprise of simple and complex, delicate and robust, cheap and expensive etc. such as single and multi-core cables, 5kVA and 1000kVA standby systems, fuses and circuit breakers, ring main units (RMUs) and cable lugs and contacts etc. Among the challenges one may experience during data collection is the large number of components and parts, the accessibility, as some equipments are live all the time and some are found hanging overheads and others buried underground.
The Cost Implications of Commercial Software
The traditional FMECA is known to be carried out involving a lot of paper work. The use of software facilitated FMECA in recent times reduced the need for the paper prints. Thus, the collected data, the Failure Mode and Effect Analysis (FMEA) worksheets which always precede the FMECA [2] and the criticality matrix can be recorded, analysed, processed, presented and stored without need for prints. Shopping for the appropriate software for analysis of the mined data could somehow not be an easy task as the prices of the items were found to be high even at promotional rates, a summary shown in Table 1. The reviewed prices of the software could be attributed to the number of applications they contain, which for FMECA sake could be a waste and add to the complications of the software packages. Imagine a large team being expected to carry out a work in this case study in a more comprehensive manner, for example a 1000kVA standby to be taken as unit to be decomposed for FMECA. The cost of the software to be used will definitely be much higher. Since FMECA has been traditionally simple, the trend should be maintained using software or any other tools.
Development of ELECTRACE as Alternative
Objectives at this juncture should be directed at provision of simplified or smart software tool as an alternative to the high cost and complicated commercial software for purpose of carrying out FMECA with a speed and less stress at a reduced cost. The efforts here are to address costs and many other applications contributed complications of commercially available software. Two approaches were therefore explored for achieving this aim.
Modifications of existing software to suit the present needs.
Generate codes for developing the target software.
The first approach was proved to be most suitable for this purpose and Microsoft Office was used. The choice of Microsoft Office is influenced by its popularity, availability and low cost, which can be obtained as low as £79. Thus, Microsoft was adopted and deployed in the following manner.
The FMEA worksheets were produced by modifications and manipulations of Microsoft Excel platform.
The criticality matrix was produced by adding labels on XY scatter chart on Microsoft virtual basic
Since the software tool developed for this work is for tracing of failure modes in electrical systems, it is branded as ELECTRACE, having the unique features as follows;
Easy access to the data stored.
Easy trace of the information such as items’ description, failure modes, failure effect(s), frequency and severity values etc.
Auto-sum or Auto-product of the data values.
Direct reflection of changes on the criticality matrix when implemented on the FMEA worksheets.
Comprehensive nature of the FMEA worksheets.
Clear dashboard presentation of failure modes on criticality matrix based on failure modes’ criticality ranking
The Implementation of FMECA using ELECTRACE
The FMECA implementation can be simplified successfully using ELECTRACE. The worksheets and criticality matrix where predetermined for ELECTRACE to present results for analysis. The worksheets contain entries such as codes for identification of modules and analysis,
descriptions of the modules, function of the modules and their failure modes. The worksheets also contain local and system failure effects, the failure detection method and severity class of the failure modes. Loss frequency was derived from the products of base failure rates λb, environmental stress factors α, and duty stress factors were obtained from the US Army TM-5-698-5 [3] and Moss [2] respectively. The entries were based on modified Mil-Std-1629A standard [4]. The modifications of the Mil-Std-1629A were due to short comings of the Mil-Std-1629A for factors such as aging, which is addressed by newer standards such as BS-5760-5, IEC-60812, SAEAIR-4845-93 etc. [5] The criticality matrix is produced by ELECTRACE as a 4×4 matrix, upon which criticality ranking of all the failure modes are determined. With criticality matrix as a tool, failure modes are exposed based on criticality rankings, which may be used as a prompt for action towards mitigation. The criticality rankings in this regard are classified based on the frequency of occurrence from the data earlier obtained from case study and severity of occurrence according to the products of contributing factors’ indices. The classification of the criticality ranking thus goes as follows [1]; ? Widely Acceptable (WA): A band within which risks are tolerated and conveniently operated with. Risks within this band continue to exist because there cannot be 100% elimination of risks whatsoever. ? Fairly Acceptable (FA): The failure modes falling within this band are allowed without mitigation temporarily for period of time pending when opportunity comes up for the periodic and/or scheduled activities. It is important to note that ignoring failure modes within this criticality band for longer time may cause the failure modes to migrate to a band of higher criticality ranking. ? Fairly Unacceptable (FU): These ranks of failure modes cannot be accepted and calls for immediate action towards mitigation. This may however only affect part(s) involved, module or subsystem. Consequences could be losses due to downtime and minor injuries. ? Widely Unacceptable (WU): An emergency action need to be taken as failures within this band can cause loss to life, permanent injuries, colossal damages or loss of investments. This indicates zero tolerance to failure modes appearing on this band of ELECTRACE’s criticality matrix.
