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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241611EnglishN-0001November30HealthcareGARCINIA KOLA: A REVIEW OF ITS ETHNOMEDICINAL, CHEMICAL AND PHARMACOLOGICAL PROPERTIES
English0107Ekene E. N.English Erhirhie Earnest O.EnglishPlants still remain the basis for development of modern drugs for the preservation of health in the rural and urban communities worldwide in this present technological era. Garcinia kola (bitter kola) is referred to as a “wonder plant” because every part of it has been found to be of medicinal importance. Research carried out using different in vitro and in vivo techniques of biological evaluation supports most of its folkloric claims. This review compiled the ethno botanical/medicinal, phytochemistry, pharmacological, clinical and toxicological studies carried on this plant using references from various database.
EnglishGarcinia kola, phytochemistry, Ethno medicine, Bioactivities.INTRODUCTION
Historically, plant derived medicines, which have made large contributions to human health and well-being provide source of inspiration for novel drug and had served as models for western drugs (Farnsworth, 1989). It is estimated that over 70% of modern pharmaceutical products are based on herbs. For instance, artemisinin from Artemisia annua, used in the manufacture of Artesunate and other artemisinin-based drugs, which serves as potent anti-malaria drug, is a popular drug in the markets (Brisibe, et al., 2008). Plant derived medicines have many benefits such as; low toxicity status/ relative safety, accessibility and affordability. Plants parts have been a source of herbal medicine which has been shown to be effective to about 80% of population as primary health care (Akinyemi, et al., 2000). One of such plants is „Garcinia kola’, a member of the Guttiferae species found throughout West and Central Africa. Every part of Garcinia kola (bitter kola) is an important component in traditional herbal medicine worldwide (Dalziel, 1937). Considering the enormous relevance of Garcinia kola in folkloric medicine, the present review focused on its up to date experimental research covering; phytochemistry, pharmacology, toxicological and clinical studie
Garcinia kola (bitter kola) is a dicotyledonous plant belonging to the family of plants called Guttiferae. It is a perennial crop growing in the forest, distributed throughout West and Central Africa (Iwu 1993). G. kola is also found distributed in the forest zone of Sierra Leone, Ghana, Cameroon and other West African countries. In Nigeria, it is common in the South Western States and Edo State (Otor, et al., 2001). It is a medium sized evergreen tree, about 15-17m tall and with a fairly narrow crown. The leaves are simple, 6-14cm long and 2-6cm across, shiny on both surfaces and spotted with resin glands. The small flowers are covered with short, red hairs (Iwu, 1993). The fruit is a drupe of 5-10cm in diameter and weighs 30-50g. It is usually smooth and contains a yellow-red pulp. The fruit changes color during maturation from green to orange, and each fruit contains 1-4 seeds (Juliana, et al., 2006).
SCIENTIFIC CLASSIFICATION Kingdom:
Plantae Order: Malpighiales Family: ClusiaceaeGenus: Garcinia Species: G. kola Binomial name: Garcinia kola
COMMON
NAMES Garcinia kola has been referred to as a “wonder plant” because every part of it has been found to be of medicinal importance (Dalziel, 1937). It is also called bitter cola, male kola due to the reported aphrodisiac properties. It is commonly called “Orogbo” in Yoruba language, „Aku ilu? in Igbo language and „Namijin goro? in Hausa language (Dalziel, 1937).
TRADITIONAL USES AND MEDICINAL VALUES
Garcinia kola is chewed extensively in Southern Nigeria as a masticatory and it is readily served to visitors, especially among the Igbo tribe in Eastern Nigeria, as a sign of peace and acceptance of visitors. The root of the plant is used as favorite bitter chew-sticks in West Africa (Otor, et al., 2001). The stem bark is used in folklore remedies as a purgative among the natives of Eastern Nigeria
and the latex is externally applied to fresh wounds to prevent sepsis, thereby assisting in wound healing. It is also popular among the people of Nigeria for nervous alertness and induction of insomnia. Garcinia kola is highly valued for medicinal use. This plant has been referred to as a „wonder plant? because every part of it has been found to be of medicinal importance (Dalziel, 1937). The seeds are chewed as an aphrodisiac or used to cure cough, dysentery, chest colds, liver disorders, diarrhoea, laryngitis, bronchitis, and gonorrhea (Adesina, et al., 2005). The seed is used to prevent and relieve colic; it can also be used to treat headache, stomach ache and gastritis (Ayensu, 1978). It has also been reported for the treatment of jaundice, high fever, and as purgative (Iwu , 1989). In Sierra Leone, the roots and bark are taken as a tonic for sexual dysfunction in men. The bark is also added into palm wine to improve its potency (Iwu, et al., 1990). Traditional medicine practitioners in Nigeria, particularly in the Ogoni area use a decoction of Garcinia kola stem bark for the treatment of dysmenorrhoea, fever, inflammation and burns (Adesina, et al., 1995). "Bitter kola is anti-poison and helps to detoxify the system, it has the ability to repel evil men and spirits, it could sound superstitious but it works (Iwu , 1989).
SCIENTIFIC RESEARCH ON GARCINIA KOLA
Chemical constituents The phytochemical compounds isolated from G. kola include tannins, saponins, alkaloids, cardiac glycosides (Ebana, et al.,1991). Other phytochemical compounds isolated from G. kola seeds are biflavonoids such as kolaflavone and 2-hydroxybi-flavonols. Two new chromanols, garcioic and garcinal, together with tocotrienol were reported isolated from G. kola (Terashima, et al., 2002). Morabandza, et al., (2013) had also determined the chemicalcomposition of Garcinia kola Heckel (Clusiaceae) mesocarp. Anti-microbial properties Adegboye, et al., (2008) had investigated the in vitro antimicrobial activities of crude extract of Garcinia kola against some bacterial isolates comprising of both Gram-positive and Gramnegative organisms. In another study, the antimicrobial interaction between Garcinia kola seed (GKS) and gatifloxacin (GAT), a fourth generation fluoroquinolone was evaluated by a modification of the checkerboard technique using Bacillus subtilis and Staphylococcus aureus as the test organisms (Ofokansi, et al., 2008). The antimicrobial activity of five solvent extracts of Garcinia kola seeds had also been investigated against 30 clinical strains of H. pylori and a standard control strain, NCTC 11638, using standard microbiological techniques (Collise, et al., 2011). In vitro anti-Vibrio activities of methanol and aqueous extracts of Garcinia kola seeds against 50 Vibrio isolates obtained from wastewater final effluents in the Eastern Cape Province, South Africa were also investigated (Penduka, et al., 2011).The bioactivity of G. kola seeds was also assessed on Streptococcus pyogenes, Staphylococcus aureus, Plesiomonas shigelloides and Salmonella typhimurium (Christinah and Roland, 2012).Trichomonacidal effects of G. kola nuts were also investigated (Gabriel and Emmanuel, 2011). Esimone et al., 2002 also investigated the effect of Garcinia kola seed extract (100 mg/kg) on the pharmacokinetic and antibacterial effects of ciprofloxacin hydrochloride (40 mg/kg). Anti-diabetic properties The hypoglycaemic and hypolipidaemic effects of fractions from kolaviron (KV) (a Garcinia kola seed extract) were investigated in normal and streptozotocin (STZ)-diabetic rats (Adaramoye and Adeyemi, 2006). Garcinia kola seed Powder (GKP) had also been shown to have antidiabetic, antilipidemic and anti-atherogenic properties with a tremendous potential to protect against coronary
heart disease (Udenze, et al., 2012). Significant hypoglycaemic and hypolipidemic activity of Garcinia kola in alloxan-induced diabetic Wistar rats had been reported (Nwangwa, 2012). Hepatoprotective and anti-oxidant activities The hepatoprotective effect of Garcinia kola seed extract against paracetamol induced hepatptoxicity had been investigated in rats (Alade and Ani, 1990).The protective effects of Garcinia kola against a dose of Carbon-Tetrachloride (CC14)-induced liver damage in experimental rats were also investigated (Mathew and Blessing, 2007). Antioxidant potentials of five fractions (ME1–ME5) of methanolic extract of Garcinia kola seeds was also studied (Tebekeme, 2009). Effects on fertility Garcinia kola seed meal had been shown to improve semen characteristics and sexual drive (libido) in matured rabbit bucks (Iwuji, and Herbert, 2012). In another study, long- term ingestion of Garcinia kola seed diet had been shown to cause a significant reduction in sperm count, sperm motility, and ultimately infertility in the male wistar rat (Mesembe, et al., 2013). Garcinia kola seed at 200mg/kg body weight altered oestrous cycle and partly inhibits ovulation in female rats (Akpantah, et al., 2005). Other studies on Garcinia kola Anti-ulcer potential and proton pump inhibitory activity of kolaviron (KV) isolated from Garcinia kola Heckel had been evaluated using different ulcer models and was suggested to emerge as a potent anti-ulcer compound (Onasanwo, et al., 2011). Garcinia kola (Heckel) seed extract evaluated in albino Wistar rats possess significant anti-pyretic activity, which justified its ethnomedicinal use (Kakjing, et al., 2014). Garcinia kola 0.5% aqueous solution eye drop significantly reduces intraocular pressure (IOP) as compared to baseline (Adebukunola, et al., 2010). Comparative study on the efficacy of Garcinia kola in reducing some heavy metal accumulation in liver of Wistar rats was also carried out. Garcinia kola has the highest hepatoprotective
effect to Cd followed by Hg and least protection against Pb toxicity in rats and its administration was beneficial in reducing heavy metal accumulation in the liver (Nwokochaa, et al., 2011). Administration of Garcinia kola for a period of six weeks in rabbits elicited no observable histo-pathological effects on the histology of the liver (Charity, et al., 2012). Garcinia kola had been shown to enhance erythropoiesis in rabbits and rats and as well has no long term significant toxicological implication (Unigwe and Nwakpu, 2009; Esomonu, et al., 2005). In another study, Garcinia kola significantly reduced tissue damage induced by lipopolysaccharide (LPS) (Okoko and Ndoni, 2009). Daily administration of Garcinia kola (G. kola) in growing Wistar rats for a period of 70 days showed a depressive effect on appetite and water intake with resultant poor feed utilization efficiency and mass gain of rats in a dosedependent manner. Plasma alanine aminotransferase (ALT) and aspartate aminotransferase (AST) activities were elevated (PEnglishhttp://ijcrr.com/abstract.php?article_id=840http://ijcrr.com/article_html.php?did=840REFERENCES
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241611EnglishN2014June13HealthcareEXTRA NASOPHARYNGEAL ANGIOFIBROMA OF THE SPHENOID SINUS: A RARE CASE REPORT
English0813P. KarthikeyanEnglish Davis Thomas PulimoottilEnglishAim: This study aimed to find the effect of preoperative tumor embolization and transnasal endoscopic excision of a sphenoid sinus angiofibroma on the postoperative outcome. Case Report: A thirteen year old male presented to the Outpatient ENT Department of a tertiary care centre, with a history of recurrent left-sided spontaneous painless epistaxis since one year. Diagnostic Nasal Endoscopy showed a pink globular mass seen occupying the left choana and extending into the left nasal cavity. CT Paranasal sinuses (Plain and Contrast) revealed a well-defined moderately enhancing soft tissue lesion seen predominantly at the base of sphenoid sinus on the left side, extending into the choanal region with destruction of the base of the sphenoid bone. Patient underwent Diagnostic Angiography in view of pre-operative embolisation and the patient later underwent embolisation of feeder artery supplying the massusing Gelfoam. Subsequently the patient underwent Transnasal Endoscopic Excision of the tumour under general anaesthesia and the specimen was sent for histopathological examination, which revealed features suggestive of Angiofibroma. Discussion: Extranasopharyngealangiofibromas are vascular fibrous nodules occurring outside the nasopharynx and are rare, benign neoplasms characterized by a different biological history and clinical features with respect to nasopharyngeal tumours, and for these reasons, should be regarded as a separate clinical entity. Conclusion: Although it sometimes involves the sphenoid sinus, angiofibroma rarely originates from this site and only five such cases have been reported in the literature.
EnglishExtranasopharyngealangiofibroma, sphenoid sinus, epistaxis, transnasal endoscopic excisionINTRODUCTION
Angiofibromas are benign, highly vascular and locally aggressivetumours observed most frequently in adolescent males and are the most common benign tumours of the nasopharynx, accounting for 0.5% of all head and neck neoplasms1 . It originates from the sphenoid foramen at the junction of the root of the sphenoid process of palatine bone, horizontal ala of vomer and pterygoid process of sphenoid bone2,3. When it occurs out of this site, it is termed as extranasopharyngealangiofibroma (ENA) or atypical angiofibroma. In 1980, De Vincentiis and Pinelli7 reviewed a series of 704 cases of angiofibroma and found that 13 cases manifested outside the nasopharynx, thus suggesting that extranasopharyngeal localization of the tumour is possible, although rare. This rare tumour usually displays variable clinical presentation and was recently termed as “atypical angiofibroma” due to its distinct characteristic features4-6 . Thus, extranasopharyngealangiofibromas can constitutea challenge in terms of diagnosis and treatment. A high level of suspicion is needed for prompt diagnosis and treatment of such lesions. A review of world literature revealed more than 65 cases of extranasopharyngealangiofibromas. The maxilla was the most common site, followed by ethmoids, nasal septum, nasal cavity and sphenoid sinus8 .
CASE REPORT
A 13-year-old male presented to the Department of Otorhinolaryngology of a tertiary care centre with the complaints of intermittent episodes of bleeding from the left nasal cavity since one year. The nasal bleed was intermittent, profuse and which started and stopped spontaneously and was associated with left-sided nasal obstruction. There was no history of any aggravating or relieving factors. There was no previous history of trauma or bleeding diathesis. The patient was not on any regular medication. There was no history in the family of similar illness or of bleeding disorders. A complete ENT examination was done. Anterior rhinoscopy revealed the nasal septum to be deviated to the left with thick mucopurulent discharge in the left nasal cavity. Neurologic examination was normal. Diagnostic nasal endoscopy revealed a pink, globular mass seen occupying the left choana with thick mucopurulent discharge (Fig. I). Contrast enhanced computerized tomography (CT) of the paranasal sinuses showed a well-defined moderately enhancing soft tissue lesion noted predominantly at the base of the sphenoid sinus on the left side, extending inferiorly upto the choanal region, with destruction of the base of the sphenoid bone (Fig. II, III). The patient was referred to the Department of Cardiology and subsequently underwent Diagnostic Angiography in view of pre-operative embolisation to identify the feeder vessels. Selective gel foamembolisation of the feeder artery (Internal Maxillary Artery) was done using 2.8F Progress microcatheter with good results. Following this, the patient was taken up for Transnasal Endoscopic Excision of the tumour. Intraoperatively, the size of the tumour was found to have reduced significantly post-embolisation. The sphenopalatine artery was identified and cauterized. Partial middle turbinectomy was performed on the left side, to aid better exposure and visualization of the tumour. Subsequent to the entry into the sphenoid sinus, the smooth-surfaced tumour was seen seen arising from the base of the sphenoid sinus on the left side, measuring 3.5 x 2.5 cm. The tumour was elevated from the underlying periosteum and was removed en bloc under endoscopic guidance. Intraoperative bleeding was minimal. The left sphenoid sinus and the left nasal cavity werepacked for 48 hours. Post-operative recovery was uneventful. The pack was removed after 48 hours and the patient was discharged without any complications. The histopathological examination of the excised specimen revealed tissue bits lined by respiratory epithelium with squamous metaplastic change focally. The underlying stroma was variable from loose oedematous with stellate cells and mast cells to densely packed spindle cells and collagenous stroma. Numerous vessels ranging from dilated stellate shaped venules with flattened epithelium to small capillaries with plump endothelial lining were present (Fig. IV). These findings were consistent with angiofibroma. At 6 months followup, the patient was free of recurrence.
DISCUSSION
Angiofibroma is the most common tumour of the nasopharynx and makes up 0.5% of all head and neck tumours. It typically occurs in the nasopharynx of young males in the first and second decades1,4. More recently, the term extranasopharyngealangiofibroma has been applied to vascular fibrous nodules occurring outside the nasopharynx. However, extranasopharyngealangiofibroma have virtually nothing in common with nasopharyngeal tumours and the use of the term angiofibroma for these lesions may therefore be confusing. These rare, benign neoplasms are characterized by a different
biological history and clinical features with respect to nasopharyngeal tumours, and for these reasons, they should be regarded as a separate clinical entity. Compared to nasopharyngeal angiofibromas, patients affected are older, females can be involved, symptoms develop more quickly, and hypervascularity is less common1,3. Isolated extranasopharyngealangiofibroma is rare. A review of 65 extranasopharyngealangiofibroma cases showed that the average age of these patients was 22.9 and only 25-26% of patients were female3 . Extranasopharyngealangiofibroma most commonly arises in the maxillary sinus, followed by the ethmoid sinus. The nasal septum, larynx, external ear, cheek, conjunctiva, oropharynx, retromolartrigone and middle and inferior turbinates are other reported sites of occurrence. To the best of our knowledge, only 5 cases originating from the sphenoid sinus have been reported in the literarture previously. The clinical presentation of extranasopharyngealangiofibroma depends mainly on the localization and extent of the tumour. According to histopathology, extra nasopharyngeal angio fibromas constitute a more heterogenous group. Classic radiological findings characterizing nasopharyngeal angiofibromas are not shared by extranasopharyngealangiofibromas. Most extranasopharyngealangiofibromas enhance after contrast medium injection, however, enhancement is not a constant sign, and may vary from intermediate to strong. Unlike nasopharyngeal angiofibromas, radiological presentation of extranasopharyngealangiofibromas is much more variable due to their various locations. These tumours may spread to adjacent areas by widening of natural foramina and fissures or by erosion of bony structures, which is well demonstrated on CT2,15,16. Lack of hypervascularity on angiograms does not exclude the diagnosis of extranasopharyngealangiofibroma. The blood supply to the extranasopharyngealangiofibroma depends on its point of origin and location,
whereas in nasopharyngeal angiofibromas, the main feeder is the maxillary artery.17 Radiological examination is essential for establishing the correct diagnosis, making an appropriate treatment plan, determining the extent of the lesion and identifying the feeding vessel. Measures such as CT, MRI and angiography can be used. Selective angiography clearly reveals the vascular pattern and hemodynamics of the tumour; however absence of hypervascularity in angiography does not fully exclude ENA.3 CT and MRI can determine the extent of tumour including the skull base involvement, intracranial spread and its relationship with important vascular and neurological structures.9 Although bony erosion can be determined with CT, MRI is usually sufficient to show the cortical erosion and trabecular bone formation stimulated by the tumour. Imaging of nasopharyngeal angiofibroma with a contrast agent leads to diffuse and usually homogenous involvement in CT and MRI T1 scans. In contrast, ENA enhances moderate amount of contrast or none due to its weak vascular involvement.10,14Embolization can be utilized in cases with increased vascularity. Arteriography before biopsy or removal of tumour may reduce the risk of active bleeding. In this patient, selective embolisation of the feeder artery was done preoperatively to reduce the blood supply to the tumour. Owing to the small size and limited extent of the tumour, transnasal endoscopic excision was preferred. The treatment of choice for angiofibroma is total surgical excision. Other treatment modalities include radiotherapy, cryosurgery, embolization, hormone therapy, chemotherapy, arterial ligation, sclerotherapy and watchful observation with the hope of spontaneous regression. Radiotherapy is less effective for ENA compared to nasopharyngeal angiofibroma.3 Tillaux11 suggested that nasopharyngeal angiofibromas originated from the fibrocartilaginous barrier in the lower border of the sphenoid bone, in front of the atlas. Brunner12
described this structure as „fascia basalis? because he found no cartilage in it. Later, Hiraide and Matsubana13 reported a case of angiofibroma located in the anterior third of the nasal septum and showed that this tumour originated from the periosteum of the perpendicular lamina of the ethmoid bone, away from the fascia basalis. These reports support the presence of ectopic tissue as the most common theory to explain the site of origin of extranasopharyngealangiofibromas.
CONCLUSION
A strong index of suspicion is required to diagnose an extranasopharyngealangiofibroma. CT and MRI are sufficient to diagnose such lesions. Biopsy is to be avoided as it may cause profuse bleeding. Preoperative tumour embolization is an important measure to reduce intraoperative bleeding and to reduce tumour size. Surgical excision is the treatment of choice for such tumours. Transnasal endoscopic excision is a useful surgical modality in the case of limited lesions. Angiofibroma should be included in the differential diagnosis of vascular tumours of the nasal cavity and paranasal sinuses. Whether these lesions represent an angiofibroma or a variant of another lesion is debatable.
CONFLICT(S) OF INTEREST: NONE
ACKNOWLEDGEMENT \
The 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 and editors of all those articles and journals from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=841http://ijcrr.com/article_html.php?did=841REFERENCES
1. Akbas Y, Anadolu Y. Extranasopharyngealangiofibroma of the head and neck in women. Am J Otolaryngol 2003;24:413-4.
2. Huang RY, Damrose EJ, Blackwell KE, Cohen AN, Calcaterra TC. Extranasopharyngealangiofibroma. Int J PedOtorhinolaryngol 2000;30:59-64.
3. Windfuhr JP, Remmert S. Extranasopharyngealangiofibroma: etiology, incidence and management. ActaOtolaryngol 2004;124:880-9.
4. Nomura K, Shimomura A, Awataguchi T, Murakami K, Kobayashi T. A case of angiofibroma originating from the inferior nasal turbinate. AurisNasus Larynx 2005;33:191-3.
5. Handa KK, Kumar A, Singh MK, Chhabra AH. Extranasopharyngealangiofibromas arising from the nasal septum. Int J PediatrOtorhinolaryngol 2001;58:163-6.
6. Somdas MA, Ketenci I, Unlu Y, Canoz O, Guney E. Extranasopharyngealangiofibroma originating from the nasal septum. Otolaryngol Head Neck Surg 2005;133:647.
7. De Vincentiis G, Pinelli V. Rhinopharyngealangiofibroma in the pediatric age group. Clinical-statistical contribution. Int J PediatrOtorhinolaryngol 1980;2:99-122.
8. Kitano M, Landini G, Mimura T. Juvenile angiofibroma of the maxillary sinus. A case report. Int J Oral MaxillofacSurg 1992;21:230-232.
9. Schick B, Kahle G. Radiological findings in angiofibroma. ActaRadiol 2000;41:585-93.
10. Harrison DF. The natural history, pathogenesis and treatment of juvenile angiofibroma. Personal experience with 44 patients. Arch Otolaryngol Head Neck Surg 1987;113:936- 42.
11. Tillaux P. Traited?AnatomieTopogaphiqueAvee Applications e la Chirurgie. 2nd edn. Paris: P. Asselin, 1978:348–9.
12. Brunner H. Nasopharyngeal fibroma. Ann Otol 1942;51:30-65.
13. Hiraide F, Matsubara H. Juvenile nasal angiofibroma: a case report. Arch Otorhinolaryngol 1984;234:235-41.
14. Celik B, Erisen L, Saraydaroglu O, Coskun H. Atypical angiofibromas: a report of four cases. Int J PediatOtorhinolaryngol 2005;69:415-21.
15. Tsunoda A, Kohda H, Ishikawa N, Komatsuzaki A. Juvenile angiofibroma limited to the sphenoid sinus. J Otolaryngol 1998;27:37-39.
16. Antoniades K, Antoniades DZ, Antoniades V. Juvenile angiofibroma: a report of a case with intraoral presentation. Oral Surg Oral Med Oral Path Oral RadiolEndod 2002;94:228-232.
17. Szymanska A, Szymanski M, Morshed K, Czekajska-Chehab E, Scczerbo-Trojanowska M. Extranasopharyngealangiofibroma: clinical and radiological presentation. Eur Arch Otorhinolaryngol 2013;270:655-660.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241611EnglishN2014June13HealthcareMATURE CYSTIC TERATOMA HARBOURING SQUAMOUS CELL CARCINOMA - A CASE REPORT
English1417Krishnendu DasEnglish Arindam KarmakarEnglish Debanjan BhattacharjeeEnglishAim: Squamous cell carcinoma arising in a mature cystic teratoma is an extremely rare event. This effort aims at adding authors’ experience to the pool of knowledge of this very rare but ominous tumour. Case Report: Herein, we report a case of squamous cell carcinoma in mature cystic teratoma of right ovary in a 45-year-old woman presenting with abdominal mass which was diagnosed after surgery. The tumour was large and cystic. An exhaustive search was made to rule out the possibility of metastasis into the ovary. Discussion: Benign or malignant tumours that arise in a benign cystic teratoma are rare. Malignant transformation occurs in only 1-3% of benign cystic teratomas1, 2, 3. Preoperative diagnosis is difficult because of the lack of specific symptoms and signs to suggest malignancy 4. Factors such as age, tumour size, tumour markers and tumour imaging characteristics help in preoperative risk assessment. Better understanding of the pathology and prognostic factors of this group of tumours is required for early and proper management. Conclusion: This report emphasizes on the sinister nature of malignant transformation of mature teratoma and the importance of comprehensive investigations for early diagnosis and treatment.
