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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241610EnglishN-0001November30General SciencesDEVELOPING CARBON SEQUESTRATION MODEL FOR INDONESIAN PEAT SWAMP FORESTS USING SOIL AND BIOMASS CARBON STOCK AS PROXY: OPTIONS AND OPPORTUNITIES FOR PEATLAND MAPPING AND CARBON TRADING IN INDONESIA
English0107Syed Aziz Ur RehmanEnglish Wahid UllahEnglish Muhammad KhurshidEnglishPeat C loss in Indonesia has never been estimated using the C stock change method in a synchronic experiment because of difficulty in Identifying an after-Land Use Change (LUC) location with an initial peat depth similar to that of the before-LUC location due to substantial spatial variability of peat depth, lack of maps locating the position of peat domes and sporadic presence of pristine peatlands at close distance to converted lands. Nevertheless, indirect methods so-called proxy variables or “proxies” can be used for assessing the emission reduction and establishing carbon sequestration scenarios. The vegetation proxy approach provides the basis for peatland GHG accounting which covers all main factors that determines ecosystem level carbon dynamics. Therefore we recommend carbon stocks in soil and biomass as a proxy tool for developing carbon sequestration model which is a more conservative approach, easily adaptable and having other associated benefits like resource inventory and national level peat swamp forest (PSF) mapping. This can be done for both PSF already converted and also for developing carbon markets and climate change mitigation scenarios in future. This involves a synchronic experiment of carbon stock determination and comparison by taking PSF-vegetation and soil in intact-state versus any land uses in post-converted statuses. This methodology disregards the debate of separating heterotrophic and autotrophic respiration and instrumental shortcomings for flux measurement; instead the net CO2 emission overtime time can be estimated as the difference of carbon stocks in land units with similar permanent soil characteristics but different management interventions today.
EnglishCarbon Sequestration, Carbon trading, GHG Fluxes, Land use change, Modelling, Proxy, Tropical Peat Swamp ForestsINTRODUCTION
Globally, peatlands cover an area of 400 million hectare, equivalent to 3% of the Earth?s land area and storing terrestrial carbon, as much as 528 Pg or one-third of global soil carbon (Murdiyarso., et al. 2010). The tropical peatland area is 439,238 km2 (~11% of global peatland area) of which 247,778 km2 (57%) is in Southeast Asia. A single country, Indonesia, holds the largest share (57.4 Gt, 65%) (Page. et al. 2011), approximately21Mha, distributed mainly in Sumatra (7.2Mha), Kalimantan (5.8Mha) and Papua (8.0Mha) (Murdiyarso., et al 2008). Peatlands provide many important ecosystem services, including water regulation, biodiversity conservation, (Murdiyarso., et al 2005) and carbon sequestration and storage (Page., et al 2004).Any change to the natural balance between water, soil and vegetation will result in GHG emissions (Joosten., et al 2012). The most rapid degradation of tropical peatland is currently taking place in Southeast Asia where there are strong economic and social pressures for timber, land for agriculture and plantations of oil palm and pulp trees (Koh et al., 2009, Hooijer., et al 2010,). Thus currently prominent land uses on organic wetland soils include agriculture (oil palm, rice, sago palm and vegetable crops), silviculture (timber estates, rubber plantations) and aquaculture (shrimp and fish ponds; largely confined to converted mangroves) (Murdiyarso, et al 2012). Since 1990, 5.1 Mha of the total 15.5 Mha of peatland in Peninsular Malaysia and the islands of Borneo and Sumatra has been deforested, drained (Hooijer., et al 2010) and burned while most of the remainder has been logged intensively (Jauhiainen., et al. 2012). Thus these ecosystems no longer are functioning as Caccumulating systems. Anthropogenic activity is the principal cause of this shift (Jaenicke., et al 2008), although longer-term climate induced changes are also important in some locations (Miettinen., et al 2010), resulting in net carbon flux to the atmosphere and loss of carbon sequestration function (Page ., et al 2010). The mean rate of peat C loss associated with oilpalm cultivation (5.2 Mg of C per hectare per year) is more than 7 times that of peat C accumulation rate in the forest which demonstrates how fast and intensively LUCC in tropical peatlands may affect the C cycle (Murdiyarso., et al 2010). Losses from the biomass amounted to be 158 Mg C ha-1 whereas those from the peat reached 270 Mg C ha-1 over 25 years (see Fig. 1), which is the rotation period of an oil palm plantation .(Verchot., et al 2012). Belowground carbon pools of tropical wetlands are quite high (Warren., et al 2012) and therefore peat C loss associated with LUCC (249.9 Mg of C per hectare over 25 y) is greater than C loss from the change in aboveground biomass C stocks. However, peat losses will not cease after this period and will persist as long as management promotes organic matter oxidation. Additionally, the mineral contact beneath the peat is not always regular. Thus, calculating both the volume and the carbon density of tropical peat is often not possible without very intensive measurements at each site (Murdiyarso., et al 2010).While the links between peatland utilization and CO2 emission are relatively well established for temperate and boreal peatlands there is relatively little information on CO2 emission from drained peatlands in the tropics (Hooijer., et al 2010).
Proxy analysis for carbon sequestration in Peat Swamp Forests
To be able to determine the carbon-effects of conversion of the peat swamp forests, it is crucial to quantify the carbon content and carbon dynamics of these forests and to combine that with data on the status of the peat swamp forests that remain today (Verwer., et al 2010).An accurate assessment of soil carbon stock changes following land use change requires carbon stock measurements over the full depth of the peat profile, because changes occur at greater depths in drained soils; losses are not limited to the top 30 cm as they are in mineral soils (Verchot., et al 2012). There is a pressing need for accurate C assessments in tropical wetland ecosystems to establish baseline C stocks, and real and potential C losses from disturbance (Warren. et al 2012). Thus scientists believe that an improved understanding of the magnitude of the tropical peatland carbon store is now essential given the current interest in: (1) Emissions of greenhouse gases (GHGs) from drained and degrading tropical peatlands.(2) The role that tropical peatlands could play in carbon offset and carbon trading agreements (Page., et al 2007., Page., et al 2011). Standardized methods and protocols are needed for effective monitoring, reporting and verification of emissions from land use and land cover change in tropical wetlands (Murdiyarso. et al 2011). Carbon emissions from LUC can be estimated by quantifying either the changes in C stocks or the changes in C fluxes (IPCC 2006). Both approaches can be applied diachronically (measurement at two points in time, at least, at one site being converted during the monitoring period) or synchronically (measurement at the same time in at least two sites, which have the same initial state). Diachronic experiments are generally opportunistic and rare because they require a long period of field observation. Synchronic experiments are far more common and are classically applied for estimating biomass C stock changes. A synchronic assessment of peat C loss uses the stock change method i.e. by calculating the difference of stocks before and after LUC, requires C stocks measurements over the full depth of the peat profile. Peat C loss in SEA has never been estimated using the C stock change method in a synchronic experiment. Identifying an after-LUC location with an initial peat depth similar to that of the beforeLUC location is nearly impossible due to the substantial spatial variability of peat depth, the lack of maps locating the position of peat domes, and the sporadic presence of pristine peatlands at close distance to converted lands (Hergoualc?h et al 2013). Indeed, adequate techniques exist to measure these fluxes in detail, but these are generally too complex and too expensive for widespread monitoring. Therefore, indirect methods via so-called proxy variables or “proxies” are used for assessing the emission reduction (Joosten and Couwenberg, 2009). Also in climate politics the most important variables GHG fluxes are often addressed via proxies i.e. carbon stock change. We can use carbon stock changes to estimate CO2 fluxes from vegetated land, where simultaneous uptake of CO2 by photosynthesis and emission of CO2 by respiration of plants, animals, and microbes make assessing net CO2 fluxes complicated. Instead of measuring all fluxes to and fro, it is simpler to determine the change in carbon stock, which integrates all fluxes over longer time. Whereas carbon stock change can thus be seen as a proxy for CO2 fluxes, the stocks themselves are also not directly assessed e.g. using allometry and regression equations. Further in forests we estimate the average increase in wood volume (m3 /ha/yr), multiply by the average C- content of wood and use the C-to-CO2 conversion factor of 44/12 to estimate the volume of sequestered CO2 (ton/ha/year) (Joosten., et al 2009). Thus vegetation proxy approach may provide the basis for peatland GHG accounting (Worrall, et al 2010); and according to Couwenberg., et al 2011, vegetation seems to be well qualified for indicating GHG fluxes because: ? It is a good indicator of water level, which in turn strongly correlates with GHG fluxesIt is controlled by various other site factors that determine GHG emissions from peatlands such as nutrient availability, soil reaction (pH) and land use (history) ? It is itself directly and indirectly responsible for the predominant part of the GHG emissions by regulating CO2 exchange, by supplying organic matter (including root exudates) for CO2 and CH4 formation, by reducing peat moisture and by providing possible bypasses for methane fluxes via aerenchyma „shunt species? ? It reflects long-time water level conditions and thus provides indication of average GHG fluxes on an annual time scale ? It allows for fine-scaled mapping, e.g. on scales 1:2,500–1:10,000
Options and Opportunities for Carbon trad
in Tropical Peat Swamp forests of Indonesia Indonesia is one of the greatest emitters of GHGs in the world, with about 80% of national emissions coming from land use and land use change. Recent estimates suggest that carbon loss associated with the conversion of peat swamp forest to oil palm plantation contributes more than 63% to total losses.(Verchot., et al 2012). In 1981, “planned deforestation” in Indonesia was legislated; involving 30 Mha of conversion forests. In addition to plantation forests, most of the conversions were allocated for agricultural land development, such as oil palm. Furthermore, in early 2009, the government of Indonesia issued a regulation that allows the development of oil-palm plantations in peatlands with peat depth less than 3 m, which could potentially trigger further deforestation and peatlands degradation (Murdiyarso, et al 2010). In September 2011, Indonesia issued a presidential decree on land-based NAMAs (Nationally Appropriate Mitigation Actions) combining REDD+, peatland emission reductions, restocking of above- and below-ground carbon pools regardless of forest/non-forest status of the land, and reduction of CH4 and N20 emissions from agriculture (Presidential Decree No. 61 of 2011). This likely makes Indonesia the first Non- Annex-I country in the world to have such a holistic perspective on emissions from the land based sectors. The presidential decree gives substance to the country?s NAMA commitments to reduce its 2020 emissions by 26 percent. Within 12 months of issuance, all districts and cities (more than 400 in total) are meant to provide their own action plans within the sectoral priorities that were established at the national scale (Joosten., et al 2012). From 2013 onwards, coinciding with the second commitment period of the Kyoto Protocol, Annex I Parties to the United Nations Framework Convention on Climate Change (UNFCCC) are given the opportunity to account for GHG emissions by sources and removals by sinks resulting from “Wetland Drainage and Rewetting” (WDR) under Article 3.4 of the Kyoto Protocol. This means that Annex I countries can use peatland rewetting to meet their emissions reduction targets (Joosten., et al 2012). Peat-land restoration usually involves techniques to stabilize eroding surfaces, re-establish a suitable vegetation cover and raise and stabilize the water table, and hence encourage waterlogged conditions and wetland vegetation that will enable peat to form again (Worrall, et al 2011). In Indonesia Forested wetlands, such as floodplain forests, peatland forests and mangrove forests are thus eligible sites for emission reduction projects because they meet the forest definition requirements given in Intergovernmental Panel on Climate Change IPCC guidelines (VCS., 2013). Alternative income sources from peatlands can involve a variety of options, including carbon trading, water, biodiversity and tourism. Oil palm, pulp or rubber plantations could, under certain conditions, help to promote sustainable development of deforested and degraded peatland areas but, in view of the related CO2 emissions, such development should preferably be contemplated for non-peat areas. There are millions of hectares of alang-alang (deforested, abandoned grassland) landscape in Indonesia that could beused for development (Diemont et al., 2001). For large scale developers these areas pose significant constraints as they are already under tenure of local people, and purchasing this land in sufficiently large blocks will bring a variety of administrative nightmares and headaches (Silvius., et al 2007). The country also have some 40 Mha of forestland classified as non-forested or degraded by the Ministry of Forestry. A large portion of degraded lands which are characterized by mineral soils may be allocated for sustainable pulpwood and oil-palm development. Therefore, carbon-rich peatlands can be preserved and targeted for rehabilitation as part of enhancement of sinks activities under variety of carbon trading schemes (Murdiyarso., et al 2010). The economic worth of the baseline and the mitigation activity can be compared by considering the minimum price of carbon at which land owners/decision makers would be indifferent between pursuing the Conversion forever or stop conversion activity, for the lifespan of the mitigation project1 . To do so, we will determine the Net Present Value (NPV) that will fulfill the condition:
Thus at local scales with willingness to stop conversion and when emission reduction potential is being calculated carbon trade off schemes can be implemented which will preserve ecosystem resistance and resilience to climate change and can be recommended as cost-effective and ecologically sound adaptation strategies.
CONCLUSION AND RECOMMENDATIONS It is thus concluded that Converting pristine peat swamp forests ecosystem to agroecosytems and industrial plantation leads to decline in organic carbon stocks both in soil and biomass; and that the net carbon emission during course of time is analogous to the net drop of carbon stocks since the time of logging. Similarly the land units with closest distance to intact peat swamps and permuted land uses have similar ecological conditions in general while topography and hydrology in particular, therefore the fall in the carbon stocks of the transformed loci is a function of human induced activities and time elapsed. Thus we conclude that the proxy based methodology is more reliable and less biased in calculating the site-specific GHG emissions based on the existing carbon stocks and has more conservative approach. Since the land conversion and agriculture expansion in Indonesia is going on with an alarming rate therefore finding virgin peat swamp forests adjacent to plantation and agriculture lands with matching characteristics is challenging. But we recommend proxy analysis to be easily follow-able protocol for determining the GHG emissions that can be adopted by current policy makers and resource managers working on resource mapping, sorting and landuse planning requiring less expertise, low technology and finance. However it is recommended that countries which are less technologically advance shall install permanent sampling plots where diachronic experiments can be performed to have more accurate carbon inventories because in peatlands the large proportion of carbon is stored in soil, which have huge spatial variation even in closeproximities therefore in cases where permanent sampling plot and historic data exist proxy analysis is not recommended. Similarly it is further suggested that the field surveys in carbon inventories are inevitable because satellite imageries and remote sensing data can be used only to estimate biomass, but soil properties and peat-land parameters like hydrology and depth are decisive factors and will help in selecting comparable plots for any carbon sequestration project.
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
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30. Worrall, F., Chapman, P., Holden, J., Evans, C., Artz, R., Smith, P., and Grayson, R. (2010). Peatlands and climate change. Report to IUCN UK Peatland Programme, Edinburgh. www. iucnukpeatlandprogramme.org/scientificrevie ws
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241610EnglishN-0001November30HealthcareHONEY PHONOPHORESIS VERSUS LOW INTENSITY LASER THERAPY IN FEMALE GENITAL HERPES
English0815Intsar Salim WakedEnglish Abdel Hamid N. DeghidiEnglish Randa ShalaanEnglishObjective: To compare the efficacy of honey phonophoresis versus low intensity laser therapy in female genital herpes simplex II. Research Methodology: Forty female patients suffering from genital herpes simplex type II assigned randomly into 2 groups; honey phonophoresis group (A) and low intensity laser group (B). Intensity of pain and serological response were recorded before and after 3 weeks of treatment. Results: The results of study showed that there were significant differences between both groups post-treatment as p value< 0.05. Percentage of improvement in VAS, IgG, IgM after intervention were 60%, 45%, 8%, respectively for group (A ) while for group (B) were 82%, 66%, 56%, Respectively. Conclusion: The study concluded that low intensity laser was more effective than Honey phonophoresis in the treatment of genital herpes type II.
EnglishLow intensity laser, genital herpes, honey phonophoresis, serological response, polymerase chain reaction.INTRODUCTION
Herpes simplex virus type II (HSV-2) gives rise to a variety of clinical disorders and is a major cause of morbidity and mortality worldwide. HSV-2 infections are common in genital area. Genital herpes infections are a major source of morbidity. These infections are responsible for significant health problems, including direct physical discomfort associated with outbreaks, potential complications such as neonatal transmission, and the often devastating psychological effects of a chronic illness1 . Herpes genitals is characterized by small, grouped, painful vesicles or pustules on an erythematous base, which break and form ulcers in 2-4 days. One of the important characteristics of all herpes viruses is latency. The life cycle of the herpes simplex virus is complex, comprising multiple stages. Following infection, the virus establishes life-long latency in its host and can reactivate at any time as a recurrent infection2 . There is evidence that latent infection also develops in tissues such as the epithelium of the vagina. The dormant virus then awaits a “trigger” to reactivate it. Triggers may include psychological stress, onset of menses, illness and physical trauma. Many patients experience a burning, tingling or itching sensation (a prodromal) at the location where a lesion later appears3. Herpes diagnosis is achieved by assessing the patient’s history and physical examination. However, further tests are necessary when HSV infection is asymptomatic, subclinical or atypical, or shows wide expression. The management of herpetic infection is indeed challenging, since none of the different methods of treatment guarantees full remission4 . Recently a range of infections can be potentially treated with honeyThis can include the common cold, eye infections such as conjunctivitis, as well as Herpes cold sores and genital lesions. Honey has antibacterial, antifungal and antiviral properties. Honey has also considerable anti-inflammatory properties as Antiinflammatory effects of honey in human plasma were measured5 . Phonophoresis is actually a combination of ultrasound therapy with topical drug therapy to achieve therapeutic drug concentrations at selected sites in the skin.. Honey had proven to be the best phonophoretic agent for transmission of ultrasound waves as honey is known to contain 17.20% water which is believed to be the best coupling agent in terms of acoustic properties as it reflects only 0.2 % of the sound waves at the water-soft tissue interface6 . Among treatment options, low-level laser therapy (LLLT) has shown promising clinical results as a longer-lasting suppression therapy. Additionally, it has been shown that this type of phototherapy might have an effect on several immunologic reactions7-9 . These findings have influenced a number of uncontrolled clinical studies about the effect of low-intensity laser therapy on herpes simplex infection10,11. . The purpose of this study was to evaluate the efficacy of honey phonophoresis versus low intensity laser therapy in female genital herpes.
PATIENTS AND METHODS
Subjects Forty female patients had genital herpes simplex infection type II were admitted to dermatology unit at El-Mataria Teaching Hospital, Cairo, Egypt, between July 2012 and September 2013. Age ranged from 25 to 45 years. Patients were free from any other diseases and not under any medications that could affect the immunity and influence the results.PATIENTS AND METHODS Subjects Forty female patients had genital herpes simplex infection type II were admitted to dermatology unit at El-Mataria Teaching Hospital, Cairo, Egypt, between July 2012 and September 2013. Age ranged from 25 to 45 years. Patients were free from any other diseases and not under any medications that could affect the immunity and influence the results.
Measurement procedures
A) Measurement of pain
Intensity of pain was measured by visual analogue scale (VAS). A VAS is usually a horizontal line, 100 mm in length, anchored by the verbal descriptors "No pain" and" Worst pain imaginable". Measurement was conducted by asking the patient to place a vertical mark on the line below which indicate how she feel pain at the time of assessment. The VAS score was determined by measuring in millimeter from left hand end of the line to the point that patient marked and was represented by a number from total ten 12.Fig (1).
b) Laboratory Assessment Serological Response and polymerase chain reaction ELISA reader and ELISA washer equipment were used for laboratory assessment of (HSV-II) IgG and (HSV-II) IgM.
Treatment Procedures Honey
Phonophoresis Treatment
Nonius, sonopuls 434, S. No. 03-202 type 1463.900 is a therapeutic US device manufactured by Enraf Holland. The Enraf nonius machine delivered the ultrasound wave, with a frequency of 1-3 MHz. Sonopuls 434 has a digital screen for time and intensity. It allows either pulsed or continuous mode Honey phonophoresis group received honey phonophoresis for 5 minutes; once daily for 3 weeks. Honey was the ultrasound coupling medium and was obtained from the National Research Center. The treated area was divided into zones which are approximately 1.5 times the area of the ultrasound treatment head, and then treat for 1 minute per zone, Frequency was 1.0 MHz, intensity was 1 w/cm2 pulsed waves 13 .
Low intensity Laser Treatment
Patients in the laser group received low-intensity laser therapy by an infrared diode laser with a wave length 905nm, intensity 0.2 mw, frequency 100 Hz and enegy 20 mJ per cm2 for 100 seconds once daily for 3 wk at the site of original lesion. Protective glasses were worn during application of laser to avoid permanent eye damage resulting from direct exposure to laser beam14 .