It is worthy of note that the software tool is easy to be used for implementation because its features are simple, clear and inexpensive. The four criticality bands also are easily interpreted and mastered. The implementation of FMECA for the case study using ELECTRACE was done with ease and speed as expected. It is usual to have the analysis in FMEA worksheets before the emergence of criticality matrix. The worksheets presented by ELECTRACE were comprehensive and changes can be implemented with high flexibility. The criticality matrix presents all the failure modes analysed by the worksheets, prioritising those with higher severities and frequencies of occurrence (fig. 3). The matrix at this stage can hence be used by design or maintenance engineers to take action towards mitigation against disturbing failure modes and continue to retain those with lower ranks. In events where higher ranked failure modes are mitigated, those with lower ranks are exposed more and remain the decision of the project team (design or maintenance).
THE ELECTRACE’S FMECA RESULTS AND ANALYSIS
From the ELECTRACE’s criticality matrix, larger number of failure modes concentrates within WA bands of the three units (33kv substation, main control and standby units) of the distribution networks. The FA bands also contains fairly large number of failure modes, but the most interesting side of the analysis is only two failure modes appear at FU bands, with none appearing at WU band. Thus, mitigations at this instance are only two within unacceptable regions, although it may require scheduled action. This indicates largely a healthy situation at the distribution system, but an immediate actions need to be taken against 3.4/1 Short circuitand 2.7/1 Short circuit (not shown) appearing at FU band of the criticality matrix. Failure modes at FA band of the matrix such as 1.3/1 coil short circuit (shown in Fig. 3) could be given a softer mitigation handling, may be a planned preventive or opportunity maintenance. Other failure modes which are found at WA band could conveniently be tolerated. This could however be a factor of expertly managerial decision.
CONCLUSIONS
With ELECTRACE as a tool, a very complex system of electrical power distribution of an international airport can be analysed with greater speed and ease and at relatively lower cost. The application of ELECTRACE can be extended to other facilities within airport and beyond. The entire work carried out to in this study apart from data collection was done solo. Data collection was indeed tedious due to size of the distribution facilities. Being stranger to the network one may need engineers and technicians on ground for familiarisations towards the success of the data collection.. This indicates the effectiveness of the software used in this analysis. This implies that other facilities within or outside airports, simple or complex such as meteorology, navigational aids, service stations etc. can be analysed successfully with ELECTRACE, which was developed for this work. The large number of maintenance requirements in this analysis being exposed by ELECTRACE’s criticality matrix somehow appeared to be disturbing. Application of Reliability Centred Maintenance (RCM) could be a form of effective solution to the high maintenance demands in terms of cost due down time and logistics.
ACKNOWLEDGEMENT
The author appreciates the contributions of Dr Chakib Kara-Zaitri and Mr Mukhtar I Bello of University of Bradford, United Kingdom for their guidance and support in the literature, data mining, software development etc. I as well acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The author is also grateful to authors 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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