Englishmature cystic teratoma, squamous cell carcinoma, ovaryINTRODUCTION
Benign cystic teratoma (Dermoid cyst) is the most common ovarian neoplasm, comprising 25% or more of all ovarian tumours. Secondary malignancies, which typically occur in postmenopausal woman, are extremely rate 1, 2, 3 . Presenting complaints are nonspecific and include abdominal or pelvic pain, abdominal distension, or a palpable mass. Secondary neoplasms are usually unilateral, but the contralateral ovary may contain a benign cystic teratoma. Nevi, sebaceous adenomas and other cutaneous adnexal neoplasms, benign salivary gland type tumours, meningioma, glomus tumour, and haemangiomatous vascular proliferations are among the benign neoplasms that arise in benign cystic teratoma5 . In situ malignant tumours that have been reported include squamous cell carcinoma in situ and Paget’s disease. Invasive squamous cell carcinoma comprises about 85% of secondary malignancies arising in benign cystic teratoma6 . The remainders are other types of cutaneous carcinoma, such as basal cell carcinoma or sebaceous carcinoma7 , melanoma, adenocarcinoma, various types of sarcoma, and other rare tumour types. Rare mucinous epithelial tumours that arise in a teratoma give rise to pseudomyxoma peritonei8
CASE REPORT
A 45-year-old multigravida presented with history of abdominal pain. She didn’t have any medical co morbidity. There were no complaints of alteredbowel and bladder habits. Per vaginum bimanual examination revealed unilateral adnexal mass. On pelvic ultrasonography, right sided ovarian cystic masses with solid component were demonstrated. Computed tomography scan of abdomen and pelvis showed a 10×7 cm right adnexal mass with ossified elements in ovary. Radiological impression favored a diagnosis of teratoma of right ovary with possible malignant transformation. There was no free fluid in the abdomen. The serum CA-125 level was found to be 885 IU/ml (normal 0-35 IU/ml). A tentative preoperative diagnosis of teratoma with possible malignant transformation was entertained, and the patient was counseled to undergo an exploratory laparotomy with total abdominal hysterectomy, bilateral salpingo-oophorectomy. At laparotomy, the right ovarian mass appeared to be partly cystic partly solid areas. The capsule was intact, and there were no significant pelvic or para-aortic lymph nodes. The omentum was grossly unremarkable. On gross examination, the right ovarian tumour measured 10×7×5 cm which on cut section showed approximately 50% solid area and 50% cystic. Cyst contained hair (Fig. 1). Microscopically, sections from the right ovarian tumour showed a moderately differentiated squamous cell carcinoma in mature cystic teratoma Fig. 2 and Fig. 3). The tumour was confined to right ovary. Uterus showed features of adenomyosis, hyperplastic endometrial polyp and cystic endometrial atrophy while cervix revealed chronic inflammation. Left ovary, both the right and left fallopian tubes and omentum were free of tumour.
DISCUSSION
Mature cystic teratomas make up almost 20% of all ovarian neoplasm and also constitute the most common ovarian tumour in childhood. Malignant transformation of this benign lesion is an extremely rare incidence 1, 2, 3 . Although mature cystic teratomas are frequently bilateral, malignant change has usually been reported on only one side. Squamous cell carcinoma (SCC) arising in mature cystic teratoma most probably develops from epidermal elements (80%), although an origin from bronchial epithelium is a possibility. In favour of former origin is finding of squamous cell carcinoma in situ adjacent to carcinoma. Alternatively, it can arise from endometriosis or Brenner tumour. S quamous cell carcinoma may also be seen as metastatic deposits from squamous cell carcinoma elsewhere especially cervix, even though that tumour may have occurred many years previously. Our patient however did not reveal such source. The carcinoma begin at or near dermoid protuberance, continue to grow without clinical evidence, eventually penetrating full thickness of the wall, developing direct extension and malignant adhesions to the neighbouring organs. In majority of the cases, invasion or metastases have occurred before diagnosis. Spread beyond the capsule can produce peritoneal seeding and symptoms such as pain, ascites and signs of peritoneal irritation, such cases being prognostically poor. Fortunately our case didn’t show any evidence of metastasis. Several authors pointed out the importance of intact capsule regarding good prognosis if confined to the cyst. Preoperative diagnosis of malignant change in benign teratoma is extremely difficult providing a substantial challenge and confusion regarding a need for surgical staging and adjuvant therapy. Risk factors for malignancy in mature teratoma include age of the patient, tumour size, imaging findings and serum tumour markers. It has been observed that in teratoma, malignant transformation occurs in relatively older patient population; the mean age range reported being 45-60 yrs. Frequency of malignant change, rises with increasing age, reaching up to 19% in women after menopause. Hence, the need for the thorough search for such malignant change, in dermoid cyst after the age of 45years.Larger tumours correlate with increased risk of malignant transformation. Kikkawa et al 9 , in their study found that tumour diameter >9.9cm was 86%
sensitive for malignant change. Relevance of tumour markers is studied in many studies. According to Kikkawa et al 9 it was found that CEA (Carcinoembryonic antigen) was the best screening marker followed by SCC (Squamous cell carcinoma) antigen, both of these being superior to CA-125 and CA-19-9. It was finally recommended that measurement of CEA and SCC Ag levels in patients aged 45years or older, who have mature teratoma like ovarian tumour larger than 9.9cm in its greater diameter would provide a effective clinical strategy for preoperative risk assessment and help in making differential diagnosis between mature teratoma and SCC in mature teratoma. In yet another study Mori et al 10 reported that age >40years and serum SCC Ag >2.5ng/ml were77% sensitive and 96% specific for malignant transformation which has also been useful in monitoring for recurrent disease. Tumor imaging characteristics which may aid preoperative risk assessment have also been studied. According to Lai et al 11 characteristic CT scan findings such as adnexal mass with fat, calcification, soft tissue component and areas of invasion through the teratoma wall are highly suggestive of associated malignancy. Kido et al 12 on Magnetic resonance imaging correlated malignancy with presence of solid component with contrast enhancement, transmural or trans-septal extension, evidence of adherence to the surrounding structures, necrosis and haemorrhage. Regarding optimal management careful gross inspection of the tumor and frozen section analysis are essential whenever there is a preoperative suspicion of malignant transformation complete tumor excision and proper staging are integral to prognosis. Whole pelvis radiation and concurrent weekly platinum based chemotherapy may be beneficial in patients with stage III disease. Patient with stage III disease have poor prognosis and should be offered platinum based chemotherapy regimens
CONCLUSION
This case emphasizes on the diagnosis of malignant transformation of mature cystic teratoma because the great difference of prognosis in tumors with and without malignant change. It also highlights the importance of finding the association between clinical, radiological, biochemical and pathological findings in a middle aged female with ovarian tumor.
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 of this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=842http://ijcrr.com/article_html.php?did=842REFERENCES
1. Genadry R, Parmley T, Woodruff J D. Secondary malignancies in benign cystic teratoma. Gynecoloncol 1979;8:246-51.
2. Stamp G W H, McConnell E M. malignancy arising in cystic ovarian teratomas. A report of 24 cases. Br J ObstetGynaecol1983;90:671- 75.
3. Hirakawa T, Tsuneyoshi M, Enjoji M. Squamous cell carcinoma arising in mature cystic teratoma of the ovary. Clinicopathologic and topographic analysis. Am J Surg Pathol 1989;13:397-405.
4. Hurwitz JL, Fenton A, McCluggage WG, McKenn S. Squamous cell carcinoma arising in a dermoid cyst of the ovary: a case series. BJOG 2007 Oct; 114(10):1283-7.
5. Itoh H, Wada T, Michitaka K et al. Ovarian teratoma showing a predominant haemangiomatous element with stromal lutenization: report of a case and review of literature. Pathol Int 2004;54:279-84.
6. Tseng C J, Chou H H, Huang K G et al. Squamous cell carcinoma arising in mature cystic teratoma of the ovary. Gynecol oncol 1996;63:364-70.
7. Vartanian R K, McRae B, Hessler R B. Sebaceous carcinoma arising in a mature cystic teratoma of the ovary. Int J Gynecol Pathol 2002;21:418-21.
8. Ronnett B M, Seidman J D. Mucinous tumours arising in ovarian mature cystic teratomas: relationship to the clinical syndrome of pseudomyxomaperitonei. Am J Surg Pathol 2003;27:650-57.
9. Kikkawa F, Nawa A, Tamakoshi K, et al. Diagnosis of Squamous cell carcinoma arising from mature cystic teratoma of the ovary. Cancer 1998 ; 82(11):2249-55.
10. Mori Y, Nishii H, Takabe K, et al. Preoperative diagnosis of malignant transformation arising from mature cystic teratoma of the ovary. Gynecol Oncol 2003; 90(2):338-41.
11. Lai PF, Hsieh SC, Chien JC, Fang CL, Chan WP, Yu C. Malignant transformation of ovarian mature cystic teratoma: Computerized tomography findings. Arch Gynecol Obstet 2005;271(4):355-57.
12. Kido A, Togashi K, Konoshi I, et al. Dermoid cysts of the ovary with malignant transformation: MR appearance. Am J Roentgenol 1999;172(2):445-49.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241611EnglishN2014June13HealthcareA STUDY OF PERCEPTION OF NURSES ON WORKING ENVIRONMENT IN TERTIARY CARE HOSPITAL IN MUMBAI
English1823Vijaykumar S. SinghEnglish Smita ChavanEnglish Subita PatilEnglish Vikas JaiswalEnglish Sagar KambleEnglishBackground: Nurses forms an important health care delivering force in tertiary care hospitals.Positive working environment in hospital has enhancing effect on work efficiency and quality of care provided by nurses. Aim: The aim was to find out perception of nurses on working environment and related problem of tertiarycare hospital in Mumbai. Objectives: To know the perception of nurse on problems related to work load, patient related problems and problems due to lack of resources. Materials and Methods: A work site cross-sectional descriptive study was conducted amongst 202 consented nurses of tertiary care hospital in Mumbai. Data was collected by personal interview. Pre-designed semi-structured standardized interview schedule consisting of questions related to Socio-demographic factors, work load, patient related problems and to lack of resources included. Results:In this study 104/202(51.5%) subjects always perceived work load was too much. 84/202 (41.6 %) subjects had to always compromise quality of work because of work load.47/202 (23.3%) subjects always face difficulty in dealing with serious patient33/202 (16.3%) always face difficulty when patient do not recover for long time.136/202(67.3%) subjects always feel that the staff was inadequate to accomplish work properly.97/202 (48.0%) subjects always feel that equipments and supplies were never adequate. Conclusions: Components of working environment in the present tertiary care hospital play a majorrole interfering with work efficiency of nurses and patient care. Proper training and management support needed to make service successful perceived by nurses.
EnglishWorking environment, work load, tertiary hospital, work efficiency performance, patient care.INTRODUCTION
Working environment of the hospital is sum of prevailing external factors which has bearing on the working population. Nursing profession is recognised as stressful profession involvesskilful and multitasking work which include to follow orders of clinicians, timely management of patients, the wards, getting work done by class four employees, communicating with patient, relatives, higher authorities and administration etc. Nurses face difficult working conditions with limited resources, health hazards, over work and certain special situation causing detrimental effects on physical, mental and social health.1 Healthy work environment is very important to potentiate the work efficiency and for providing quality care.A number of studies conducted within past decade have shown that the nurses in hospitals with better care environments reported more positive job experiences and fewer concerns
with care quality.2 This study was undertaken in tertiary care public hospital which has speciality departments such as Medicine, Surgery, Paediatrics, Obstetrics and Gynaecology etc. and super speciality departments such as Neurology, Cardiology, Neurosurgery, Plastic Surgery etc. The hospital is catering to the large number of population, often exceeding to its bed and human resource capacity which result in overburdening of work on nursing staff. Thus the present study was conducted among nursing staff to explore different components in hospital care environment which may have influence on work efficiency of nurses and the quality of patient care. Outcome of this study might enable concern authority to provide the appropriate environment, supervision, guidance and training programs and to evaluate the additional human resource need for healthcare facilities.
MATERIALS AND METHODS
This is a cross-sectional, questionnaire based, observational study carried out in a tertiary care hospital under Municipal Corporation, Sion, Mumbai, India. The sample size comprised of 202 staff nurses, Permanent employee of place of study, working at least for two years, were selected using a convenience sample. Thestudy toolwas a Pre-designed,Pre-tested, semi-structured questionnaire. Confidentiality was assured interview schedule consisting of questions related to Socio-demographic factors, questions related to work load, problems related to patient care and lack of resources are included. The ethics committee of the institute approved the study. The pilot study was done in which questionnaire was pre-tested on subsample of 20 nurses. None of the subject was forced or reimbursed. The Subjects who were on any leave or in probation period or on contractual basis and staff nurses intermittent night duties every 3 months were excluded from the study Data was collected by personal interview method by visiting the subjects at their workplace by prior appointments i.e. wards, operation theatres, and departments or at nursing station. The care was taken that they do not get disturbed during emergency care of patients. Attempts were made to establish good rapport with the study subjects by personal contact. The objectives and of the study were explained in details to the subjects in the language understand best and written informed consent is taken from the participants. Even after prior appointments, if subjects were found busy in their emergency work, care was taken not to interrupt them in their work and again suitable time was taken. Study tool was filled personally by interviewing the subjects. Recruitment and collection of data continued for six months and the process was carried out by the author and one assistant professor and one second year resident medical officer who were previously trained. The details regarding socio-demographic factors, work load problems, patient related difficulties, work place problems, problems due to lack of resources, conflict with other health professionals were obtained from study subjects. Lastly study subjects were asked to give their suggestions too
RESULTS
In relation to workload problems it was observed from table no.1 that104/202(51.5%) subjects always perceived work done by them was too much.129/202 (63.9%) of subjects feel that their job is multitasking.41/202(20.3%) subjects felt that they never get enough time to complete task on the same day.150/202(74.3%) feel that they always had to take care of too many patients.50/202(24.75%) feel that their duty hours were always too long and 67/202 (33.16%) feel the same sometimes.89/202 (44.1 %) of subjects always feel that they do not get time to relax during duty hours and72/202 (35.6%) feels the same sometimes.62/202 (30.7%) subjects always compromise lunch hours for completing their work while 109/202 (54%) do the same sometime.84/202 (41.6%) subjects had to always compromise quality of work because of work
load.48/202 (23.1%) perceived that they or their colleagues always compromise patient care. 32/202 (15.8%) always came across confusion for doing different things because of work load and 75/202 (37.1%) sometimes while97/202(47%) never came across confusion. Patient related problems as perceived by study subjects shown in table no.2, it shows that 47/202 (23.3%) subjects always and 72/202 (35.6%) sometimes face difficulty in dealing with serious patients.47/202(23.3%) subjects always 98/202 (48.5%) sometime face difficulty in dealing with situation when patient expires.33/202 (16.3%) always and 104/202 (51.5%) sometimes face difficulty when patient do not recover for long time 42/202 (20.8%) always and 94/202 (46.5%) sometimes face difficulty in maintaining nursepatient relationship.14/202 (6.93%) always and 97/202 (48.01%) sometimes feel that patient might be physically abusive. 23/202 (11.4%) always and 46/202( 22.8) sometimes feel not to work while taking care of dirty, stinking, bed sores patients. As regards with perception on lack of resources, observation in table no.3 shows that136/202(67.3%) subjects always feel that the staff was inadequate to accomplish work properlyand 55/202 (27.2%) sometimes and 11/202 (5.4%) never feels the same.105/202 (52.0%) subjects always feel that there was lack of enough training and workshops sessions and49/202 (24.3%) sometimes while48/202 (23.8%) never feels the same 97/202 (48.0%) subjects always feel that equipments and supplies were always inadequate while taking care of the patient 71/202 (35.1%) sometimes while34/202 (16.8%)never feels the same 65/202 (32.2%) subjects always feel that working conditions were always poor or not pleasant at workplace and92/202 ( 45.5%) sometimes while 45/202 (22.3%) never had such feeling
DISCUSSION
As shown in Table no 1, 51.5% subjects always perceived work done by them was too much and 74.3% perceived that they always had to take care of too many patients. 44.1 % of subjects always perceived that they do not get time to relax during duty hours.30.7% always and 54% sometimes had to compromise lunch hours for want of completing their work. 41.6% accepted that they had to always compromise quality of work because of work load. 15.8% of the subjects always and 37.1% sometimes came across confusion because of work load. Lambert V.A. Lambert C.E. Ito M. (2002) in their study showed workload on the first step of regression analysis and it was accounted for 1.7%.3 This study also support current study
findings of workload was a major factor.A study by Al-HussamiM et al4 supports the findings of present study who examined concentration as one of the psychological concepts related to work environment that 28% of respondent felt that their concentration is low. The nurses experience physical and mental workload since their job involves standing, walking, bending, lifting and making decisions about patient care and other administrative work. All this leads to exhaustion, which disturbs concentration.103 Present study finding also comparable with study by O. Orji et al which revealed that 83.3% of health care workers had work-related stress.5 Table no 2 shows that23.3% subjects always face difficulty in dealing with serious patients and in case of death of a patient. 16.3% when patient do not recover for long time.20.8% in maintaining nurse-patient relationship and 6.93% always feel that patient might be physically abusive while11.4% always feel not to work while taking care of dirty, stinking, bed sores patients.The survey of 2,00,000 physicians and nurses from 130 general hospitals in Netherlands revealed that 90% have suffered mental and physical violence, 78% have sexual intimidation and over 50% hospital staff have been threatened with weapons.6 Our study finds less percentage of perception of physical violence which may be due to poor patients taking treatment from this public hospital who are usually helpless and dependent on hospital staff. The above table 3 shows that out of total study subjects (n=202), majority i.e. 67.3% feel that staff was always inadequate to accomplish hospital work.48.0% feel that equipments and supplies were always inadequate while taking care of the patient.52.0% feel that there was always lack of enough training and workshops sessions. 32.2% feel that working conditions were always poor or not pleasant at workplace.Study by Pratibha Kane indicated that 66% percent of the nurses were interested in training for new skills and 60% desired more training for their present job. Ongoing training and job rotation are yet not an established initiative taken up by HR mangers in hospitals.7The current study findings about perception of lack of enough training sessions supported by this study. Our study shows even higher percentage for need of training and workshop sessions.Similar findings like current study stated by Nikbakht8who found that Iranian nurses were confronted with many difficulties in two domains: (1) difficulties relating to work settings, such as personnel shortages, heavy workloads, unclear tasks, lack of registered and auxiliary nurses, equipment deficiencies and low salary; and (2) difficulties relating to a poor public image and a low social status of nurses8 .In India, some of the issues related to nurse retention still remain to be tackled – job insecurity for the contractual staff, low pay in both the government and private sectors, lack of a conducive work environment and infrastructure facilities.9 This statement of WHO strongly support our current study findings related to problems due to lack of resources.
CONCLUSION
Workload of the indoor patients in the hospital is the one of the main factor as perceived by the nurses. Dealing with serious, chronically ill and in case of death of patients is another major factor perceived by them causing physical and mental stress. Inadequate staff, inadequate equipment and supplies make the work of the nurses and working conditions poor and unpleasant. It can be concluded that components of working environment in the present tertiary care hospital play a major role interfering with work efficiency of nurses and patient care.
RECOMMENDATIONS
There should be limit of admitting patients in municipal hospitalswhich distort the nurse patient ratio or by increasing indoor facilities including increasing the nursing post so that more patients can be admitted. In service training in personal management, communication skill, stressmanagementand support by the administration needed to make service successful perceived by nurses.
ACKNOWLEDGEMENT
The authors expresses the sense of gratitude to Dean, the staff and research society,Prof and head,Dept of community medicine, Matron and nursing schoolof LTMMC and GH, Sion, Mumbai for permitting, ethical clearance and helping to do the above study. The authors acknowledge the immense help received from the scholars whose articles are cited and included in the references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals, books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=843http://ijcrr.com/article_html.php?did=843REFERENCES
1. Occupational Health Hazards Of Hospital Staff Nurses. Part II Physical, Chemical And Biological Stressors. Triolo PK, American Association of Occupational Health Nurses Journal 1989 July; 37(7); 274-9.
2. Aiken LH et al, Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. J NursAdm, volume 42, page S10.
3. Lambert V.A. Lambert C.E.. Ito M.. ‘Work place stressors, ways of coping and demographic characteristics as predictors of physical and mental health of Japanese hospital nurses’, Int. J. Nurse Stud. 2004: 41: 85-97.
4. Al-Hussami M., Saleh M.Y.N., Abdalkader R.H. andMahadeen A.I. Predictors of nursing faculty members organizational commitment ingovernmental universities, Journal ofNursing Management(2011), 19, 556–566.
5. O. Orji. O. B. Fasubaa. Occupational health hazards among health care workers in an obstetrics and gynaecology unit of a Nigerian teaching hospital 2002; Vol. 22, No.l:Pp75-78.
6. Franx Occupational Health And Safety Management. Nurses article pg 10-11. 2005
7. Pratibha Kane ,Stress causing psychosomatic illness among nurses, American Journal of Nursing 2009 Vol 13 Issue 1: Pp 28-32
8. Nikbakht , Emami, ParsaYekta, Nursing experience in Iran, International Journal of nursing Practice, 2003(9):78-85
9. Hewitt JB et al 1993 Health hazards of nursing: identifying workplace hazards and reducing risks. A WHO NNS Clinical Issues in Perinatal And Women’s Health Nursing 4(2): 320-7
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241611EnglishN2014June13HealthcareENZYMES AND ANTIOXIDANT AS BIOMARKERS IN BREAST CANCER
English2429Pavithra V.English Sathisha T. G.English K KasthuriEnglish D. Siva MallikaEnglish S. Jeevan AmosEnglishObjectives: Current study was undertaken to determine the clinical utility of enzyme biomarkers like Alkaline phosphatase and Lactate Dehydrogenase as well as antioxidant like uric acid in diagnosis , prognosis and metastasis. Methods: 50 clinically and histopathologically confirmed female breast cancer patients of the age group of 30-65 years served as cases and 50 normal healthy females in the same age group served as controls. The parameters were estimated by standard biochemical methods. Results: Serum Alkaline Phosphatase and Lactate Dehydrogenase levels are significantly higher in cases than controls. Where as uric acid levels are non significantly increased in cases. Conclusions: Significant increase of serum enzymes Alkaline phosphatase and Lactate Dehydrogenase along with simultaneous non significant increase of uric acid was observed in the study. These biomarkers can be utilized in remote areas where smaller labs operate at low cost and unexposed to sophisticated knowhow.
EnglishBreast cancer, Alkaline phosphatise, Lactate Dehydrogenase, Uric Acid, BiomarkerINRODUCTION
Breast cancer is the most devastating cancer for women though for that matter any cancer is catastrophic. This breast cancer doesn’t spare women of either developed or developing countries. It affects both countries and in developing countries like India higher than 40% of total breast cancers are prevalent. [1,2] Oxidative stress causing cellular injury has been implicated in the initiation and progression of cancer.[3] Animal and human studies support the part of oxidative stress in the causation of breast cancer.[4,5,6] Antioxidants help in scavenging, disposal and inhibit the production of free radicals or oppose their action and increase with the degree of the disease. [7] Current study is done to reveal the changes in oxidant antioxidant status in breast cancer patients by estimating uric acid an antioxidant. Lactate Dehydrogenase mediates conversion of pyruvate to lactate which is the bottle neck step of anaerobic glycolysis. Increased rates of glycolysis is found in tumour cells producing more amount of lactate by upregulation.[8] Cancers have elevated rate of glycolysis causing high Lactate Dehydrogenase levels. High Lactate Dehydrogenase may mark presence of neoplasia. Alkaline phosphatase is a serum hydrolase enzyme causing removal of phosphate group from nucleotides and proteins in an alkaline medium. Though present in all tissues, it is predominantly concentrated in liver, bile duct, kidney, bone and placenta. Osteoblats produce high quantity of enzyme whenever there is bone repair activity like bone metastasis. Even a mild biliary obstruction is indicated by ALP which implicates liver involvement. Half of all breast cancers go for distant metastases.[11] Current study was undertaken to determine the clinical utility of enzyme biomarkers like Alkaline Phosphatase and Lactate Dehydrogenase as well as antioxidant like uric acid in diagnosis, prognosis and metastasis.