Statistical procedures
Mean, the standard deviation and the standard error were calculated for all patients. Paired t-test used to compare within each group to detect level of significance in each group. Unpaired t-test was used to detect significance level between two groups. The statistical package for social science (SPSS) was utilized for data analysis and the level of significance was set at the 0.05 level .
RESULTS
Data concerning age, VAS, IgG, IgM had been collected at the beginning of the study. Follow up evaluation of VAS, IgG, IgM, variables had been performed after three weeks of treatment. As shown in table (1), there were no statistical significant differences (P>0.05) observed between both groups concerning age, VAS, IgG, IgM, before intervention.
Results of group B (Laser group)
As shown in table (3) the mean value, standard deviation and p value of VAS, IgG, IgM, for group B pre and after intervention. The results showed highly significant difference as p value Englishhttp://ijcrr.com/abstract.php?article_id=858http://ijcrr.com/article_html.php?did=858REFERENCES
1. Lavoie SR, Kaplowitz LG. Management of genital herpes infection. Semin Dermatol. 1994 Dec;13(4):248-55.
2. S Faro; A review of famciclovir in the management of genital herpes; Infect Dis Obstet Gynecol. 1998; 6(1): 38–43.
3. Siegel MA. Diagnosis and management of recurrent herpes simplex infections. J Am Dental Assoc 2002; 133:1245-1249.
4. Fiddian AP, Yeo JM and Stubbings RF, (2006) :“Successful treatment of herpes simplex with topical acyclovir”. Br. Med. . (Clin. Res. Ed.), 286:1699-1701.
5. Armon TT, (2009): "the use of honey in the treatment of infected wounds". Trop. Doct; 10:91.
6. Sanya AO and Oluseye KA (2000): Relative transmissivity of local substitutes for the manufacturer's ultrasonic transmission medium. J Nig Soc Phys 2000; 10(2): 23-25.
7. Ohta, A, Abergel, RP, Uitto, J: Laser modulation of human immune system: inhibition of lymphocyte proliferation by a gallium-arsenide laser at low energy. Lasers Surg Med 1987 7:199–201.
8. Yu, W, Chi, L, Naim, JO, Lanzafame, RJ: Improvement of host response to sepsis by photobiomodulation.Lasers Surg Med 1997b 21:262–268.
9. Schindl, A, Schindl, M, Schindl, L: Successful phototherapy with low intensity laser irradiation of a chronic radiation ulcer in a patient with lupus erythematosus and diabetes mellitus. Br J Dermatol 1997a 137:840–841.
10. Haichenberger-Wildner, I, Michels, H: Laserstrahlen bei Herpeserkrankungen. Med Cosmetol 1981 11:142–144,
11. Landthaler, M, Haina, D, Waidelich, W: Behandlung von Zoster, postzosterischen Schmerzen und Herpes simplex recidivans in loco mit Laser-Licht. Fortschritte Med 1983 101:1039–1041.
12. Cork RC, Isaacc IG and El-Sharydah AR, (2004): “A comparison of the verbal rating scale and the visual analog scale for pain assessment”. The Internet Journal of Anaesthesiology, 8(1):227-236.
13. Pfister WR and Hsieh DS, (2007): Permeation enhancers compatible with transdermal drugdelivery systems. Part II. System design considerations. Pharm Tech: 14(10):54-60.
14. Deissl LP and Frenkel NS, (2006): “Herpes simplex virus amplicon: Cleavage of concatameric DNA is linked to packaging and involves amplification of the terminally reiterated a sequence”. J. Virol., 57:933.
15. Fatahzadeh MS and Schwartz RA, (2007): “Human herpes simplex. ”. Clinical and Experimental Dermatology, (32):625-630.
16. Al-Waili NS, (2004): Topical honey application vs. acyclovir for the treatment of recurrent herpes simplex lesions. Medical Science Monitor, 10(8), 94-98
17. Molan PC (1992) The antibacterial activity of honey. The nature of the antibacterial activity. Bee World 73: 5–28.
18. Booth S (2004) Are honey and sugar paste alternatives to topical antiseptics? Journal of Wound Care 13(1): 31–3.
19. Kwakman PH, te Velde AA, de Boer L et al (2010) How honey kills bacteria FASEB J 24(7): 2576–82 20. Tunér, J., Hode, L.: Low Level Laser Therapy - clinical practice and scientificbackground, 1999, ISBN 91-630- 7616-0.
21. Donnarumma G, De Gregorio V, Fusco A, Farina E, Baroni A, Esposito V, Contaldo M, Petruzzi M, Pannone G , Serpico R. Inhibition of HSV-1 replication of laser diodeirradiation: possible mechanism of action. Int J Immunopathol Pharmacol. 2010 OctDec;23(4);1167-76.
22. Sanchez PJM, Femenias JLC, Tejeda AD, Tuner J. The Effect of 670-nm Low Laser Therapy on Herpes Simplex Type 1. Photomedicine and Laser Surgery. ahead of print. 0.1089/pho.2011.3076. Online Ahead of Print: November 2, 2011.
23. Schindl A, Neuman R. Low-intensity laser therapy is an effective treatment for recurrent herpes simplex infection. Results from a randomized double-blind placebocontrolled study. J Invest Dermatol. 1999: 113 (2): 221- 223
24. Marotti J, Aranha AC, Eduardo Cde P, Ribeiro MS.Photodynamic therapy can be effective as a treatment for herpes simplex labialis. Photomed Laser Surg. 2009;27(2): 357-63.
25. De Carvalho RR, de Paula Eduardo F, Ramalho KM, Antunes JL, Bezinelli LM, de Magalhães MH, et al. Effect of laser phototherapy on recurring herpes labialis prevention: an in vivo study. Lasers Med ScI 2010;25(3):397-402
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241610EnglishN-0001November30HealthcareETIOLOGY AND PATHOPHYSIOLOGY OF RECURRENT APHTHOUS STOMATITIS: A REVIEW
English1622Arun Kumar M.English Vasanthi AnanthakrishnanEnglish Jaisri GoturuEnglishRecurrent aphthous stomatitis is the most common oral mucosal ulcer disease. It causes severe pain and occurs repeatedly, causing discomfort in daily routine activities. The description of etiology is varied and none of the explanations given so far are satisfactory. Clinically this condition presents itself in three forms: major, minor and herpetiform ulcers. Causes for the ulcers could be related to host and / or environment. Host factors include genetic, nutritional deficiency, immune dysregulation and stress which can again be multifactorial. Environmental factors include trauma (both physical and chemical) and infections. There are several clinical syndromes which are associated with RAS like Behcet’s syndrome. There are several causes acting together in initiating formation of ulcer unlike a single etiological factor as was thought previously. This means combination of host and environmental factors are essential not only for triggering the ulcer but also for an increase in size. The severity of etiological factors to which an individual is exposed would decide the type of ulcer. Identification of the trigger for a particular individual seems to be important in management of the disease. Hence understanding etiopathogenesis for recurrent aphthous stomatitis would be helpful in formulation of individualized treatment modalities. This review is intended to understand the cause and pathogenesis of recurrent aphthous stomatitis.
EnglishRecurrent Aphthous Stomatitis, Oral Ulcers, RAS syndromesINTRODUCTION
Recurrent aphthous stomatitis (RAS)) is a disease of the oral mucosa which appears typically as ulcers in the mouth and causes severe pain. Repeated occurrence of ulcers is very debilitating. The prevalence, clinical presentation, etiology and pathogenesis of recurrent aphthous stomatitis will be discussed in this review.
Prevalence of RAS (Recurrent aphthous stomatitis)
RAS is a common oral mucosal condition and has been reported as affecting 20% of the general population at any given time. It reaches a peak of50% in selected populations such as university students1 . RAS usually appears first during childhood, with a tendency for ulcers to diminish in frequency and severity with age2 . In about 80 percent of patients with RAS, the condition develops before 30 years of age3 .
Clinical Presentation
The ulcers are typically seen on the buccal mucosa, the labial mucosa, the floor of the mouth or the tongue. A prodrome of localized burning or pain for 24 to 48 hours usually precedes the ulcers. The lesions are painful, with well defined margins and shallow necrotic center. All ulcers have yellow-grayish membrane at the base and are surrounded by raised margins and erythematous haloes. The pain is severe and gets aggravated on eating, swallowing and speaking. The pain usually persists for three to four days3 .
Three clinical presentations of RAS are:
Minor aphthous stomatitis (Minor or Mikulicz’saphthea or mild aphthous ulcers), Major aphthous stomatitis (MjRAS or periadenitis mucosanecrotica recurrence or Sutton’s disease) and Herpetiform ulcers.
Minor RAS: This is the commonest type of RAS and 75-85% of RAS are of this type. They typically measure 5-10 mm in size, last for 10-14 days and heal without scarring. Followingthe healing of the ulcers, there is a variable ulcer free intervalof about 3–4 weeks. Major RAS: They typically measure more than 10 mm in size, last for more than two weeks to months and generally heal by scarring. 10-15% of RAS are of this type. MjRAS may produce lesions
throughout the entire oral cavity, including the soft palate, tonsillar areas, and oropharynx. The longer duration simulates the malignant ulcer. Herpetiformulcers: They typically occur as crops of multiple ulcers measuring less than 5mm which may coalesce to form larger confluent areas of ulceration, usually with marked erythema. They last for 10-14 days but severity of pain is more than other forms. 5-10% of RAS are of this type. They resemble ulcers of primary Herpes simplex virus (HSV) infection. The recurrence period may be variable1,2 .
Etiology ofRecurrent aphthous stomatitis:
There are many hypotheses that are put forth for the etiology of RAS. There is no conclusive evidence regarding the etiopathogenesis of RAS.
Genetic Factors:
Field and Allan in 2003 described that there is a genetic predisposition for RAS and more than 40% of affected individuals have first degree relatives with RAS2 . Scully et al 2004 found that the likelihood of RAS is 90% when both parents are affected, but only 20 % when neither parent has RAS. A family history of recurrent aphthous ulcers is evident in some patients. A familial connection includes a young age of onset and symptoms of increased severity. Recurrent aphthous ulcers are highly correlated in identical twins4 . HLA subtypes like HLA B-515 , HLA-B52, HLA-B446 , HLA-DRW10 and DQW17 antigens were found to be closely associated with RAS. 2.
Nutrition: Foods such as chocolate, coffee, peanuts, cereals, almonds, strawberries, cheese, tomatoes (even the skin of the tomatoes) and wheat flour (containing gluten) may be implicated in some patients. In one study of patients with RAS who previously were diagnosed in patch tests as reactive to agents such as benzoic acid, 50% showed clinical improvement when certain foods were excluded from the diet8 .
3. Vitamin Deficiency:
Hematinic (iron, folic acid, vitamins B-6 and B-12) deficiencies were twice as common in patients with RAS9 . As many as 20% patients with RAS had a hematinic deficiency. Lower dietary intake of folate and vitamin B-12 is more common among persons with aphthous ulcers and treatment with 1000 mcg/d has shown benefit in individuals regardless of serum vitamin B12 levels10. A small group of adolescents were shown to have reduced incidence and pain from RAS when given 2000 mg/d of ascorbic acid11 .
4. Immune Dysregulations:
Immune dysregulations may play a significant role but no conclusive evidence has been noted.Cytotoxic action of lymphocytes and monocytes on the oral epithelium seems to cause the ulceration, but the trigger remains unclear. Upon histologic analysis, RAS consists of mucosal ulcerations with mixed inflammatory cell infiltrates. T-helper cells predominate in the pre-ulcerative and healing phases, whereas T-suppressor cells predominate in the ulcerative phase12 . There is reduced response of patients' lymphocytes to mitogens. There may be alterations in the activity of natural killer cells in various stages of disease13. Increased adherence of neutrophils and reduced quantities and functionality of regulatory T cells in tissue with lesions and release of tumor necrosis factor-alpha (TNF-alpha) is seen14 . There is significant involvement of mast cells in the pathogenesis of RAS. Reduced cellular expression of heat shock protein 27 and interleukin 10is seen15 in aphthous lesions16 . There is an increase in the Toll-like receptor activity in RAS17 . Oxidative stress markers (glutathione and malondialdehyde) show altered levels and impaired balance18. Serum IgE levels were found to be increased in RAS patients by several investigators. Scully et al reported that increased IgE concentrations might be related to cell-mediated phenomena in the immunopathogenesis of RAS. The expression of protein C, protein S and Ddimer were increased, while t-PA (tissue plasminogen activator) was reduced in patients with RAS and Behcet‘s disease. Remarkably, the expression of PAI-1(Platelet activator inhibitor-1) was significantly elevated in both Behcet’s Disease and RAS patients compared with that in healthy controls19. The results suggest the abnormal fibrinolytic activity is due to increased inhibition of tissue plasminogen activator20 . 5. Trauma: Local trauma may play a role in initiating the mucosal injury which leads to ulcers in patients with RAS. This study was
initiated to determine whether standardized mechanical injury would lead to ulcers in patients prone to aphthous stomatitis when compared with normal controls. In this study experimental biopsies failed to disclose any histological differences between mechanically induced and spontaneous ulcers21 .
6. Physical or Psychological stress: Psychological stress may play a role in the manifestation of recurrent aphthous stomatitis as a trigger or a modifying factor22. No studies have conclusively proved stress as a causative or precipitating factor for RAS.
7. Infections: The possible immunopathological destruction of oral mucosa by viridian streptococci was under consideration until 1986 but was disproved23 .Streptococcus sanguisor its L-form has been implicated, as has autoimmunity to the oral mucosal homogenate. A common or cross-reactive antigen between streptococci and oral epithelium has been suggested and demonstrated between the streptococcal 60–65 kD heat shock protein (HSP) and oral mucosal tissue. Significant increase in serum antibodies to HSP has been detected in patients with RAS24 . Helicobacter pylori has been detected in lesional tissue of oral ulcers, but the frequency of serum immunoglobulin G antibodies to H pylori is not increased in recurrent aphthous ulcers, and the organisms have never proven causative25,26 . 8. Tobacco smoking: Patients suffering from RAS usually are nonsmokers, and there is a lower prevalence and severity of RAS among heavy smokers as opposed to moderate smokers. Some patients report an onset of RAS after smoking cessation, while others report control on re-initiation of smoking. The use of smokeless tobacco is associated with a significantly lower prevalence of RAS. Nicotine-containing tablets also appear to control the frequency of RAS27 .
Recurrent aphthous stomatitis Associated Syndromes
i. Behcet’s disease (BD)is a multisystemic, chronic, relapsing vasculitis that affects nearly all organs and systems. It is associated with multiple oral, genital ulcers, arthritis, hematemesis, melena, and epigastric pain as predominant manifestations. Seung-Ho Rhee et al 2005 in their study described that RAS and BD had similar presenting symptoms like oral lesions and abdominal pain. There was no clinical, endoscopical, histopathologicalor serological difference between patients with intestinal BD, RAS and healthy volunteers in Anti-Neutrophil Cytoplasmic Antibodies (pANCA) 28 . ii. RAS is a part of
PFAPA syndrome which includes the Periodic Fever, Aphthous stomatitis, Pharyngitis and cervical Adenitis. PFAPA syndrome is regarded as a nonhereditary disease of unknown etiology although the clinical observation is that, in a small proportion of cases, one of the parents or a more distant relative had similar symptoms in childhood29 .
MAGIC syndrome: Mouth And Genital ulcers with Inflamed Cartilage syndrome (also known as "MAGIC syndrome") is a cutaneous condition2 .
iv. Imerslund-Grasbeck syndrome (IGS) is characterized by Juvenile megaloblastic anemia due to vitamin B12 deficiency and proteinuria. All the three cases of ImerslundGrasbeck syndrome described in the study ArnonBroides et al 2006 were associated with RAS. Though it was described that defective neutrophil phagocytosis and neutropenia caused by the Vitamin B12 deficiency may be the possible mechanism for the causation of stomatitis, none of the patients had neutropenia. The cause of RAS in IGS was inconclusive30 .
v. Sweet’s syndrome, also known as acute febrile neutrophilicdermatosis, is characterizedby fever, neutrophil leukocytosis, erythematous skin plaques or nodules and, often, classical RAS. It may occur in conjunction with malignant conditions, such as leukemia2
vi. Celiac disease (CD) is caused by gluten sensitivity of the small intestines. According to study by SelimAydemir et al 2004 the CD prevalence (40%) in patients with RAS is higher than in the normal population. It is also described that RAS may be the presenting sign of the disease and may be used as a marker for the CD31 .
vii. Crohn’s disease: The intraoral involvement in Crohn’s disease (CD) is observed in approximately 9% of cases and oral inflammation precedes intestinal symptoms in about 60% of these patients. Hence it is important to consider the differential diagnosis of Crohn’s disease in subjects with intestinal symptoms and RAS32 .
Pathophysiology of Recurrent aphthous stomatitis:
The complex interactions of various etiological factors together can trigger ulcer formation. Etiological factors can be classified into predisposing factors and precipitating / triggering factors. The factors like HLA associations, immune dysregulation, nutritional deficiency, personality type A are the predisposing factors. Microtrauma, infections, stress could be the initiating or triggering factor for ulcer formation. Those individuals who are susceptible when exposed to the triggering factors for certain duration tend to develop ulcers. Based on the intensity and duration of the triggering factors, ulcer starts growing till the factors are removed. Pain suffered by the patients is directly proportional to the size of the ulcer and severity of the triggering factors. For example the serum cortisol level: which is a biomarker of the stress was increased in thesubjects with RAS and the increase was directly proportional to the ulcer size33 .
CONCLUSION
Recurrent aphthous stomatitis or aphthous ulcers are more common in younger adults. There are several causes that have been explained for ulcer formation but no single cause is definitive. The cause is still nonspecific. There are multiple factors which may be acting together in a complex manner in initiating the formation of ulcer unlike a single etiological factor as was thought previously. This means a combination of host and environmental factors are essential not only for triggering the ulcer but also for an increase in size. The severity of etiological factors to which an individual is exposed would decide the type of ulcer. Underlying mechanisms relating to pathogenesis need to be explored inorder to establish the treatment protocol.
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=859http://ijcrr.com/article_html.php?did=859REFERENCES
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14. Taylor LJ, Bagg J, Walker DM, Peters TJ. Increased production of tumour necrosis factor by peripheral blood leukocytes in patients with recurrent oral aphthous ulceration. J Oral Pathol Med. Jan 1992; 21(1):21-5.
15. Hasan A, Childerstone A, Pervin K, et al. Recognition of a unique peptide epitope of the mycobacterial and human heat shock protein 65-60 antigen by T cells of patients with recurrent oral ulcers. ClinExpImmunol. Mar 1995;99(3):392-7. 16. Miyamoto NT Jr, Borra RC, Abreu M, Weckx LL, Franco M. Immune-expression of HSP27 and IL-10 in recurrent aphthous ulceration. J Oral Pathol Med. Sep 2008;37(8):462-7. 17. Borra RC, de Mesquita Barros F, de Andrade Lotufo M, Villanova FE, Andrade PM. Toll-like receptor activity in recurrent aphthous ulceration. J Oral Pathol Med. Mar 2009;38(3):289-98. 18. Arikan S, Durusoy C, Akalin N, Haberal A, Seckin D. Oxidant/antioxidant status in recurrent aphthous stomatitis. Oral Dis. Oct 2009; 15(7):512-5. 19. Seung-Ho Rhee, Young-Bae Kim, Eun-So Lee. Comparison of Behcet’s Disease and Recurrent Aphthous Ulcer according to Characteristics of Gastrointestinal Symptoms. J Korean Med Sci 2005; 20: 971-6. 20. Hong Shang, Jingjing Ye, Min Ji. Anticoagulant and Fibrinolytic Disorders in Patients with Behçet’s Disease and Recurrent Aphthous Ulcer. Chinese Journal of Physiology 2011; 54:1-6. 21. David Wray, Edward A Graykowski, Abner Louis Notkins. Role of mucosal injury in initiating recurrent aphthous stomatitis. British Medical Journal 1981; 283: 1569- 1570. 22. Camila de Barros Gallo, Maria Angela Martins Mimura, Norberto Nobuo Sugaya. Psychological stress and recurrent aphthous stomatitis. Clinics 2009; 64(6):645-648. 23. Hoover, J. A. Olson, J. S. Greenspan. Humoral Responses and Cross-reactivity to Viridans Streptococci in Recurrent Aphthous Ulceration. J Dent Res 1986; 65(8):1101-1104. 24. A Hasan, A Childerstone, K Pervin, et al. Recognition of a unique peptide epitope of the mycobacterial and human heat shock protein 65-60 antigen by T cells of patients with recurrent oral ulcers. ClinExpImmunol. 1995; 99(3): 392–397. 25. Birek C, Grandhi R, McNeill K, Singe;r D, Ficarra G, Bowden G. Detection of Helicobacter pylori in oral aphthous ulcers. J Oral Pathol Med. May 1999;28(5):197- 203. 26. Elsheikh MN, Mahfouz ME. Prevalence of Helicobacter pylori DNA in recurrent aphthous ulcerations in mucosa-associated lymphoid tissues of the pharynx. Arch Otolaryngol Head Neck Surg 2005;131(9): 804-808. 27. KamileMarako?luand RecepErolSezeret al. Recurrentaphthous stomatitis frequency in the smoking cessation people: Clin Oral Invest 2007; 11:149–153. 28. Seung-Ho Rhee, Young-Bae Kim, Eun-So Lee. Comparison of Behcet’s Disease and Recurrent Aphthous Ulcer according to Characteristics of Gastrointestinal Symptoms. J Korean Med Sci 2005; 20: 971-6. 29. Kelly L Brown1, Per Wekell et al., Profile of blood cells and inflammatory mediators in periodic fever, aphthous stomatitis, pharyngitis and adenitis (PFAPA) syndrome: BMC Pediatrics 2010, 10:65.30. ArnonBroides, Baruch Yerushalmi, Rachel Levy et al. Imerslund-Grasbeck Syndrome Associated With Recurrent Aphthous Stomatitis and Defective Neutrophil Function. J PediatrHematolOncol 2006: 28(11); 715-720. 31. SelimAydemir, NilgünSolakTekin, ErolAktunç et al. Celiac disease in patients having recurrent aphthous Stomatitis. Turk J Gastroenterol 2004; 15 (3): 192-195. 32. Roy S. Rogers III.Recurrent aphthous stomatitis: Clinical characteristics and associated systemic disorders. Seminars in Cutaneous Medicine and Surgery 1997; 16 (4): 278-283. 33. Arunkumar M, VasanthiAnanthakrishnan, JaisriGoturu. Role of Serum Cortisol in Recurrent Aphthous Stomatitis. Biomedicine 2012, 32(3), 331-336.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241610EnglishN-0001November30HealthcareASYMPTOMATIC PULMONARY ARTERIOVENOUS MALFORMATION: A CAUSE FOR PERIOPERATIVE HYPOXEMIA IN PREGNANCY WITH BRAIN ABSCESS - A CASE REPORT
English2327Dhanabagyam GovindarajuluEnglish Ganesan C.English Periyanarkunan Ramaiya MurugesanEnglish Vinodhadevi VijayakumarEnglishAim: The importance of clinical history, meticulous clinical examination, perioperative monitoring, team work in diagnosing and treating rare diseases for a better patient outcome. Case report: 26 year old Gravida 2 at term was admitted with sudden onset of severe bifrontal headache, vomiting and diagnosed to have frontal lobe abscess with mass effect. Considering that she was at term, Lower segment caesarean section (LSCS) was done prior to emergency craniotomy for better fetal outcome. Discussion: Due to persistent perioperative hypoxemia, post operatively the possibilities of congenital heart disease and deep vein thrombosis were ruled out. Computerized Tomographic pulmonary angiogram (CTPA) revealed multiple AVMs in left upper lobe and an AVM in the anterior segment of left lower lobe. On reevaluation history and clinical findings clinched the clinical diagnosis of Osler-Weber- Rendu Syndrome (OWR) or Hereditary hemorrhagic telangiectasia (HHT). Fortnight later she underwent surgical excision of PAVMs. Conclusion: This case report highlights the importance of clinical history, meticulous clinical examination, perioperative monitoring and team work in diagnosing rare entities like PAVM, Hereditary hemorrhagic telangiectasia, in a term pregnancy with cerebral abscess.
EnglishPulmonary Arteriovenous, Brain Abscess, LSCSINTRODUCTION
Pulmonary arteriovenous malformation (PAVM) or pulmonary arteriovenous fistula (PAVF) is due to abnormal communications between pulmonary arteries and veins. PAVM is a rare congenital vascular anomaly, associated with Osler-WeberRendu syndrome (OWR) or Hereditary hemorrhagic telengiectasia (HHT). Although PAVMs are rare and therefore likely to be under diagnosed, they are present in 24% of patients with HHT. 1 The natural course of PAVM is not benign. These lesions can be associated with complications, such as hemothorax, hemoptysis, stroke and brain abscess. 2 Clinical manifestations can be subtle and may remain undiagnosed until complications arise in adulthood 3 as in our patient.
CASE REPORT
A 26 year old Gravida 2 Para 1 Live 1 at term on regular antenatal followup elsewhere, referred to our hospital with history of severe bifrontal headache and vomiting of sudden onset. There was no history of fever or focal neurological deficits. Her previous pregnancy and parturition was uneventful.On general examination she had grade II clubbing, Glasgow coma scale (GCS) was 15/15 with bilateral pupils size of 3mm reacting to light. Her heart rate was 62/min, blood pressure 130/90mmHg, respiratory rate 20/ minute with SpO? of 90% at room air and 96% with 6 litres of oxygen. On auscultation respiratoy system was clear. Other systemic and spine examination revealed no abnormalities. On abdominal examination uterus corresponded to 37 weeks of gestation with good fetal heart rate.Her blood investigations were normal. Hemoglobin was 14.3 grams/dl. Clinical findings were not suggestive of preeclampsia. Chest X-ray showed haziness in the left upper zone [Figure 1].
Magnetic resonance imaging of brain showed right frontal lobe abscess with mass effect. Clinically, Cardiologist ruled out cardiac abnormalities. Considering that the patient was at term and requiring emergency craniotomy for cerebral abscess evacuation, lower segment caesarean section (LSCS) was planned prior to craniotomy for better fetal outcome. On Preoxygenation with 100% oxygen, SpO2 improved to 96 - 97%. During general anesthesia with controlled ventilation she continued to have low oxygen saturation varying from 92% to 95% with Fraction of inspired O2 (FiO2) of 0.5. LSCS followed by right frontal craniotomy and evacuation of abscess was uneventful. At the end of surgery patient was fully awake, spontaneously breathing with regular respiratory efforts. As patient did not have respiratory distress
clinically and was maintaining SpO2 of 92-94% with FiO2 of 0.5, she was extubated on table. Postoperatively, repeat chest X ray showed persistent hazinesss in the left upper zone. ABG showed pH 7.395, PaCO2 36.1 mm Hg, PaO2 62 mm Hg, SaO2 91.6%, Lactate 2.6 mmol/lit with FiO2 of 0.6. Transthoracic echocardiography showed mild left atrial and left ventricular dilatation and no pulmonary artery hypertension. In view of persistent hypoxemia, opacities in the chest x ray, mild left atrial and left ventricular dilatation with no pulmonary hypertension and normal lower limb dopplers, Pulmonologist suggested computerized tomographic pulmonary angiogram(CTPA) suspecting PAVM. CTPA revealed multiple AVMs in left upper lobe and an AVM in the anterior segment of left lower lobe[Figure 2].
On reevaluating the patient, there was history of recurrent epistaxis, family history of epistaxis and mild central cyanosis clinched the clinical diagnosis of Osler-Weber- Rendu Syndrome (OWR) or Hereditary hemorrhagic telangiectasia (HHT).
In view of large AVM and non suitability for interventional closure she underwent left lung upper lobectomy [Figure 3] with left lower lobe anterior segmentectomy a fortnight later
Post operatively her room air SpO2 improved to 99 % and was uneventful. On follow up she had two episodes of seizures and is on anti epileptics. There is no further pulmonary complications.
DISCUSSION
Osler-Weber-Rendu Syndrome (OWR) or Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder characterized by multiple telangiectasia of mucocutaneous tissues and various organs. The four diagnostic criteria for HHT are epistaxis, telangiectasia, visceral lesions and an appropriate family history. The HHT diagnosis is definite if three criteria are present. 4 A plain chest radiograph shows abnormalities in about 98% of patients. 5 A cerebral abscess may be the first manifestation in HHT of an otherwise asymptomatic PAVM. 6 Cerebral abscesses may be due to: 1) hypoxemia decreases resistance of cerebral tissue to infection; 2) arterial thrombosis due to secondary polycythemia causes cerebral ischemia/infarct which is optimal to bacterial growth; and 3) septic embolus through PAVM. 7 Risk of this complication increases during pregnancy because of greater cardiac output and increased level of progesterone that causes relaxation of arteriolar smooth muscle within the PAVM, reducing their resistance and further increasing blood flow through the PAVM. 8 Positive pressure ventilation likely worsens hypoxemia by increasing pulmonary capillary resistance and redistributing blood flow to the AVMs, thereby worsening right-to-left shunting. 9 This explains the cause for post intubation fall in SpO2 from 96 to 92% with FiO2 of 0.5 in our patient. Pulmonary angiography is considered the gold standard in detection of PAVMs. All symptomatic PAVMs and asymptomatic PAVMs larger than two cm, or if feeding arteries are larger than two mm, should be treated with surgery or embolisation because of the risk of paradoxical embolism.5. The purpose of treatment includes prevention of neurological complications, progressive hypoxia and its resultant effects and high output cardiac failure. Surgical resection of a PAVM is an acceptable option in those patients who are not amenable to embolisation. 10 Pulmonary AVM’s might have been the cause for right to left shunt producing mild central cyanosis, clubbing, polycythemia, relative left sided volume overload, failure of normal filtering mechanism of the lungs would have resulted in frontal lobe abscess in our patient. Due to large AVM’s and nonsuitability for interventional procedures she underwent left upper lobectomy with lower lobe anterior segmentectomy.
CONCLUSION
This case report highlights the importance of clinical history, meticulous clinical examination, perioperative monitoring and team work in diagnosing rare entities like Hereditary hemorrhagic telangiectasia, PAVM in a term pregnant patient with cerebral abscess and persistent hypoxemia. The decision making in craniotomy with concurrent LSCS followed by surgical excision of PAVMs resulted in successful materno-fetal outcome. Cerebral abscess in a young patient with asymptomatic persistent hypoxemia, polycythemia and clubbing, do consider PAVM after ruling out cyanotic congenital heart disease.
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from Dept of anaesthesiology, neurosurgery and cardiothoracic surgery of PSG Institute of Medical Sciences and Research, Coimbatore.We also acknowledge .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=860http://ijcrr.com/article_html.php?did=860REFERENCES
1. Kjeldsen AD, Oxhoj H, Andersen PE, Green A, Vase P. Prevalence of pulmonary arteriovenous malformations (PAVMs) and occurrence of neurological symptoms in patients with hereditary haemorrhagic telangiectasia (HHT). J Intern Med 2000;248(3):255-62.
2. Dinkel HP, Triller J. Pulmonary arteriovenous malformations: embolotherapy with superselective coaxial catheter placement and filling of venous sac with Guglielmi detachable coils. Radiology 2002;223:709-14.
3. Tse KC, Ooi GC, Wu A, Ho PL, Ip SK, Jim MH, et al. Multiple brain abscesses in a patient with bilateral pulmonary arteriovenous malformations and immunoglobulin deficiency. Postgrad Med J. 2003;79(936):597-9.
4. Shovlin CL, Guttmacher AE, Buscarini E, Faughnan ME, Hyland RH, Westermann CJ, et al. Diagnostic criteria for hereditary hemorrhagic telangiectasia (Rendu-OslerWeber Syndrome). Am J Med Genet. 2000;91(1):66-7.
5. Dines DE, Arms RA, Bernatz PE, Gomes MR. Pulmonary Arteriovenous fistulas. Mayo Clin Proc 1974;49:460-5.
6. Harkonen M. Hereditary hemorrhagic telangiectasia (osler-weber-rendu disease) complicated by pulmonary arteriovenous fistula and brain abscess. Acta Med Scand 1981;209(1-2):137-9.
7. Meacham WF, Scott HW Jr. Congenital pulmonary arteriovenous aneurysm complicated by bacteroides abscess of brain: successful surgical management. Ann Surg 1958;147:404-8.
8. Elliott JA, Rankin RN, Inwood MJ, Milne JK. An arteriovenous malformation in pregnancy: a case report and review of the literature. Am J Obstet Gynecol 1985;152:85-8.
9. Friedman BC1, McGrath BJ, Williams JF. Pulmonary arteriovenous fistula: mechanical ventilation and hypoxemia. Can J Anaesth. 1992;39(9):963-5.
10. Khurshid I, Downie GH. Pulmonary Arteriovenous Malformation. Postgrad Med J 2002;78:191–7.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241610EnglishN-0001November30HealthcareBENIGN FIBROUS HISTIOCYTOMA OF CALCANEUM - A RARE CASE REPORT
English2832Jaya Ganesh P.English Suresh Gandhi B.English Vimal Chander R.English Ganthimathy SekharEnglishIntroduction: Benign fibrous histiocytoma of the calcaneum is an extremely rare neoplasm and it is essential to differentiate it from other common giant cell lesions of bone particularly giant cell tumour of bone. Case Presentation: We present a case of a 38 year old female with an osteolytic lesion in the left calcaneum with a clinical and radiological diagnosis of giant cell tumour of the bone. The definitive diagnosis of benign fibrous histiocytoma was confirmed by histopathological examination and P63 immunomarker negativity. Conclusion: This case is presented due to the rarity of its occurrence in the calcaneum and to stress the significance of using p63 as an immunomarker in differentiating from giant cell tumour.
EnglishBenign fibrous histiocytoma, Giant cell tumour, P63.INTRODUCTION
Benign fibrous histiocytoma (BFH) is a soft tissue tumour of fibrous histiocytic type rarely occurring in the bones, especially the calcaneum. It is a spindle cell neoplasm of the bone and needs to be differentiated from non-ossifying fibroma and giant cell tumour of bone. [1] Very few cases of benign fibrous histiocytoma arising in the calcaneum have been reported in the literature. We report a case of benign fibrous histiocytoma in the calcaneum occurring in a middle aged female and the role of P63 in differentiating it from the giant cell tumour. [2]
CASE REPORT
A 38 year old female presented with pain in the left foot mainly on weight bearing which gradually increased in intensity for the past six months. There was no significant swelling or other relevant history of injury noted. Clinical examination of the foot revealed bony tenderness with the X-rayshowing an osteolytic lesion in the left calcaneum. Haematological and biochemical parameters were within normal limits. In view of the radiological appearance, a diagnosis of giant cell tumour of bone / chondromyxoid fibroma was considered.
[Figure 1] Under spinal anaesthesia, curettage of the osteolytic lesion was done and sent for histopathological examination. Histopathology revealed only tiny fragments of bony tissue with sheets of foamy histiocytes. There were no osteoclastic giant cells to suggest giant cell tumour or chondromyxoid fibroma. Since the material was very minimal, a repeat curettage was advised and planned for a confirmatory diagnosis. Under spinal anaesthesia, repeat curettings of the entire lesion was done and sent for histopathological examination. The intraoperative and postoperative period was uneventful. Macroscopically, multiple yellowish and grey white bony and soft tissue fragments measuring 3x2x1.5 cm in aggregate were seen. [Figure 2] Microscopic examination revealed a lesion composed predominantly of foamy histiocytes and scattered spindle cells arranged in a storiform pattern. [Figure 3] There were osteoclastic giant cells scattered throughout but not seen uniformly in a spatial relationship as in a giant cell tumour of bone. A diagnosis of benign fibrous histiocytoma was made and confirmed by negative immunostaining for p63. [Figure 4] Patient came for follow up and is doing well.
DISCUSSION
Benign fibrous histiocytoma is a spindle cell neoplasm with varying degrees of spindle cells, foam cells and multinucleated giant cells. They occur very rarely within bones and approximately 86 cases have been reported in literature with this case being only the second case to be reported in the calcaneum, a very unusual site. [1] Benign fibrous histiocytoma, a tumour known to occur in the dermis and soft tissues, comprised about ten cases out of 11087 skeletal tumors studied by Dahlin and Unni. [3] The cases were adults between the ages of 23 to 60 years and the male: female ratio was 4:3. In a series reported by Grohs et al, a median age of 28 years and male: female ratio of 4:6 was noted.[4] Many authors actually suggest that it is a non ossifying fibroma, and the location of the lesion with clinical history of pain and the age group is essential in making a diagnosis of BFH. [2] Local pain is the main symptom in benign fibrous histiocytoma in contrast to nonossifying fibroma and the X-ray shows an osteolytic lesion with sharply defined sclerotic borders in a typical case of benign fibrous histiocytoma. In the present case reported there was no thick sclerotic rim. [5] Nonossifying fibroma is usually an incidental radiological finding and is seen in patients younger than 20 years. It is unusual after skeletal maturation. The most common site is the distal femur and proximal tibia. Benign fibrous
histiocytoma occurs in adults and usually in the long bones and pelvis. In a case series comprising ten benign fibrous histiocytomas of bone, the common sites were femur, pelvis, humerus, tibia, fibula, ribs and spine. [3] Benign fibrous histiocytoma also needs to be differentiated from the common clinical and radiological diagnosis of giant cell tumour of bone as in our case. Most neoplasms of the bone may contain giant cells but uniform spatial arrangement of osteoclastic giant cells with mononuclear stromal cells is critical in making a diagnosis of giant cell tumour. Lesions with osteoclastic giant cells and spindle cells if present in flat bones also need to be differentiated from hyperparathyroidism and aneurysmal bone cyst which have other distinctive histological features. [5] The diagnosis of giant cell tumour needs to be consisdered strongly as collections of foam cells dominate the picture and mononuclear cells may become spindled and have even a storiform pattern, in which case a mistaken diagnosis of benign fibrous histiocytoma can be made.[2] A lesion with all the clinical and radiological features of giant cell tumor has to be diagnosed as giant cell tumour even if the predominant pattern is of benign fibrous histiocytoma and only minor foci shows osteoclastic giant cells. [2] In such cases p63 immunostaining can be of immense help in differentiating benign fibrous histiocytoma (p63 negative) from giant cell tumour (p63 positive).[6] p63 is a p53 homolog expressed in normal epithelial tissues and in epithelial malignancies. It is mainly used as a marker for mammary myoepithelial cells and prostatic basal cells and recent studies have indicated moderate nuclear staining in the stromal cells of giant cell tumor of bone. Non ossifying fibroma shows less than 10% staining for p63 and generally most of the soft tissue tumors do not express p63.[7] The behaviour of benign fibrous histiocytoma is benign in contrast to the locally aggressive behaviour of giant cell tumor of the bone. [8]
CONCLUSION
Benign fibrous histiocytoma can occur in the calcaneum and the X-ray picture may be atypical as in our case and the significance of using p63 as an immunomarker in differentiating from the clinical and radiological diagnosis of giant cell tumour is stressed in doubtful cases where microscopic features are equivocal. This case is presented due to the rarity of its occurrence in the calcaneum, as to the best of our knowledge, this is the second case to be reported in the calcaneum in literature.
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=861http://ijcrr.com/article_html.php?did=861REFERENCES
1. Keskinbora M, Kose O, Karsliogluy, Demiralp B, Basbozkurt M. Another cystic lesion in the calcaneus: Benign Fibrous Histiocytoma of bone. J Am Podiatr Med Assoc. 2013;103(2):141-4.
2. Inwards CY, Oliveira AM. Tumors of the Osteoarticular System. In: Fletcher DM, Diagnostic histopathology of tumors. 4th ed. Elsevier, Saunders. 2013. pp 1907-8.
3. Unni KK, Dahlin DC, Dahlins. Bone tumours, general aspects and data on 11087 cases. Fifth edition. Philadelphia, PA: Lippincott williams and wilkins: 1996: 211-216
4. Grohs JG, Nicolakis M, Kainberger F, Lang S, Kotz R. Benign fibrous histiocytoma of bone: a report of ten cases and review of literature. Wien Klin Wochenschr. 2002 Jan 15;114(1- 2):56-63.
5. Forrest M, Tomeno A, Vanel D. Orthopaedic surgical pathology. Diagnosis of tumours and pseudotumoral lesions of bone and joint. Edinburg churchill livingstone: 1997:317-21.
6. Gustavo de la Roza G. P 63 expression in giant cell containing lesions of bone and soft tissue. Arch Pathol Lab Med 2011;135(6):776- 9.