MATERIALS AND METHODS
Our study consisted of 50 breast cancer women and 50 apparently healthy women who are age matched with them were selected. The cancer patients were from Manipal Super Specialty Hospital and City Cancer Centre, Vijayawada. Controls were randomly selected women attending the above hospital. The duration of study was from 2011-2012. Institutional ethical clearance was obtained and informed consent was taken from patients. Inclusion criteria: freshly diagnosedfemale breast cancer Patients and controls in the age group 30- 60 years. Exclusion criteria: Female Patients or controls suffering from tuberculosis, rheumatic fever, hemolyticanemia, hypertension , diabetes mellitus, hepatitis, jaundice, pregnancy or breast feeding, bone diseases, pancreatic disease, congestive cardiac failure, myocardial infarction, ulcerative colitis, other malignancies and patients who had already received or were under treatment for malignancy were excluded from study. Clinical investigations and questionnaires formed the basis of enquiry. Collection of blood Under strictly aseptic conditions 5ml of fasting venous blood was drawn from median CUBITAL /BASILIC vein into BD red capped plain Vacutainers. Vacutainers were made to stand for 10 min at room temperature to allow clotting. Later they were centrifuged at 3000rpm for 10 minutes using Remi8RC centrifuge. Serum was separated and parameters assayed on same day. The parameters were estimated by UV- Visible Spectrophotometer CHEM 7 [manufacturer TransAsia ] using Tulip diagnostics (P) Ltd kits. Alkaline Phosphatase: pNPP method ALP at alkaline pH hydrolyses pnitrophenylphospahate to p-nitrophenol and phosphate. The rate of formation of p-nitrophenol is measured as an increase in absorbance which is proportional to the Alakaninephospahatase activity measured at Hg 405nm Lactate Dehydrogenase: Modified IFCC method Lactate Dehydrogenase catalyses the reduction of pyruvate with NADH to form NAD. The rate of oxidation of NADH to NAD is measured as decrease in absorbance which is proportional to activity of Lactate Dehydrogenase. The wave length used is 340nm. Estimation of uric acid Uricase method Uricase converts uric Acid to allantoin and hydrogen peroxide. The hydrogen peroxide formed further reacts with phenolic compounds and 4-aminoantipyrine by the catalytic action of peroxidase to form a red coloredquinonimine dye complex. The intensity of color formed is directly proportional to the quantity of uric acid present. Statistical method The results were tabulated and analyzed by SPSS software version 16.0 using Independent samples T Test.
RESULTS
Significant stepping up of enzymes Alkaline Phospahatase (p=0.08) and Lactate Dehydrogenase (p=0.02) observed in cases than controls in association with non significant rise of uric acid in cases.
DISCUSSION
Reactive oxygen species (ROS) imbalance generation causes the promotion and progression of breast cancer. [12] Human body encounters these free radicals by enzymatic and non enzymatic antioxidant systems.[13] Purine metabolism end product is uric acid. It being an antioxidant scavenges free radicals there by reducing oxidative stress. [14, 15, 16] Uric acid enhances human life span by protecting against oxidative stress induced aging and cancer. Our study showed non-significant higher levels of uric acid in breast cancer patients. Greater amounts of serum uric acid observed in previous studies establish the protective action against oxidative stress.[17,18]. The elevated levels of serum uric acid may be a compensatory mechanism to regulate the increased oxidative stress. Lactate Dehydrogenase exists in fiveisoenzymes in human tissue. It consists of four monomers composed of two major subunits M and H encoded by Ldh –A and Ldh –B. Ldh-A is mainly expressed in neoplastic cells was revealed by a immunohistochemical study. This property of Ldh-a can be exploited as a biomarker for malignancies.[19,20] Ldh –A the important isoform is expressed in breast tissue. It essays a major role in glycolysis, growth properties as well tumour maintenance of breast cancer cells.[21]. Its activity is up regulated in cancer tissue and serum of breast cancer patients.[22] The up regulation gene for Ldh-A causes its elevated levels in serum. High levels of serum LDH enzyme activity is because of the rupture of cell membrane of a major portion of dividing malignant cells whose metabolism is characterized by anaerobic glycolysis.[23] Our study revealed significant elevation in the serum Lactate Dehydrogenase in breast cancer patients than controls is in accordance with these studies.[24,25,26,27] Alkaline Phosphatase is a very sensitive indicator of liver affection. High serum levels indicate bone or liver metastases. [28] Breast cancer death autopsies reveal 55-75% of them had hepatic metastases.[29] Patient survival relies mainly on hepatic metastases.[30] Hence early diagnosis of liver metastases leads to better prognosis by timely treatment. CT, MRI, PET support in diagnosing liver metastases originating from breast cancer.[31,32] Symptoms of hepatic pathology like jaundice, hepatomegaly, ascitis are found at a later stage of involvement and they bring about worst prognosis. [33] Our study had significant increased serum Alkaline Phosphatase in women affected with breast cancer is supported by these studies.[34,35,36].
CONCLUSION
Our study demonstrated significant increase of serum enzymes Alkaline Phosphatase and Lactate Dehydrogenase along with simultaneous non significant increase of uric acid. Both these enzyme markers can be utilized as one of the biomarker in diagnosis of breast cancer in developing country like India and in remote areas where smaller labs operate at low cost and unexposed to sophisticated knowhow.
ACKNOWLEDGEMENTS
We sincerely remember with gratitude Dr. Anupama K, Consultant Pathologist, Manipal Super speciality Hospital, Vijayawada for permitting to work in their lab. We thank Oncologists Dr Krishna Reddy of Manipal Super Speciality Hospital and Dr. M Gopichand of City Cancer Centre, Vijayawada as well oncosurgeon Dr.Srikanth, Manipal Super Speciality Hospital, Vijayawada for providing us samples and guiding us. Authors acknowledge the immense help received from the scholars whose articles are citied and included in references of this manuscript. The authors are also grateful to authors/ editors/ publishers of all those articles, journals and books from where the literature of this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=844http://ijcrr.com/article_html.php?did=8441. Coughlin, S.S., and Ekwueme, D.U. Breast cancer as a global health concern. Cancer Epidemiology 2009; 33:315-318.
2. Jemal A, Siegel R, Xu J, et al. Cancer statistics, 2010. CA Cancer J Clin 2010; 60: 277-300.
3. Halliwell, B. Oxidative stress and cancer: Have we moved forward? Biochemical Journal 2007; 401: 1-11.
4. Kasapovi?, J., Peji?, S., Stojiljkovi?, V., Todorovi?, A., Radoševi?-Jeli?, L., Sai?i?, Z.S. and et al. Antioxidant status and lipid peroxidation in the blood of breast cancer patients of different ages after chemotherapy with 5-fluorouracil, doxorubicin and cyclophosphamide. Clinical Biochemistry 2010; 43: 1287-1293.
5. Yeon, J.Y., Suh, Y.J., Kim, S.W., Baik, H.W., Sung, C.J., Kim, H.S. et al. Evaluation of dietary factors in relation to the biomarkers of oxidative stress and inflammation in breast cancer risk. Nutrition 2011; 27: 912-918.
6. Mianying Wang, KapilDhingra, Walter N Hittelman, Joachim G, LiehrMariza de Andrade, Donghui Li. Lipid Peroxidation induced Putative Malondialdehyde - DNA Adducts in Human Breast Tissues’. Cancer Epidemiology, Biomarkers and Prevention 1996; 5:705-10.
7. Singh R, Singh RK, Mahdi AA, Singh RK, Kumar A, Tripathi AK. Circadian periodicity of plasma lipid peroxides and other antioxidants as putative markers in gynecological malignancies. In Vivo 2003; 17:593-600.
8. Cross W.E. et al. Control Mechanisms in Cancer .eds, Raven Press, New York 1976; 411-423.
9. Arathi G, Sachdanandan P. Therapestic effect of Semecarpusanacardium Linn, nut, milk extract on carbohydrate metabolizing and mitochondrial TCA cycle and respiratory chain enzymes in mammary carcinoma rats. Journal of Pharmacy and Pharmacology. Inc 2003; 55 : 1283-1290.
10. Surya Surendren P., Jayanthi G and Smitha K.R. In Vitro Evaluation of the Anticancer Effect of Methanolic Extract of Alstoniascholaris leaves on Mammary Carcinoma. Journal of Applied Pharmaceutical Science 2012; 02 (05):142-149
11. Er O, Frye DK, Kau SW, et al. Clinical course of breast cancer patients with metastases limited to the liver treated with chemotherapy. Cancer J 2008; 14: 62-68.
12. Aghvami T, Djalali M, Kesharvarz A. Plasma level of antioxidant vitamins and lipid peroxidation in breast cancer patients. Iran J. Publ. Health 2006;35- 42
13. Yeh CC, Hou MF, Tsai SM, Lin SK, Hsiao JK, Huang JC, et al. Superoxide anion radical, lipid peroxides and antioxidant status in the blood of patients with breast cancer. ClinChimActa 2005; 381(1-2): 104–111.
14. FarukTas, Hansel H, Belce A, Ilvan S, Argon A, Camlica H, et al. Oxidative stress in breast cancer. Med Oncol 2005; 22 (1): 11-15.
15. Ames, B.N., Cathcart, R., Schwiers, E. and Hochstein, P. Uric acid provides an antioxidant defense in humans against oxidant and radical caused aging and cancer. Proceedings of the National Academy of Sciences.1981. A hypothesis lipid peroxidation/ascorbic acid/pri- mate evolution/erythrocyte aging.1981;78:6858- 6862
16. Cohen, A.M., Aberdrotha, R.E. and Hochstein, P. Inhibition of free radical induced DNA damage by uric acid. FEBS Letters, 1984;174: 147-150
17. Muraoka, S. and Miura, T. Inhibition by uric acid of free radicals that damage biological molecules. Toxicology and Pharmacology 2003; 93: 284-289. 18. Stinefelt, B., Leonard, S.S., Blemings, K.P., Shi, X. and Klandorf, H. Free radical scavenging, DNA protection, and inhibition of lipid per oxidation mediated by uric acid. Annals of Clinical and Laboratory Science 2005; 35: 37-45.
19. O. M. E. Abdel-Salam et al. Open Journal of Molecular and Integrative Physiology 2011; 1: 29-35
20. G. Krishna Veni Et Al. Clinical Evaluation of oxidative stress in women with breast cancer.Recent Research in Science and Technology 2011; 3:55-58.
21. Ming Zhou, Yuhua Zhao, Yan Ding1, Hao Liu, ZixingLiu,Oystein Fodstad, Adam I Riker, et al. Molecular Cancer 2010; 9:33.
22. Mark. E, Stark, MD, CPT, Usaf.MC, Morgan C. D, et.al. Fatal Acute TumorLysis Syndrome with Metastatic Breast Carcinoma. Cancer 1987; 60:762-764.
23. Koukourakis, M., Kontomanolis, E., Giatromanolaki, A.,et al. Serum and tissue LDH levels in patients with breast gynaecological cancer and benign diseases. Gynecologic and Obstetric Investigation. 2009; 67(3):162-168.
24. Jawed Akther, ShabeehNasar and NajninKhanam. Role of LDH as Prognostic Biochemical Marker for Breast Cancer among Poor Patients, a Study at Rural Hospital Md. Indian Journal of Surgery. 10.1007/s12262- 012-0618-1
25. ChandrakanthKh, Nagaraj, JayaprakashMurthy, D, Satishkumar D, and AnandPyati. Study Of Serum Levels Of Gamma- GlutamylTransferase, Lactate Dehydrogenase, Malondialdehyde And Vitamin-E, In Breast Cancer. International Journal of Pharma and Bio Sciences 2011 OctDec; Vol 2, issue 4.
26. Sandhyamishra, D.C.Sharma and Praveen Sharma. Studies of Biochemical parameters in Breast cancer with and without metastasis. Indian Journal of Clinical Biochemistry 2004;19(1): 71-75.
27. Konjevic, G., Jurisic, V., and Spuzic, I. Association of NK cell dysfunction with changes in LDH characteristics of peripheral blood lymphocytes (PBL) in breast cancer patients. Breast Cancer Research and Treatment. 2001; 66(3):255-263.
28. Crivellari, D., Price, K. N., Hagen, M., et al. Routine tests during follow-up of patients after primary treatment for operable breast cancer. International (Ludwig) Breast Cancer Study Group (IBCSG). Annals of Oncology: Official Journal of the EuropeanSociety for Medical Oncology / ESMO. 1995; 6(8):769-776.
29. Hoe AL, Royle GT, Taylor I. Breast liver metastases--incidence, diagnosis and outcome. J R Soc Med 1991; 84: 714-716
30. Singletary SE, Walsh G, Vauthey JN, et al. A role for curative surgery in the treatment of selected patients with metastatic breast cancer. Oncologist 2003; 8: 241-251.
31. Clevert DA, Jung EM, Stock KF, Weckbach S, Feuerbach S, Reiser M, et al. Evaluation of malignant liver tumors: biphasic MSCT versus quantitative contrast harmonic imaging ultrasound. Z Gastroenterol 2009; 47: 1195- 1202
32. .Berman CG, Clark RA. Diagnostic imaging in cancer. Prim Care 1992; 19: 677-713.
33. Wyld L, Gutteridge E, Pinder SE, et al. Prognostic factors for patients with hepatic metastases from breast cancer. Br J Cancer 2003; 89: 284-290.
34. Ramaswamy, G., Rao, V.R., Krishnamoorthy, L., Ramesh, G., Gomathy, R. and Renukadevi, D. Serum levels of bone alkaline phosphatase in breast and prostate cancer with bone metastasis. Indian J. Clin. Biochem.2000; 15 (2): 110-113.
35. Lamerz, R., Stieber, P. and Fateh - Moghadam, A. Serum marker combinations in human breast cancer (review). In Vivo 1993; 7 : 607-13
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241611EnglishN2014June13HealthcareSEX DETERMINATION IN FEMUR: PRESENCE OR PROMINENCE OF ITS FEATURES
English3035Sayee RajangamEnglish Vidhya REnglish Siva CharanEnglish Flossie JayakaranEnglishObjectives: The present study was undertaken to find out whether the ‘general features’ in the femur by their presence or prominence could aid in its sex determination. Material and Method: 63 femur available at the International Medical School Bangalore were subjectively grouped into 34 male and 29 female femur. The total of the studied features becomes 504 (63x8). The features were graded as single ‘+’ and double ‘++’ for their presence or prominence. Results: The presence or prominence of the features in male and female femur was observed to be around 50%. Between the right and left sides, the total was more for the right side for the presence (141/251) or prominence (147/253) of the features. Within the right side, the prominence of the features was more (147/288) and within the left side the presence of the features was more (110/216). For the male femur, the presence (54%) or prominence (58%) of the features was found to be high for right side; within the right it was prominence (50.2%) and within the left (53.3%) it was presence of the features. For the female femur too, the presence (59%) or prominence (58.3%) were found to be high for the right; but, within the right (51.5%) and left (52%) it was the prominence of the features. For male femur, the high scores (22/34) were found for the presence of the medial epicondyle and depth of intercondylar fossa and for female femur, it was the prominence of nutrient foramen (25/29,86.2%). Conclusion: From the present study, it is seen, that the nutrient foramen could be ‘the’ constant feature in the sex determination of female femur followed by ‘prominence of the features.’
Englishfemur, features, male, female, right, left.INTRODUCTION
The process of sex determination in unknown skeletal materials, in case it has to be accurate, usually depends on the (i) available fragmented or isolated remains; (ii) aging (iii) non-availability of ‘standards’. That is why, it is reported that the problems exist between the objective (‘descriptive measures, experience’) and subjective (measurements, statistical methods) sexing methods. (Krogman 1962)1 For the long bones of the adult, the ‘size alone’ could be the key factor in sex determination. (Stewart 1951-cited in Krogman 1962)1 Moreover, from the standard text book in Anatomy, it is seen, that the typical male long bones are ‘large, long, rough and massive’ than the typical female long bones.(Standring 2008)2 It is well known, that among long bones, it is the femur, which is the most ‘studied’ bone. (Krogman 1962)1 During osteology lesson in femur, the general and specific features are described. At that time, it was observed that there are some general features, which seemed to be ‘prominent’. Hence, the present study was undertaken to find out whether ’just the presence or the prominence of the features’ could contribute to the subjective method of sex determination in femur.
MATERIAL AND METHOD
A total of 63 femur available at the International Medical School, Bangalore were subjectively grouped into 34 male and 29 female femur. There were 36 right and 27 left femur. Further grouping of the femur were done as per the subjective sexing and the sides: Male: 19 right and 15 left; Female: 17 right and 12 left. A total of 8 features were studied for their presence or prominence in the femur. On multiplication, it is seen that the total features were 504 (63x8=504); out of which for the male femur, it was 272 (34x8) and for the female femur, it was 232 (29x8). The grading given to the presence of the features was single plus (+) and for the prominence was double plus (++). In Appendix 1 is listed the 8 features. The percentage analysis and the X2 test were the applied statistical measures to the obtained values of the 8 features.
RESULTS
The values gathered for the 8 features from femur were studied under 6 categories for their ‘presence or prominence’: total for the male and female (1.1) and the right and left sides (1.2); total for the right and left sides of male and female femur (1.3 and 1.4); total between the right and left of male and female femur (1.5 and 1.6).
1.1: The total of the ‘presence or prominence’ of the features in the femur was observed to be more or less of equal percentage i.e. around 50%. 1.2: Between right and left sides, the total was more for the right for both the presence (141/251) as well as the prominence (147/253) of the features. When only the sides were considered, within the right, ‘prominence’ of the features was more (147/288) and within the left, ‘presence’ of the features was more (110/2161). 1.3: For the male femur, between right and left, ‘presence (54%) and prominence (58%)’ of the features were found to be of high percentages for the right; within the right it was ‘prominence (50.2%)’ and within the left (53.3%) it was ‘presence’ of the features. ‘presence (59%) and prominence (58.3%)’ of the features were found to be of high percentages for right; but, within the right (51.5%) and left (52%), it was ‘prominence’ of the features. 1.5: Between male and female femur of right side, male femur showed high percentages both for ‘presence (53.2%) and prominence (52.4%)’ of the features. 1.6: Between male and female femur of left side, male femur showed high percentages both for ‘presence (58.2%) and prominence (52.8%)’ of the features. The X2 test showed significant values for sex and side determination of the femur.
It was seen that in male femur, the high scores (22/34) were found for the presence (+) of the features numbered 4 and 8 (medial epicondyle, depth of intercondylar fossa); whereas for the female femur, it was for the feature number 1(21/29,72.4%) (lesser trochanter). It is to be noted, that, among the 8 features, the feature that stood out was nutrient foramen number 2;86.2%) in the female femur.
DISCUSSION
From literature review, it was seen, that the long bone that has been studied in detail in the human skeleton is the femur. In 1985, Meindel et al analysed the application of non-metric (subjective) versus metric (objective) parameters for sex determination in the skeletal material and found ‘no significant difference in the accuracy; so long care and skill are employed’. (Meindel et al 1985)3 Studies in femur have reported subjective and or objective methods of sex determination. (Soni et al 2010, Bhosale and Zambare 2013)4,5 In the present study, from the regular description of the general features of the femur, 8 were selected for their ‘presence or prominence’ and its application to sex determination.
Present study
Interpretations
=The total occurrence of the ‘presence or prominence’ of the 8 features in the male and female femur was observed to be more or less the same.
= Both ‘presence or prominence’ of the features have occurred more on right femur.
= Both male and female right femur showed more number of ‘presence as well as prominence’ of the features.
= Male femur for the occurrence of the features within the right or left sides showed for the right side; ‘prominence’ and for the left side ‘presence’ of the features.
= Female femur when considered for the occurrence of the features within the sides showed ‘prominence’ of the features on both sides. The X2 test showed that the features selected could contribute significantly in the sex determination of femur.
The ‘prominence of the features’ in the female femur may be correlated to them performing more tasks; especially pertaining to their ‘daily chore activities’.
Krogman1 in 1962 has summarized on 3 issues on the sexing of the skeletal remains and they are given below more or less in verbatim. i) sexing of unknown skeletal material could depend relatively on the availability of the complete skeletal material. The proposed percentage of the accuracy for the adult long bones alone is around 80%. In the present study, the subjective sexing was carried out on the available known and complete skeletal material i.e. femur. The feature which showed 86.2% is the nutrient foramen in the female femur. ii) The estimates are usually based on description, dimensions, proportions which are the morphology and morphometry methods. It seems that the ‘elaborate statistical analysis does not raise appreciably the average’. Hence, it is paraphrased, that with statistics ‘one can be sure or at least more sure in an individual case’. In the present study, the X2 test did made it sure that the 8 features could be utilized in sex determination of the femur and has identified the ‘nutrient foramen as the feature in female femur.’ iii) The standards of the ‘morphological and morphometric sex differences’ in the skeletal material may differ depending on the population of the samples. This notion is considered to be true with reference to ‘dimensions and indices’. As a general rule, the standards should be used with reference to the group from which they were drawn and upon which they are based and they are not ‘ordinarily interchangeable’. In the present study, the observed differences could be due to the sample size and the selected features. Moreover, as mentioned by Krogman1 the femur were available; but there was lack of information about their ‘population sample. In view of the non-availability of any publications similar to the present study, the study could not be discussed further. The ‘presence or prominence of the features’ could be because of the genetic, hormonal, environmental conditions, such as nutrition and bio-mechanic forces on the bones/joints/movements. It may be noted, that a paper on ‘Variations in the presence and prominence of the features in the long bones of the limbs’ has been published (Rajangam et al 2014)6 . In that study, for femur, 16 features were analysed. As a continuation, for the present study 8 were selected in tracing their contribution towards the subjective way of determining the sex in femur.
CONCLUSION
It may be concluded, that for subjective sex determination of the femur, in addition to the thickness, size, length, robustness and massiveness, the features and their findings from the present study could also be applied.
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=845http://ijcrr.com/article_html.php?did=8451. Krogman WM. The Human Skeleton in Forensic Medicine. Illinois: Charles C Thomas Pub Ltd; 1969.
2. Standring S. Gray’s Anatomy. The Anatomical Basis of Clinical Practice. 40th edition. London: Churchill Livingstone Elsevier; 2008.
3. Meindl RS, Lovejoy CO, Meneforth RP, Don Carlos L. Accuracy and Direction of Error in the Sexing of the Skeleton: Implications. AJPA 1985; 68, 79-85.
4. Soni G, Dhall U, Chhabra S. Determination of Sex from Femur: Discriminant Analysis. Journal of Anatomical Society of India 2010; 59(2): 216-221.
5. Bhosale RS, Zambare BR. Sex Determination from Femur using Length of Femur in Maharashtra. J of Dental and Medical Sciences 2013; 3(4): 1-3.
6. Sayee Rajangam, Vidhya R, Shiva Charan, Flossie Jayakaran. Variations in the presence and prominence of the features in the long bones of limbs. Int J Cur Rev 2014; 6(7):58- 64.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241611EnglishN2014June13HealthcareRESULTS OF EARLY EXCISION OF POST TRAUMATIC HETEROTROPHIC OSSIFICATION OF ELBOW -FOLLOW UP REPORTS ON 17 PATIENTS
English3642Ravichandran S.English Surendher Kumar R.English Ramesh PeriyasamyEnglish Krishnagopal R.EnglishWe review our results of 17 patients, who had early excision 5 months (3-8 months) of post traumaticHeterotrophic ossification (HO) of elbow,followed by medical treatment with indomethacin to prevent recurrence, in our study. The average age group of our patients is 24 years (15-38). There were 12 males and 5 females. The patients were followed up for average of 58 months (38-90 months). The mean preoperative Mayo Elbow Performance Score (MEPS) was 63(40-80), and the mean MEPS core at final follow up is 90(75-100). According to MEPS, 13 patients had excellent result and 4 patients had good result. All the patients were asymptomatic at the time of final follow up. One patient with intra operative ulnar nerve injury recovered partially, and remained with some disability at final follow up. Patient with pre operative median nerve palsy recovered completely at 3 months post operatively.