7. Wu CS, Pollack A, Czerniak B, Chyle V, Zagars GK, Dinney CP, Hu SX, Benedict WF. Prognostic value of p53 in muscle-invasive bladder cancer treated with preoperative radiotherapy. Urology. 1996 Mar;47(3):305- 10.
8. Clark BE, Xipell JM, Thomas DP 1985 Benign fibrous histiocytoma of bone. Am J Surg Pathol 1985;9:806-15.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241610EnglishN-0001November30HealthcareEFFECT OF HANDEDNESS AND SAMPLE COLLECTION TYPES ON BLOOD LACTATE MEASUREMENTS
English3336Brinnell CaszoEnglish Vinod George ThykadavilEnglish Justin GnanouEnglishIntroduction: Blood (plasma) lactate levels estimated from samples collected from different body sites may vary. Lactic acid is produced by skeletal muscle, and since skeletal muscle mass has been shown to be higher on the dominant upper limb, we hypothesized that blood lactate levels from the “dominant” upper limb will be higher than that of the “non-dominant” side at rest. Hence this study was designed to assess the effect of handedness on blood lactate levels drawn from the right and left upper limb. Material and Method: We compared lactate levels in venous blood samples from the right and left antecubital vein and an arterial sample collected from the right upper limb from 14 men and 6 women. Results and Discussion: We found that blood lactate levels between the right and left upper limb sites were comparable. They were also comparable with the arterial blood lactate levels. These findings were observed in both male and female subjects. Thus we conclude that in our sample of subjects’, handedness or site of collection of blood sample had no effect on the lactate levels and handedness was not influenced by the sex of the subjects.
Englishblood lactate, handedness, pre-analytical variation, dominant and nondominant hand, arterial and venous lactateINTRODUCTION
Blood (plasma) lactate levels are used in the sports medicine to assess skeletal muscle function and aerobic capacity. Blood lactate levels are estimated from samples collected from different sites such as toe, ear and fingertip and studies have shown that blood lactate levels vary with different sites of blood collection (1). Variation in blood lactate levels may also be due to difference in activity in particular muscles/ muscle groups, the size of the muscle group, and also whether the blood sample is arterial, venous or mixed capillary blood (2). Literature comparing muscle mass and strength between the upper limbs of right and left handed individuals indicate the dominant hand has 10% greater power than the non dominant hand. Such differences have also been found on the lower limb and trunk of the “dominant side” (3, 4). Similarly arm muscle area was found higher in the dominant limb and this increase in muscle area contributed to increase in muscle strength and power. Thus muscle strength and area could contribute to differences in blood lactate level between dominant and non-dominant limbs. Total skeletal muscle mass is also increased in males compared to females and this can be one of the factors for the difference observed in blood lactate levels between male and female subjects under similar physiological conditions. We hypothesize that blood lactate levels from the “dominant” upper limb will be higher than that of the “non-dominant” side at rest. Also in an ideal
clinical set up, arterial blood samples are preferred, however, while collecting samples in the field, venous blood is often preferred for logistic reasons. Hence our secondary aim is to show that the difference between arterial and venous sampling would not be significant.
MATERIALS AND METHODS Subjects
Twenty healthy right-handed subjects (14 men and 6 women) consented to participate in this experiment. The subjects were between the age groups of 20-35 years. Informed consent was obtained from each subject after explaining the objective and protocol of the study and the potential risks involved. Approval for the study was obtained from the Institutional Ethical Review Board of St. John’s Medical College.
Experimental Design
The subjects were explained about the study and the procedures to be carried out prior to the collection. After a mandatory 30-minute rest period, three samples were collected from each subject, one arterial blood sample from the left radial artery at the wrist and two venous samples from the right and left antecubital vein as per the NCCLS (National Committee for Clinical Laboratory Standards) standard guidelines (5). All collections were made between 7.00am to 10 am. Samples were collected without the application of tourniquet and were kept on ice at 4°C. Both the arterial and venous blood was mixed with fluoride/EDTA (Ethylene Diamine Tetra Acetic acid) reagent in the ratio of 2 ml of blood with 0.08ml of the reagent. Samples were then immediately centrifuged at 4°C in a refrigerated centrifuge at 4000 rpm for 5 minutes. The plasma was separated and stored in duplicate aliquots and lactate was analysed immediately using a spectrophotometric method which uses the rabbit muscle lactate dehydrogenase to catalyze the oxidation of lactate to pyruvate with simultaneous production of NAD+ (Nicotinamide Adenine
Dinucleotide). The formation of NADH, which is proportional to lactate concentration, was monitored as the difference in absorbance at 340 nm (6). The results are presented as mean ? standard deviation. Student’s t test and Pearson’s regression analysis was performed to compare arterial lactate concentration and right and left arm venous lactate concentrations using software package SPSS 16.1.
RESULTS
The mean arterial lactate level was 6.33 ± 1.91 mmol/l, while the average venous levels were 6.33 ± 1.82 mmol/l (Table 1). Lactate from blood sampled from the left arm was 6.35 ±1.89 mmol/l while from the right arm it was 6.31± 1.80 mmol/l. The values correlated very well with each other (Table 2) and when compared with a paired student’s t test showed no significant difference between the lactate levels from the 3 collection points. We also observed that though all our subjects were right-handed, venous lactate levels were on average greater on the left arm, when compared with both arterial and venous lactate levels from the right arm. We looked at the effect of gender, and found that though males had higher levels of lactate, they were comparable with the values obtained from the female subjects.
DISCUSSION
Lactate in the body is produced as an intermediary metabolite of carbohydrate metabolism, especially during anaerobic break down glucose. The brain, skin, renal medulla, red blood cells, skeletal muscles and liver all produce lactate; however the liver produces most it. It is metabolized by the liver and kidneys and its blood levels reflect a balance between these processes. Lactate measurements in blood require special blood collection precautions such as a 30 minute rest period for the subject prior to collection, avoiding the usage of tourniquet, and minimal manipulation while collection (5). Though these precautions can be standardized and followed to reduce the pre-
analytical variability, there are two other preanalytical variations to consider. The first factor is the type of blood sample (arterial or venous). In our study we found that lactate levels between arterial and venous collection showed a good positive correlation and were comparable. The data from our study shows that lactate levels from venous samples collected with proper precautions are comparable to the gold standard arterial blood lactate level. The second factor we investigated was handedness of the subjects. Lactate levels correlate with increasing muscle activity and muscle mass. Since muscle mass is increased on the “dominant” side (7), we felt that is may contribute to an increased lactate level on blood sampled from that side. However, data from our study showed no differences between right and left hand and both the value were comparable with the arterial measurements. Gender too appeared to have no effect on the lactate levels of the subjects. As we expected, males subjects tended to have a higher lactate level. This may correlate with the differences in body composition between males and females; since males tend to have higher percentage of body muscle mass compared to females. However, we acknowledge that the number of female participants in this study were fewer when compared to the males and may have influenced our results.
CONCLUSION
Thus muscle mass, strength or power does cause lactate measurement differences and this finding was consistent in both genders. Thus we conclude that lactate measurements are not influenced by type of collection (arterial or venous) as well as by the handedness.
ACKNOWLEDGMENTS
The authors acknowledge the immense help received from the scholars whose articles are citedand 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. The authors wish to acknowledge the staff of Special Diagnostic Laboratory at Department of Biochemistry, St.John’s Medical College, Bangalore, India for their efforts in performing the laboratory analysis.
Englishhttp://ijcrr.com/abstract.php?article_id=862http://ijcrr.com/article_html.php?did=862REFERENCES
1. Forsyth JJ, Farrally MR. A comparison of lactate concentration in plasma collected from the toe, ear, and fingertip after a simulated rowing exercise. Br J Sports Med 2000;34:35- 8.
2. Yoshida T. Effect of exercise duration during incremental exercise on the determination of anaerobic threshold and the onset of blood lactate accumulation. Eur J Appl Physiol 1984;53;196–9.
3. Ho RW, Chang SY, Wang CW, Hwang MH Grip and key pinch strength: norms for 15- to 22-year-old Chinese students. Zhonghua Yi Xue Za Zhi 2000;63:21-7.
4. Ayse Ozcan, Zeliha Tulum, Lamia PInar, Ferdi Baskurt. Comparison of Pressure Pain Threshold, Grip Strength, Dexterity and Touch Pressure of Dominant and Non-Dominant Hands within and between Right- and LeftHanded Subjects. J Korean Med Sci 2004;19: 874-8.
5. CLSI/NCCLS. Evaluation of precision performance of clinical chemistry devices; approved guideline. CLSI/NCCLS document EP5-A; 1999.
6. Toffaletti JG. Blood lactate: biochemistry, laboratory methods, and clinical interpretation. Crit Rev Clin Lab Sci 1991;28:253-68.
7. Petersen P, Petrick M, Connor H, Conklin D. Grip strength and hand dominance: challenging the 10% rule. Am J Occup Ther 1989;43:444-7.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241610EnglishN-0001November30HealthcareCASE REPORT OF PATIENT WITH DESMOPLASTIC AMELOBLASTOMA
English3744Gopal SharmaEnglish Reema RaoEnglish Preeti TalrejaEnglish Mahesh B PokleEnglish Resha SawlaEnglish Sameer ZopeEnglishAim: Presenting a case of Desmoplasticameloblastoma with an attempt to differentiate it from fibro-osseous lesion and ameloblastoma Case Report: In this paper we present a case report of a 50yr male who patient presented with a painless swelling in the lower left jaw since 1year. Discussion: Desmoplasticameloblastoma (DA) was included in the World Health Organization Classification of Head and Neck Tumors (WHO-2005) as a variant of ameloblastoma with specific clinical, histological and radiological features to differentiate it from other entities. Radiological and Cone beam volumetric imaging (CBVI) was performed which showed a mixed lesion suggestive of fibro-osseous lesion whereas Incisional biopsy was suggestive of DA. Hence we have attempted to differentiate the three lesions to avoid further misdiagnosis. Conclusion: Desmoplasticameloblastoma cannot be differentiated based only on clinical or only radiological features. A proper collaboration between the physician, radiologist and pathologist is necessary for a proper diagnosis.
EnglishAmeloblastoma, Cone beam volumetric imaging, fibro-osseous lesion.INTRODUCTION
Ameloblastomas are categorized as benign epithelial odontogenic tumours though malignant forms exist, they represents about 1% of all oral epithelial odontogenic tumours and 11% of all odontogenic tumors.(1) The annual incidence rates per million for ameloblastomas are 1.96, 1.20, 0.18 and 0.44 for black males, black females, white males and white females respectively.(2) Clinically and radiographically ameloblastomas are classified into three main kinds a) Solid or multicystic (conventional) ameloblastoma which is radiographically multilocular b) Unicystic ameloblastoma which is radiographically multilocular (mural ameloblastoma) c) Peripheral ameloblastoma i.e. ameloblastoma present in the soft tissue Histologically, ameloblastoma has been classified as follicular, plexiform, acanthomatous, granular cell, desmoplastic, and basal cell.(3)The age of primary presentation ranges from 17 to 83 years with a mean age of 41.9 years (males: 44.6 years, females: 39.0 years) and a median age of 42.0 years. Though the first case of Desmoplastic Ameloblastoma (DA) was cited in by Eversol in 1984who called it an "ameloblastoma with pronounced desmoplasia” there are very few
INTRODUCTION Ameloblastomas are categorized as benign epithelial odontogenic tumours though malignant forms exist, they represents about 1% of all oral epithelial odontogenic tumours and 11% of all odontogenic tumors.(1) The annual incidence rates per million for ameloblastomas are 1.96, 1.20, 0.18 and 0.44 for black males, black females, white males and white females respectively.(2) Clinically and radiographically ameloblastomas are classified into three main kinds a) Solid or multicystic (conventional) ameloblastoma which is radiographically multilocular b) Unicystic ameloblastoma which is radiographically multilocular (mural ameloblastoma) c) Peripheral ameloblastoma i.e. ameloblastoma present in the soft tissue Histologically, ameloblastoma has been classified as follicular, plexiform, acanthomatous, granular cell, desmoplastic, and basal cell.(3)The age of primary presentation ranges from 17 to 83 years with a mean age of 41.9 years (males: 44.6 years, females: 39.0 years) and a median age of 42.0 years. Though the first case of Desmoplastic Ameloblastoma (DA) was cited in by Eversol in 1984who called it an "ameloblastoma with pronounced desmoplasia” there are very few
reported cases.(4,5) the incidence of DA among ameloblastomas ranges from 0.9% to 12.1% in different races. Though ameloblastoma in general are more common in the posterior region, Desmoplastic ameloblastoma are located anterior to premolar. The incidence were 82.4% of lesion in the maxilla and 54.8% of lesion in mandible were present in the anterior region.(6) It has also been recently included in the World Health Organization’s Classification of Head and Neck Tumors.(7) Radiographically the diagnosis of DA presents a challenge as it is often mistaken for a fibroosseous lesion.(8) Keeping all this in mind the purpose of this paper is to report a case of desmoplastic ameloblastomaand to highlight the differences between ameloblastoma, desmoplastic ameloblastoma and fibro-osseous lesion, thus making the diagnosis of DA simpler.
CASE REPORT
A 50 yrs male patient reported to the department of oral medicine and radiology, YMT Dental College and hospital, Kharghar, Navi Mumbai with a chief complain of swelling in the lower left region of jaw since 1yr. The patient reported that the swelling was smaller in size 1yr back, which increased to its present sizesince the last 3months. There is no associated pain, paresthesia or loss of sensation in the area. The patient’s medical history revealed that he is a diabetic and is on medication (Tab. Gluconol 120mg) since 13 yrs. Extra-orally there is a gross facial asymmetry with an oval swelling in the left parasymphysis region of the jaw (Figure. 1A and 1B) measuring approximately about 3 X 3 cm in size. It extends anteriorly from the symphysis region to 3cm posteriorly over the body of mandible. Superiorly it is extends from line joining the angle of mouth to tragus to 1cm above the inferior border of the mandible. Skin over the region is stretched and there is no change of colour of overlying skin. It is bony hard and nontender on palpation with no
local rise of temperature, patient is afebrile with no cervical lymphadenopathy. Intraorally there is vestibular obliteration extending from the distal aspect of 33 to the distal aspect of 36(Figure. 2A). Cortical expansion seen which is round to oval on both the sides (buccal and lingual) in relation with 33, 34, 35, 36 (Figure. 2B). Maximum expansion was seen with 34 and 35. The mucosa appears of normal colour, textureand consistency. The teeth in relation with swelling i.e. 33, 34, 35, 36 were vital and immobile. There is displacement seen with 34 in mesial direction and 35 in distal direction. The periapical radiograph shows mixed radiolucent and radioopaque image and it shows displacement of the roots with 33, 34 and 35. (Figure 3A) Occlusal radiograph shows cortical expansion equal on buccal and lingual sides teeth displacement is seen over the buccal aspect. (Figure 3B) Panoramic radiograph and lateral oblique radiograph reveled poorly defined, mixed, radiolucent-radiopaque image suggesting of benign fibro-osseous lesion (Figure 3C and 3D). Cone beam volumetric imaging (CBVI) has been performed for the mandibular arch extending from the mandibular left 1st molar to the mandibular right 2nd premolar region to determine the proper extension and for surgical planning of the lesion (Figure 4A and 4B). Section shows a well defined expansile lesion in the body of mandible extending from the left mandibular canine region to the left mandibular 1st molar region. The interior of the lesion appears to be multilocular with multiple granular appearing septae. There is significant expansion of the buccal and lingual cortical plates. The outline of the inferior alveolar nerve canal is not seen clearly within the lesion. The mental foramen is also not traceable. The inferior cortical plate appears to be intact. The mandibular 2nd premolar appears to be displaced (Figure.4A). All these findings suggest a diagnosis of benign tumor in the mandible. With a differential diagnosis of ameloblastoma and odontogenic myxoma is given.
Incisional biopsy was performed and the histopathological evaluation of the specimen (Figure 5A and 5B) shows irregular, bizarrely shaped odontogenic epithelial islands and cords in a moderately cellular fibrous connective tissue with abundant thick collagen fibers that appear to compress the odontogenic islands giving them a stellate appearance. It also shows the presence of microcyst formation. Based on all these findings final diagnosis of Desmoplastic Ameloblastoma (DA) was given. A segmental resection from teeth 33 to 36, maintaining the lower border of the mandible, was performed under general anesthesia.
DISCUSSION
In the WHO classification, desmoplastic ameloblastoma (DA) is considered as a rare variation of ameloblastoma.According to an English literature review carried out by Sun et al.(9) in 2009, there are 115 casesreported of DA. The DA occurs more frequently in the4th and 5th decades of life, and presents nopredilection toward either gender. It affects maxilla and mandible equally, whereas ameloblastoma shows a marked predilection for the mandible in ratio of 5:1(mandible: maxilla). DA shows a marked predilection for anterior (anterior premolar region) region of mandible and maxilla, whereas ameloblastoma is more common in posterior region of the mandible.(10) Clinically, maxillary lesions are more dangerous than mandibular ones as they can invade the adjacent sinus and orbit and involve vital structures. Additionally, the thin maxillary bone is a weak natural barrier for tumors as compared to the thicker mandible.(11) DA differs from the solid/multicystic ameloblastomas, whichare more prevalent in mandibular molar or ramus regions, with variable sizes of swelling; pain tends to be rare, but rootresorption of adjacent teeth is common.(12, 13) Desmoplastic ameloblastoma exhibits a more aggressive behavior than other types of ameloblastoma. This aggressiveness may be due to 1) a potential to
grow to a large size; 2) the common location in the maxilla leading to an early invasion of adjacent structures; 3) the diffuse radiographic appearance, and 4) histological finding of bone invasion. (14) Tooth displacement is a common feature in desmoplastic ameloblastoma in almost 92% of the cases and root resorption is seen in just 33% of the cases.(15) As reported in prior literature, the present case of DA was also found and located in the anterior premolar region of the mandible, presenting as a painless swelling withbuccal expansion and tooth displacement but no root resorption.(16,17,18) Radiographically, desmoplastic ameloblastoma may show either a multilocular, mixed radiolucent/ radioopaque appearance or multifocal appearance of minute flecks of bone similar to that seen in benign fibro osseous lesions. The mixed radiolucent / radioopaque appearance of DA can be attributed to the infiltrative growth pattern of tumour cells into surrounding marrow spaces and simultaneous vigorous osteoblastic activity leading to number of bony flecks.(19) It may also present as a massive expansible osteolytic lesion with honeycomb, mottled or multilocular appearance. According to Philipsen et al, radiographicaly illdefined borders suggest an infiltrative process with propensity to recur.(20) The panoramic radiograph, conventional computed tomography and magnetic resonance images of desmoplastic ameloblastoma are not specific; they are compatible with those of fibro-osseous lesions and can mimic the radiographic appearance of fibrous dysplasia, chronic sclerosing osteomyelitis, and if well-circumscribed, an ossifying fibroma. Therefore, it is necessary to include these in the differential diagnosis. CT scan can delineate the internal structure of the lesion more accurately and is particularly helpful in determining its margins and extension into adjacent structures.(11) MRI shows heterogeneous low to intermediate signal intensity on T1W images, heterogeneous high signal intensity on
Histologically, solid / multicystic ameloblastomas contain two main histopathologic patterns: follicular and plexiform. These patterns consist of proliferating, irregularly shaped islands of the narrow cords of odontogenic epithelium embedded in a connective tissue stroma. By contrast, DA has appeared as irregularly shaped odontogenic epithelial islands surrounded by a narrow zone of loose-structured connective tissue embedded in desmoplastic stroma. (19,20) The tumor cells of desmoplastic ameloblastoma have shown positive immunoreactivities for cytokeratin (CK), CK 8, 13, 19, filaggrin and
ameloblastoma antibodies, retaining the odontogenic epithelial characteristics.(22) The management of solid/multicystic ameloblastomas and DA has been controversial due to the high rate of recurrence, especially in conservative treatments (enucleation and/or curettage).(23) Sun et al.(9) (2009) identified a 15.9% rate of recurrence in DA cases treated by enucleation and/or curettage, with an average recurrence period of 36.9 months. The majority of DA cases reported in the literature have been treated by resection, most likely due to ill-defined borders, thus suggesting an infiltration process and an aggressive biological behavior, which has also been reported by some authors.(24,25) Resection is the most preferred treatment option for desmoplastic ameloblastoma although some cases were treated by enucleation and/or curettage. However curettage leaves islands of tumor within bone, which later manifest as recurrences. Keszler et al.(25) reported a higher recurrence rate (21.4%) for desmoplastic variant than the other types (10.1%) of ameloblastoma. In the present case report, the patient is currently showing no signs of recurrence.
CONCLUSION
Thus, we conclude on the available information that since desmoplastic ameloblastoma shows radiographic appearance resembling fibro osseous lesions, diagnosis is based not only on the clinical and radio graphical appearance but also on the histopathological findings. In spite of the apparent and gross circumscription of the desmoplastic lesion, they have the potential for recurrence because they fail to produce a capsule; it is therefore recommended that DAs should always be treated by complete surgical resection. Further investigation of a larger number of more cases must be carried out in an attempt to predict the behavior and prognosis of this entity.
ACKNOWLEDGEMENT
We acknowledge the immense help received from the scholars whose article are cited and included in references of this manuscript. We 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=863http://ijcrr.com/article_html.php?did=863REFERENCES
1. White and Pharoah. Oral radiology, Principle and Interpretation. Fifth edition. New Delhi, Elsevier : 2006
2. Shear M, Singh S. "Age-standardized incidence rates of ameloblastoma and dentigerous cyst on the Witwatersrand, South Africa". Community Dent Oral Epidemiol1978 6 (4): 195–9
3. Kishino M, Murakami S, Fukuda Y, Ishida T. Pathology of the desmoplastic ameloblastoma. J Oral Pathol. 2001; 30: 35-40
4. Eversol LR, Leider AS, Hansen LS. Ameloblastomas with pronounced desmoplasia. J Oral Maxillofac Surg. 1984; 42:735-40.
5. Savitri V, Janardhan M, Suresh R, Kumar RV. Desmoplastic ameloblastoma with osteoplasia: Review of literature with a case report. J Oral Maxillofac Pathol 2013; 17:298-301
6. Sun Z J, WuYR,Cheng N,Zwahlen R A,Zhao Y F. Desmoplastic ameloblastoma – A review, Oral Oncology 45 (2009) 752–759
7. Barnes L, Eveson JW, Reichart PA, Sidransky D. World Health Organization classification of tumors pathology and genetics of tumours of the head and neck. Lyon: IARC; 2005
8. Kawai T, Kishino M, Hiranuma H, Sasai T, Ishida T. A unique case of desmoplastic ameloblastoma of the mandible: report of a case and brief review of the English language literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999; 87(2):258–63.
9. Sun ZJ, Wu YR, Cheng N, Zwahlen RA, Zhao YF. Desmoplastic ameloblastoma- A review. Oral Oncol. 2009; 45:752-9
10. Beckley ML, Farhood V, Helfend LK, Alijanian A. Desmoplastic ameloblastoma of the mandible: A Case report and review of literature. J Oral Maxillofac 2002; 60:194-8.
11. Rastogi R, Jain H. Case report: desmoplastic ameloblastoma. Head Neck Radiol. 2008; 18: 53-5.
12. Manuel S, Simon D, RajendranR, Naik BR. Desmoplastic ameloblastoma: a case report. J Oral Maxillofac Surg. 2002;60: 1186-8
13. Wakoh M, Harada T, Inoue T. Folliculardesmoplastic hybrid ameloblastoma with radiographic features of concomitant fibro-osseous and solitary cystic lesions.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002; 94:774-80.
14. Mintz S, Velez I. Desmoplastic variant of ameloblastoma: report of two cases and review of the literature. J Am Dent Assoc 2002;133:1072-5
15. Shashikanth MC, Neetha MC, Ali IM, Shambulingappa P. Desmoplastic ameloblastoma in the maxilla: a case report and review of literature. Indian J Dent Res 2007;18:214-7
16. Kawai T, Kishino M, Hiranuma H, Sasai T, Ishida T. A unique case of desmoplastic ameloblastoma: report of a case and a brief review of the English language literature. Oral Surg Oral Med Oral Pathol Oral Radio Endod. 1999;87:258-63
17. Durmus E, Kalayci A, Ozturk A, Gunhan O. Desmoplastic ameloblastoma in the mandibleCraniofac Surg. 2003;14:873-5
18. Smullin SE, Faquin W, Susarla SM, Kaban LB. Peripheral desmoplastic ameloblastoma: report of a case and literature review. Oral Surg Oral Med OralPathol Oral Radiol Endod 2008;105:37 40
19. Kishino M, Murakami S, Fukuda Y, Ishida T. Pathology of desmoplastic ameloblastoma. J Oral Pathol Med. 2001; 30:35-40.
20. Philipsen HP, Ormiston IW, Reichart PA. The desmo and osteoplastic ameloblastoma. Histologic variant or clinicopathologic entity? Case reports. Int J Oral Maxillofac Surg 1992; 21:352-7.
21. Minami M, Kaneda T, Yamamoto H, Ozawa K, Itai Y, Ozawa M. Ameloblastoma in the maxillomandibular region: MR imaging. Radiology. 1992; 184: 389-93
22. Kumamoto H, Kamakura S, Ooya K. Desmoplastic ameloblastoma in the mandible: Report of a case with an immunohistochemical study of epithelial cell markers. J Oral Med Pathol. 1998; 3: 45-8.
23. Nakamura N, Higuchi Y, Mitsuyasu T, Sandra F, Ohishi M. Comparison of long-term results between different approaches to ameloblastoma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002; 93:13-20.
24. Ng KH, Siar CH. Desmoplastic variant of ameloblastoma in Malaysians. Br J Oral Maxillofac Surg. 1993;31:299-30
25. Keszler A, Paparella ML, Dominguez FV. Desmoplastic and non-desmoplastic ameloblastoma: a comparative clinicopathological analysis. Oral Dis. 1996; 2:228–31.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241610EnglishN-0001November30HealthcareSPOT AND EARLY MORNING SPUTUM REPORT STUDY FOR DIAGNOSIS OF PULMONARY TUBERCULOSIS AT DMC OF MEDICAL COLLEGE VADODARA, GUJARAT: A RETROSPECTIVE ANALYSIS
English4550Meghna M. PatelEnglish Apurv N. PatelEnglish Jitendra A. SisodiaEnglish K. R. PatelEnglish Kalpita ShringarpureEnglishTuberculosis, caused by Mycobacterium Tuberculosis is a major public health problem. India is the highest tuberculosis burden country across the globe. Under the Revised National Tuberculosis Control Programme (RNTCP) diagnosis of pulmonary tuberculosis is done by sputum smear microscopy using Zeil-Nelson staining method. For sputum microscopy, two sputum (spot and early morning) samples are collected. Spot sample is collected at the time of first visit of patient to laboratory and early morning sputum is collected the next day. This study is based on retrospective analysis of spot and early morning sputum microscopy samples tested in the year 2012 and 2013 at Designated Microscopy Center (DMC) of Government Medical College, Vadodara, Gujarat. This study showed that the observed difference in sputum sample positivity in the two groups, viz. spot sample and morning sample in diagnosis of TB is statistically insignificant (Chi-square value 1.703 and 0.00584 respectively, P value 0.191 and 0.939 respectively).
EnglishTuberculosis, Sputum microscopy, Spot sputum, Early morning sputumINTRODUCTION
Tuberculosis (TB) is an infectious disease caused by Mycobacterium Tuberculosis. It typically affects the lung but also affects the other systems as well (Extra-pulmonary TB). In 2012 there were an estimated 8.6 million incidents case of TB and 1.3 million people died from the disease globally1 . India is the highest TB burden country with WHO statistics giving the total incidence of 2.2 million case of TB out of a global incidence of 8.7 million cases and an estimated TB prevalence of 3.1 million (2011). It is estimated that 40% of Indian population is infected with TB2 . Infectious sputum-positive TB patients with pulmonary disease produce droplet nuclei through coughing, sneezing and talking. It is estimated that one infectious case, on an average, infects about 10 -15 new cases every year. The concentration of bacilli in the sputum of a TB case correlates well with the infectivity of the TB patient. This is the reason why smear microscopy is a sensitive tool for identifying infectious cases and it is used as the mainstay diagnostic tool for tuberculosis control in India3 . In 2011, the new sputum positive (NSP) case detection rate was 71% and treatment success rate was 87%. Quality assured sputum smear examination facilities are available through more than 13,000 Designated Microscopy Centers (DMCs) across the country. The new vision of
RNTCP under the next five year plan (2012-2017) is of a TB free India and for achieving this vision, one of the targets is early detection and treatment of at least 90% estimated TB cases in the community including HIV-associated TB4. The older RNTCP guidelines required examination of three sputum specimen (spot-early morning -spot) by Zeil-Nelson (Z-N) stain for acid fast bacilli over two consecutive days. From 1st April 2009, under RNTCP two sputum specimens are collected over one, or two consecutive days. Of the two sputum specimens, one is collected on the spot and the other is an early morning specimen collected at home by the patient5 . The spot sample is collected at the first visit at laboratory and for the second early morning sample, sputum container is given to the patient, who collects the sputum early in the morning and submits it to the laboratory. Microscopy services currently require patients to make repeat visits to the healthcare facility. This is associated with considerable patient costs and patient drop-out during diagnosis. The new WHO definition of a smear positive case does not require confirmatory smears. This allows patients to be diagnosed on the basis of a single smear6 . A two day visit of patients to the health facility affects patients’ daily wages. Many patients do not come for submitting second early morning sputum sample due to cost, job related issues or due to some other reasons. Patients have to spend time and money behind it. Because of this, many patients remained undiagnosed and untreated. Undiagnosed and untreated sputum positive TB cases are the source of infection in community3 . If two sputum examinations are done on the first day of visit, it will reduce the number of visits and patient dropout rate. Objective To compare the sensitivity and specificity of spot and morning samples versus spot+ morning sample.
MATERIALS AND METHOD
This retrospective analytic study was carried out in Department of Pulmonary Medicine, based on sputum samples collected at DMC of Medical College, Baroda. In this study retrospective analysis of spot and early morning sputum sample result was done. At DMC, Sputum sample examination is done by Z-N stain for AFB and laboratory register is maintained as per RNTCP guidelines7 . Data of sputum examination results was collected from laboratory register of DMC for calendar year 2012 and 2013. In the laboratory records, spot sample is registered as sample A and early morning sample as sample B. As per RNTCP guide line if one sample out of two is positive then it is labeled as sputum positive5 . Inclusion Criteria: Data of sputum examination of both spot and early morning samples was collected from register. Exclusion Criteria: Record of sputum examination in which either spot or early morning result was missing were excluded in data collection. Statistical methods The sensitivity, specificity, positive predictive value, negative predictive value of two samples was calculated. Test of association between spot and early morning sample was done using ChiSquare test.
ESULTS
In 2012, total 5331 TB suspects were examined and amongst them 1017 were found to be positive and 4314 were negative. Out of total 1017 positive cases , total number of patients with both spot and early morning positive sputum report were 924, only spot positive were 20 in number and only early morning positive were 73 in number [Table 1 and 2]. Spot sample when compared with spot plus early morning sample gave sensitivity of 92.67%, specificity 100.16%, positive predictive value 97.88%, negative predictive value 98.33%. While early morningsample when compared with spot plus early morning sample gave sensitivity of 97.88%, specificity 98.33%, positive predictive value 92.67%, negative predictive value 99.53%. In 2013 total 5495 TB suspects were examined and amongst them 937 patients were found to be sputum positive and 4541 patients were sputum negative. Out of total 954 positive cases , total number of patients with both spot and early morning positive sputum report were 902, only spot positive were 24 in number and only early morning positive were 28 in number [Table 3 and 4]. Spot sample when compared with spot plus early morning sample gave sensitivity of 96.98%, specificity 99.47%, positive predictive value 97.40%, negative predictive value 99.38 %. While early morning sample when compared with spot plus early morning sample gave sensitivity of 97.40%, specificity 99.38%, positive predictive value 96.98% negative predictive value 99.47 %. There is no significant difference in sputum positivity as detected using spot or morning sample alone for sample collected in 2012 and 2013 (P value 0.191 and 0.939 respectively). [Table 5 and 6]
DISCUSSION
In 1993, the WHO declared tuberculosis to be a global health emergency.8 The most common and widely used diagnostic method for diagnosis is sputum smear microscopy in which bacteria are observed in sputum sample under microscope1,9 . The current RNTCP guideline recommends two sputum examinations, one is spot and other is early morning sputum5 . It requires two days visit to health facility, thereby increasing chances of patient drop out. If sputum examination is done on the first day of visit then patient will save the cost of travelling and daily wages, reduce chances of transmission of tuberculosis while travelling and reduce the number of visit and thereby the patient dropout rate.
Statistical analysis for association between positivity of samples in present study showed that spot sample is as good as early morning sample for diagnosis of sputum positivity and difference between two samples is by chance. Few studies by T. Jaya Chandra, Dr. Shafiyabi S. et al and Yassin MA et al showed that one day method test approach was equally effective as two days method in identifying cases10, 11, 12 . However, cross-sectional study conducted by Priyakanta et. al. showed that same day sputum microscopy method missed 17% of smear positive cases in their study13 . A pilot study conducted by Myneedu VP et.al. concluded that same day sputum microscopy does not seem to be a promising step towards improving quality of sputum14 . If result of one sputum turns out to be positive, the second sputum sample examination may not be much helpful without compromising quality of sputum. Examination of first day two sputum specimens taken one hour apart is much more convenient to the patient and as well as for operational purpose in RNTCP. Diagnosis of smear negative pulmonary tuberculosis can be increased by doing Chest X- ray examination on same day.
CONCLUSION
From this study, it may conclude that spot sample is as good as early morning sample sputum sample for diagnosis of sputum positive pulmonary tuberculosis. Same day two spot specimen examination one hour apart will be helpful for early diagnosis and reduce patients’ dropout rate for follow up visit on next day. Because of patient friendly strategy, diagnosis of smear negative Pulmonary Tuberculosis cases may increase indirectly and it will possible to implement it on operational grounds under programmatic condition. However, multi-centric large scale studies are required to effectively implement this strategy under RNTCP. This provides furtherscope for studies for diagnosis based on two spot and one overnight or same day versus routine protocol for sputum examination.
ACKNOWLEDGEMENT
We would like to express our gratitude to Dean and Medical Superintendent of Medical College Vadodara for their constant encouragement and guidance for research publication. We authors are very much thankful to District TB officer and all staff members at Designated Microscopy center at Medical College, Vadodara for their constant and valuable support. Our heartfelt thanks especially to laboratory technicians of DMC who gives their valuable guidance in collecting data for study. The authors would like to acknowledge all authors whose cited articles guided us in conducting this retrospective study and provided very much insight in preparing this research article. The authors are very much thankful to editors and publishers of books and of journal from where we got literature for making this article successful. Last but not least we are very much thankful to our residents doctors for their support and enthusiasm.
Abbreviations: DMC : Designated Microscopy Center TB : Tuberculosis AFB : Acid Fast Bacilli Z - N Stain : Zeil - Nelson Stain RNTCP : Revised National Tuberculosis Control Programme WHO : World Health Organization
Englishhttp://ijcrr.com/abstract.php?article_id=864http://ijcrr.com/article_html.php?did=864REFERENCES
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3. Roy Dipanjan, Chauhan L.S. Epidemiology of Tuberculosis. Tuberculosis Control in India. Directorate General of Health Services, Ministry of Health and Family Welfare New Delhi: Elsevier 2005. URL: http://tbcindia.nic.in/pdfs/Tuberculosis%20Co ntrol%20in%20India-Final.pdf Access date:05/02/2014
4. Sachdeva KS, Ashok Kumar, Dewan Puneet, Kumar Ajay, Satyanarayana Srinath. New Vision for Revised National Tuberculosis Control Programme (RNTCP): Universal access-“Reaching the un-reached” Indian J Med Res May 2012;135:690-94. Access date:05/02/2014
5. Diagnosis of smear positive pulmonary TB New guidelines, effective from 1st April2009. URL:http://www.tbcindia.nic.in/pdfs/1b%20% 20Diagnosis%20of%20smear%20positive%20 pulmonary%20TB.pdf. Access date:06/02/2014
6. New laboratory diagnostic tools for tuberculosis control, stop TB partnership. URL:http://www.stoptb.org/assets/documents/ global/retooling/Diagnostic_Brochure_Print_2 009_Jan_29.pdf Access date:06/02/2014
7. Chauhan MM, Mahadev B, Balasangameshwara VH (Editors). Manual on isolation, identification and sensitivity testing of Myco. tuberculosis. National Tuberculous Institute Bangalore. Govt. of India Edition 2, 1998 . URL:http://ntiindia.kar.nic.in/cddistrictlevel/ie learn%5Ccategory%5CBooks%5CNMCMCH 98.pdf Access date:01/02/2014
8. Maru DS, Jason Andrews. Epidemiology: Global Perspective. In: Tuberculosis. India: Jaypee,2009; 6:103. Surendra K Sharma,Alladi Mohan(Editors).
9. Partnership Stop TB(2006): The global plan to stop TB,2006-2015. Action for life: towards aworld free of tuberculosis. Int J tuber Lung Dis 10: 240-241. Pubmed : 16562700. Access date:31/01/2014
10. T. Jaya Chandra. Same day sputum smear microscopy approach for the diagnosis of pulmonary tuberculosis in a microscopy center at Rajahmundry. Indian journal of Tuberculosis; 59:141-144. Access date:15/02/2014
11. Shafiyabi S., Ravikumar R., Ramaprasad, Krishna S. Study of same day sputum smear examination in diagnosis of Pulmonary Tuberculosis under RNTCP. Sch. Acad.J.Biosci.2013;1(7)):352-356. Access date: 28/02/2014
12. Yassin MA, Luis E. Cuevas. How many sputum smears are necessary for case findings in pulmonary tuberculosis? Tropical medicine and international health,2003;8(10):927-932. Access date: 15/02/2014
13. Nayak P ,Ajay M.V Kumar, Mareli Claassens, Donald A. Enarson, Srinath Satyanarayan, Debashish Kundu et al. Comparing same day sputum microscopy with conventional sputum microscopy for diagnosis of tuberculosisChhattisgarh, India. PLoS ONE 8(9): e74964. Access date:02/03/2014 14.
14. Myneedu VP,Verma Ak, Sharma PP,Beher D.A pilot study of same day sputum smear examination,its feasibility and usefulness in diagnosis of pulmonary TB. Indian J Tuberc.2011 Oct; 58(4):160-7. Access date:10/03/2014
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241610EnglishN-0001November30HealthcareTHE EFFECTS OF AQUEOUS EXTRACT HIBISCUS SABDARIFFA ON SPERMATOGENESIS AND SPERM PARAMETERS OF MICE
English5156Omer H. ArabiEnglish Mutman A. KahilEnglish Nasir A. IbrahimEnglishThis study was aim to evaluate the effect of aqueous fruit extract of Hibiscus sabdariffa Linn on spermatogenesis and sperm of mice. Adult male mice (n=30) included in the present study. The mice were eight weeks old and their average weight was 28±3g. Male mice housed in temperature controlled rooms (25°C) with constant humidity (40-70%) and 12h/12h light/ dark cycle according experimental protocols. Thereafter, the mice were randomly divided into control (n=10) and experimental group (n=20). The control group received daily 8 ml distilled water, group-1 of the experimental group received 50 gm/Kg/BW and group-2 received 100 gm/Kg/BW of aqueous extract of Hibiscus sabdariffa. The experiment extended for 21 days. The results of this study showed that there was an increase in the average body weight in the experimental groups compared with the control group with a significant difference (pEnglishAqueous, Hibiscus sabdariffa, spermatogenesis, sperm parameters, miceINTRODUCTION
The roselle (Hibiscus sabdariffa) is a species of Hibiscus native to the Old World tropics, used for production of bast fiber and as an infusion (Chau, J. W et. al. 2000). The calyces, which are rich in phenolic compounds contain gossypetin, glucoside, hibiscin, hibiscus anthocyanin and hibiscus protocatechuic acid, diuretic and choleretic effects, decreasing viscosity of the blood, reducing blood pressure and stimulating intestinal peristalsis (Ali and Salih, 1991; Owulade et al., 2004). Tseng et al., (1996) found that the mechanism of this protective effect associated with the scavenging of free radicals Hibiscus protocatechuic acid also inhibits lipopolysaccharide induced rat hepatic damage. Although the mechanism of action of H. Sabdariffa as a cholesterol-lowering agent was not elucidated in this work, it hypothesized, albeit with no experimental evidence, that the extract may contain some compounds that activate hormonal secretions, such as adrenocortical
hormones, which stimulate the metabolic pathway of cholesterol by conversion into other compounds. The anti cholesterol action of Hibiscus sabdariffa (0.5% or1%) confirmed in rabbits fed cholesterol for 10weeks. This treatment was effective in reducing the serum concentrations of triglycerides, total cholesterol and low-density lipoprotein cholesterol, and in mitigating atherosclerosis in the aorta (Chen et al., 2003). Kanokwan Sukjail and Ampa Luangpirom (2010) studied aqueous seed extract of Hibiscus sabdariffa in male rats, and found that all treated groups showed decreasing of sperm concentration, percentage of normal motile sperms and vital sperms, while the percentage of abnormal sperms increased. The lactogenic effect of ethanol seed extract of Hibiscus sabdariffa was also found in both sexes of albino rats, and median lethal dose (LD.50) of this extract was above 5000 mg/kg BW of rats (Gaya I, et al.2008). In Nigeria, Hibiscus sabdariffa Linn. Seed tea was use traditionally to enhance lactation in case of poor milk production in human (Gaya I, et al.2008).