EnglishHeterotrophic Ossification, MEPS, Early ExcisionINTRODUCTION
Heterotrophic ossification of elbow occurs in approximately two to three percent of patients with the local trauma1 .The severity of the trauma can vary from soft tissue injury to fracture, and fracture dislocation of the elbow. The factor that increases soft tissue injury such as passive stretching2 is believed to predispose to the formation of heterotrophic ossification of elbow. The choice of treatment ofpre existingHO of elbow associated with functional disability is surgical excision3,4,5,6,7. The timing of surgical excision4,5,6,7,8,9,10,11 , the method of prevention of recurrence9,11, and the actual risk of recurrence9,11,12,however, remains a controversial subject of debate mainly due to unpredictable outcome reported in the literature. In our study, we retrospectively reviewed our results of early excision of heterotrophic ossification of elbow in patients with trauma in young age.
PATIENTS AND METHODS
From 2006 to 2012, we encountered 47 patients with ankylosis of elbow in our hospital. Nine patients had complete osseous ankylosis of elbow.Fifteen patients had fibrous ankylosis of elbow without HO. Twenty three patients had ankylosis with HO. All the patients were less than 40 years of age, with history of local trauma, either soft tissue or bony injury, who presented to us early, (arbitrarily within 8 months)were included in our study. Patients with associated head injury, more than 40 years of age and with duration more than eight months were excluded from our study. Eighteen patients met our selection criteria. Adequate clinical data and radiographs were collected from the medical records. One patient lost to follow up. Thus, we report our results of 17 patients in our study. The average age of the patients was 24 years (15-38).
Twelvepatients were male and five females. The right hand was involved in ten patients and all were dominant on the same side, left hand was involved in seven patients, with one patient dominant on the injured side.Fifteen patients had native treatment, which includes massage of affected area using oil, eggs and bandage, which are commonly practiced in developing countries. Three patients had untreated posterior dislocation of elbow. One patient underwent open reduction and internal fixation for intercondylar fracture of humerus, and another patient had conservative treatment in the form of above elbow slab application for three weeks.The patients had functional disability as the main complaint, and showed no improvement in arc of motion after 4 weeks of supervised physiotherapy.Pre operativeanteroposterior and lateral radiograph of the affected elbow were taken.The heterotrophic ossification was predominantly postero medial in five patients, posteromedial and lateral in ninepatients,and anterolateral in three patients. All patients were treated with excision of heterotrophic ossificationand soft tissue contracture release. One patient had displaced fracture distal shaft of humerus, and underwent simultaneous internal fixation with DCP and autogenous bone grafting. Three patients had unreduced posterior dislocation. All of them were reduced after adequate soft tissue release by both medial and lateral approach. No patient required triceps lengthening. The approach was selected appropriate to the site of heterotrophic ossification. Thus onepatient had medial approach, ten patients required bothmedial and lateral, five patients lateral, and one patient posterior approach. Post operatively patients were treated with oral Indomethacin 25 mg three times a day for 6 weeks,along with Pantoprazole 40 mg once a day in empty stomach.Three doses of first generation of cephalosporin, preoperatively one dose and two doses postoperatively at 8 hours interval, was given prophylactically for all the patients. The active and active assisted motion was started from the nextday of surgery and continued approximately for 12-18 months to consolidate the gain in arc of motion.The patients with untreated posterior dislocation were immobilized for two weeks in cast and mobilization started thereafter. The clinical evaluation was done with MEPS pre operatively, and at final follow up. Radiographs in antero posterior and lateral views taken pre operatively, post operatively, and at final follow up, for the assessment.
RESULTS
The mean duration from the time of injury and time of surgical excision is 5 months (3-8 months). The mean duration of follow up was 58 months (38-90 months).The average mean preoperative arc of motion is 41deg(0-110deg). The mean post operative value of extensionis 17 deg (0-40 deg),flexion of 124deg(100-140),and the arc of motion is 104deg(60-140). The mean pre operative rotation is 91deg (40-140)and the mean post operative arc of rotation is 132deg(100-160). The mean post operative MEPS increased to 90(75-100) at final follow up, from the pre operative value of 63(40-80). Three patients developed grade 1 mild laxity on the medial side, but remained unaffected on their routine activities at final follow up.According to MEPS, 13 patients had excellent result and 4 patients had good result. The three patients who underwent bony procedure had complete union.
There was no evidence of recurrence of heterotrophic ossification. One patient with intra operative ulnar nerve injury recovered partially, and remained with some disability at final follow up. Patient with pre operative median nerve palsy recovered completely at 3 months post operatively. Seven patients had mild abdominal discomfort initially at one week of Indomethacin treatment, but were able to complete the course without any further complaints. All the patients remained satisfied with the procedure at final follow up.
DISCUSSION
The causes for heterotrophic ossification are varied13,14,15. They include local injury, head injury, spinal cord injury, surgery to the elbow,neurological conditions such as stroke, poliomyelitis, thermal and electrical burns. The hip, elbow, knee, and shoulder are commonly involved in heterotrophic ossification3 . The clinical course is usually progressive initially, and then remains static17, and may spontaneously resolve in some case 16. The choice of treatment in patient withpre existing HOwith functional disability is surgical excision. The timing of surgical treatment is still a matter of debate. The earlier studies have largely reported delayed surgical exciosion of HO, approximately 18-20 months, after maturation of HO3,4,5,6. The maturation of the bone was decided based on serum alkaline phosphatase, radiographs, bone scans, which were subsequently found to be unreliable indicators. Moreover, the status of maturity of bone, levels of alkaline phosphatase, and positive bone scans were not predictive of recurrence risk of HO after surgical excision3,9 . Several authors have favored early excision as it makes the procedure easier, less traumatic and decrease the period of functional disability and provides equally good functional results with low rate of recurrence 8,9,12,18,19,20.The reported number of patients in the literature treated with early excision is less, and the etiologies are varied in those papers. Our series had young patients with only trauma as single etiology. The early surgical intervention in our series also helped us to reconstruct the fracture in one patient, and relocate the elbow in three cases with unreduced dislocation of elbow.The functional outcome is significantly improved as assessed by MEPS score.The complication was also comparable with other series, with one patient developing ulnar nerve palsy,which recovered partially.Thus the early excision, apart from making surgery easier and limiting soft tissue contracture8,9,10, provides good functional results compared to delayed excision of HO3,12 . Regarding the method of prophylaxis, despite the proven success of radiotherapy, or indomethacin, or combination of both in the hip following primary arthroplasty, acetabular fracture reconstruction, and post surgical excision of HO21,22,23,24,25, the evidence in case of elbow is inadequate. The risk of recurrence of HO of elbow in patients with head injury is postulated to be substantial than due to trauma3 . Though theoretically the risk of recurrence is high, except for one series in which patients with head injuries were included3 , the other series have reported low recurrence rate without prophylaxis7, 12, or with radiotherapy9,11. The high recurrence rate in DE Garland series 3 have been attributed to the severity of the neurological status of the patient. Also, the risk of wound complications, and the theoretical risks of sarcoma due to radiation in young patients with longevity of life have been also debated in the literature 9,12. Since the risk of recurrence contemplated to be low for the patients with trauma18,19,20, ease and low cost of administration of Indomethacin despite its gastrointestinal side effects, and cost of radiotherapy, we treated our patients with early excision, and prophylaxis with Indomethacin.There was no case of recurrence of HO in our patients at final follow up. The major problem associated with Indomethacin is its gastrointestinal side effects.
CONCLUSION
Our series is unique in the way that it consist 17 patients, one of the large series to have undergone early excisionin a single etiology group. The drawback in our study is nature of the study, retrospective, and the limited number of cohorts to provide a statistical significance. Despite these limitations, we favor early excision of Heterotrophic Ossificationof elbow in post traumatic patients, along with prophylactic oral Indomethacin and early ROM exercise, which is evident with our encouraging results.
Englishhttp://ijcrr.com/abstract.php?article_id=846http://ijcrr.com/article_html.php?did=8461. Thompson, H. C., III; and Garcia, A.: Myositis ossificans: aftermath of elbow injuries. Clin.Orthop. 1967; 50: 129-134.
2. Evans EB. Orthopedic measures in the treatment of severe burns. J Bone Joint Surg Am. 1966;48:643-69.
3. Garland, D. E.; Hanscom, D. A.; Keenan, M.A.; Smith, C.; and Moore, T.: Resection of heterotopic ossification in the adult with head trauma. J. Bone and Joint Surg. Oct. 1985; 67- A:1261-1269.
4. Hoffer, M. M.; Brody, G.; and Ferlic, F.:Excision of heterotopic ossification aboutelbows in patients with thermal injury. J.Trauma1978; 18:667-670.
5. Peterson, S. L.; Mani, M. M.; Crawford, C.M.; Neff, J. R.; and Hiebert, J. M.:Postburn heterotopic ossification: insights for management decision making. J. Trauma 1989; 29:365-369.
6. Roberts, J. B.; and Pankratz, D. G.: The surgical treatment of heterotopic ossification at the elbow following long-term coma. J.Bone and Joint Surg. July 1979; 61-A:760- 763.
7. David Ring, Jesse B. Jupiter. Operative Release of Complete Ankylosis of the Elbow Due to Heterotopic Bone in Patients without Severe Injury of the Central Nervous System.J Bone Joint Surg Am. 2003;85:849-857
8. Beingessner DM, Patterson SD, King GJ.Early excision of Heterotopic bone in the forearm. J Hand Surg [Am]. 2000;25:483-8.
9. McAuliffe JA, WolfsonAH.Early excision of heterotopic ossification about the elbow followed by radiation therapy. J Bone Joint Surg Am. 1997;79:749-55.
10. Viola RW, HanelDP.Early “simple” release of posttraumatic elbow contracture associatd with heterotopic ossification. J Hand Surg [Am]. 1999;24:370-80.
11. GARLAND. D. E., and RHOADES, M. E.: Orthopaedic Management of Brain-Injured Adults. Part II. Clin.Orthop., 131: 111-122, 1982.
12. Alok Gaur, Marc Sinclair, Enzo Caruso, Giuseppe Peretti and David Zaleske. Heterotopic Ossification Around the Elbow Following Burns in Children: Results After Excision .J Bone Joint Surg Am. 2003;85:1538-1543.
13. DE Garland, CE Blum and RL Waters.Periarticular heterotopic ossification in head-injured adults.Incidence and location.J Bone Joint Surg Am. 1980;62:1143-1146
14. R. H. Wittenberg, U. Peschke, U. B?tel;Heterotopic Ossification After Spinal Cord Injury Epidemiology And Risk Factors,Bone Joint Surg [Br] 1992; 74-B :215- 8.
15. T. W. Axelrad,B. Steen,D. W. Lowenberg,W. R. Creevy;T. A. Einhorn. Heterotopic ossification after the use ofcommercially available recombinant human bone morphogenetic proteins in four patients,J Bone Joint Surg [Br] 2008;90-B:1617-22
16. Munster AM, Bruck HM, Johns LA, Von Prince K, Kirkman EM, RemigRL.Heterotopic calcification following burns: a prospective study. J Trauma.1972;12:1071-4.
17. L. Sazbon, T. Najenson, M. Tartakovsky, E. Becker, Z. Grosswasser. Widespread Periarticular New-Bone Formation In LongTerm Comatose Patients. British Editorial Society Of Bone And Joint Surgery 1981; Vol. 63-B, No. 1, 1981, 120-125
18. Garland, D. E.: A clinical perspective on common forms of acquired heterotopic ossification. Clin.Orthop.1991; 263:13-29.
19. Hastings, H., II; and Graham, T. J.: The classification and treatment of heterotopic ossification about the elbow and forearm.HandClin. 1994; 10:417-437.
20. Jupiter, J. B.: Heterotopic ossification about the elbow. In Instructional Course Lectures,The American Academy of Orthopaedic Surgeons. Vol. 40, pp. 41-44. Park Ridge,Illinois, The American Academy of Orthopaedic surgeons, 1991.
21. T. N. Board,A. Karva,R. E. Board,A. K. Gambhir,M. L. Porter.The prophylaxis and treatment of heterotopic ossification following lower limb arthroplasty.J Bone Joint Surg [Br]2007;89-B:434-40.
22. Ahrengart L, Lindgren U, Reinholt FP. Comparative study of the effects of radiation,indomethacin, prednisilone and ethane-1-hydroxy-1, 1-disphonate (EHDP) in the prevention of ectopic bone formation. ClinOrthop 1988;229:265-73.
23. Burd TA, Lowry KJ, Anglen JO. Indomethacin compared with localized irradiation for the prevention of heterotopic ossification following surgical treatment of acetabular fractures. J Bone Joint Surg [Am] 2001;83-:1783-8.
24. Matta JM, Siebenrock KA. Does indomethacin reduce heterotopic bone formation after operations for acetabular fractures?: a prospective randomised study. J Bone Joint Surg [Br] 1997;79-B:959-63.
25. McLaren AC. Prophylaxis with indomethacin for heterotopic bone after open reduction of fractures of the acetabulum. J Bone Joint Surg [Am] 1990;72-A:245-7.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241611EnglishN2014June13HealthcareTO STUDY THE EFFECTIVENESS OF THERAPEUTIC INSOLES IN PATIENTS WITH OSTEOARTHRITIS
English4346Rhucha JadhavEnglish James GhagareEnglish Rachana DabadghavEnglish Savita RairikarEnglish Ashok ShyamEnglish Parag SanchetiEnglishObjective: To find out if there are any significant pain relief, change in stiffness and change with respect to difficulty in performing activities of daily living. Methods: Thirty patients suffering from osteoarthritis were taken and they were evaluated on the basis of Western Ontario and McMaster Universities Arthritis Index (WOMAC) scale. The patients who had a verbal analog scale (VAS) more than 15 were put in an experimental group and the remaining 15 were put in the control group. A removable therapeutic insole was given to the experimental group for a period of 3 weeks. They were then reevaluated based on the WOMC scale. Results: Therapeutic insoles show to have no significant effect on the pain, stiffness or on the activities of daily living p?0.05. Conclusion: There was no significant difference seen in components of pain, stiffness, difficulty in Activities of daily living (ADLs) in patients of controlled and experimental group which derives that the conventional therapy for osteoarthritis is beneficial alone and the conventional therapy used along with modification of insole makes no significant changes in pain component of the patient.
EnglishOsteoarthritis, WOMAC, physiotherapy, insole.INTRODUCTION
Osteoarthritis is the most common type of Arthritis and generally develops in people who are above 50 years of age.It tends to be more common in women than in men. It affects most commonly the knees, hips and small joints of hands. The biomechanical stresses that affect thearticular cartilage and subchondral bone1, 3 Typically, the joints affected by Osteoarthritis show the features mainly damage to cartilage (cartilage lines the bones and reduces friction, allowing the joints to move smoothly and easily). Bony growths developing around the edge of the joints after cartilage loss the bone starts wearing down and the body creates new bone to keep up with the wear they are termed as Osteophytes.Mild inflammation of tissues around the affected joints termed as synovitis.1, 2, 4 Insoles help attain a correct posture, through proprioception, so the muscles keep the feet and body balanced. They help in maximum shock absorption, are efficient in off - loading. Most of the insoles are scientifically designed to match foot contours which help in maximum reduction of shear stress. 8,9,10 The Insoles that our study provides to the patient is made up of synthetic sheets and Evasheets. They are designed to provide shock absorption and high resistance to compressive deformation.10 The main purpose of our study is mainly to focus on pain reduction through footwear modification as most of the studies focus on dealing with osteoarthritis with the help of diet modification, regular exercise, use of assistive devices like canes / stick but there is very few research done on footwear modification on patients with osteoarthritis which would help them lead a pain free lifestyle.
MATERIALS AND METHODS
The study was done on 30 subjects. The study was approved by the ethics committee of the institution and a written informed consent was taken from all the subjects. The subjects wereselected according to inclusion and exclusion criteria and were divided into controlled and experimental group.Inclusion criteria was patients with osteoarthritis who are mobile, independent and able to do activities of daily living ,who use footwear like sandals or sports shoes during their activities of daily living and those diagnosed as Osteoarthritis by surgeons and physicians. Exclusion Criteria werepatients with previous ankle surgeries or LL fractures or total knee replacement surgery,with existing limb length discrepancy,with any neurological deficit,using existing footwear modifications like orthosis.Both the groups were asked to continue with their diet modification and regular exercise.The sampling was done on the basis on Pain evaluation and verbal analogue scale was noted,those whose pain was more than 5/10 were selected for experimental study. An evaluation was done prior to modification of insole which was mainly done using WOMAC scale. Follow up was done at the end of intervention period (3 weeks) and they were again evaluated on using WOMAC scale.
RESULTS
The result was analysed using SPSS software version 12. The between group analysis was done using Mann Whitney test and within group analysis was done using Wilcoxon sign rank test. Table 1 shows significant difference p0.05
DISCUSSION
The purpose of our study was to find out if there were any significant changes in pain, stiffness and of daily living in patients with osteoarthritis.Osteoarthritic patients normally show changes in gait pattern due to various changes like increase in knee adduction,weakness of quadriceps muscles and antalgic gait due to reduction of medial joint space which causes friction and pain during walking, stair climbing or similar activities.The concept of introducing an therapeutic insole in the patients footwear was to ensure uniformity of weight distribution, reducing direct stress on the knee joint and help in maximum shock absorption which in turn reduces the wear and tear of the joint.8.9It was found that there was significant reduction in pain during activities of daily living which was done in pre and post intervention period using WOMAC scale. It was mainly due to properties of insoles which is made of synthetic materials mainly Evasheets which add to the cushioning effect and help in maintaining the foot contours and get moulded according to the footwear shape. This type of insole mainly is efficient as it doesn’t wear with time or over use as in contrast to use of silicon which wears out with time and hence prove less efficient in serving the purpose. Also the patients were following conventional treatment of exercise and there was uniformity in the exercise they performed so the reduction in pain in pre and post WOMAC can also be due to the exercise regime followed by the patient through the duration of 3 weeks. There was no significant changes in controlled group against experimental group of patients which was mainly due to the controlled group undergoing conventional treatment of osteoarthritis which helped in strengthening of muscles as against the patients who used insole and followed the conventional treatment of osteoarthritis along with modification in which the insole might have just added slight complementary benefit in addition to the benefits provided by exercise.
CONCLUSION
The conclusion of our study shows that the therapeutic insoles show significant changes in components like pain reduction and components of difficulty in ADLS in experimental group who were taking conventional exercises for osteoarthritis along with insole modification. The study shows that the insole doesn’t have any significant changes on stiffness which is a rough guide to inflammatory process in the jointsand it cannot be corrected with use of any external modification like insole. There was significant difference in the Pre WOMAC scale and Post WOMAC scale of the patients with osteoarthritis which shows the effectiveness of insole in patients which is due to the conventional treatment taken by the patients There was no significant difference seen in components of pain, stiffness, difficulty in ADLS in patients of controlled and experimental group which derives that the conventional therapy for osteoarthritis is beneficial alone and the conventional therapy used along with modification of insole makes no significant changes in pain component of the patient.
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles were 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.We would also like to thank all our participants and for their valuable time and participation.
Englishhttp://ijcrr.com/abstract.php?article_id=847http://ijcrr.com/article_html.php?did=8471. Altman R, Alarcón G, Appelrouth D, Bloch D, Borenstein D, Brandt K, Brown C, Cooke TD, Daniel W, Gray R et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hand. Arthritis Rheumatology.1990;33 (11): 1601–10.
2. Van Manen MD, Nace J, Mont MA.Management of primary knee osteoarthritis and indications for total knee arthroplasty for general practitioners.Journal of American Osteopathy Association. 2012;112 (11): 709–15
3. De Silva V, El-Metwally A, Ernst E, Lewith G, Macfarlane GJ. Evidence for the efficacy of complementary and alternative medicines in the management of osteoarthritis: a systematic review. Rheumatology. 2011; 50 (4): 1-10.
4. Brandt KD, Dieppe P, Radin E. Etiopathogenesis of osteoarthritis. Rheumatic Diseases Clinics of North America.2008;34(3):531-59
5. Baliunas AJ, Hurwitz DE, Ryals AB, Karrar A, Case JP, BlockJA, Andriacchi TP. Increased knee joint loads during walkingare present in subjects with knee osteoarthritis. OsteoarthritisCartilage. 2002;10(7):573–79.
6. Sharma L, Cahue S, Song J, Hayes K, Pai YC, Dunlop DD.Physical functioning over three years in knee osteoarthritis:Role of psychosocial, local mechanical, and neuromuscular factors. Arthritis Rheumatology journal. 2003;48(12):3359–70.
7. Hurwitz DE, Ryals AR, Block JA, Sharma L, Schnitzer TJ, AndriacchiTP. Knee pain and joint loading in subjects with osteoarthritis of the knee. Journal of Orthopaedic Research. 2000; 18 (4): 572-9.
8. Hunter D, Gross KD, McCree P,Li L, Hirko K, Harvey WF. Realignment treatment for medial tibiofemoralOsteoarthriits: Randomised trial. Annals of Rheumatic Diseases.2012;71:1658-1665
9. Cerejo R, Dunlop DD, Cahue S, Channin D, Song J,Sharma L. The influence of alignment on risk of kneeosteoarthritis progression according to baseline stage ofdisease.Arthritisand Rheumatism. 2002; 46(10):2632-6.
10. Col Jain S K.Foot and foot orthosis:,chapter 3(2.3 ,2.4) chapter 6(orthotic management) page 76,77,78
11. McKee P and Leanne M. Orthotics in Rehabilitation: Splinting the Hand and Body: F A Davis Company: 1998
12. Prosthetics & orthotics:Dr K Janardhanam , chapter 18 and 19, page 93,94
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241611EnglishN2014June13HealthcarePERCEPTION OF BENEFICIARIES INVOLVED IN AN INNOVATIVE COMMUNITY HEALTH CARE PROGRAM (CHCP) IN ADOPTED VILLAGE OF WARDHA DISTRICT: A CROSS SECTIONAL STUDY
English4751Abhay MudeyEnglish Meenakshi KhapreEnglish Smrutiranjan NayakEnglish Shubhangi Baviskar BhagatEnglish Yogesh RautEnglish V. K. DeshpandeEnglishBackground of study: CHCP is an innovative, inter-disciplinary and unique approach launched by DMIMS (DU) first time in India in 2011. The main aim of the program was to introduce a comprehensive health care approach in the community along with the development of team spirit in newly entered medical and Para-medical students. This study is designed to evaluate the perception in terms of benefits of this innovative programme from beneficiaries involved in the program Methodology: A community based Cross sectional study, which was conducted from Feb to July. A comprehensive team comprised of 150 medical, 100 dental and 100 nursing students structured at the beginning of academic session and 5 families are allotted to each team of 3 medical +2 dental + 2 nursing students. Faculty members from all the three disciplines were designated for the program to give expert guidance to students. Randomly total 50 villagers i.e. one from each 5 allotted families of health team, who belong to the adopted area of programme, were selected for study. Result: Findings were that 90 % perceived that program was useful for them. Out of them 66.7% had perception that they get free, dental and nursing advice together.59.57% perceived that if students guide them, fear of hospital is minimized. In all community is benefited through Routine Health check-up, early detection, Removes the fear, anxiety, myths of some diseases & doorstep health education Conclusion: Beneficiaries get doorstep services by medical, dental and nursing students free of cost. They are also happy because of the counseling & health education by these students to remove fear and psychological tension regarding their diseases.
EnglishComprehensive health, Community health care, primary care, Doorstep serviceINTRODUCTION
Community based medical education (CBME) consists of activities that use the community extensively as a learning environment, where students, teachers, community members and representatives of other sectors are actively engaged throughout the educational experience in providing medical education that is relevant to community needs. It may be an urban or a rural community, though at present in developing countries most of the people live in rural areas. Primary care stands at the centre of health care systems. CBME is a broad concept, providing students with opportunities to interact with people from a wide range of social, cultural and ethnic backgrounds. It is directed towards the priority health needs and development of professional competencies. CBME might involve visiting families or taking part in community projects. It provides students with opportunities to become increasingly involved in health issues and, as their competency grows, to plan and provide care.[1] Rural population comprises 60% of total population of India. Nearly 3o% of population even today does not have access to health care facilities even in modern e-health era. In 1942 Bhore committee addressed same problem and assigned one year compulsory internship in rural community and concept of community physician was also introduced way back.[2,3] But if we look deep into the solution of this under serving problem we can make out that inculcation of this concept of serving in rural community can be done in very early stages of medical career. The classroom lectures or the bed-side clinics in the wards do not take into account the total factors, which have bearing on health and disease. The approach should not only be in the area of medical care but also sensitive to the political, economical and environmental factors. Hence there is need for a community based teaching. [4] In India too Reorientation of Medical Education (ROME) was introduce to make the medical students to be responsive to community need. But the above program commences from Internship where students are posted in rural and urban health centre apart from hospital training. CHCP is an innovative, inter-disciplinary and unique approach launched by DMIMS (DU) first time in India in 2011. In this programme students are introduce in community from first year onwards till completion of course. The aim of above study was to assess perception of beneficiaries in community in terms of services made available to them through introduction of this program.
MATERIAL AND METHODS
DMIMS is an experienced community based public charitable trust committed to providing comprehensive and holistic health care to over 3,50,000 poor and marginalized patients hailing from surrounding districts of central India. Nachangaon is adopted for 2012-2013 batches for giving comprehensive health care through health team by this innovative CHCP programme Study design A community based Cross sectional study Study duration 6 months (1st Feb to 31st July) Study participants Beneficiaries from the community of adopted villages. Sampling method One family member from 5 adapted families of each health team was selected for interview so that total members involved were from 50 families. Study tools Form to record data from the family members of adopted villages involved in the programme referred to as Family Form
METHODOLOGY
In DMIMS (DU), a comprehensive team of 150 Medical, 100 Dental and 100 Nursing students was structured at the beginning of academic session and 5 families were allotted to each team of 3 Medical +2 Dental + 2 Nursing students. This team is referred as “Health Team Unit”. All the students were given introductory lectures regarding their role in program. Faculty members from all the three disciplines were designated for the program to give expert guidance to students. Each health team visited their families fortnightly on Saturday morning. They interact with family members regarding their health and health problems; impart health education and the members of families who need medical help are refer to hospital. After an exposure to the program for approximately 6 months we have conducted this study of assessment of perception regarding this innovative approach of CHCP programme.
For this assessment data was collected from family members included in the programme by pre designed and pre tested questionnaire. Interviews in community were conducted at home. The questions were translated and asked and later they were analysed.
OBSERVATIONS AND RESULTS
In case of beneficiaries, findings were that 90 % perceived that program was useful for them. Out of them 66.7% had perception that they get free medical dental and nursing advice together. 75.5% of all the participants stated that they personally were benefited from the initiative. Out of them 70.6% perceived concession was the most beneficial part followed by the facility of regular health check-up (14.7%) 59.57% perceived that if students guide them, fear of hospital is minimized. Just half of the participants were of the perception that the concession services they are getting regarding the laboratory investigations are of satisfactory level. On asking the beneficiaries of the program regarding continuing the program, more than two third (80%) stated that it should be continued.
DISCUSSION
94 % of respondents had positive attitude towards the utility of program. It had mainly motivated them for regular health check-up. Easy to access health care as the students themselves go to their allotted family and escort them to hospital for regular health check-up or during emergency. They are also benefited by health education given by students. Seven families were motivated for using FP methods and two for vasectomy. Three cases of hypertension and one of diabetes were detected while one with frequent history of epileptic fits was put on medication. Also the team approach was highly appreciated by the community. There is paucity of research on community’s attitude towards the community centric medical education. A study conducted at the University of Natal, Durban in 1998 notes that the active participation of community in the educational process is very uncommon. [5]The study indicates the shortcomings of medical schools as lack of “fulfilling their social contract at the level of the community. When it was implemented in a manner to “facilitate development of a health programme desired by the community a good compliance was received from community. Same approached was used in our program too. Before the implementation the political leader, influential person in village, Youth group and Mahila Mandal were contacted. The program was tailored according to their needs and expectations and implemented only after the final acceptance of the blue print from community. Therefore a good response was seen in his study. Next was the practical question of how many were benefited and how? 75.5 % were benefited by different means given in result section. It had also helped many of them to remove the fear of hospital as the students guide the patient. Only half of them felt the concession on lab test to be satisfactory. Most of them were advised for the test other than routine for which they have to do out of pocket expenditure. About four in five families share their health information with students and want the program to continue further with some modifications like availability of drugs, renewal in concession etc. Thirty-five years after Alma Ata declared primary health care as the tool to achieving Health for all, growing health inequities still persist. Therefore it is important that the community leaders and members play a crucial role in the identification of the health need which need to be addressed by health professionals by such type of community oriented educational programme. In the CHCP, the health is viewed through the eyes of community. Thus the CHCP approach in training of the under graduates gives better understanding of the subject and benefit to community.
CONCLUSION
Community people get doorstep services by medical, dental and nursing students free of cost. They are also happy because of the counseling & health education by these students to remove fear and psychological tension regarding the different diseases. However there is a scope for strengthening this innovative CHCP programme by making meaningful changes in the planning and reorganizing the complete programme to be implemented from next academic year based on study findings.
Englishhttp://ijcrr.com/abstract.php?article_id=848http://ijcrr.com/article_html.php?did=8481. Critchley J, DeWitt DE, Khan MA, Liaw ST: A required rural health module increase students' interest in rural health careers. Rural Remote Health 2007, 7:688.
2. Government of India, Census. The Registrar General and Census Commissioner, India. New Delhi, Ministry Of Home Affairs. Government of India; Census, 2011
3. Govt. of India (1946). Report of the Health Survey and Development Committee, Govt. of India Press, Shimla.
4. Baumslag N. (1973) Family Care: A Guide. Baltimore USA: The Williams and Williams Co, Bennett M, Wachford. Selection Student for Training in Health Care: WHO. Geneva: WHO Offs Pub; 74, 1983
5. Williams, R. L., Reid, S. J., Myeni, C., Pitt, L., & Solarsh, G. (1999). Practical skills and valued community outcomes: The next step in community-based education. Medical Education, 33(10), 730-737.)
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241611EnglishN2014June13HealthcareUPPER GI ENDOSCOPY 'WITHOUT WEEP OR SLEEP' - 'EVIDENCE BASED MEDICINE'
English5257N. S. KannanEnglish C.P.Ganesh BabuEnglishObjectives: As per „Evidence Based Medicine?, premedication or sedation is not necessary for upper gastro intestinal endoscopies. We are presenting our experience with more than 3000 upper gastro intestinal endoscopies done by us over a period of six years in a district head quarters hospital. Methods: All the patients were screened to rule out co- morbidities. They were prepared with over night starvation. Each patient was given pre procedure counselling about the actual procedure and in what way he is expected to cooperate during the procedure. Their baseline stress level was accessed before admission and those who were found to be uncooperative or demanded pre medication or sedation were referred to the centre were the procedure is done under sedation. Results: While performing upper gastro intestinal endoscopy without premedication or sedation the scopist was comfortable and all the patients also cooperated well during the procedure. Discussion: Unless the requirements defined under ?S3 Guideline: Sedation for gastrointestinal endoscopy 2008? of Riphaus A et al, are met with, sedation should either be avoided or, if sedation is indicated and/or the patient wants sedation, the patient should be transferred to a facility that does fulfil these requirements. Upper gastro intestinal endoscopy without sedation is considered to be a safe, quick, and well tolerated procedure. The avoidance of sedation related morbidity and mortality is an obvious advantage and undoubtedly saves significant time and cost. Conclusion: Our study adds to the „Evidence Based Medicine? in favour of performing simple procedures like upper GI endoscopy safely and cost effectively, without any form of premedication or sedation.
EnglishUpper Gastro Intestinal Endoscopy, Premedication, Sedation, S3 Guideline.INTRODUCTION
In the past few years, interest in sedation in gastrointestinal endoscopy has increased. It is currently the subject of much debate, some of it very lively. One major issue is the exact indication for sedation. Premedication is not necessary for all gastroenterological endoscopic interventions. Whether it is required depends on the nature of examination, its duration, its complexity, its invasiveness, and on the individual patient?s characteristics. Of late there are many articles published based on „Evidence Based Medicine? to support the concept performing simple procedures like upper gastro intestinal endoscopy without any form of premedication or sedation. We are presenting in this article our experience with more than 3000 upper gastro intestinal endoscopies done by us over a period of six years in a district head quarters hospital without any form of premedication or sedation.
MATERIALS AND METHODS
In the district head quarters hospital Pudukkottai, India, we did upper gastro intestinal endoscopy procedure minimum 5 to 8 cases per day on Mondays and Thursdays. All the cases were referred from peripheral hospitals and out patient department of district head quarters hospital Pudukkottai. All the patients were screened with basic investigations to rule out co- morbidities. ECG was also taken for all patients and physician?s opinion obtained regarding fitness for the procedure with specific reference to cardiovascular and respiratory system. They were prepared with over night starvation after night dinner. In cases with suspected gastric outlet obstruction Ryle?s tube stomach was given prior to procedure. All the patients were allowed to sit in the waiting room before procedure. In the pleasing ambience of the waiting room they felt comfortable listening to melodious light music as a part of stress buster1,2. Apart from that they used to chat with each other especially with the patients who had come for repeat procedure for some reason or other. This made them mentally prepared to face the procedure comfortably. Each patient was given pre procedure counselling about the actual procedure and in what way he is expected cooperate during the procedure without any form of premedication and sedation. This was in addition to the awareness created in their mind by the referring family consultant. Proper informed consent was obtained from each patient before procedure. Their baseline stress level was accessed before admission using „The State-Trait Anxiety Inventory? (STAI) method3 . Those who were found to be uncooperative or demanded pre medication or sedation were referred to the centre were the procedure is done under sedation. But this group consisted only negligible percentage since all the patients were referred by their family consultants and were trust based due the familiarity of the team doing the procedure. And also most of the patients were of poor economic status and the procedure was done absolutely free of cost. Informed consent was obtained from each patient. Based on „Evidence Based Medicine? simple procedures like upper gastro intestinal endoscopy can be performed without any form of premedication or sedation. Incidentally it is cost effective since it is not mandatory to have qualified anaesthesiologist or staff/technician anaesthetist to monitor the patient under sedation with high tech-equipments. At the same time, the patient?s right for safety and possible untoward event happening when the procedure is done without any form premedication or sedation was always kept in mind and the endoscopy console was located within the operation theatre complex. The procedure was done only during day time when regular operation list was going on, so that full-fledged resuscitative team with all infrastructures was always available. . Before the procedure the outer surface of the scope was smeared with xylocaine jelly for lubrication purpose only to make the insertion of scope easier in addition to routine cleaning in between procedures. The procedure was assisted by well qualified staff nurse in endoscopy assistance. Patient's vitals were being monitored by another qualified staff nurse through out the procedure.
RESULTS
While performing upper gastro intestinal endoscopy without premedication or sedation the scopist was comfortable and did not experience any difficulty. All the patients also cooperated well during the procedure. Nil untoward events happened, necessitating any procedure abortion or resuscitative intervention. All the patients were willing to have repeat procedure, if needed without any premedication or sedation.
DISCUSSION
Riphaus A et al in their article4 have stated: „In the past few years, interest in sedation in gastrointestinal endoscopy has increased. It is currently the subject of much debate, some of it very lively. One major issue is the exact indication for sedation. Premedication is not necessary for all gastroenterological endoscopic interventions. Whether it is required depends on the nature of examination, its duration, its complexity, its invasiveness, and on the individual patient?s characteristics?. The same authors also have given guidelines intended to complement and link up with the already existing recommendations on sedation for gastrointestinal endoscopy by non anaesthetists with the aim of improving patient safety in the medium and long term5,6,7,8,9,10,11,12,13,14 On principle, simple endoscopic examinations (gastroscopy, sigmoidoscopy, colonoscopy, etc.) can be performed without sedation in suitable patients. (Recommendation grade A, evidence level 2b, strong consensus.)2 . The type and intensity of the sedation and the drug used should be selected according to the type of intervention and the patient?s ASA grade and individual risk profile. There are particular requirements in respect of facilities, equipment, and qualified personnel. Unless the requirements defined under Section 2.3.4 “Monitoring/ structure quality” of Riphaus A et al?s ?S3 Guideline: Sedation for gastrointestinal endoscopy 2008?, are met with, once the risk-benefit balance and the patient?s wishes have all been weighed up, sedation should either be avoided or, if sedation is indicated and/or the patient wants sedation, the patient should be transferred to a facility that does fulfil these requirements. (Recommendation grade A, evidence level 5, strong consensus.)2 . TK Danshmend15 in his nationwide survey identified a total of 119 respiratory arrests, 37 cardiac arrests, and 52 deaths when oesophago gastro duodenoscopy (OGD) was done under sedation oesophago gastro duodenoscopy without sedation is considered to be a safe, quick, and well tolerated procedure16,17. The use of lignocaine for oropharyngeal topical anaesthesia carries potential hazard, for example, methaemoglobinaemia and there may also be an increased risk of aspiration with the pharynx anaesthetised15. The avoidance of sedation related morbidity and mortality is an obvious advantage and undoubtedly saves significant time and cost. Other studies, however, suggest that unsedated oesophago gastro duodenoscopy is unpleasant, at least for some patients18,19,20. Patients should be well informed not only about the benefits but also the risks and discomfort associated with the procedure. This will help them to make a balanced decision. Gastrointestinal endoscopy is a commonly performed procedure. Patients? wishes are, therefore, of paramount importance especially in the context of informed consent and clinical governance21. Sedation is not required to perform a technically adequate gastroscopy but does improve patient satisfaction, comfort, and willingness to repeat particularly in the elderly and those with decreased pharyngeal sensitivity22 Prospective audit of upper gastrointestinal endoscopy done by MA Quine et al23 in 36 hospitals across two regions provided data from 14149 gastroscopies of which 1113 procedures were therapeutic and 13036 were diagnostic. Most patients received gastroscopy under intravenous sedation; midazolam was the preferred agent in the North West and diazepam was preferred in East Anglia. Mean doses of each agent used were 5.7 mg and 13.8 mg respectively, although there was a wide distribution of doses reported. Only half of the patients endoscoped had some form of intravenous access in situ and few were supplied with supplementary oxygen. The death rate from this study for diagnostic endoscopy was 1 in 2000 and the morbidity rate was 1 in 200; cardiorespiratory complications were the most prominent in this group and there was a strong relation between the lack of monitoring and use of high dose benzodiazepines and the occurrence of adverse outcomes. In particular there was a link between the use of local anaesthetic sprays and the development of pneumonia after gastroscopy (p existent recovery areas. In addition, a number of junior endoscopists were performing endoscopy unsupervised and with minimal training Phyllis R. Bishop et al24 in their study inferred unsedated esophago gastro duodenoscopy (EGD) can be performed safely and successfully in children with good patient tolerance. There was a significant decrease in total procedure time for children who have unsedated esophago gastro duodenoscopy. Unsedated esophago gastro duodenoscopy should be considered a viable option for motivated children. Sedation is usually safe; however, complications may occur, although in various proportions depending on a number of factors, including the type, dose and mode of administration of sedative drugs, as well as the patient?s age and underlying chronic disorders. A large number of side effects, including hypotension, desaturation, bradycardia, hypertension, arrhythmia, aspiration, respiratory depression, vomiting, cardiac arrest, respiratory arrest, angina, hypoglycaemia, and/or allergic reaction, have been reported. Important medical and legal issues regarding sedation have been raised during recent years. Such issues include informed consent of the patient, difficulties in assessing withdrawal of consent in a sedated patient, and the need for sedation monitoring that meets accepted standard of care guidelines25. Other controversies possibly related to medico-legal aspects include both the use of propofol and the administration of sedation by anaesthesia personnel. The former controversy is extremely important from a legal point of view if the continuously increasing use of propofol in Gastro Intestinal Endoscopy by nonanaesthesiologists is taken into account. In a related article, Axon AE26 emphasises the possible clinical negligence that could be associated with sedation administration. Interestingly, while the law recognises the desirability of sedation in endoscopy procedures, the facts of a particular case will be scrutinised to determine possible responsibilities of the endoscopist if an adverse outcome occurs. Such questions related to the administration of sedation during gastro intestinal endoscopy are discussed in detail in their article by John K Triantafillidis et al27. Rana S. et al, in their study of 2015 cases, it was reported that in 94% of these cases, the upper gastrointestinal system endoscopy was well tolerated without preendoscopic sedation and topical anaesthesia, and that the endoscopic procedure was performed more easily28 . The The British Society of Gastroenterologists (BSG) recommends performing endoscopy in well designed endoscopy units29. BSG also recommends that two assistants, at least one of whom must be a qualified nurse, are required at each table30. A study was performed by Hoya et al, at the digestive endoscopy service of a 150-bed acute care hospital in Japan31 has proved that providing an optimal soothing environment (OSE) before and during gastroscopy is useful to minimize patient anxiety regarding experiencing a gastroscopy. This non- pharmacological method is a simple, inexpensive, and safe method of minimizing anxiety before and during gastroscopy.
CONCLUSION
Our study adds to the „Evidence Based Medicine? in favour of performing simple procedures like upper gastro intestinal endoscopy without any form of premedication or sedation, provided the basic mandatory precautions are observed as detailed in the methodology section of our article. Performing upper gastro intestinal endoscopy without any form of premedication or sedation is not only safe but also cost effective.
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=849http://ijcrr.com/article_html.php?did=8491. H. EL-Hassan, K. Mckeown, A. F. Muller. Clinical trial: music reduces anxiety levels in patients attending for endoscopy. Alimentary Pharmacology and Therapeutics. 2009; 30(7):718–724.
2. Hayes A, Buffum M, Lanier E, et al. A music intervention to reduce anxiety prior to gastrointestinal procedures. Gastroenterol Nurs 2003; 26: 145–9.
3. Spielberger, C. D. (1989). State-Trait Anxiety Inventory: Bibliography (2nd ed.). Palo Alto, CA: Consulting Psychologists Press.
4. Riphaus A et al. S3 Guideline: sedation for gastrointestinal endoscopy 2008… Endoscopy 2009;41:787–815
5. Clinical practice guidelines: safety and sedation during endoscopic procedures. Available from: http://www.bsg.org.uk/pdf_word_docs/sedati on.doc
6. Stufe 1 Leitlinie Sedierung und Analgesie (Analgosedierung) von Patienten durch Nicht-Anästhesisten. 2008.Available from: http://www.dgai.de/06pdf/13_573- Leitlinie.pdf, http://intranet/awmf11/001– 011. htm
7. Hofmann C, Jung M. Sedierung und Überwachung bei endoskopischen Eingriffen. 2003.Available from: http://www.dgvs.de/media/1.2.Sedierungueberwachung.pdf
8. American Society of Anesthesiologists Task Force. Practice guidelines for sedation and analgesis by non-anesthesiologists: an updated report by the American Society of Anestesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology 2002;96:1004–1017
9. American Society for Gastrointestinal Endoscopy. Guidelines for conscious sedation and monitoring during gastrointestinal endoscopy. Gastrointest Endosc 2003; 58:317–322
10. American Society of Anesthesiologists. Practice guidelines for postanesthetic care: a report by the American Society of Anesthesiologists Task Force on Postanesthetic Care. Anesthesiology 2002;6:742–752
11. Joint statement of aWorking Group from the American College of Gastroenterology (ACG), the American Gastroenterological Association (AGA), and the American Society for Gastrointestinal Endoscopy (ASGE). Recommendations on the administration of sedation for the performance of endoscopic procedures. 2006.Available from: www.gi. org/physicians/nataffairs/trisociety.asp
12. Schreiber F. Austrian Society of Gastroenterology and Hepatology (OGGH) – guidelines on sedation and monitoring during gastrointestinal endoscopy. Endoscopy. 2007;39:259–262
13. American Society for Gastrointestinal Endoscopy. Guidelines for training in patient monitoring and sedation and analgesia. Gastrointest Endosc. 1998;48:669–671 14. Waring JP, Baron TH, Hirota WK et al. Guidelines for conscious sedation and monitoring during gastrointestinal endoscopy. Gastrointest Endosc. 2003;58:317–322 15. T K Daneshmend, G D Bell, R F Logan Sedation for upper gastrointestinal endoscopy: results of a nationwide survey. Gut 1991;32:12-15 16. Al-Atrakchi HA. Upper gastrointestinal endoscopy without sedation: a prospective study of 2000 examinations. Gastrointest Endosc. 1998;35:79-81. 17. Chuah SY, Crowson CP, Dronfield MW. Topical anaesthesia in upper gastrointestinal endoscopy. BMJ. 1991;303:695. 18. Ross WA. Premedication for upper gastrointestinal endoscopy. Gastrointest Endosc. 1989;35:120-6.
19. Gordon MJ, Mayes GR, Meyer GE. Topical lidocaine in preendoscopic medication. Gastroenterology.1976;71:564-9. 20. Hedenbro JL, Ekelund M, Jansson O, et al. A randomised double blind, placebo-controlled study to evaluate topical anaesthesia of the pharynx in upper gastrointestinal endoscopy. Endoscopy. 1992;24:585-7. 21. Scally G, Donaldson LJ. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ. 1998;317:61-5. 22. Neena S Abraham, Carlo A Fallone, Serge Mayrand, Jack Huang, Paul Wieczorek and Alan N Barkun. Sedation versus No Sedation in the Performance of Diagnostic Upper Gastrointestinal Endoscopy: A Canadian Randomized Controlled Cost Outcome Study The American Journal of Gastroenterology. 2004; 99: 1692–1699 23. MA Quine, G D Bell, R F McCloy, J E Charlton, H B Devlin, A Hopkins Prospective audit of upper gastrointestinal endoscopy in two regions of England; safety, staffing, and sedation methods Gut. 1995; 36: 462-467 24. Phyllis R. Bishop, Michael J. Nowicki, Warren L. May, David Elkin, Paul H. Parker,Unsedated upper endoscopy in children Gastrointestinal Endoscopy. 2002;55(6):624-630. 25. Feld AD. Endoscopic sedation: medicolegal considerations. Gastrointest Endosc Clin N Am. 2008;18:783-788. 26. Axon AE. The use of propofol by gastroenterologists: medico-legal issues. Digestion. 2010;82:110-112. 27. John K Triantafillidis, Emmanuel Merikas, Dimitrios Nikolakis, and Apostolos E Papalois, Sedation in gastrointestinal endoscopy: Current issues. World J Gastroenterol. 2013;19(4): 463–481. 28. Rana S, Pal LS. Upper gastrointestinal endoscopy: is premedication or topical anesthesia necessary? Gastrointest Endosc. 1990;36:317-8. 29. The British Society of Gastroenterology. Provision of gastrointestinal endoscopy and related services for a district general hospital. London: 1992 30. The British Society of Gastroenterology. Report of a working party on the staffing of endoscopy units. London: 1987 31. Hoya, Yoshiyuki, Matsumura, Izumi , Fujita, Tetsuji, Yanaga, Katsuhiko. The Use of Nonpharmacological Interventions to Reduce Anxiety in Patients Undergoing Gastroscopy in a Setting With an Optimal Soothing Environment. Gastroenterology Nursing: 2008;31(6):395–399
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241611EnglishN2014June13HealthcareARTERIAL SEGMENTATION OF HUMAN KIDNEYS
English5862Gyata MehtaEnglish Vasanti AroleEnglishObjectives: Awareness about variations in renal morphology is indispensable for a surgeon doing partial nephrectomy and segmental renal resections. The advent of conservative surgical methods in renal surgery has necessitated a more precise knowledge. The aim of this study was to establish and demarcate the arterial segments of the human kidney. Methods: The study was carried out on fifty kidneys, from adult human cadavers. They were treated with 5%“Potassium hydroxide” solution for 72 hours prior to dissection. Dissection of the kidneys was done meticulously keeping in mind the orientation of poles, borders and surfaces. The branches of renal arteries were traced through the kidney substance and the renal segments were demarcated according to the segmental arteries. Results: Twenty five kidneys (50%) showed five arterial segments. Fifteen kidneys (30%) showed foursegments, five kidneys (10%) showed three segments, four kidneys (8%) showed six segments and one kidney (2%) showed only two segments. The area of distribution on anterior and posterior surfaces showed varied patterns. Conclusion: Considering the significance of knowledge of renal vascular patterns in conduct of various renal surgeries and in interventional radiology, conservative surgery and oncologic surgery, it was thought necessary to reassess the pattern of arterial segmentation in the human kidney. Keeping in mind the ever evolving knowledge and yet unexplained facts of the subject, this study was undertaken.