MATERIALS AND METHODS
Experimental animals Adult mice (n=30) included in the present study. The mice were 8 weeks old with average weight 28±3g each. Male mice housed in temperature controlled rooms (25°C) with constant humidity (40-70%) and 12h/12h light/ dark cycle according experimental protocols. All animals treated in accordance to the Principles of Laboratory Animal Care. All mice fed a standard diet. The daily intake of animal water monitored at least one week before start of treatments to determined the amount of water needed per experimental animal. Thereafter, the mice were randomly divided into control (n=10) and experimental groups (n=20). The control group received daily 8 ml distilled water. However, the experimental groups split into two groups each included ten mice. Group-1, received 50 gm/Kg/BW and group-2, received 100vgm/Kg/BW of Hibiscus sabdariffa for 21 consequence days.
Epididymis sperm count, viability and motility
Sperms from the cauda epididymis released by cutting into 2 ml of medium containing 0.5% bovine serum albumin .After 5 min incubation at 37°C (with 5% CO2), the cauda epididymis sperm reserves determined using the standard hemocytometric method and sperm motility analyzed with microscope (Olympus IX70) at 10 field and reported as mean of motile sperm according to WHO method.
Hormones measured
Serum collected at termination used for assaying for total testosterone, FSH and LH. Testosterone, FSH and LH measured using a commercial ELISA kit.Which is based on competive binding of hormones on immbilised antibody. Horse radish peroxidase was use for color development and absorbance at 420nm measured on a plate reader. Value are reported as ng/ml of serum.
Histology and Light microscopy
The testes fixed in 10% formalin and embedded in paraffin. Five-micron thick sections prepared and stained with Hematoxylin and Eosin (H&E). The specimens examined under Olympus/3H light microscope-Japan
Statistical analysis
Statistical comparisons were made using the ANOVA test for comparison of data in the control group and the experimental groups. The results expressed as mean ± S.E.M (standard error of means). Significant difference is written in parentheses.
RESULT
Spermatogenesis and Sperm Parameters:
Effects of Hibiscus sabdariffa on Spermatogenesis and Sperm Parameters summarized in table.1.&2 the obtained data shows that there were statistically high significant (pEnglishhttp://ijcrr.com/abstract.php?article_id=865http://ijcrr.com/article_html.php?did=865REFERENCES
1. Ali, M. B. and Salih, W. M. (1991). Investigations of the antispasmodic potential of Hibiscus sabdariffa calyces. Journal of Ethnopharmacol 31: 249–257.
2. Chau, J. W.; Jin, M. W.; Wea, L. L.; Chia, Y. C.; Fen, P. C.; Tsui, H. T. (2000). "Protective effect of Hibiscus anthocyanins against tertbutyl hydroperoxide-induced hepatic toxicity in rats". Food and Chemical Toxicology 38 (5): 411–416.
3. Chen, C-C., Hsu, J-D., Wang, S-F. (2003). Hibiscus sabdariffa extract inhibits the development of atherosclerosis in cholesterolfed rabbits. Journal of Agric Food Chem. 51: 5472–5477.
4. Craig, W.J. (1999). Health-promoting properties of common herbs. Am J ClinNutr.70(suppl): 491S-499S.
5. Kanokwan Sukjail and Ampa Luangpirom (2010). Effect of aqueous hibiscus sabdariffa linn. seed extracton plasma prolactin and seminal qualiry in male mice. " 4'h Sino-Thai Intemational conference.
6. Gaya I, Mohammad, O.M.A', Suleiman, A.M., Maje, M.l. and Adekunle, A.B. (2008). Toxicological and lactogenicstudies on the seed of Hibiscus sabdariffa Linn. (Ma\vaceae) extract on serum Prolactin Levels Of Albino Wistar Rats. Journal of Endocrinology 5(2). 1540-2606.
7. Omotuyi1, I,O., Ologundudu1, A. Onwubiko V. O., Wogu M. D. and Obi F. O.(2010)
8. Hibiscus sabdariffa Linn anthocyanins alter circulating reproductive hormones in rabbits (Oryctolagus cuniculus). Journal of Diabetes and Endocrinology Vol. 1(3), pp. 36-45,.
9. Orish E, Danladi C and Onyenmechi J.(2004).Testicular effects of sub-chronic administration of Hibiscus sabdariffa calyx aqueous extract in rats. J Reproductive Toxicology, 18, 2: 295–298
10. Owulade MO, Eghianruwa KI, Daramola FO. (2004). Effects of aqueous extracts of Hibiscus sabdariffa calyces and Ocimum gratisimum leaves in intestinal transits in rats. Journal of Biomed Res. 7: 31–33.
11. Tseng, T.H., Hsu, J.D., Lo, M.H., Chu, C.Y., Chou, F.P and Huang, C.J. (1998). Inhibitory effect of Hibiscus protocatechuic acid on tumour promotion in mouse skin. Cancer Letter. 126 (2): 199-207
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241610EnglishN-0001November30HealthcareA STUDY ON ATTEMPTED SUICIDE, ITS CLINICAL AND SOCIO-DEMOGRAPHIC VARIABLES IN A TERTIARY LEVEL HOSPITAL OF AHMEDABAD
English5763Nimesh ParikhEnglish Prateek SharmaEnglish Hitendra GandhiEnglish Girish BanwariEnglishBackground and Objective: Suicide attempt is one of the top five causes of acute admissions inhospitals and the area is scantily explored. This study aims to identify the socio-demographic and clinical variables in patients of attempted suicide in a tertiary level hospital of Ahmedabad. Method: After IRB approval, we approached the patientsof attempted suicide inpsychiatry OPD over a period of 3 months; demographic details were obtained from the consenting patients. They were then analyzed for presence ofmental illness in an interview based on DSM-IV TR andevident stressors. Beck`s Suicidal Intent Scale was applied on each study patient to know the severity of intent. The results were analyzed by spss v.20. Results: 78 out of 115 cases approached, consented to be a part of this study of which 56.4%werefemales.66.6%patients were less than 30 years of age, 84.6% were less than 12th standard educated, 74.3% were single and 87.5% of the unemployed patients, were housewives. In our study, 93.6% of suicide attempters had underlying psychiatric illnesses. 53.8% were diagnosed to have adjustment disorder. 65% of the patients having serious suicidal intent, were females. Conclusion: In our study, patients who are housewives (p=0.000); age EnglishNimesh Parikh, Prateek Sharma, Hitendra Gandhi, Girish BanwariINTRODUCTION
Suicide, also known as completed suicide, is the "act of taking one's own life"1 . Sigmund Freud explained suicide as “aggression turned inwards” and Karl Menninger conceived it as “inverted homicide”. Attempted suicide or non-fatal suicidal behavior is self-injury with the desire to end one's life that does not result in death2 . It is one of the top five causes of acute admission to general hospitals in both males and females3 . Depression, adjustment disorder, substance use (alcohol, cannabis), borderline personality disorder, conduct disorder, autism spectrum, anhedonia are associated with suicide attempts. Other risk factors include past history of attempted suicide4 , family history of suicide, hopelessness or the presence of traumatic brain injury.It is assumed to be linked to attention or help seeking behavior, which however is found to be of a false association in some studies5 . Globally, it is the 10th leading cause of death6 . There are an estimated 10 to 20 million non-fatal attempted suicides every year.7 According to American Association of Suicidology, for every 25 non fatal attempts, there is a case of successful suicide attempt8 . According to Synopsis of
Psychiatry by Kaplan and Saddock, 10% of suicide attempters subsequently suicide within 10 years. In Indian scenario, according to the recent nationwide compilation by NCRB (National Crimes Record Bureau) of The Ministry of Home Affairs, titled Accidental Deaths and Suicides in India 2010; last year there were about 15 suicides in India per hour, 23.9% growth in suicide rate was seen in last decade while the population growth rate was 18.3%. Gujarat ranked 17nth and witnessed about 6207 reported suicidal deaths. State`s suicidal rate was 10.7 as compared to the national average of 11.49 . The people who attempt suicide generally present to hospitals and small scale clinics with the medical complications. This makes a study of this group, an utmost priority as some of them might not even be able to avail adequate psychiatric care. The area is scantily explored in Gujarat, particularly Ahmedabad. Past suicide attempt is considered to be one of the best indicator of a future suicide. With this much to look at, the present study aims to identify the sociodemographic correlates, psychiatric morbidity and suicidal intent in patients of attempted suicide coming to Psychiatry OPD of a tertiary level hospital in Ahmedabad city.
MATERIAL AND METHODS
The study was carried out in the outpatient setting of Psychiatry Department of a tertiary level teaching hospital in Ahmedabad. IRB (Institutional Review Board) approval for the study was takenfrom the parent institute and the patients who had attempted suicide, coming to psychiatry OPD for management, were approached directly.Those who were willing to participate in form of giving written consent and ensuring confidentiality, were asked to fill a semi structured performa for demographic details. These patients were evaluated for the presence or absence of mental illnesses along with the reason of current event (according to patient). Then Beck`s Suicide Intent scale10(BSIS) was applied to
the study group as many previous studies have established reliability and validity of this instrument in the patients for screening of suicidal intent11. The complete scale is a 15-item survey: Items 1 to 8 cover objective circumstances of the attempt (e.g., isolation, precautions against discovery, suicide note); Items 9 to 15 report subjects intentions and expectations regarding the attempt. Allitems are scored on a 0-2 scale of severity and added. The total score range is 0 to 30 with scores above 28 indicating high suicidal intent, 20-28 indicating medium and 15-20 indicating low suicidal intent. All the patients of attempted suicide were explained regarding voluntary involvement in the study, and that their not taking part in the study will in no way interfere with the treatment decisions. The data thus obtained was analyzed by SPSS v. 20. Descriptive statistics were used to describe the data i.e. frequencies for categorical variables; chi square test to compare the socio-demographic details of patients, explanations for attempting self harm, final diagnosis (according to DSM-IV TR) and suicidal intent on BSIS, with the gender. Significance was set at pEnglishhttp://ijcrr.com/abstract.php?article_id=866http://ijcrr.com/article_html.php?did=866REFERRENCES
1. Stedman's medical dictionary (28th ed.). Philadelphia: Lippincott Williams and Wilkins. 2006.
2. World Report on Violence and Health (Vol. 1). Genève: World Health Organization. p. 185.
3. Hawton K, Fagg J. Trends in deliberate selfpoisoning and self-injury in Oxford, 1976-90. Br Med J 1992;304:1409-11.
4. Chang B; Gitlin D; Patel R . "The depressed patient and suicidal patient in the emergency department: evidence-based management and treatment strategies". Emergency medicine practice 2011:13 (9); 1–23.
5. Suyemoto, K. L. "The functions of selfmutilation". Clinical Psychology Review 1998;18 (5): 531–554.
6. Hawton K, van Heeringen K. "Suicide". Lancet2009:373 (9672); 1372–81.
7. BertoloteJM, Fleischmann A. "Suicide and psychiatric diagnosis: a worldwide perspective". World Psychiatry2002:1 (3); 181–5.
8. JL McIntosh. USA suicide 2006 Official final data: for the American Association of Suicidology 2009.
9. Accidental Deaths and suicides in India. National Crime Records Bureau.Ministry of home affairs. Government of India; 2010.
10. BeckaT., Herman I and Schuyledr. Development of suicidal intent scales. In A. T. Beck, H. L. P. Resnik, and D. Lettieri (Eds.), Measurement of suicidal behauiors. New York: Charles Press, 1973, in press.
11. MinkoppK ., Bergmane., Beck A . T., and Beckr. Hopelessness, depression and attempted suicide. Am. j. Psychiatry.,1973: 130; 455- 459.
12. Rao VA. Attempted suicide. Indian J Psychiatry 1965;7:253-64.
13. Badrinarayana A. Suicidal attempt in Gulbharga. Indian J Psychiatry 1977;19:69-70.
14. Lal N, Sethi BB. Demographic and socio demographic variables in attempted suicide by poisoning. Indian J Psychiatry 1975;17:100-7.
15. Vijayakumar L, Rajkumar S. Are risk factors for suicide universal? A case?controlled study in India. ActaPsychiatrScand 1999;99:407?11.
16. Conwel Y, Duberstein PR, Cox C, Herrmann JH, Forbes NT, Caine ED.Relationship of age and axis I diagnosis in victims of completed suicide: A psychological autopsy study. Am J Psychiatry 1996;153:1001?8.
17. Sureshkumar. Kerela. Indian J Psychiatry 2004;46:144?9.
18. Shukla GD, Verma BL, Mishra DN. Suicide in Jhansi city. Indian J Psychiatry 1990;32:44?51.
19. Nandi DN, Mukherjee SP, Banerjee G, Ghosh A, Horal GC, Choudhary A, et al. Is suicide preventable by restricting the availability of lethal agents?A rural survey of West Bengal. Indian J Psychiatry 1979;21:251?5.
20. Das PP, Grover S, Avasthi A, Chakrabarthi S, Malhotra S, KumarS.Intentionalself harm seen in psychiatric referrals in a tertiary care hospital. Indian J Psychiatry 2008;50:187-91.
21. Srivastava A. Study of hundred completed suicides. Indian Journal of Psychiatry 2013;55(3):268-72.
22. Kessing LV. Severity of depressive episodes according to ICD?10:Prediction of risk of relapse and suicide. Br J Psychiatry 2004;184:153?6.
23. Harris EC, Barraclough BM. Suicide as an outcome for mental disorders: A meta?analysis. Br J Psychiatry 1997;170:205?28.
24. Baxter D, Appleby L. Case register study of suicide risk in mental disorders. Br J Psychiatry 1999;175:322?6.
25. Jain V, Singh H, Gupta SC, Kumar S. A study of hopelessness, suicidal intent and depression in cases of attempted suicide. Indian J Psychiatry1999;41:122-30.
26. Sarkar P, Sattar FA, Gode N, Basanar DR. Failed suicide and deliberate self harm: A need for specific nomenclature. Indian J Psychiatry 2006;48:78-83.
27. Ponnudurai R, Jeyakar J, Saraswathy M. Attempted suicides in Madras.Indian J Psychiatry 1986;28:59-62.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241610EnglishN-0001November30HealthcareCOMPARISON OF 'CUT AND PASTE (USING FIBRIN GLUE)' VS 'CUT AND SUTURE (USING 8-0 VICRYL SUTURES)' TECHNIQUES OF PTERYGIUM SURGERY
English6476Kumar NishantEnglish Vireshwar PrasadEnglish Asif ShahnawazEnglish Muazzam Ali AkbarEnglishBackground: In recent times, the universal trend toward simpler, quicker and more comfortable surgical procedures have fostered the development of suture-less techniques and hence use of fibrin glue for attaching conjunctival autograft after pterygium excision. Objectives: To assess and compare the mean surgical time, post-operative discomfort and recurrences among patients undergoing Pterygium excision and conjunctival autografting using fibrin glue; with Pterygium excision and conjunctival autografting using 8-0 Vicryl sutures. Materials and methods: 60 patients with primary pterygium randomized into two groups. Group A (n=30) underwent autografting using fibrin glue; Group B (n=30) underwent autografting using 8-0 Vicryl suture. P-value EnglishPterygium, Conjunctival autografting, 8-0 Vicryl suture, Fibrin glueINTRODUCTION
Pterygium is one of the oldest diseases known in the history of medicine. It is a common condition in India, which is part of the ?Pterygium belt? described by Cameron1 . Besides the cosmetic appearance, the patient may complain of discomfort with recurrent redness of eye, swelling, tearing, burning sensation and occasionally pricking or gritty sensation. When the axial area of the cornea is invaded, vision gets increasingly affected. This occurs even before the Pterygium itself has reached the area, because of irregular astigmatism produced by corneal folds. In advanced Pterygium, ocular motility may be restricted leading to diplopia in certain field of gaze. Though the disease is known since time immemorial, no satisfactory treatment has yetbeen evolved up till now. Among the eye diseases which often are prone to recurrence, Pterygium is one of the commonest. The treatment of Pterygium is mainly surgical. A wide range of surgical maneuvers for removal of Pterygium have been reported. Bare sclera is the simplest method of Pterygium excision but is associated with a very high recurrence rate ranging from 24% to as high as 89%. Pterygium recurrence after bare sclera excision may be highly aggressive and in severe cases ocular morbidity may far exceed the primary lesion. To avoid this, adjunctive treatment such as ß-irradiation, Thiotepa, Mitomycin-C, 5-Fluorourail etc are used. Newer techniques include conjunctival autografting with or without limbal stem-cell transplantation and amniotic membrane grafting. Of all these newer methods, conjunctival autografting is most commonly performed and is associated with low rates of recurrences. The autograft can be attached to bare sclera with the help of 8-0 Vicryl suture; this is associated with increased surgical time, more post-operative pain, discomfort, watering and prolonged healing time. In recent times, the universal trend toward simpler, quicker and more comfortable surgical procedures have fostered the development of sutureless techniques and hence use of tissue adhesives for attaching conjunctival autograft. This technique claims to reduce the surgical time, cause less postoperative pain, irritation, watering, induce less inflammation, reduce healing time and recurrences. Fibrin glue is the most recent among all adhesives and is gaining acceptance world over for use in treatment of various ocular conditions. RelisealTM (manufactured by Reliance Life Sciences)is a two component tissue adhesive namely human fibrinogen and human thrombin. The resultant mixture simulates the natural physiological phenomenon of blood clotting at the bleeding site and forms a viscous clot. Thus, the formed clot acts like a seal to arrest bleeding or glue tissues. The fibrin clot also supports wound
healing process. It gets absorbed over several days to weeks by the naturally occurring endogenous fibrinolytic enzymes. Hence, a study was conducted to assess and compare the mean surgical time, post-operative discomfort and recurrences among patients undergoing Pterygium excision and conjunctival autografting using fibrin glue; with Pterygium excision and conjunctival autografting using 8-0 Vicryl sutures.
MATERIALS AND METHODS
In view of different techniques for Pterygium surgery, a prospective hospital based study has been conducted during March 2010 to September 2011to compare ?Cut and paste (Sutureless) technique‘ with ?Cut and suture technique‘ of pterygium surgery in terms of mean surgical time, postoperative discomfort and complications and recurrences. Written informed consent was obtained from all the participants before enrolment in the study and clearance from Institution‘s Ethics Committee was taken
Inclusion Criteria:
Study population was selected from the patients attending Ophthalmology Out-patient Department of the hospital with primary pterygium. Selected patients (total number 60) were randomly divided into 2 groups: Group A (n=30 patients): Corneo-scleral resection of pterygium with conjunctival autografting using Fibrin Glue. Group B (n=30 patients): Corneo-scleral resection of pterygium with conjunctival autografting using 8-0 Vicryl Sutures. Exclusion Criteria: 1. Cases with cystic, atrophic or inflamed pterygia. 2. Patients with associated ocular surface disorders like Sjogren‘s syndrome. 3. Patient with recurrent pterygia. 4. Pregnant patients and lactating mothers.All patients in the study were subjected to a thorough general and ocular examination.