EnglishRenal vascular pattern, arterial segmentation, conservative surgeries, segmental resectionINTRODUCTION
The concept of renal vascular segmentation was first recognized and mentioned by John Hunter. 1However the present day concept of segmental arterial supply of kidney is based on the work of Graves. 2 In his study, conducted on more than thirty kidneys by cast method and angiography, the renal parenchyma was divided into five segments on the basis of segmental arteries. They were named as apical, upper, middle, lower and posterior segments. The apical and lower segments were common on both anterior and posterior surfaces. However variations to this pattern exist, hence a detailed study of renal morphology becomes essential.This is of value in nephro-lithotomy and segmental resections of the kidney. As per literature, renal segmental arteries are endarteries.3 “From the clinical point of view, occlusion of a segmental artery causes necrosis of a supplied segment that would cause absence of functionally essential junctions. However, surgeons confirm frequent difficulties with hemostasis during segmental renal resection, which are not always explicable by a blurred limit of segments, collateral circulation from capsular anastomoses or by imperfections in surgical techniques.4 Intrarenal arterial collateral circulation may develop in cases of renal artery stenosis or occlusion as demonstrated by angiographic studies.5-8 ”
MATERIAL AND METHODS
The study was carried out on fifty kidneys from formalin preserved adult cadavers. They were treated with 5% “Potassium hydroxide” solution for 72 hours prior to dissection. This made the renal tissue soft and facilitated the tracing of arteries through the substance of kidney. Dissection of the kidneys was done meticulously keeping in mind the orientation of poles, borders and surfaces. The branches of renal arteries were traced through the kidney substance and renal segments were demarcated. Segmental arteries were said to be those branches which were arising from renal arteries or accessory arteries outside the hilum of kidney. The segments were delineated depending on the number of segmental arteries. The variations in the number and position of segments were observed and noted. The kidneys were preserved in 10% formalin solution after the dissection.
RESULTS
Twenty five kidneys (50%) showed five arterial segments. However the number of segments varied from two to six. The area of distribution on anterior and posterior surfaces showed varied patterns. On the posterior surface a nil segment was considered where a separate segmental artery was not seen, and it was presumed that, rest of the posterior surface was supplied by corresponding anterior segmental artery through the renal substance.
DISCUSSION
Anatomically the kidney is divided into five arterial segments- apical, upper (anterior), middle (anterior), lower and posterior, depending upon the number of segmental arteries3 . “As there is no constant arterial segmental pattern of the kidney, it may often not be possible to forecast beforehand the type of partial nephrectomy which might or might not be possible in a particular case. Very often the decision to perform a segmental resection of the kidney shall have to be taken on operation table by surgeon after exploration of kidney orbefore operation by angiography. But it may be of importance for surgeon to be acquainted with different types of cases that are unsuitable for segmental resections and this will put the surgeon on guard to exercise greater cautions.9 ” The work of Roberts10and Chatterjee AK11supported the conventional segmentation of human kidney into five segments, whereasSykes12 showed 83.1% kidneys to have five segments and 8.4% kidneys to have three segments .Some authors have reported as few as three arterial segments13and also as high as sevenarterial segments.14However Hegedushas stated that a strict division of the kidney into segments is not possible.15 The present study showed a variation ranging from two to six segments.These findings correspond to the earlier studies. Sapte&Bordei 16reported five segments in 42.7% kidneys,four segments in 39.6%,threesegments in 10.8% and six segments in 6.7% kidneys.Longia et al17showed a slight variation as five arterial segments were seen in 53% kidneys, four segments in 46% and three segments in 1% kidneys.Sampaio18reported five segments in 61.2% kidneys and four segments in 38.8% kidneys. “Intra renal collaterals at capsular, inter-lobar or arcuate arteries have been documented onocclusion of the main artery or in cases of renal artery stenosis.5-8 ”
CONCLUSION
The knowledge of renal vascular patterns in conduct of various renal surgeries, interventional radiology, conservative surgery and oncologic surgery is of great importance. Variations in the arterial segments of the kidney are significant for the surgeons performing partial nephrectomy operations to aid renal tissue preservation.
ACKNOWLEDGEMENTS
“Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature of this article has been reviewed and discussed.”
Englishhttp://ijcrr.com/abstract.php?article_id=850http://ijcrr.com/article_html.php?did=8501. Hunter J. Inflammation and Gunshot wounds. G Nicol, London 1794 (vide infra ref 9)
2. Graves FT. The anatomy of the intrarenal arteries and its application to the segmental resection of the kidney. Br J Surg 1954; 42:132-139
3. GrayH.Kidney.In:Gray’s Anatomy The Anatomical Basis of Clinical Practice 40thedn.Susan Standring. Elsevier Churchill Livingstone. London ; 2008: p1231-1232
4. “Szpinda M, Kochan J, Stanislaw M. Arterial kidney anastomoses in human fetuses. Med SciMonit 1999; 5(1): 21-24”
5. MengChien-Hsing, Elkin Milton, Smith Theodore. Intra renal arterial collateral. Radiology 1973; 109: 59-64
6. Pastershank SP, Mackay RW. Intrarenal arterial collateral circulation. Canadian Med Assoc J 1975; 112: 461-462
7. Kirks DR, Fitz CR, Korobkin M. Intrarenal collateral circulation in the paediatric patient. PediatRadiol 1977; 5:154-159
8. Hietala SO, Kunz R. Collateral circulation in stenosis or occlusion of the renal artery. CardiovascRadiol 1979; 2: 249-255
9. “Ajmani ML Ajmani K. To study the Intrarenal vascular segments of human kidney by corrosion cast technique. Anat Anz1983;154:293-303”
10. Roberts JBM. Conservative renal surgery-an anatomical basis. Br J Surg 1960; 48:1-8
11. Chatterjee SK, Dutta AK. Anatomy of the intra renal distribution renal arteries of the human kidney. J Indian M A 1963; 40:155- 161
12. Sykes D. The arterial supply of the human kidney with special reference to accessory renal arteries. Br J Surg 1963; 50 : 368-374
13. Di Dio IJA. The anatomosurgical vascular segments of the human kidney .Anat Rec 1961; 139: 299
14. Faller J, Ungvary G. Die arterielle segmentation der NierreZblChir 1962; 87: 972 (vide infra 15)
15. Hegedus V. Arterial anatomy of the kidney. ActaRadiol diagnosis 1972; 12: 604-618
16. SapteE ,Bordei P. Anatomical considerations in renal arterial segmentation. Rev Med ChirSoc Med Nat Iasi 2005; 109(3):597-602
17. Longia GS, Kumar V, Saxena SK, Gupta CD. Surface projection of arterial segments in the human kidney. . ActaAnatomica 1982; 113:145-150
18. Sampaio FJB, Schiavini JL, Favorito LA. Proportional analysis of the kidney arterial segments. Urol Res 1993; 21: 371-374
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241611EnglishN2014June13HealthcareEFFECT OF POSTURAL CORRECTION ON NECK PAIN IN COMPUTER OPERATORS
English6366Nirav VaghelaEnglish Deepak GanjiwaleEnglishIntroduction: Prolonged use of computers during daily work activities and recreation is often cited as a cause of neck pain. Several studies have been carried out for work related musculoskeletal disorders; neck shoulder and arm disabilities.However, evidences focussing on neck pain are seldom obtained. Therefore, this study has been undertaken to throw light on effect of postural correction on neck pain in computer workers. Methodology: This is the retrospective study done from data routinely collected for the individual who ware working the computer more than 15 hrs per day and having the neck pain more than 3 months at shreekrishan hospital and PrayasEnf. Ltd. Anand, Gujarat. Data of 48 patients (43 males and 5 females) were analysed for the study. Neck Disability Index(NDI) and cranivertebral angle(CV) were used for the data collection. Result: Statistically and clinically significant improvement was observed in Pre and postNDI andCV angle. (PEnglishNeck pain, posture, neck disability index, cranivertebral angle.INTRODUCTION
Prolonged use of computers during daily work activities and recreation is often cited as a cause of neck pain.12-month prevalence of neck pain in office workers of 45.5%.one year prevalence of neck pain in office workers to range from 17.7% to 63%.the most prevalent musculoskeletal symptom among studied computer operator neck pain (48.2%)followed by lower back pain(48.3%).(1) Awkward posture,prolonged sitting,working duration more than 6 years in computer field and daily working hours in front of computer more than 5 hours are the significant risk factors for having musculoskeletal symptoms.(2) The development of musculoskeletal pain or discomfort in computer operator is theorized to be multifactorial, and includes occupational ergonomic, psychosocial and demographic parameters. A review of epidemiological studies concluded that posture is an independent risk factor for development musculoskeletal disorder among computer user. Proper postures are believed to be the state of musculoskeletal balance that involves a minimal amount of stress and strain on the body. Although correct posture is desired, many people do not exhibit good posture. An ideal posture is considered to exist when the external auditory meats is aligned with the vertical postural line.(3) Proper posture maintains the musculoskeletal balance equilibrium. The most common consequence of faulty posture in computer operators is Forward head posture (FHP). Intensive computer work puts stress and strain on muscles, as well as joints, owing to continuous and repetitive nature of movements resulting in greater loading on the supporting structure and may cause sensitization and pain. Forward head posture involves flexion of lower cervical spine in combination with extension of upper cervical spine. It is often accompanied by protracted shoulders.(4) A number of randomized clinical trials have demonstrated the effectiveness of cervical strengthening exercises in the treatment of patients with neck pain.(5)Studies have also stated the effective role of neck and girdle strengthening in patients with mechanical neck pain. According to a recommendation, specific neck exercises that are simple to perform and target more specific structures related to postural neck pain and feel they should be the first line of defence in work related postural neck pain as consistent with current literature. Outcome measures; subjective and objective are a must to estimate the difference in pain and disability before and after the treatment regimen. Several studies have been carried out for work related musculoskeletal disorders; neck shoulder and arm disabilities.(6) However, evidences focussing on neck pain are seldom obtained. Therefore, this study has been undertaken to throw light on effect of postural correction on neck pain in computer workers.
OBJECTIVES
1. To compare the difference in level of neck disability before and after postural correction. 2. To note the difference in craniovertebral (CV) angle before and after postural correction.
METHODOLOGY
This is the retrospective study done from data routinely collected for the individual who ware working the computer more than 15 hrs per day and having the neck pain more than 3 months at shreekrishan hospital and PrayasEnf. Ltd. Anand, Gujarat. Data of 48 patients (43 males and 5 females) were analysed for the study. Age gender and the other demography data of the patient s were recorded . The research project was conducted after getting clearance from Human Research Ethics Committee (HREC) of the institution.Informed consent was obtained from each participant after explaining them details regarding various non-invasive procedures to be carried out during the study. The patient having Past history of cervical trauma, Radiationofpain,Parasthesia,sensory loss,Neuromusculardisorder,Rheumatic diseases,Metastasis,Higher mental dysfunction,Problems of understanding were excluded. The neck disability index(NDI) scale and cranivertebral (CV) angle were used for the date collection.
Neck Disability Index (NDI)
Herein, each recruit was asked to fill a 50 point scale consisting of 10 items. Each of the 10 items is scored from 0 - 5. The maximum score is therefore 50. Occasionally, a respondent will not complete one question or another. The average of all other items is then added to the completed items.
Cranivertebral (CV) Angle
CV angle was measured by placing markers over the spinous process of C7 vertebra and the tragus of the ear. Then a digital camera was placed on a tripod stand at 1 meter distance from the subject on the right side. Height of the camera was adjusted accordingly in order to take a picture of right lateral view. The participants were dressed adequately so as to expose the area of lower neck for placement of marker at the level of C7 spinous process. Participants were asked to stand with their left shoulder facing the wall and then perform available pain-free active range of motion thrice to promote relaxation. Picture was then captured. Following this, each picture was imported to UTHSCSA image tool software to obtain the value of CV angle. After the outcome measures had been taken, each participant was prescribed a regime of self resisted isometric neck exercises; active girdle exercises, pectoral self stretching and active postural correction (chin tucking and sitting erect with shoulders retracted). Participants were advised to follow this regime twice a day for a period of 4 weeks. All subjects received verbal instruction, visual demonstration, and graphic illustrations (Handouts) of the exercises.Subjects received a daily reminder to remind them of the suggested frequency. At the end of 4 weeks, all the outcome measures were re-recorded to note the difference in the level of neck disability change in CV angle.
RESULT
In the present study, 145 individuals were approached from SKH (75) and PRAYAS ENG. LTD. (70). 50 subjects fulfilling all inclusion criteria were recruited for the study. Loss to follow up was obtained for 2 subjects. Therefore, the sample size for the study was 48.(43 males and 5 females)The average age of subjects was 38.1 years ( min.= 24; max= 55) while average hours of work were 28.31 hours/week (min.= 20; max.= 40) The overall pre and post NDI was found to be statistically highly significant in the patients after physiotherapy rehabilitation (pEnglishhttp://ijcrr.com/abstract.php?article_id=851http://ijcrr.com/article_html.php?did=8511. Bart N Green,A literature review of neck pain associated with computer use: public health implications: J Can Chiropr Assoc. Aug 2008; 52(3): 161–167.
2. AR Ahmed-Refat, et al:Ergonomic aspect and halthharzards on computer workstation at Zagazig university :An occupational risk management approach.zagazig journal of occupational health and safety: vol1,no1(2008).
3. Yip CH,ChiyTT,PoonAT,The relationship between head posture and severity and disability of patients with neck pain.ManTher. May 2008;13(2):148-54. Epub 2007 Mar 23.
4. Vernon H, Mior S. "The Neck Disability Index: a study of reliability and validity." J Manipulative PhysiolTher. 1991 Sep;14(7):409-15.
5. Howard Vernon DC, PhD Professor, Canadian Memorial Chiropractic College, 6100 Leslie St., Toronto, Ontario, Canada
6. To study efficacy of physiotherapy intervention in hospital employees identified with work related low back pain. Division Chiropractic College, Toronto, Ontario.J Manipulative PhysiolTher 1992 Jan;15(1)
7. SoutherstBsch D, Nordin M, Côté P, Shearer H, Varatharajan S, Yu H, Wong JJ, Sutton D, Randhawa K, van der Velde G, Mior S, Carroll L, Jacobs C, Taylor-Vaisey A. is exercise effective for the management of neck pain and associated disordered whiplashassociated disorder systematic review by the Ontario protocol for traffic injury management collaboration. .Spine J. 2014 Feb 14. pii: S1529-9430(14)00210-1. doi: 10.1016/j.spinee.2014.02.014. [Epub ahead of print]
8. Kay TM, Gross A, Goldsmith CH, Rutherford S, Voth S, Hoving JL, Brønfort G, SantaguidaPL.Exercise for mechanical neck disorders.Cochrane Database Syst Rev. 2012 Aug 15;8:CD004250. doi: 10.1002/14651858.CD004250.pub4. Review.
9. Kietrys DM, McClure PW, Fitzgerald GK.The relationship between head and neck posture and VDTscreen height in keyboard operators.PhysTher. 1998 Apr;78(4):395-403.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241611EnglishN2014June13HealthcareEFFECT OF OBESITY ON VENTILATOR FUNCTION OF MEDICAL STUDENTS
English6770Heena Kauser G. H.English Irani F. BEnglish Shinde P. U.EnglishIntroduction: Obesity is a disorder of energy balance contributing foraltered respiratory functions. Method: A total of 30 non obese and 30 obese medical students in age group of 18-25 years who have satisfied inclusion and exclusion criteria and have consented to participate in study were enrolled. Each enrolled subjects height, weight and baseline blood pressure (BP) was recorded and evaluation of ventilatory function was done using Wright’s peak flow meter. Result: There was significant decline in ventilatory functions in obese normotensive as compare to non obese students. In long term we can conclude that obesity adversely affects lung functions and which is controlled adequately if active interventions are taken. (Weight reduction, life style changes and physical exercise) to prevent obesity related respiratory sequelae in future.
EnglishBMI, peak flow meter,ventilator functionsINTRODUCTION
Obesity is an individual clinical condition, which is increasingly being viewed as a seriouspublic health problem.Obesity develops when energy intake exceeds energy expenditureover time, leading to accumulationof adipose tissue with a corresponding increase in lean bodymass (from the necessarily enlarged muscle,bone and connectivetissue). It is important to recognize that even a small dailyenergy imbalance eventually results in significant weight gain;Prevalence of overweight and obesity is increasing in adolescents in India which is a concern in terms of the complications being seen in the later stage of life if not taken care of in time[1,2,3,4]Obesity is a life style disease. With advent of civilization, civilized men have free access to food on the table without any limitation and no physical activity is involved in procuring food. Over the years, accumulation of energy as fat resulted in high prevalence of obesity. This can be called as a “Disease of 21st century” and acts as a base for many other diseases like hypertension, dyslipidemia, and coronary artery disease [5] Obesity can profoundly alter pulmonary function and diminish exercise capacity by its adverse effects on respiratory mechanics, resistance within the respiratory system, function of respiratory muscles, work and energy cost of breathing, control of breathing, and gas exchange. Obesity places the patient at risk of aspiration pneumonia, pulmonary thromboembolism and respiratory failure. It is the most common precipitating factor for obstructive sleep apnea and is a requirement for the obesity hypoventilation syndrome, both of which are associated with substantial morbidity and increased mortality [6] . Hence respiratory systems have been reported to be major system reflecting the adverse effects of obesity. Peak expiratory flow rate is measure of maximum rate of air flow during a sudden forced expiration. It indicates largecentral airway obstruction.It is a simple and fundamental test to measure dynamic lung volumes to diagnosis and assess of airways disease [7] . In the current study we are going to stress on the correlation between obesity and associated alterations in respiratory functions.
MATERIAL AND METHOD
Study Design: 60 Students in the age group 18-25 years were randomly selected to obtain mixed group of students from M.G.M. Medical College and were screened to identify the 1) Non obese group: healthy with BMI23 Kg/m2 .
METHOD
Inclusion criteria included 1) Students in the age group of 18-25 years. 2) Students who are obese to their respective age and sex were selected. 3) 30 obese students and 30 non-obese students were selected according to the parameters mentioned. Exclusion criteria were 1) The exclusion criteria comprised of students suffering from any medical ailments. 2) Anxious, apprehensive and uncooperative students. 3) Any history of smoking, addiction of tobacco, use of any medications to be excluded from the study. Institutional ethical clearance was obtained. Bodymass index was calculated as per the formula: Body mass index = Weight (Kilograms)/Height (Meter2 ). The students having BMI of more than the cut-off value for their respective age and sex were designated as the test/obese group (both overweight and obese students to be clubbed together). Identical number of age and sex matched non-obese medical students served as controls.Students were explained about the procedures to be undertaken. A brief personal history was taken and written consent was obtained as per Helinski declaration modified according to the test protocol The subjects were made to rest for 10 min before recording their baseline systolic and diastolic blood pressure along with mean blood pressure as per standard procedure. Respiratory parameters (lung function tests) Peak expiratory flow rate was measured using advanced computerized spirometer according to standard procedure. Peak expiratory flow rate (PEFR): the subject was made to sit upright on chair. After taking a deep breath was made to hold mouth piece in his mouth, gripping it tightly with his teeth and his lips and blow hard as possiblein a short sharp blast. Three readings were taken after adequate period of rest between each attempt and maximum value was recorded. Statistical analysis: Results were analyzed by using Unpaired Student T-test with “P” value < 0.05 for significance.
RESULTS
60 subjects (group A non obese n-30) and (group B obese n-30) that have satisfied the inclusion and exclusion criteria were selected.
DISSCUSSION
In the present study, ventilatory function,peak expiratory flow rate wasestimated in normal and obese normotensive Medical undergraduate subjects in comparable age group. It was observed that there was a significant reduction PEFR in the obese normotensive subjects when compared to normal lean individuals. There was significant difference in ventilatory functions between obese normotensive and lean subjects. Our data shows that body composition and fat distribution are associated with lung function in middle-aged men, in that a central pattern of fat distribution is associated with a decrease in lung functions .The altered lung function is suggestive of an obstructive airway dysfunction. The amount of body fat and a central pattern of fat distribution might be related to lung function by several mechanisms. Mechanical effects of diaphragm to impeding its descent.Reduction in compliance of chest wall, work of breathing and elastic recoil of lungs[9]. Adiposity and visceral fat tend to increase with age [10]. Enright PL et al reported that maximal inspiratory and expiratory pressures which are indices of strength of diaphragm and strength of abdominal and inter costal muscles decreased in obesity.Abdominal fat deposition may directly impede the descent of the diaphragm where as fat deposition in the chest wall may diminish rib cage movement and thoracic compliance, both of which lead to restrictive impairment of respiration. Other mechanisms include the possibility that abdominal fat deposition leads to redistribution of blood to the thoracic compartment that reduces vital capacity (VC). [11]In obese subjects the diaphragm is in the upper position, which results in a low functional residual capacity (FRC). Such modification in resting end expiratory lung volume may result in a passive change in airway resistance related to an increasing in transmural pressure across the bronchial wall. In addition, chest wall resistance and increased respiratory resistance could also be due to existence of upper airway obstruction and fat deposition or lax pharyngeal muscle tone in obesity.[12]
CONCLUSION
Obesity is important risk factor for the pathophysiologic changes contributing for altered ventilatory functions in obese subjects in comparison to non obese subjects. In long term we can conclude that obesity adversely affects ventilatory functions and which is controlled adequately if active interventions are taken. In our study it was observed that obese normotensives exhibit a significant decline in lung functions like PEFR, when compared to normal subjects.
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=852http://ijcrr.com/article_html.php?did=8521. Whitlock G, Lewington S, Sherliker P, et al. Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies. Lancet 2009; 373: 1083- 96.
2. Hancox RJ, Milne BJ, Poulton R. Association between child and adolescent television viewing and adult health: a longitudinal birth cohort study. Lancet 2004; 364: 257-62.
3. Pereira MA, Kartashov AI, Ebbeling CB, et al. Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis. Lancet 2005; 365: 36-42.
4. Irani FB, Shinde PU, HeenaKauser GH, Evaluation of autonomic functions in obese and non- obese medical students. Int. J. Med. Sci. and Pub.Health. 2014; vol3 , No 6
5. John Pilcher MD, Dana Reiss MD, TeriveDuperier MD, Lloyd Stegemann MD, Michael Seger. New Dimensions Weight Loss Surgery.2005;www.NewDimensionsWLS.co m.
6. Koenig, Steven M. MD. Pulmonary complications of Obesity.American Journal of the Medical Sciences. April 2001; 321(4):249- 279.
7. GunnarGudmundsson, Melba Cerveny, and D. Michael Shasby.Spirometric Values in Obese Individuals, effects of body position. Am. J. Respir. Crit. Care Med., September 1997; Vol 156, No 3: 998-999
8. World Health Organization .Obesity; preventing and managing the global epidemic. Geneva: WHO 1998.
9. Lazarus R, Sparrow D, Weiss ST. Effects of obesity and fat distribution on pulmonary function: the Normative Aging Study. Chest 1997;111: 891-898.
10. Zamboni M, Armellini F, Milani MP et al. Body fat distribution in pre and post menopausal women: metabolic and anthropometric variables and their interrelationships. Int J ObesRelatmetabDisord 1992; 16: 495-504.
11. S Goya Wannamethee, A Gerald Shaper and Peter H Whincup. Body fat distribution, body composition, and respiratory function in elderly men.American Journal of Clinical Nutrition.November 2005; Vol. 82, No. 5: 996-1003.
12. R Lazarus, D Sparrow and ST Weiss. Effects of obesity and fat distribution on ventilatory function: the normative aging study. Chest 1997;111;891-898.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241611EnglishN2014June13HealthcareSTUDY OF LEFT VENTRICULAR MASS IN CHRONIC SEVERE ANEMIA
English7178Farquana QushnoodEnglish Ruqia AsnaEnglish Salim A. DhundasiEnglish K. K. DasEnglishBackground and Objectives: In chronic anemia the heart has to entertain a hyperdynamic circulation in order to compensate for reduced oxygen carrying capacity of blood. Chronic alterations of cardiac workload results in changes of LV geometry. The diagnosis of left ventricular hypertrophy (LVH) based on LV mass has been incorporated in the clinical practice as an important marker of CVD. Hence, present study was undertaken with the objective of estimating the LV mass in pts with chronic severe anemia and comparing with controls. Methodology: Present study was conducted in Al-Ameen Medical College and District Hospital, Bijapur. 31 anemic patients (aged 18-40 yrs) with Hb ? 7 gm% and equal no. of age and gender matched normal subjects were selected. All anemic patients and controls were subjected for hemoglobin estimation and M mode 2D Echocardiography. Echocardiographic parameters IVSTd, LVPWd, LVIDd were studied, LVM and LVMI were derived. Statistics-by Student’s unpaired‘t’ test, correlation analysis. Results: Our study demonstrated increased LVM and LVMI in anemic patients compared to controls. Both correlated negatively with Hb levels. Interpretation and Conclusion: Left ventricular mass is an independent risk factor for prediction of cardiovascular events.Echocardiography is a simple, noninvasive imaging method in the evaluation of cardiac morphology and dynamics, hence can be used to evaluate LVM in chronic anemia. The findings of increased LVM and LVMI in anemic patients of our study are indicative of LV hypertrophy. Hypertrophy of cardiac myocytes occurs to meet the demand of increased rate of use of mechanical energy in response to sustained Hemodynamic overloading of the heart.
EnglishLeft ventricular Mass, Chronic anemia, LVH, Echocardiography.INTRODUCTION
Chronic severe anemia is a common disease. Optimal tissue oxygenation requires the functional integrity of heart, lungs and blood. If one of this fails in joint task, the other has to carry extra load. In chronic anemia the heart has to entertain a hyper dynamic circulation in order to compensate for reduced oxygen carrying capacity of blood. Such profound and chronic alterations of cardiac workload results in changes of left ventricular geometry.1 Anemia significantly alters circulatory dynamics and so burdens circulatory system.Hemodynamic changes brought about by this condition have consequences that could both predispose and aggravate existing cardiac disease. One potential mechanism for the adverse health effects associated with chronic anemia may be an increased cardiac output, which may lead to the development of ventricular dilation, increased LV mass (LVM), and LV hypertrophy (LVH). In turn, LVM and LVH are well established predictors of cardiovascular morbidity and mortality. There is evidence to suggest that experimentally induced anemia causes myocardial hypertrophy in a rat model. The diagnosis of LVH has been incorporated in the clinical practice as an important marker of cardiovascular disease. Echocardiography has been clinically employed, becoming one of the most important noninvasive imaging methods in the evaluation of cardiac morphology and dynamics.2 Clinical studies suggest that correction of anemia causes regression of left ventricular hypertrophy.There are limited data,that have evaluated the relationship between chronic anemia with LVM or LVH. Hence the present study was undertaken with the objective of estimating the LV mass in patients with chronic severe anemia and comparing data with that of control group.
MATERIALS AND METHODS
The present study was undertaken in the department of physiology Al-Ameen Medical College, Bijapur. Thirty one (31) patients (20 females, 11 males) with severe anemia hemoglobin (Hb) ≤ 7gm%, between 18yrs to 40 yrs age visiting Al-Ameen medical college hospital and District Hospital Bijapur were selected. Equal number of age and gender matched individuals with normal Hb levels were controls. Patients presenting with acute blood loss, pregnancy, hypertension, any underlying heart disease, chronic obstructive pulmonary disease (COPD), patients with hyperdynamic circulatory states like hyperthyroidism, beriberi, AV fistulas were excluded from the study. All anemic patients underwent history taking and a thorough clinical examination. Physical parameters viz Height, Weight were recorded. Body surface area (BSA) in Sq. mts (m2 ) was calculated by Duboi’s nomogram. Their hemoglobin levels were estimated. Transthoracic Echocardiography was done using PHILIPS Envisor C (model no MCMD02AA) diagnostic Ultrasound System using 3.5 MHz transducer, probe (PA 4- 2) by physician experienced in Echocardiography. Measurements were made according to the recommendations of the American Society of Echocardiography (ASE) at end diastole and end systole.3 Echocardiographic parameters viz- LVPWd (Posterior wall thickness at end diastole), LVIDd (Left ventricular inner dimension at end diastole), IVSTd (septum thickness at end diastole)were recorded. Left ventricular mass was calculated in each case using Devereux formula.4 LV Mass= 1.04 [(LVIDD + PWTD +IVSTD)3 - (LVIDD)3 ]-13.6 gms Where 1.04 is the specific gravity of cardiac muscle. LV Mass index (LVMI) was calculated as LVM/Body surface area. LV Mass more than 131 gms in males and more than 90 gms in females were considered as abnormal and indicative of Left Ventricular Hypertrophy (LVH). Statistics: Student’s unpaired‘t’ test was performed (using Graph pad Prism 5 statistical software) to analyze the echocardiographic changes between anemic patients and control group. Pearsonscorrelation and regression analysis was applied to correlate Hb levels with LVM and LVMI in anemic pts. A ‘p’ value 0.05). The mean weight of anemic patients was found to be less than that of controls, which was statistically significant; (t = 4.277, p < 0.0001). The mean value of BSA of anemic patients was more than that of controls, which was statistically significant; (t = 3.451, p < 0.01) and (t = 4.46, p < 0.0001) respectively. The mean ± SEM of hemoglobin in anemic patients was 4.958 ± 0.22 gm/dl; in controls 13.46 ± 0.13 gm/dl. Table No.2 shows mean ± SEM of Echocardiographic parameters in anemic patients. The mean value of IVSTd was numerically more in anemic patients as compared to the controls. But the difference was not statistically significant; (t = 1.692, p > 0.05).The mean value of LVIDd in anemic patients was 0.54 cms more as compared to that of controls. This difference was found to be highly statistically significant; (t = 5.064, p < 0.0001).The was no statistically significant between the mean value of LVPWd of anemic pts and controls; (t = 1.886, p > 0.05). Mean ± SEM of LVM in anemic pts was more 113.56 ± 5.7 gms, when compared to controls 94.03 ± 3.4 gms. This difference was statistically significant; (t = 2.94, p < 0.01). In anemic pts Mean ± SEM of LVMI was 111.71 ± 5.01 gms/m2 which was higher than that of controls 86.68 ± 2.9 gm/m2 , this difference turned out to be highly statistically significant; (t = 4.32, p < 0.0001). Table No.3 shows the total % of anemic pts with and without LVH. Based on the cutoff values of LV Mass of more than 131 gms in males and more than 90 gms in females, Left ventricular hypertrophy was found in 20 ptsi.e 64.5% of the total, where as 11 ptsi.e 35.5% of pts were without LVH. Fig 1 shows the same in pie chart form.However when corrected for body surface area, i.ebased on LVMI 19 pts (61.3%) showed LVH and 12 pts (38.7%) were found to be without LVH. Table No.4 shows the % of male and female anemic pts with LVH. 45.5% of male pts were found with LVH (Fig. 2). Based on LVM, 70% and based on LVMI 75% of female pts (Fig.3) were found to have LVH. Table No.5 shows the correlation analysis of Hb with LVM and LVMI in anemic patients.LVM showed statistically significant negative correlation with hemoglobin levels (r = -0.591, p < 0.001). Similar result was obtained when LVMI was correlated with Hb levels (r = -0.627, p < 0.0001).
DISCUSSION
Anemia is a common cause of morbidity in India especially in low socioeconomic group and is a serious health problem. It affects an estimated 50% of the population. According to NFHS (National Family Health Survey) II, 52% of women have some degree of anemia, 35% of women are mildly anemic, 15% are moderately anemic, and 2% are severely anemic.5 Takahashi M et.al 1990, conducted a study on 28 patients with iron deficiency anemia in which changes in hemodynamic parameters were observed before and after treatment in 14 subjects with moderate to severe anemia and then were compared with those of normal subjects. The LV diastolic diameter (LVIDd) as measured by Mmode echocardiography decreased after treatment in anemic patients. When compared with controls the values were higher in anemic patients.6 Patients with anemia had significantly larger left ventricles compared with control subjects as shown by the M mode left ventricular end diastolic dimensions (Bahl VK et al, 1992).7Our finding of an increased LVIDs is similar to other studies mentioned above. Probably this is due to the result of increased volume overload which in the long term causes hemodynamic alterations leading to gradual development of cardiac enlargement and LV hypertrophy. This LVH is eccentric, characterized by increased LV internal dimensions.8The transition from a high-output (compensated) cardiac state to a state of LV dysfunction (decompensated) appears to begin at a hemoglobin level of approximately 7 g/dL in anemic patient. As the hemoglobin level drops further, so does the LV function.9 Several factors have been shown repeatedly in epidemiologic studies to associate with LVH. Factors such as hematocrit have been implicated but with some inconsistency among different studies. Clinical validity and impact of such factors is controversial, but it may be important to consider them as relevant potential confounders in epidemiological studies investigating the role of novel risk factors in LVH and the role of LVH in disease prediction.4 Left ventricular mass (LVM) is an independent risk factor for prediction of cardio vascular events. Increased LVM in chronic anemia is well documented in animal models. Denis M. Medeirosand John L. Beard in their study reported the presence of eccentric cardiac hypertrophy in rats made anemic by feeding an iron-deficient diet.10In a cross sectional study of 175 patients attending a kidney disease clinic, the relationship of hemoglobin levels to echocardiographic findings was evaluated. The authors found that anemia and systolic blood pressure were the most modifiable risk factors associated with the presence of LV hypertrophy. In multiple logistic regression analysis, each 1g/ dL decrease in hemoglobin was associated with a 6% increase in risk of LV hypertrophy.11The physiologic response to anemia is a compensatory increase in cardiac output in order to maintain adequate oxygen delivery. Exercise capacity falls in correlation to the degree of anemia.12 In a study by Manish G. Amin et.al 2004, 1376 men and 1769 women who were anemic were studied. The mean hematocrit (Hct) and LVMI were 46.5% and 41.9%, and 127.3 and 95.8 g/m, respectively, in men and women. After adjustment for confounders, each 3% lower Hct was associated with a 2.6 g/m higher mean LVMI in men, and a 1.8 g/m higher mean LVMI in postmenopausal women (p ≤0.05). There was a significant quadratic relationship between Hct and LVMI in premenopausal women (p ≤ 0.01).2 Left ventricular mass was significantly increased in thalassemic patients as compared to controls in a study on 20 thalassemic pts and 20 controls done to investigate the echocardiographic features in β thalassemia patients(Taksande A et.al, 2005).13Levin A et al. 1996, demonstrated in their study the high prevalence of LVH in patients with renal insufficiency and identified two modifiable factors as important predictors of LVH, of which anemia was one factor. For each 10 g/L decrease in hemoglobin, the risk of LVH increased by 6% (P = 0.0062).11 The findings of our study are in agreement with other studies mentioned above. We demonstrated an increased LVM and LVMI in anemic patients as compared to controls. Left ventricular hypertrophy was found in 64.5% of pts based on LVM and 61.5% pts based on LVMI. 75% of female and 45.5% of male anemic patients were found with left ventricular hypertrophy. Differences in LV mass due to gender, independent of questions related to body size, may have pathophysiological implications. Women have been shown to have an increased parietal hypertrophic response to overload even after body size correction.4 Our study demonstrated 75% of female anemic pts were found with increased LVM after correction for BSA. Left ventricular mass (LVM) is an independent risk factor for prediction of cardiovascular events. Increase in LVM, as related to cardiac remodeling, can be consequent to both an adaptive and a maladaptive process.Severe anemia is known to cause reduced oxygen carrying capacity of blood. Non hemodynamic and hemodynamic mechanisms operate to compensate for anemia. Increased CO is the main hemodynamic factor mediated by lower afterload, increased preload, positive chronotrophic and inotrophic effects. With decreased afterload, the venous return and LV filling increases leading to increased LVIDd as evidenced in our study. In the long term, these hemodynamic alterations lead to gradual development of cardiac enlargement and LV hypertrophy. This LVH is eccentric, characterized by increased LV internal dimensions.8 Pathologic hypertrophy serves as an important adaptive response to regional or global increases in systolic and/or diastolic wall stress. Initially, the increase in cardiac mass serves to normalize wall stress and permit normal cardio vascular function at rest and during exercise. Nevertheless, during the compensated phase of pathologic hypertrophy, distinct alterations in myocardial gene expression occur; and these changes may serve to maintain function in the context of increased wall stress. This results in eccentric left ventricular hypertrophy. Eccentric hypertrophy results in an overall increase in myocyte length without a substantial increase in myocyte cross-sectional area and is caused by the addition of new sarcomeres in series. Volume overload leads to new sarcomeres both in parallel and in series. Hypertrophy of myocardial myocytes occurs to meet the demand of increased rate of use of mechanical energy as a response to sustained hemodynamic overloading of the heart. 14Up to a point, the increased mass of cardiac muscle is beneficial in terms of normalizing wall stress and providing for a larger number of contractile elements. However, the capacity for new cardiac myocytes to form is limited.14 Chronic anemia leads to work hypertrophy of the heart and finally to its dilatation and cardiac failure. However none of our patients were in heart failure.When anemia related LVH develops in otherwise healthy individuals without cardiovascular risk, the lesions are reversible. Continuation of this study after correction of anemia would have been of interest.
CONCLUSION
Chronic anemia leads to work hypertrophy of the heart. Left ventricular mass is an independent risk factor for prediction of cardiovascular events. Echocardiography is a simple, noninvasive imaging method in the evaluation of cardiac morphology and dynamics, hence can be used to evaluate LVmass in chronic anemia. The findings of increased LVM and LVMI in anemic patients of our study are indicative of LV hypertrophy. Hypertrophy of myocardial myocytes occurs to meet the demand of increased rate of use of mechanical energy as a response to sustained hemodynamic overloading of the heart. There is limited data on LV mass in chronic anemia; hence further studies are required in this regard. Also continuation of this study after correction of anemia would have been of interest.
ACKNOWLEDGEMENT
Authors would like to thank all the participants of the study. Authors acknowledge the immense help received from the scholars whose articles cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=853http://ijcrr.com/article_html.php?did=8531. Heribert Schunkert, Hans W Hense. A heart price to pay for anemia.Nephrol Dial Transpalant 2001; 16: 445-448.
2. Manish G. Amin, HocineTighiouart, Daniel E. Weiner, Paul C. Stark, John L. Griffith, Bonnie MacLeod et.al. Hematocrit and Left Ventricular Mass:The Framingham Heart Study. J. Am. Coll. Cardiol. 2004; 43: 1276- 1282.
3. Stritzke J, Mayer B, Lieb W, Luchner A, Döring A, Hense HW, Schunkert H. Haematocrit levels and left ventricular geometry: Results of the MONICA Augsburg Echocardiographic Substudy. J Hpertens 2007 Jun; 25 (6):1301-9.
4. MuriloFoppa, Bruce B Duncan and Luis EP Rohde.Echocardiography based left ventricular mass estimation. How should we define hypertrophy.Cardiovascular Ultrasound 2005; 3(17): 1-13.
5. National Family Health Survey NFHS 2 India 1998- International Institute for Population Sciences, Mumbai, MEASURE DHS + ORC and MACRO.
6. Takahashi M, Kurokawa S, Tsuyusaki T, Kikawada R. Studies of hyperkinetic circulatory state in chronic anemia. J Cardiol 1990; 20 (2):331-9.
7. Bahl VK, Malhotra OP, Kumar D, Agarwal R, Goswami KC, Bajaj R, et al. Non-invasive assessment of systolic and diastolic left ventricular function in patients with chronic severe anemia: A combined M-mode, twodimensional, and Doppler echocardiographic study. Am Heart J 1992; 124: 1516-23.
8. Metivier F, Marchais SJ, Guerin AP, Pannier B, London GM. Pathophysiology of anaemia: Focus on the heart and blood vessels. Nephrol Dial Transplant 2000;15Suppl 3: 14-8.
9. Alvares JF, Oak JL, Pathare AV. Evaluation of cardiac function in iron deficiency anemia before and after total dose iron therapy. J Assoc Physicians India 2000; 48: 204-6.
10. Denis M. Medeirosand John L. Beard.Dietary Iron Deficiency Results in Cardiac Eccentric Hypertrophy in Rats. ProcSocExpBiol Med. 1998 Sep; 218(4): 370-5.
11. Levin A, Singer J, Thompson CR, Ross H, Lewis M. Prevalent left ventricular hypertrophy in the predialysis population: Identifying opportunities for intervention. Am J Kidney Dis. 1996 Mar; 27(3): 347-54.
12. Varat MA, Adolph RJ, Fowler NO. Cardiovascular effects of anemia.Am Heart J 1972; 83: 415-26.
13. Taksande A, Vilhekar K, Jain M, Ganvir B. Left ventricular systolic and diastolic functions in patients with sickle cell anemia. Indian Heart J 2005 Nov-Dec; 57(6): 694-7.
14. ValentinFuster, R. Wayne Alexander, Robert A.O Rourke, Robert Roberts, Spencer B. King III, Ira S. Nash et al. Hurst’s THE HEART. 11thed. New York: McGraw Hill companies; 2004.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241611EnglishN2014June13HealthcareSTUDIES ON THE TOXICOGENOMIC EFFECTS OF ORGANOPHOSPHATE PESTICIDE DIMETHOATE [O,O-DIMETHYL S-(N-METHYLCARBAMOYLMETHYL) PHOSPHORODITHIOATE] IN CYPRINUS CARPIO L.
English7986Md. Niamat AliEnglish Hilal Ahmad GanaieEnglish ZeenatNisarEnglishAim: Since 1940s, chemical pesticides of one form or another have become a dominant and essential form of pest control throughout much of the world. Because of the widespread use of pesticides for domestic and industrial applications, the evaluation of their toxic effects is of major concern to public health. The aim of the present study was to investigate the toxicogenomics effects of dimethoate (DM), an organophosphorus pesticide, to target the chromosomes of fish. Methodology: In the present investigation, two species of Cyprinuscarpio L. i.e. Cyprinuscarpiospecularis and Cyprinuscarpiocommunis were treated with three sub-lethal concentrations of DM (5 ppm, 10 ppm, & 15 ppm.). After treatment, the frequency of micronuclei was examined at the duration of 24, 48 and 72h. The micronucleus test (MNT) was used for assessing the genotoxicity of the fishes by the preparation of slides and scoring of micronuclei. Results: The pesticide treatment caused significant changes in the frequencies of micronuclei in erythrocytes of Cyprinuscarpiospecularis and Cyprinuscarpiocommunis. Micronuclei were non-refractive small nuclei lying near the main nucleus displaying the same pattern as the main nucleus. Nuclear abnormalities were like cells with binuclei, blebbed nuclei, lobed nuclei and notched nuclei. Conclusion: It was concluded that the pesticide dimethoate possess mutagenic potential at varying extent. A time and dose dependent increase in the frequency of micro-nucleated erythrocytes was found.
EnglishToxicogenomics, dimethoate, micronucleus, CyprinuscarpioINTRODUCTION
At present, the pesticide manual includes 3,100 main entries and list over 10,400 products (1-3). Many of them are suspected to have mutagenic and carcinogenic activities (4). Organophosphate pesticides are finding increasing use in recent years since they are biodegradable and therefore persist in the environment only for a short time. Because of their low persistence, repeated applications of these pesticides for the control of pests in agricultural fields and thereby large quantities find way into water bodies (5, 6). Their extensive application may affect fish population as they enter the water through irrigation or rain. The organophosphate compounds are esterase inhibitor of neurotoxicants (7) with acute cholinergic effect preceded by inhibition of acetyl cholinesterase (8). Being neurotoxicants, organophosphate compounds interfere with many of the vital physiological functions (9, 10) and consequently alter the levels of various body constituents (11) Though the application of pesticides is based on their toxicity to selective pests, it is not specific, resulting in very hazardous effect, particularly on aquatic organisms since pesticides eventually reach aquatic ecosystems in considerable amounts as agricultural run-off and outputs from municipal water treatment and manufacturing plants. Many contaminants present in aquatic environment not only endanger the survival and physiology of the organisms but also induce genetic alterations, which may lead to mutation and cancer (12-16). DM, most widely used insecticide, is a particular concern to those exposed occupationally during manufacture, formulation and use. DM exerts toxic effects on many tissues and organs including pancreas (17- 20). It is acutely toxic, has possible links to cancer and is suspected of causing birth defects (21). DM was found to be mutagenic in E. Coli (22). Although data on acute, subchronic and chronic toxicity of DM in laboratory animals are well documented, it’s potential to induce genotoxicity remains unclear. Therefore, the present study is designed to study the genotoxic effects of DM on the two species of fishes i.e. Cyprinus carpio specularis and Cyprinus carpio communis.
MATERIALS AND METHODS
Chemical Mutagen
The commercial grade of DM was obtained from Premier Sales Agency (Srinagar, India), manufactured from Isagro (Asia) Agrochemicals Pvt. Ltd. (Bathinda, India). CAS Reg. no: 60-51- 5, Chemical formula: C5H12NO3PS2 Experimental Animal The present study is carried out by using two species of Cyprinus carpio L. (family: Cyprinidae), i.e. Cyprinus carpio specularis and Cyprinus carpio communis. These fishes were identified by the presence of heavy and strongly serrate spines in the anterior portion of its dorsal and anal fins and by the presence of two rather long, fleshy barbles on each side of its upper jaw (23). The mouth is terminal in the adult and sub terminal in the young (24). Cyprinus carpio communis (scale carp) has regular concentric scales and Cyprinus carpio specularis (mirror carp) has large scales running along the side of the body in several rows with the rest of the body naked (25). Average age of fishes was below one year, weight was 30-40 g and length was 10-12 cm. After collection of fish specimens were acclimated for 45 days at 280C prior to trials. Specimens were kept in polypropylene troughs each with 8-10 individuals/50 L of water. Water was kept O2 saturated by aeration.
Treatment of DM and selection of the dose
In the present study fishes were divided into two groups i.e. the control and the experimental group. The experimental group for each fish species were divided into three subgroups based on the selected dose of DM. On the basis of the literature data (LC50 values for each insecticide), three sub-lethal concentrations: 5, 10 and 15 ppm of DM were selected (26). After treatment with each insecticide, the frequency of micronuclei in all experimental groups were examined at three durations of 24, 48 and 72h. Ten fish specimens were used for at each duration and at each concentration.
Micronucleus Test The micronucleus test was performed on peripheral blood according to the standard protocols with slight modifications (10, 13, 15, 27) Slide Preparation Fishes were killed with a slight blow on the head region. Chemically treated and control fishes were cut in the caudal region and smears of peripheral blood made on grease free clean slides. After fixation the slides were stained with Mayer’s haematoxylin, rinsed in Scott’s tap water substitute followed by another staining of eosin (13, 28) Scoring of Micronucleus For each concentration and duration ten fish specimen were used and from each fish ten slides were studied and 1200 cells were scored under 1000X magnification. Small non-refractive, circular or avoid chromatin bodies, displaying the same staining and focussing pattern as the main nuclei, were scored. Other nuclear abnormalities were also studied and classified as binuclei, blebbed nuclei and notched nuclei (16, 29) Photomicrography The slides were carefully studied and various morphological peculiarities of nuclear material were examined under light microscope for accurate scoring of micronuclei. Later photomicrography was conducted with the help of Trinocular microscope (Leica DMLS2) to keep record of all the details observed under microscope.
Statistical analysis
Statistical analysis of data to verify the significant difference in the incidence of micronucleus between treated and control groups at 5% level of significance was performed using non-parametric criteria, Mann-Whitney U test to analyse the frequency of micronuclei. To ensure statistical accuracy, only cells with one micronucleus were considered, while rarely occurred two micronuclei and other nuclear abnormalities were eliminated from the counts.
RESULTS
The pesticide treatment caused significant changes in the frequencies of micronucleus in erythrocytes of Cyprinus carpio specularis and Cyprinus carpio communis. In these two species of fishes mature erythrocytes are large structures with least differences in size and shape of nucleus. The micronuclei observed were clearly structured with well-defined boundary, which facilitated the identification of fragments in their cytoplasm. Micronuclei were non-refractive small nuclei lying near the main nucleus displaying the same staining pattern as the main nucleus. The number of micronuclei was found restricted to one, or occasionally two, the latter being a very rare phenomenon. Other nuclear abnormalities were also observed like cells with binuclei, blebbed nuclei, lobed nuclei and notched nuclei. But all these nuclear abnormalities were rarely seen and therefore were not scored. The peak frequency of micronucleated peripheral erythrocytes was observed after longer periods of exposure and higher dose treatment. Examples of normal erythrocytes of control fish, micronucleated erythrocytes and other nuclear abnormalities of treated fish are presented (Figure. 1, A-D) The fishes were exposed to three sub-lethal concentrations of 5 ppm, 10 ppm and 15 ppm. The percentage of single micronuclei in Cyprinus carpio specularis (0.03 ± 0.01 of control) increased to 0.32 ± 0.03 from low to high concentrations after 24h and continued to increase by 0.74 ± 0.17 and 1.37 ± 0.16 after 72 h exposure respectively is shown in Table.1. In Cyprinus carpio communis the percentage of single micronuclei increased from 0.03 ± 0.01 of control to 0.39 ± 0.06 (24h), 0.76 ± 0.14 (48h) and 2.23 ± 0.49 (72h).