METHODOLOGY
All surgeries were performed by a single experienced surgeon, always using the same equipments, technique and materials in each group except instead of using fibrin glue in Group A; 8-0 Vicryl sutures were used to fix conjunctival autograft on bare sclera in Group B. Surgical Steps: 1. Peribulbar block 2. Dressing and draping 3. Superior rectus bridle suture 4. Dissection of pterygium from apex to periphery 5. Dissection of conjunctival autograft from supero-temporal area 6. Graft secured either by 8-0 Vicryl sutures or by Fibrin Glue Securing the graft in bare sclera bed was done: A. With Sutures Once the graft is secured with the 4 cardinal sutures (8-0 Vicryl Suture) at the 4 corners, the forniceal edge can then be sutured with further interrupted sutures which need not include the episclera. These help fix the graft in position and avoid displacement of the graft, which can occur as the tissue around the sclera beds contracts and retracts in the postoperative period. B. With Fibrin Glue The Fibrin glue kit (RelisealTM, manufactured by Reliance Life Sciences Laboratories, India) contains 2 major components in separate vials: 1) Freeze dried human fibrinogen 2) Freeze dried human thrombin The kit also contains: 1) Aprotinin solution (Bovine) — 3000 and 1500 kallikrein inhibitor units (kiu/ml) in 1ml and 0.5ml units respectively. 2) 1 × 5 ml ampoule of sterile water for injection 3) 4×2ml syringes for reconstitution and application, 4) 4×21G sterile needles for aspiration of the two components; 2×20G blunt application needles. 5) Fibrin glue applicator with two mixing chambers and 1 plunger guide.
Safety and viral inactivation of the product: The product is screened for HIV 1 and 2, Hepatitis B virus, HCV, Parvo virus and HAV. Solvent Detergent Technology is used to inactivate lipid coated viruses. Though, there is a remote possibility of an unknown infectious agents be present in these products.
PHARMACOLOGY
The fibrin adhesion system initiates the last phase of physiological blood coagulation cascade.
The locally applied mixture quickly sets to form a milky white to translucent mass which continues to gain strength within 2 hrs following application. As wound healing progresses, increased fibrinolytic activity is induced by plasmin and decomposition of fibrin to fibrin products is initiated. Proteolytic
degradation of fibrin is inhibited by Aprotinin (A plasmin inhibitor). The graft is excised and placed on the cornea – with the stromal side facing the surgeon and the limbal edge of the graft adjacent to the limbus of the scleral bed. The reconstituted components of fibrin glue are mixed just at the site of application of the recipient surface by specially designed ?Fibrin Glue Applicator‘. The ensuing reaction results in the formation of sticky fibrin, which anchors the graft to the sclera bed. The graft is smoothed into position and the edges are co-apted to bring about a secure adhesion of the graft to the bed and the conjunctival edges. The process of adhesion usually takes about 45 to 60 seconds, which is time enough for the surgical manipulations. The rest of the procedure is as described before. Each 1 ml reconstituted solution was used in 6-8 patients. Postoperative Care
At the conclusion of surgery, 0.5cc dexamethasone and gentamycin is injected subconjunctivally and the eye is firmly patched with antibiotic eye ointment for 24 hours. Starting the next day, topical steroids are used at 2 hourly intervals and then tapered gradually over the next 6 weeks. Antibiotic eye ointment is also used frequently in the postoperative period. Surgical time was noted as follows: 1. Total surgical time from 1st cut of conjunctival to removal of lid speculum 2. Time for excision of pterygium 3. Time to secure graft on the bed (Surgical time was approximated to nearest round figures in minutes.) Post-operatively patients were examined on 1st postoperatively day, after 7 days, one month, three months and six months. On 1st post-operatively day following were observed: Grading of postoperative discomfort(graded on scale 0 to 3 using pretested questionnaires):
Graft success was defined as an intact graft by 4th week after surgery Graft failure was defined as detachment of graft by 4 th week after surgery. Recurrence was defined as proliferating conjunctival tissue extending across the limbus more than 1 mm onto the cornea within surgical field. Graft status: properly placed or displaced or lost. In subsequent visit following things were assessed. 1. Appearance of the graft (any sign of rejection or misplacement) 2. Any sign of recurrence 3. Patients‘ comfort.
Statistical Analysis
Data analysis has been done as: All data has been summarized as frequency tables and percentages have been worked out. The mean, standard deviation and the standard error of difference have been calculated. Student T-test and Z-test have been applied wherever appropriate to find out the difference between the two groups. Asymptomatic significance (P-value) is calculated for all the variables through these statistical tests. A ?Pvalue‘ of less than 0.05 has been considered significant.
RESULTS
Of the 60 patients enrolled in study, 40 (66.67%) were male and 20 (33.33%) were female. The age distribution of the patients shows that the majority of the patients are between 31-40 years of age. (Table 1) In group A mean total surgical time for excision of pterygium and graft placement was 15.86 minutes with SD 1.187 Mean pterygium excision time was 6.2 minutes and SD 1.082 Mean time to secure graft in bed was 9.66 minutes and SD 1.588 (Table 2) In group B mean total surgical time for excision of pterygium and graft placement was 27.93 minutes with SD = 2.789 Mean pterygium excision time was 4.66 minutes and SD = 0.617 Mean time to secure graft in bed was 23.26 minutes and SD 2.49 (Table 3) Comparing (A1 B1), P value = 0.001 i.e. the total time taken for operation is comparable and highly significant* i.e. notably less in A1. Comparing (A2 B2), P value = 0.24 i.e. it is not significant. Comparing (A3 B3), P value = 0.013 and is significant* i.e. time taken to secure graft to bed is much less than that of sutures. (Table 4) Three patients (10%) in Group A and 6 patients (20%) in Group B developed subconjunctival haemorrhage which resolved completely within 4th postoperative week. Three patients (10%) in each Group A and B developed transient graft edema which gradually resolved upon treatment with topical corticosteroid within 4th post-operative week. Two patients (6.6 %) in each Group A and B had loose graft on 1st post-operative day out of which 1 patient in each group developed graft failure by 4th post-operative week while remaining 1 patient in each group showed spontaneous healing and reattachment. (Table 5) In group A, out of 30 eyes of patients, 1 patient developed recurrence, so recurrence rate in group A is 3.3%
In group B, out of 30 eyes of patients, 6 developed recurrences, and so recurrence rate in group B is 20%. The difference of recurrence rate between two groups A and group B is statistically significant or not was tested by following formula. The standard error of difference is 8.0 where as observed difference (20 – 3.3) was 16.7. The observed difference between the two groups is more than twice the S.E. of difference i.e. 2 X 8 = 16.0. Therefore observed difference between recurrence rates was significant*. (Table 6) Group A showed graft failure rate of 3.3% while group B showed graft failure rate of 13.2. Standard error of difference is 6.99 where as observed difference (13.2 – 3.3) is 9.9 which is less than twice of standard error of difference. (Not statistically significant). (Table 7) In Group A, 27 patients (90%) out of 30 experienced no post-operative discomfort while 3 patients (10%) experienced mild post-operative discomfort (Grade 1, assessed using questionnaires) In group B, 13 patients (43.3%) out of 30 experienced no post-operative discomfort while 16 patients (53.3%) experienced mild (Grade 1) postoperative discomfort. 1 patient (3.3%) experienced moderate severity of discomfort (Grade 2). None of the patients in either group experienced any Grade 3 (severe) post-operative discomfort.
DISCUSSION
The present study was carried out to assess and compare the mean surgical time, post-operative discomfort and recurrences among patients undergoing Pterygium excision and conjunctival autografting using fibrin glue; with Pterygium excision and conjunctival autografting using 8-0 Vicryl sutures. Surgical time - comparison between group A and B In group A (Fibrin glue group); the mean total surgical time for excision of pterygium and graft placement was 15.86 minutes with SD 1.187 in comparison to Group B (8-0 Vicryl Suture) where
it was 27.93 minutes with SD 2.789 (P = 0.001; Highly significant). Mean pterygium excision time in Group A and B were 6.2 minutes (± 1.082 SD) and 4.66 minutes (± 0.617SD) respectively (P = 0.24; Not significant). Mean time to secure graft in bed was 9.66 minutes (± 1.588SD) in Group A and 23.26 minutes (± 2.49 SD) in Group B (P=0.013, Significant) [Table 1 and Table 2] Thus, it is seen that time taken for surgery is definitely less for the fibrin glue group i.e. Group A (Table 3). These findings corroborate with studies performed by Koranyi et al (2003)2 on 43 patients with pterygium. Average time was 9.6minutes for glue and 18.5 min. for sutures (p < 0.001). Jiang J, Yang et al (2008)3 also found that the average operating time was significantly shorter (p < 0.001) in fibrin sealant group as compared to suture group. Bahar I, Weinberger D et al (2007)4 noted average operating time to be 16 minutes (range 14-16 minutes) in the fibrin glue group and 28 minutes in Vicryl suture group. Post-operative complications In this study subconjunctival haemorrhage was found to be more commonly associated with conjunctival autografting using 8-0 Vicryl studies, in contrary to the study by Srinivasan S et al (2009)5 which did not find any significant difference. Increased incidence of subconjunctival haemorrhage in group B may be attributed to greater traumatizing of conjunctiva during suturing process (Table 4). In this study, no other complications were found to be more common in a particular group.
RECURRENCE
The observed difference between the recurrence rates in the 2 groups was statistically significant (Table 5). This may be attributed to better and smooth anatomical approximation of conjunctival autograft on recipient bed on application of fibrin glue. Also, edges may be co-apted to bring a secure adhesion to the bed using fibrin glue promoting early graft epithelialization. Moreovergraft positioning might be easier in case of fibrin glue in contrast to Group B wherein graft may have been inadvertently scrolled up resulting in inversion of surfaces leading to graft failure. There were no new cases of recurrence at 6th month postoperative visit. Thus, all recurrences were observed within 3 months post-operatively. The observation corroborates with the study performed by Farid M, Pimazar JR (2003)6 wherein they found recurrence rate in Tisseel group was 3.7% as compared to 20% in sutured group (P = 0.035). The average time of recurrence was 3.13 months. Hall RC et al (2009)7 also found that at 3 months, there were no recurrences in the glue group and 2 recurrences in the suture group. Karalezli a et al (2008)8 also observed recurrence in 1 case (4%) in the fibrin glue group as compared to 3 eyes (12%) in the suture group (p < 0.05).
Graft status Graft failure was seen 4 times more commonly in suture group than in fibrin glue group. Graft failure rate in Group A was 3.3% while in Group B was 13.2% at 4th week post-pterygium surgery [Table-6]. All cases of graft failure ultimately lead to recurrence of pterygium. The three and six month graft failure rate was unchanged and not significantly different between glue and suture groups. Post-operative discomfort In Group A (Fibrin glue group), 27 patients (90%) out of 30 experienced absolutely no post-operative pain or discomfort while in Group B (Suture group), only 13 patients (43.3%) experienced the same [Table-7]. In Group A, 10 % patients had tolerable symptoms in form of foreign body sensation, watering or itching and were present only occasionally in whole day (graded as mild discomfort) on first post-operative day. None of the patients complained of Grade 2 (moderate) or Grade 3 (severe) discomfort.In Group B, a major fraction of patients (56.6%) experienced some form of ocular post-operative discomfort. 16 patients out of 30 (53.3%) complained of mild discomfort while 1 patient complained of moderate / grade 2 discomfort in the form of persistent watering and foreign body sensation throughout the day which gradually subsided on its own. None of the patient in the group complained of any severe/ grade 3 symptoms. In subsequent visits of the patient at 1 week, 1 month, 3 months and 6 months; none of the patients from either group complained of any ocular discomfort. This study supports the observation made by Karalezli A et al (2008)8 wherein they found the intensity of postoperative pain foreign body sensation irritation and epiphora were significantly lower in the fibrin glue group than in the suture group (p < 0.001) Kim H, Mun H J et al (2008)9 also observed that subjective symptoms disappeared in 23 out of 36 eyes (64%) in one week after surgery and all discomforts subsided within two weeks after surgery in all patients. Bahar I, Weinberger D et al (2007)4 also observed satisfaction to be higher in the fibrin glue group (p < 0.05) than in the suture group. Similar observations were also made by Uy HS, Reyes JM et al (2005)10 .
CONCLUSION
This study shows that pterygium excision with conjunctival autografting using Fibrin Glue reduces the surgical time as compared to securing graft using 8-0 Vicryl Sutures. Also, the post operative discomfort and recurrence rate is significantly less in cases with Fibrin Glue as compared to 8-0 Vicryl Sutures..This may be attributed to biocompatible nature of fibrin glue which avoids complications derived from sutures and diminishes the sensation of a foreign body in the eye following surgery. Thus, patient comfort and satisfaction is significantly higher when fibrin glue is used for
conjunctival autograftingbut the cost of Fibrin Glue makes it an expensive procedure than conjunctival autografting using Vicryl sutures. Another comparative study may be required to study the feasibility of performinga relatively expensive technique (using fibrin glue) when an inexpensive technique using sutures has been in vogue since long especially in a developing country like India. In due course of time, the cost of fibrin glue is likely to come down; making this novelpterygium surgery technique: ?the procedure of choice of the day‘.
ACKNOWLEDGEMENTS
This dissertation would be wholly incomplete if it did not carry a sincere word of thanks to everyone who has helped us during the course of this study. We wish to express my deep andheartful gratitude to our teachers of Upgraded Department of Ophthalmology Darbhanga Medical College and Hospital, Laheriasarai for their enthusiastic support, keen interest, constant encouragement, patient and friendly guidance at every step of this study.. Wealso thank our colleaguesand supportive juniorsand O.T. staffs of the Upgraded Department of Ophthalmology, Darbhanga Medical College and Hospital, Laheriasarai, whose cooperation and encouragement has helped us to complete this study. We must thank Superintendent Dr. Suraj Nayak and Principal Dr. S.N. Sinha, D.M.C.H, Laheriasarai, for their kind permission to carry out this work. Authors acknowledge the immense help received from the scholars whose articles are cited and included in reference of this manuscript. The authors are also grateful to authors/editors/publishers of all those articles, journals and books from where the literature of this article has been reviewed and discussed. We would fail in my duty if we do not thank all the subjects who volunteered for the study.Last but not the least; we must thank Mr. Manoj Kumar, New Bihar Press, Laheriasarai, Darbhanga for his invaluable co-operation and typing the manuscript of this thesis.
Englishhttp://ijcrr.com/abstract.php?article_id=867http://ijcrr.com/article_html.php?did=867REFERENCES
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11. De Kaizer RJ, Swart Vain der Bergh. Results of Pterygium Excision with Sr 90 irradiation, lamellar keratoplasty and conjunctival flaps. Doc ophthalmo 1987; 67:33-44.
12. de Wit D, Athanasiadis I, Sharma A, Moore J. Sutureless and glue-free conjunctival autograft in pterygium surgery: a case series. Eye (Lond) : Epub 2010 Jun 4, 2010 Sep; 24(9):1474-7
13. Dushku N, Tyler N, Reid TW. Immunohistochemical evidence that pterygia arise from altered limbal epithelial basal stem cells. Invest Ophthalmol Vis Science 1993; 34: 1013-20.
14. Farell PL, Smith RE. Bacterial corneoscleritis complicating pterygium excision. AJO 1989 May; 107 (50:515-7)
15. Farid M, Pirnazar JR. Pterygium recurrence after excision with conjunctival autograft: a comparison of fibrin tissue adhesive to absorbable suture. 2009 Jan;28(1):43-5.
16. Fernandes M, Sangwan V S, Bansal A K, Gangopadhaya N, Srihar M S, Garg P, Aasuri M K, Nutheti R and Rao G N. Outcome of Pterygium Surgery: Analysis over 14 years Eye (2005); 19, 1182-1190. Doi:10.1038/sj.eye.6701728; published online 29 October 2004.
17. G Koranyi, S Seregard, E D KoppCut and paste: a no suture, small incision approach to pterygium surgery. Br J Ophthalmol 2004;88:911-914.
18. Goran DH, Hollows FC. Pterygium and ultraviolet radiation: a positive correlation. Br J Ophthalmology. 1984; 68:343.
19. Hall RC, Logan AJ, Wells AP. Comparison of fibrin glue with sutures for pterygium excision surgery with conjunctival autografts. Clin Experiment Ophthalmol. 2009 Aug;37(6):584-9.
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21. Hirst LW, Battisttutta D, Green A. Risk Analysis in development of pterygia. Ophthalmology 1992 Jul; 99(7): 1056-61.
22. Jap A, Chan C, Lim L, Tan DT. Conjunctival Rotation autograft for pterygium. Ophthalmology 106: 67-71, 1991.
23. Jiang J, Yang Y, Zhang m, Fu X, Yao K. Comparison of fibrin sealant and sutures for conjunctival autograft fixation in pterygium surgery; one year follow up. 2008; 222(2): 105- 11.
24. Kamel S. Pterygium: Its nature and new line of Treatment. Br J Ophthalmology 1946; 30: 549- 63.
25. Karalezii Kucukerdonmez A, Akova Y A, R Altan, Yaycioglu, Borazan. Fibrin glue versus sutures for conjunctival autografting in Pterygium surgery: A Prospective comparative study. Br J Ophthalmology. 2008; 92 (9):1206- 1210.
26. Kim HH, Mun HJ, Park YJ, Lee KW, Shin JP. Conjunctivolimbal autograft using a fibrin adhesive in pterygium surgery. Korean J Ophthalmol.2008 Sep;22(3):147-54.
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28. Lewallen S. A randomized trial of conjunctival autografting for Pterygium in the tropics. Ophthalmology. 1989;96:1612.
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33. Neal AJ, Irwin C, Hope-Stone HF. Strontium beta irradiation in the management of pterygium. Clin Onc Coll Rad 1991 Mar; 3(2): 105-109.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241610EnglishN-0001November30HealthcareFACTORS ASSOCIATED WITH ADHERENCE TO ANTIHYPERTENSIVE TREATMENT AMONG PATIENTS ATTENDING A TERTIARY CARE HOSPITAL IN MANGALORE, SOUTH INDIA
English7785Nithin KumarEnglish Bhaskaran UnnikrishnanEnglish Rekha ThaparEnglish Prasanna MithraEnglish Vaman KulkarniEnglish Ramesh HollaEnglish Darshan BhagawanEnglish Ishita MehtaEnglishBackground: Adherence to antihypertensive medication is very important in preventing complications. Objectives: To assess the level of adherence of hypertensive patients to their anti-hypertensive medications and to study the various factors influencing the adherence among these patients. Methodology: 120 hypertensive patients were interviewed using a pre-tested semi-structured questionnaire. The Morisky 8-Item Medication Adherence scale was used. Univariate and multivariate analysis was done to determine the factors associated with good adherence. Results: The mean age of study participants was 58.41 +/- 14.4 years. 45.8% of the participants had low level of adherence. On Univariate analysis, not experiencing any side-effects, provision of free medication and regular checkups were found to be significantly associated good adherence. None of the factors were found to be statistically associated with adherence on multivariate analysis. Conclusion: The level of adherence to treatment among the participants can be achieved through better health promotion and education strategies.
EnglishAdherence, Antihypertensive medications, Morisky scale, Patient related factors, Health system related factors, MangaloreINTRODUCTION
Hypertension or high blood pressure is defined as having persistent, elevated systolic blood pressure of 140 mmHg or above and/or diastolic blood pressure of 90 mmHg or above.[1] It is rapidly emerging asa global public health challenge because of its high prevalence, especially in middle and low income countries. The risk for cardiovascular diseases including coronary artery disease, congestive heart failure, stroke (ischemic and haemorrhagic), renal failure and peripheral arterial disease increases two-fold in the presence of hypertension.[2]. Itis oneamong the leading risk factors for cardiovascular mortalityand accounts for 9.4 million deaths globally and 7 per cent of disability adjusted life years (DALYs) in 2010. The prevalence of hypertension in India is estimated to be around 20% - 40% in urban and 12% -17% in rural areas. It is also alarming to notice that more and more young adults are being diagnosed with hypertension. [3]According to a World Health Organization (WHO) report, the prevalence of hypertension in India among men and women aged 25 years or more was 23.1% and 22.6% respectively.[4]
Regular blood pressure monitoring and continuous treatment for control of hypertension can improve this scenario.Adherence to medication is very important to keep high blood pressure under check and prevent complications. The available evidence shows that reduction of blood pressure is associated with significant decrease in the incidence of stroke, ischemic heart disease, congestive heart failure, and renal failure, irrespective of age, gender, race or ethnicity, type of antihypertensive used, or severity of hypertension.[5] However adherence to antihypertensive medication is an issue of concern and poses a serious challenge to clinicians, and healthcare systems because of the mounting evidence that non adherence is prevalent.[6] Non adherence to long term medication for chronic diseases is a complex process and a complicated issue affecting patients? health, health expenditure, and resources? utilization. Non- adherence to antihypertensive medication is one of the main reason for failure to control blood pressure among those on treatment and is generally associated with bad outcomes of the disease. [7] Adherence has been often used interchangeably with the term „compliance?. However, the term adherence is preferred over compliance because the former implies an interactive, collaborative relationship between the patient and the care-giver. [8] Complianceis defined as the extent to which a person?s medication-taking behaviour coincides with the healthcare providers? medical advice and relies on patient obedience.[8,9] WHO defines adherence as ''the extent to which aperson's behaviour in taking medication, following a diet , and /or executing lifestylechanges corresponds with agreed recommendations from a health care provider.It is observed that patient adherence to treatment can be influenced by socioeconomic factors, health system and health care related factors, medication and disease related factors and finally, patient related factors.[10] The problem of non-adherence may not be limited to developing countries only, but its impact in developing countries like India is higher given the paucity of health resources and inequities in access to health care. Due to poor adherence it is inevitable that patient lands up with medical complications resulting, in himspending large amount of money on hospitalization and chronic illness care [6, 10] Even though adherence to medication can be measured using indirect methods like pill counts, pharmacy refill rates and electronic medication monitors it is rarely practiced in clinical care. [11] Self-reporting questionnaires with high validity and reliability have also been developed to measure the level of adherence to antihypertensive medication. [11, 12, 13]. However, ensuring patient adherence to therapy still remains a challenge for practitioners. Hence medication adherence has been called “The next frontier in quality improvement”and is anintegral part of cardiovascular outcomes research.[6,14] The present cross-sectional study was conducted to assess the level of adherence and the factors influencing adherence among hypertensive patientsin Coastal South India.