DISCUSSION
The use of fish biomarkers as indices of the effects of pollution are of increasing importance and can permit early detection of aquatic environmental problems (30). The micronucleus test in fish has been applied for both laboratory treatments of in-vivo and in-situ exposure to environmental pollution. Induction of micronuclei by several well-known clastogenic/mutagenic agents such as cyclophosphamide, mictomycine-C, bleomycine, colchicines, ethyl methane sulphonate and vinblastin was assessed in freshwater and marine fish species (31-33). The efficacy of the micronucleus test as an indicator of cytogenetic damage has already been proven and the studies of micronucleus formation have been successfully used as bioassay to measure the impacts after fish treatment with surface water disinfectants (34), herbicides (12-14, 35, 36) insecticides (37, 38), benzo (x) pyrene and other polyaromatic hydrocarbon compounds (39). In the present study, positive genotoxic effects, measured as micronucleus frequency in erythrocytes from both fish species (Cyprinus carpio specularis and Cyprinus carpio communis) exposed to different insecticides were observed. The results of the present study revealed a significant induction of micronuclei in peripheral erythrocytes (P< 0.01 and PEnglishhttp://ijcrr.com/abstract.php?article_id=854http://ijcrr.com/article_html.php?did=8541. Konradsen F. Acute pesticide poisoning-a global public health problem. Dan Med Bull. 2007; 54 (1):58-59.
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13. Ahmad W, Ali MN, Farah MA, Ateeq B. Computerized automated morphometric assay including frequency estimation of pentachlorophenol induced nuclear anomalies [micronucleus] in catfish Heteropneustes fossilis. Chromosoma. 2002; 110 (8), 570–574.
14. Ali MN, Ahmad W. Effect of pentachlorophenol on chromosomes of a catfish, Heteropneustes fossilis. Ind. J. Exp. Biol. 1998; 36: 304–307.
15. Minissi S, Ciccotti E, Rissoni M. Micronucleus test in erythrocytes of Barbus plabejus (teleost Pisces) from two natural environments: a bioassay for the insitu detection of mutagens in freshwater. Mutat Res. 1996; 343:121-135.
16. Carrasco K, Tilbury KL, Mays MS. Assessment of the piscine micronuclei test as an insitu biological indicator of chemical contaminants effects. Can J fish aquat Sci. 1990; 47:2123-2136.
17. Kamath V, Rajini PS. Altered glucose homeostasis and oxidative impairment in pancreas of rats subjected to dimethoate intoxication. Toxicology. 2007; 231:137- 146.
18. Kamath V, Joshi AKR, Rajini PS. Dimethoate induced biochemical perturbations in rat pancreas and its attenuation by cashew nut skin extract. Pestic Biochem Phys. 2008; 90:58-62.
19. Astiz M, Hurtado de Catalfo GE, de Alaniz MJ, Marra CA. Involvement of lipids in Dimethoate-induced inhibition of Testosterone biosynthesis in rat interstitial cells. Lipids. 2009; 44 (8):703-718.
20. Saafi EB, Louedia M, Elfeki A, Zakhama A, Najar MF, Hammami M, Achour L. Protective effect of date palm fruit extract (Phoenix dactylifera L.) on dimethoate induced- oxidative stress in rat liver. Exp Toxicol Pathol. 2010; 63:433-441.
21. Astiz M., de Alaniz MJ, Marra CA. Effect of pesticides on cell survival in liver and brain rat tissues. Ecotoxicol Environ Saf. 2009; 72(7): 2025-2032.
22. Mohn G. 5-methyl tryptophan resistance mutations in Escherichia coli k-12. Mutagenic activity of mono functional alkylating agents including organo phosphorous indecticides. Mutat Res. 1973; 20:7-15.
23. Douglas NH. Freshwater fishes of Lovisiana. Lovisiana Wildlife and Fisheries Commission Bat on Rouge, LA. 1974; 443.
24. Page LM, Burr BM. A field guide to fresh water fishes of North America north of Mexico. The Peterson Field Guide Series, 1991; Vol. 42. Houghton Mifflin Company, Boston MA. Avaibable from
25. McCrimmon H. Carp in Canada Fisheries research Board of Canada. 1968; http://animaldiversity.ummz.umich.edu/site/ accounts/information/cyprinus_carpio.html
26. Johnson WW, Finley MT. Handbook of acute toxicity of chemicals to fish and aquatic invertebrates. Resource published 137. US Department of Interior, Fish and Wildlife Service Washington, DC. 1980; 5- 17.
27. Schmid W. The micronucleus test. Mutat Res. 1975; 31: 9-15.
28. Pascoe S, Gatehouse D. The use of a simple haematoxilin and eosin staining procedure to demonstrate micronuclei within rodent bone marrow. Mutat Res. 1986; 164:237-243.
29. Hooftman RN, de Raat WK. Induction of nuclear anomalies (micronuclei) in peripheral blood erythrocytes of eastern mudminnow Umbra pygmaea by Ethyl methane sulphonate. Mutat Res. 1982; 104:147-152.
30. Van Der Oost R, Beyer J, Vermeulen NPE. Fish bioaccumulation and biomarkers in environmental risk assessment: a review. Environ Toxicol Phar. 2003; 13: 57-149.
31. Gustavino B, Scornajehghi KA, Minissi S, Ciccotti E. Micronuclei induced in erythrocytes of Cyprinus carpio (teleost, pisces) by X-rays and colchicine. Mutat Res. 2001; 494:151-159.
32. Palhares D, Grisolia CK. Comparison between the micronucleus frequencies of kidney and gill erythrocytes in tilapia fish, following mitomycin C treatment. Genet Mol Biol. 2002; 25:281-284.
33. Rodriguez-Cea A, Ayllon F, Garciavazque ZE. Micronucleus test in freshwater fish species: an evaluation of its sensitivity for application in field surveys. Ecotoxicol Environ Saf. 2003; 56:442-448.
34. Buschini A, Martino A, Gustavino B, Manfrinotte M, Poli P, Rossi C, Santoro M, Door AJM. Rizzoni M. Comet assay and micronucleus test in circulating erythrocytes of Cyprinus carpio specimens exposed in situ to lake waters treated with disinfectants for potabilization. Mutat Res. 2004; 557:119-129.
35. Ateeq B, Abdul Farah M, Niamat Ali M, Ahmad W. Induction of micronuclei and erythrocyte alterations in the cat fish Clarias batrachus by 2,4- dichlorophenoxy acetic acid and butachlor. Mutat Res. 2002; 518:135-144.
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38. Cavas T, Ergene GS. Evaluation of the genotoxic potential of lambda- Cyhalothrin using nuclear and nucleolar biomarkers on fish cells. Mutat Res. 2003; 534: 93-99.
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40. Pacheco M, Santos MA. Induction of liver EROD and erythrocyte nuclear abnormalities by cyclophosphamide and PAHs in Anguilla Anguilla L. Ecotoxicol Environ Saf. 1998; 40:71-76.
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47. Sivapiriya V, Jayanthisakthisekaran J, Venkatraman S. Effects of dimethoate (O, O,-dimethyl S-methyl carbamoyl methyl phosphorodithioate) and ethanol in antioxidant status of liver and kidney of experimental mice. Pest Biochem Physiol. 2006; 85(2):115-121.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241611EnglishN-0001November30HealthcareCOMPARATIVE CLINICAL EVALUATION OF REDUCTION IN TOOTH MOBILITY USING PERIOTEST® IN LOWER ANTERIOR TEETH POST PHAS - I THERAPY IN PATIENTS WITH MILD TO MODERATE GINGIVITIS: A RANDOMIZED CONTROLLED TRIAL
English8790Kunal A. BanavaliEnglish Pradeep ChitnisEnglish Ketaki UpadhyeEnglish Bhoomi KotakEnglishBackground: The Periotest® method is a technique for the objective assessment of tooth mobility. The aim of this study was to determine the reduction in tooth mobility following phase I therapy (scaling and root planning) in individuals aged 18-30 years using Periotest®. Materials and Methods: Initial scoring of tooth mobility was done using Periotest® followed by phase-I therapy which included scaling and root planning using ultrasonic scalers and hand instruments. The second scoring was done 14 days following phase-I therapy and instructions in oral hygiene. Patients with presence of grade I mobility with lower anterior teeth, no bone loss radiographically, no periodontal pocket and absence of pulpal pathology and severe occlusal interferences in the teeth to be treated were included in the study. Result: A significant increase in the proportion of teeth with zero mobility was observed 14 days following completion of the nonsurgical phase-I therapy. The tooth mobility pre scaling and root planning was 10-18 Periotest value (13.40±2.207) and tooth mobility post scaling and root planning after 14 days was -8-7 Periotest value (1.9000±5.319). Statistical analysis was carried out using paired T-test; the p value was statistically significant (p?0.005). Conclusion: From the above study we can conclude that abnormal tooth mobility decreased following the hygienic phase of periodontal treatment (scaling, root planing, polishing and oral hygiene instruction) using Periotest® method as objective method for measurement of tooth mobility.
EnglishPeriotest, gingivitis, oral hygieneINTRODUCTION
The significance of presence tooth mobility as a manifestation of periodontal disease is controversial.1 However, decrease in mobility is generally considered to be a desirable outcome of periodontal therapy, while increasing mobility a year or more after the treatment has been suggested to indicate a need for further dental therapy.2 Thus in selection of a modality for periodontal treatment, a favorable mobility response is one of several considerations. Furthermore, mastication on firm teeth is more comfortable than biting on mobile teeth. A reduction in hypermobility after scaling and establishing good oral hygiene has been reported in several studies,3,4 while occlusal adjustment may further decrease the mobility.4 5 Studies have included patients with or without occlusal adjustment in addition to the scaling and hygienic therapy. Considerable reductions in mobility along with good results of the periodontal therapy have been seen with or without occlusal adjustment. 2, 6,7 Furthermore, presence of tooth mobility after treatment does not seem to influence the treatment outcome, as long as the oral hygiene is good and the mobility is not increasing.2 The aim of the following study was to clinically compare the reduction in tooth mobility after phase-I therapy using Periotest® as objective method for measurement of mobility.
MATERIALS AND METHODS
Thirty patients aged 18-30 years were selected from the OPD of department periodontics of Y.M.T. Dental College and Hospital for the randomized, controlled clinical trial. Informed consent was taken from all the patients who participated in the study. Initial scoring of tooth mobility was done using Periotest® (Fig.4) followed by phase-I therapy which included scaling and root planning using ultrasonic scalers and hand instruments. The second scoring was done 14 days following phase-I therapy and instructions in oral hygiene (Fig.6). Tooth mobility was scored on basis of following Periotest® values; -8 to +9: clinically firm teeth, 10-19: first distinguishable sign of movement, 20-29: crown deviates within 1 mm of its normal position, 30- 50: mobility is readily observed. Inclusion criteria included age group from 18 to 40 years, presence of grade I mobility with lower anteriors, no bone loss radiographically, no periodontal pocket and absence of pulpal pathology and severe occlusal interferences in the teeth to be treated (Fig.3) Exclusion criteria included trauma from occlusion with lower anteriors, localized periodontitis with lower anteriors, patient undergoing orthodontic treatment, pregnancy or lactating mothers, participants should not have systemic disease that could modify the periodontal disease. Results obtained were statistically analyzed using paired T-test.
RESULTS
A significant increase in the proportion of teeth with zero mobility were observed 14 days following completion of the nonsurgical phase-I therapy (Bar graph: 1).This table illustrates an increase in the proportion of firm teeth after the phase-I therapy (initial scaling and root planning). The tooth mobility pre scaling and root planning was 10-18 Periotest value (13.40±2.207) and tooth mobility post scaling and root planning after 14 days was -8-7 Periotest value (1.9000±5.319). Statistical analysis was carried out using paired Ttest; the p value was statistically significant (p?0.005) (Statistics table: 1). Thus all patients recruited in the study showed reduction in tooth mobility.
DISCUSSION
The slight but gradual decrease in mobility after the initial treatment may be a manifestation of a slow reorganization of the periodontal supporting structures under good maintenance care. The specific structural and biological phenomena responsible for these changes are not known. It was also interesting to note that, as reported by Rateitschak in 1963, teeth with higher initial mobility values had a greater tendency to improve (get lower mobility) than teeth with initially low mobility values. He also found a gradual, slight decrease in mobility over 2 to 3 years using a mechanical measuring device.8 Wust indicated a 25.3% reduction in tooth mobility 559 days after local periodontal treatment. His subjects had generalized marginal periodontitis, and required soft tissue curettage, selective occlusal grinding, and surgical treatment.9 Persson demonstrated diminishing mobility following oral hygiene instruction and supra- and subgingival scaling in patients with moderate periodontal disease from a period of 3 months to 1 year.10
CONCLUSION
The most fundamental and widely used method of periodontal treatment is the removal of deposits from teeth. Although it has never been conclusively proven that dental accretions are a direct cause of periodontal disease, it has long been recognized that removal of these deposits initiates a return to health. From the above study we can conclude that abnormal tooth mobility decreased following the hygienic phase of periodontal treatment (scaling, root planing, polishing and oral hygiene instruction). Hence decrease in tooth mobility can be a method of assessment of the outcome of periodontal treatment procedures.
Englishhttp://ijcrr.com/abstract.php?article_id=855http://ijcrr.com/article_html.php?did=8551. Ramfjord, S. P., and Ash, M. M., Jr.: Significance of occlusion in the etiology and treatment of early, moderate and advanced Periodontitis. J Periodontol 52: 511, 1981.
2. Lindhe, J., and Nyman, S.: The role of occlusion in periodontal disease and the biological rationale for splinting in treatment of Periodontitis. Oral Sci Rev 10: 11, 1977.
3. Fehr, C, and Mühlemann, H. R.: Objective Erfassung der Wirkungeiner internen Parodontal Therapie ("Biostimulin"). Parodontologie 4: 152, 1956.
4. Wüst, B. P., Rateitschak, K. H., and Mühlemann, H. R.: Der Einfluss der lokalen parodontal Behandlung auf die Zahnlocherung und der Entzündungsgrad des Zahnfleisches. Helv Odontol Acta 4: 58, 1960.
5. Kegel, W., Selipsky, H., and Phillips, C: The effect of splinting on tooth mobility. I. During initial therapy. J Clin Periodontol. 6: 45, 1979.
6. Lindhe, J., and Nyman, S.: The effect of plaque control and surgical pocket elimination on the establishment and maintenance of periodontal health. A longitudinal study of periodontal therapy in cases of advanced disease. J Clin Periodontol 2: 67, 1975.
7. Rosling, B., Nyman, S., and Lindhe, J.: The effect of systematic plaque control on bone regeneration in infrabony pockets. J Clin Periodontol 3: 38, 1976.
8. Rateitschak, K. H.: The therapeutic effect of local treatment on periodontal disease assessed upon evaluation of different diagnostic criteria. I. Changes in tooth mobility. J Periodontol 34: 540, 1963
9. Wust, B. P., Rateitschak, K. and Muhlemann, H. R.: Influence of local periodontal treatment on tooth mobility and gingival inflammation. D. Abs., 6:270, 1961.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241611EnglishN2014June13HealthcareROLE OF OXIDATIVE STRESS IN DIABETIC RETINOPATHY
English9196Sri Hari AttiEnglish Angirekula SaseekalaEnglish Varun Siri A.EnglishObjective: Diabetic retinopathy is the most commonest form of complications of diabetes mellitus which leads to vision loss if untreated. It has been hypothesized that oxidative damage may be involved in the pathogenesis of development of diabetic retinopathy. The aim of our present study is to evaluate the role of oxidative stress in diabetic retinopathy patients. Methods: We tried to assess the role of oxidative stress in patients by estimating the levels of lipid peroxidation assessing plasma Malondialdehyde(MDA) levels and antioxidant status by reduced glutathione(GSH), Vitamin-E ,Vitamin-C in blood. For this, we have taken 50 cases of diabetic retinopathy compared with 25 age matched controls . Results: There were significant increase in the levels of MDA and significant decreases in the levels of antioxidants like GSH, vitamin-E and Vitamin-C in patients when compared with controls. Conclusion: Our results indicate that oxidative stress is associated with the development of diabetic retinopathy which needs further studies.
EnglishDiabetes, retinopathy, oxidative stress, antioxidants.INTRODUCTION
Diabetes mellitus comprises a group of common metabolic disorders that share the phenotype of hyperglycemia. It is the most common endocrine metabolic disorder, affecting about 170 million people worldwide(1). The incidence of diabetes mellitus and its complications are increasing rapidly in India due to an aging population and the westernization of lifestyles. The ophthalmic complications of diabetes include corneal abnormalities, glaucoma, iris neovascularisation, cataracts and neuropathies. However, the most common and the potentially most blinding of these complications is diabetic retinopathy(2). Diabetic retinopathy is caused primarily by microvascular injury and the duration of diabetes, hyperglycemia, hypertension, and Hyperlipidemia have been shown to be risk factors for diabetic retinopathy(3). It is known that 20-50% of the long duration cases show proliferative diabetic retinopathy. In diabetes, the retina experiences increased oxidative stress(4), and reactive oxygen species are considered as a link between elevated glucose and the metabolic abnormalities important in the development of diabetic complications.(5).Oxidative stress increases in diabetes owing to an increase in the production of oxygen free radicals and a deficiency in the antioxidant defense mechanisms. The lipid peroxidation of the cellular structures, a consequence of the increased oxygen free radicals is thought to play an important role in the atherosclerosis and the microvascular complications(6).Elevated glucose causes a hypoxia like imbalance by increasing the NADH to NAD ratio. This altered ratio has been hypothesized to be a mechanism for ischemic retinopathy(7) and a cause of increased production of the superoxide ion(8). Greater ischemia manifested by capillary non perfusion of the retina leads to greater risk of extraretinal neovascularization and proliferative diabetic retinopathy, which is partly in response to up regulation and release of VEGF(9). Increased superoxide ion increases the oxidative load with greater reactive oxidative intermediates and advanced glycation end products, which also lead to increased release of VEGF(10) and the risk of neovascularization(11). Both ischemia and increased oxidation can lead to an increased production of lipid peroxides, which are themselves angiogenic(11). Taking the above facts into consideration, the present study was planned to evaluate the possible role of oxidative stress and antioxidant status in the pathophysiology of diabetic retinopathy patients.
MATERIALS AND METHODS
The present study was conducted at the Department of Opthalmology and the department of biochemistry at S.V.Medical college, Tirupati. A total of 50 known cases of diabetes mellitus patients of age group 45-75 were selected for this study. Age and sex matched 25 normal healthy adults were selected as controls. Informed consent from all cases and controls were obtained. Ethical clearance was obtained for this study. A detailed medical history was obtained to identify those with known or suspected systemic hypertension, peripheral or coronary artery disease, venous thrombotic events, cerebrovascular disease, alcohol abuse, smoking and current use of cholesterol lowering drugs or vitamin supplements. All subjects underwent a complete opthalmoscopic examination including visual acuity, slit lamp examination, intraocular pressure measurement using tonometry, gonioscopy, and dilated fundoscopic examination and systemic examination. Based on ophthalmic and systemic examinations, the study had two groups. Group 1 included 25 age matched healthy adults as controls and Group 2 included 50 patients of type-2 diabetes with retinopathy out of which 23 had non proliferative diabetic retinopathy and 27 had proliferative diabetic retinopathy. 10 ml of fasting blood samples were collected by venipuncture and for the separation of sera, 5ml of blood was centrifuged at 3000rpm for 5min and the remaining 5ml of blood was taken into a plain vial containing EDTA and was centrifuged at 3000rpm for 10min for the separation of plasma. The plasma MDA levels were estimated by using thiobarbituric acid reacting substances(TBARS) by the method of Yagi(12) and Sinnhuber et al(13). Reduced glutathione was determined by the method of Beutler et al(14). Serum Vit-E was measured by the method of Baker on the basis of reduction of ferric ions to ferrous ions by Vit-E and the formation of red colored complex with 2-2’ dipyridyl at 520nm(15). The activity of Ascorbic acid was determined by the method of Teitz(16). All the results were expressed as mean±SD and statistical comparisons were done using student t-test using the SPSS package and ANOVA correlation study.
Evaluation of oxidative stress is done based on the levels of MDA and statistically significant increase in the levels of MDA was observed in diabetics with retinopathy when compared to controls. Statistically significant decreases were observed in the levels of enzymatic antioxidants like GSH and non enzymatic antioxidants like vitaminE and C in cases when compared to controls.
DISCUSSION
Diabetic retinopathy is one of the most common microvascular complications of diabetes and ranks as a common cause of blindness worldwide(17). Diabetic retinopathy could become a major threat to public health in the future due to the global prevalence of diabetes of diabetes, which is projected to affect 438 million people by 2030(18). Both the duration of diabetes and its metabolic control have been identified as the risk factors most strongly associated with the development of diabetic retinopathy(19). Diabetic retinopathy occurs in 70% of all persons having diabetes for more than 15 years. The prevalence of diabetic retinopathy among urban subjects with diabetes in India was reported to be about 17%(20), whereas in a clinical study it was found to be 34% among patients with type 2 diabetes(21). The prevalence of diabetic retinopathy was 0.5% in the general rural populations of south India and 10.5% among patients with diabetes(22). Diabetic retinopathy is characterized by the appearance of vascular lesions of increasing severity, culminating in the growth of new vessels. Several hypotheses have been tested on the cause and pathogenesis of diabetic retinopathy. In non proliferative retinopathy, prolonged hyperglycemia may produce microaneurysms because of the selective decrease of cells in the vicinity of the retinal microvasculature and may also induce thickening of the vascular fundus membrane, endothelial proliferation, microvascular dilatation due to decreased endothelin-1 synthesis, increased vascular permeability and vascular occlusion in microvascular endothelial cells. In addition, prolonged hyperglycemia may increase blood flow and viscosity, resulting in increase of shear stress against the vascular wall, as well as injury of the vascular wall, in severe cases, it is known to induce macular edema(23). However, the main pathogenesis of proliferative retinopathy is known to be neovascularization caused by several factors including insulin like growth factor released from a retinal ischemic area(23). Recently, four biochemical pathways including enhanced glucose flux through the polyol pathway, increased intracellular formation of advanced glycation end-products, activation of protein kinase C isoforms, and stimulation of the hexosamine pathway have been suggested for eye disorders caused by hyperglycemia induced vascular injury in diabetes. These pathogenic mechanisms also appear to be associated with superoxide overproduction by the mitochondrial electron transport chain(24). In our study it was found that MDA levels of subjects with diabetic retinopathy were significantly higher than the levels of healthy controls. MDA level acted as markers of lipid peroxidation which represents oxidative stress and the reasons for increased lipid peroxidation products may be due to increased oxygen products as a result of auto-oxidation of glucose and glycosylated proteins, polyol pathways and decreased non enzymatic antioxidants. In addition, hyperglycemia increases the formation of triose phosphate, whose oxidation causes the formation of two free radicals alpha aldehyde and hydrogen peroxide(25). The increased levels of lipid peroxides can cause oxidative injury to blood cells, cross linking of membrane lipids and proteins, increasing of cell ageing, imbalance of prostacyclin/prostaglandin and vasoconstriction(26).GSH has a key role in enzymatic defense systems and helps in removing peroxides. In our study, there was statistically significant decrease in the levels of reduced glutathione when compared to healthy subjects. In the literature, different results have been reported in different organs and tissues regarding the levels of these two enzymes in diabetes mellitus. The low levels of antioxidant enzymes in diabetes mellitus may be because of the inactivation of the antioxidant enzymes by non enzymatic glycation due to persistent hyperglycemia or GSH could be overused implying a reduction of protection against reactive oxygen species, possibly due to a defective redox cycle or it may be due to defective intracellular synthesis. Statistically significant low levels were observed in the levels of vitamin- C and E in cases when compared to controls. Vitamin-C is water soluble vitamin and vitamin-E is fat soluble and they are the most important antioxidant vitamins, inactivates free radicals found in the cytosol, plasma and extracellular environment. The low levels of these vitamins suggest the overusage which again increases the oxidative stress. Thus, this study concluded that the increased oxidative stress and the decreased antioxidant status can predict the micro-vascular complications in diabetes mellitus. The raised MDA levels indicate the oxidative stress and the decreased GSH, Vitamin-C and E levels indicate the reduced anti oxidative status in diabetic retinopathy.
CONCLUSION
Hence, for the early detection and prevention of diabetic retinopathy, it is advisable to estimate the oxidative stress markers. It is also advised that vitamin supplements should also be taken to allow the non enzymatic and enzymatic antioxidant systems to respond to oxidative stress.
ACKNOWLEDGEMENTS
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors/editors/publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
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