METHODOLOGY
This cross-sectional study was conducted among the hypertensive patients attending the peripheral outreach clinics belonging to the Department of Community Medicine, and the Medicine OPD at the hospital attached to Kasturba Medical College, Mangalore.The study participants were above 18 years of age and on anti-hypertensive treatment for more than 6 months. The sample size of 119 was calculated taking the level of adherence to antihypertensive medication as 60%. [15, 16, 17] with a relative precision of 15% and 95% confidence interval. Adding a non-response error of 10%, the sample size to be studied was 131.The data was collected using a pretested semi-structured questionnaire consisting of 4 sections: Section AParticipant?s general information, Section BDiagnosis and treatment details of hypertension, Section C - Health System related details and Section D -The Morisky 8-Item Medication
Adherence Questionnaireto assess the level of adherence to the anti-hypertensive medication. The questionnaire consists of a set of 8 questions with a yes or no answer. 1 point was awarded for every yes response and a zero for every no. A total score of >2 meant low adherence, 1 or 2 is medium adherence and a 0 shows high adherence.[18] Ethics Committee approval was obtained from the Institutional Ethics Committee of Kasturba Medical College, Mangalore (affiliated to Manipal University), India prior to the commencement of the study. After obtaining the required permission from the hospital/Medical college, the study participants were briefed about the nature and the purpose of the study, and were included in the study after taking a written informed consent. The socioeconomic status was assessed using the Kuppuswamy Scale. [20]
STATISTICAL ANALYSIS
The collected data was entered in, and analyzed using SPSS (Statistical Package for Social Sciences) version 11.5 (SPSS, Inc., Chicago, IL, USA). The data was analyzed in terms of descriptive statistics (Mean, Standard deviation and IQR) and the results were expressed in proportions. We undertook both unadjusted and adjusted logistic regression to assess the various (Patient related, Medication related and Health system related) factors favoring adherence to anti-hypertensive medication among patients. The fit of the logistic model was assessed with the Hosmer and Lemeshow goodness-of-fit test; P < 0.05 was considered evidence of a statistically significant difference between predictive and outcome variables. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) are reported
RESULTS
A total of 120 hypertensive patients were assessed about their level of adherence towards antihypertensive medication giving a response rate of 100%. The mean age of study participants was 58.4 +/- 14.4 years. Majority (n =76, 63.3%) of the participants were males and a higher proportion (n=66, 55.0%) were above 55 years of age. The family history of hypertension was present in 33.3% (n=40) of study participants. Comorbidities were present among 50.8% (n=61) of the participants of which Diabetes Mellitus (n=44, 72.1%) was the most common comorbid illness. The baseline characteristics of the study participants are shown in Table1. The mean duration of hypertension among the patients was 5 years (IQR 3-12) More than half (n=76, 63.3%) of the participants were diagnosed to be hypertensive in a private clinic. By self-report 116 (96.7%) of 120 patients were adherent to their anti-hypertensive medications. However on assessing the adherence level using Morisky scale it was observed that 54.2% of the participants had a medium level of adherence and 45.8% had poor level of adherence to their medication. There were no participants with high level of adherence to antihypertensive medication in our study. For the purpose of comparison, participants with medium level of adherence were considered to have a good adherence and those with low level of adherence were considered to be having poor adherence to medication. Table 2 shows the patient factors determininggood adherence to anti-hypertensive medication as measured by Morisky adherence scale.Adherence rate towards anti-hypertensive medications was better among participants above 60 years of age (57.4%)compared to those below 60 years (51.5%), (OR =0.8, CI= 0.4 – 1.6, p=0.520), but was not found to be statistically significant. Even though adherence rates were found to be better among married participants, those with positive family history of hypertension and among those who understood the doctor?s advice, none were found to be statistically significant in determining good adherence behaviour. Table 3 shows the medication related factors determining adherence to antihypertensive medications. Not experiencing any side-effects due to medicationwas found to be associated with good adherence and the association was found to be
statistically significant. (OR=0.1, 0.03-0.52, p=0.003) Table 4 shows the health system related factors determining good adherence to antihypertensive medications. Participants who were taking free medication were found to have better adherence towards their hypertensive medications and it was statistically significant. (OR=0.4,0.2-0.9,p=0.030) Even though on Univariate analysis, not experiencing any side-effects, provision of free medication and regular checkups were found to be significantly associated good adherence, on multivariate analysis none of the factors were found to be statistically associated with adherence. (Table-5)
DISCUSSION
Non-adherence to chronic disease medication is a major public health problem that has been called an "invisibleepidemic”. Reviews from developed countries such as the United States have shown that only 51% of the patients treated for hypertension adhere to the prescribed treatment where as in developing countries like China, Gambia and the Seychelles, only 43%, 27% and 26%, respectively, of patients adhere to their antihypertensive medication regimen.[10]The present study was conducted to assess the level of adherence to antihypertensive medication among the hypertensive patients in Mangalore, a Coastal city in South India. In our study by self-report 96.7% of the participants felt they were adherent to their prescribed medications. However on assessment using the Morisky scale 54.2% were found to have a moderate level of adherence to their hypertensive medication and 45.8% had a poor level of adherence.Our study findings are similar to studies from China [17] and Malaysia [11] where overall 52% and 53.4% of the participants were found to be adherent to their anti-hypertensive medication respectively. Similar studies from other parts of the globe have reported the prevalence of adherence to hypertensive medications to be ranging from 60% to 77%. [15, 16, 20-25].In a study in Birmingham, UK [26] only 44.8% of the participants were adherent to their hypertensive medication.The wide range inprevalence of adherence to antihypertensive medication across various studies may be due to the use of different scales to assess adherence. However there is no denying the fact that non-adherence to medication is a matter of huge concern. It is evident from our study as well as from others mentioned above; the problem of non-adherence is universal and not just limited to developed or developing countries.But its impact may be more onthose countries with limited resources since poor adherence poses a huge challengefor improving health in poor populations, and also results in underutilization of already limited treatment resources.[10] Various studies across countries have identified different factors influencing adherence to antihypertensive medication. In a study from Malaysia [11] females were found to be more adherent towards their medication compared to males, where as in UK [26]males were found to be more adherent towards medication which was similar to our study finding. Instudies from China [21] and Pakistan [25] age seemed to be an important factor influencing adherence with older patients being more adherent compared to younger patients. Similar observations were made in our study. The latter study also reported better awareness about the disease as an important factor for adherence towards medication which was also reported by study in Northwestern Ethiopia. [15] To add to this finding, in a study in Bangladesh[27] lack of information about the disease was an important factor for non-adherence to medication. The adherence was seen to be higher among patients on more medications. [16, 25].In a study in Greece [7], fear of complications of hypertension, personal relationship with the treating physician favored adherence.In the health system related factors the people who live closer to the hospital and those who get free drugs were seen to be more adherent to their medications than those who had to
come from a distance and had to pay for their drugs. Distance to the hospital as a factor which caused non adherence was also reported by other studies. [16, 24] Absence of any side effects to the medications, availability of free antihypertensive drugs and regular checkup of blood pressure were found to be associated with good adherence to antihypertensive medication in our study which were not found to be significant after multivariate analysis. On stratifying the factors, as well as those reported from other studies, the multifactorial nature of the problem of non-adherence is evident. Not one factor can be solely held responsible for influencing non-adherence among patients.The interventions planned to combat the problem should be targeted towards social, economic, medical, behavioral and health system related factors. The limitation of our study would be that the Morisky adherence questionnaire used in this study has not been validated in the Indian population. Also the sample size of our study is small to generalize the findings to a large extent. However there is a paucity of literature on adherenceto antihypertensive medications in the Indian subcontinent. We would like to recommend further studies in the region as well as across the country to assess the adherence level as well as the various factors influencing it. The clinicians should spend quality time with their patients and make them aware of the risk of complications arising from poor adherence to treatment. Health education plays an important role as well in creating awareness about the complications of hypertension among patients in general, with display of posters and flipcharts which can have an added effect. Patient self-help groups need to be formed and promoted where in the patients can discuss their reasons for non-adherence and try to solve it.The health system needs to be strengthened to make sure lack of medication is never a cause for non-adherence. The proposed National Programme on Prevention and Control of Diabetes, Cardiovascular diseases and Stroke (NPDCS) should address the issue of Non
adherence to medication and recognize it as one of modifiable risk factor for complications of hypertension. By preventing this risk factor, the qualities of life for individuals with hypertension can be improvedand will reduce the overall cardiovascular morbidity and mortality.
CONCLUSION
From our study, as well as those reported from other studies, the multifactorial nature of the problem of non-adherence is evident. Not one factor can be solely held responsible for influencing non-adherence among patients.The interventions planned to combat the problem should be targeted towards social, economic, medical, behavioral and health system related factors. The limitation of our study would be that theMorisky adherence questionnaire used in this study has not been validated in the Indian population. Also the sample size of our study is small to generalize the findings to a large extent. However there is a paucity of literature on adherence to antihypertensive medications in the Indian subcontinent. We would like to recommend further studies in the region as well as across the country to assess the adherence level as well as the various factors influencing it. The clinicians should spend quality time with their patients and make them aware of the risk of complications arising from poor adherence to treatment. Health education plays an important role as well in creating awareness about the complications of hypertension among patients in general, with display of posters and flipcharts which can have an added effect. Patient self-help groups need to be formed and promoted where in the patients can discuss their reasons for nonadherence and try to solve it. The health system needs to be strengthened to make sure lack of medication is never a cause for non-adherence. The proposed National Programme on Prevention and Control of Diabetes, Cardiovascular diseases and Stroke (NPDCS) should address the issue of Nonadherence to medication and recognize it as one of modifiable risk factor for complications of
hypertension. By preventing this risk factor, the qualities of life for individuals with hypertension can be improved and will reduce the overall cardiovascular morbidity and mortality.ACKNOWLEDGEMENTS The authors are grateful to the study participants who voluntarily took part in the study. We wish to acknowledge the support provided by the Department of Community Medicine, Kasturba Medical College, Mangalore and Manipal University for encouraging research and its publication in international journals of repute. Authors also acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=868http://ijcrr.com/article_html.php?did=868REFERENCES
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2. WHO 2013.A global brief on HypertensionSilent killer, global public health crisis. Available at URL:http://apps.who.int/iris/bitstream/10665/7 9059/1/WHO_DCO_WHD_2013.2_eng.pdf.Ac cessed on: 23/11/2013.
3. Mohan S, Campbell N, Chockalingam A.Time to effectively address hypertension in India.Indian J Med Res 2013; 137:627-631.
4. WHO 2012.World Health statistics 2012.Available at URL:http://www.who.int/gho/publications/worl d_health_statistics/EN_WHS2012_Full.pdf. Accessed on: 23/12/2013.
5. Chobanian AV. Impact of non-adherence to antihypertensive therapy. Circulation 2009; 120(16): 1558-60.
6. Ho PM, Bryson CL, Rumsfeld JS. Medication adherence: its importance in cardiovascular outcomes. Circulation 2009; 119(23):3028-35.
7. Tsiantou V, Pantzou P, Pavi E, Koulierakis G, Kyriopoulos J. Factors affecting adherence to antihypertensive medication in Greece: results from a qualitative study. Patient Prefer Adherence 2010; 4: 335-43.
8. Nichols – English G, Poirier S. Optimizing adherence to pharmaceutical care plans. J Am Pharm. Assn 2000; 40: 475 – 485.
9. Haynes RB, McDonald H, Garg AX, Montague P. Interventions for helping patients to follow prescriptions for medications. Cochrane Database Syst Rev 2002; 2: CD 000011.
10. WHO 2003.Adherence to long-term therapiesEvidence for action. Available at URL:http://whqlibdoc.who.int/publications/2003/9 241545992.pdf. Accessed on: 24/12/2013.
11. Ramli A, Ahmad NS, Paraidathathu T. Medication adherence among hypertensive patients of primary health clinics in Malaysia. Patient Prefer Adherence 2012 ; 6:613-22.
12. Koschack J, Marx G, Schnakenberg J, Kochen MM, Himmel W. Comparison of two self-rating instruments for medication adherence assessment in hypertension revealed insufficient psychometric properties J ClinEpidemiol 2010 ;63(3):299-306.
13. Lambert EV, Steyn K, Stender S, Everage N, Fourie JM, Hill M. Cross-cultural validation of the hill-bone compliance to high blood pressure therapy scale in a South African, primary healthcare setting. Ethn Dis 2006; 16(1):286-91.
14. Heidenreich PA. Patient adherence: the next frontier in quality improvement.Am J Med. 2004; 117:130 –132.
15. Dessie A, Asres G, Meseret S, Birhanu Z Adherence to antihypertensive treatment and associated factors among patients on follow up at University of Gondar Hospital, Northwest Ethiopia. BMC Public Health 2012; 12:282.
16. Mweene MD, Banda J, Andrews B, Mweene MM, Lakhi S. Factors Associated With Poor Medication Adherence in Hypertensive Patients In Lusaka, Zambia. Med J Zambia 2010; 37:3.
17. Hsu YH, Mao CL, Wey M. Antihypertensive Medication Adherence among Elderly Chinese Americans. J TranscultNurs 2010; 21(4):297- 305.
18. Morisky8-Item Medication Adherence Questionnaire. Available at URL:http://media.mycme.com/documents/30/1 1-136_case_3_table_2_rev_7413.pdf. Accessed on: 23/11/2013.
19. Kumar BPR, Dudala SR, Rao AR. Kuppuswamy?s socio-economic status scale –A revision of economic parameter for 2012.Int Journal Res and Dev Health 2013; 1(1):2-4.
20. Lowry KP, Dudley TK, Oddone EZ, Bosworth HB. Intentional and unintentional nonadherence to antihypertensive medication. Ann Pharmacother. 2005; 39(7-8):1198-203.
21. Lee GK, Wang HH, Liu KQ, Cheung Y, Morisky DE, Wong MC. Determinants of medication adherence to antihypertensive medications among a Chinese population using Morisky Medication Adherence Scale. PLoS One 2013; 8 (4): e62775. doi:10.1371/journal.pone.0062775
22. Patel RP, Taylor SD. Factors affecting medication adherence in hypertensive patients.Ann Pharmacother 2002; 36 (1):40-5.
23. Atulomah NO, Florence MO, Oluwatosin A. Treatment adherence and risk of non-compliance among hypertensives at a Teaching Hospital in Ogun state, southwest Nigeria.acta SATECH 2010; 3(2):143- 149.
24. Chelkeba L, Dessie S. Antihypertension medication adherence and associated factors at Dessie Hospital, North East Ethiopia, Ethiopia. Int J Res Med Sci 2013;1(3):191-197.
25. Hashmi SK, Afridi MB, Abbas K, Sajwani RA, Saleheen D, Frossard PM et al.Factors associated with adherence to anti-hypertensive treatment in Pakistan. PLoS One. 2007 Mar 14;2 (3):e280.
26. Gohar F, Greenfield SM, Beevers DG, Lip GY, Jolly K. Self-care and adherence to medication: a survey in the hypertension outpatient clinic. BMC Complement Altern Med 2008; 8:4. doi: 10.1186/1472-6882-8-4.
27. SM Hussanin, C Boonshuyar, ARMS Ekram. Non-adherence to antihypertensive treatment in essential hypertensive patients in Rajshahi, Bangladesh. Anwer Khan Modern Medical College Journal 2011; 2(1):09-14.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241610EnglishN-0001November30HealthcareAPOLIPOPROTEIN B / APOLIPOPROTEIN A1 RATIO: AN IMPROVED MARKER OF CARDIOVASCULAR RISK IN HYPOTHYROIDISM
English8689Priyanka G. RakshasmareEnglish P. N. JoshiEnglishIntroduction: Hypothyroidism is a condition with decreased levels of thyroid hormones and elevated levels of Thyroid stimulating Hormone. Hypercholesterolemia is the characteristic feature of hypothyroidism and is also predisposing factor of atherosclerosis. Cholesterol in the body is transported through lipoproteins called Low density lipoprotein (LDL) and High density lipoprotein (HDL). The ratios, LDL/HDL and total cholesterol/HDL reflectthe direction of transport of cholesterol and are conventionally used to assess risk of cardiovascular diseases. ApolipoproteinB (apo B)present in Very low density lipoprotein(VLDL), Intermediate density lipoprotein (IDL), and LDL; is considered as atherogenicwhereas apolipoproteinA1 (apoA1) present in HDL, is antiatherogenic, anti-inflammatory with antioxidative properties. ApoB/apoA1 ratio represents the balance of proatherogenic and antiatherogenic lipoproteins. So the case control study was carried out to know the effectiveness of this improved ratio in hypothyroidism. Objective: To find out levels of total cholesterol (TC), LDL, HDL, apoB,andapo A1 2) To find out ratios- LDL/HDL, TC/HDL and apoB/apoA1 3) To check the effectiveness of apoB/apoA1 ratio as marker of cardiovascular risk in hypothyroidism. Methodology: Group A consists of 30 clinically diagnosed and biochemically confirmed cases of hypothyroidism. The levels of TC, HDL estimated using the kit, LDL using Friedewald formula, apoB and apoA1 byimmuno-turbidimetricmethod and result were compared with Group B (n=30) age and sex matched controls. Results: The levels of TC, LDL, and apoB were found to be increased highly significantly (pEnglishHypothyroidism, hypercholesterolemia, apolipoprotein B/ apolipoproteinA1 ratio, cardiovascular risk.INTRODUCTION
Hypothyroidism is a condition with decreased levels of thyroid hormones (T3, T4) and elevated levels of thyroid stimulating hormone (TSH)1,2 . Hypothyroidism is categorized into: - Primary hypothyroidism - a condition characterized by the failure of the thyroid gland to produce sufficient thyroid hormones.Secondary hypothyroidism (central thyroid disease) occurs as a result of pituitary or hypothalamic disease that produces a
deficiency in Thyroid stimulating hormone (TSH), thyroid releasing hormone (TRH) or both2 . According to various studies on thyroid disease, it has been estimated that about 42 million people in India suffer from thyroid diseases. Recent population-based study reported the prevalence of hypothyroidism as 3.9%3 .Thyroid hormones have significant effects on the synthesis and metabolism of lipids mainly cholesterol4,5,6 . Thyroid hormones regulate lipid metabolism by different ways: 1) up regulation of the low density lipoprotein receptors, which results in enhanced catabolism of the low density lipoproteins (LDL) particles, 2) stimulation of the cholesteryl ester transfer protein (CETP), an enzyme which transports cholesteryl esters from HDL 2 to the very low density lipoproteins (VLDL) and intermediate density lipoproteins (IDL) and triglyceride to the opposite direction. 3) Activation of the lipoprotein lipase, which hydrolyzes the triglyceride rich lipoproteins.4) Stimulation of hepatic lipase (HL),which catabolises HDL2 to HDL3 and IDL to LDL4,12.Hypercholesterolemia is the characteristic feature of hypothyroidism and is also predisposing factor for atherosclerosis. Cholesterol in the body is transported by low density lipoprotein (LDL) and high density lipoprotein(HDL)4,5,6,7. The ratios, LDL/HDL and TC/HDL reflect thedirection of transport of cholesterol and are conventionally used to assess risk of cardiovascular diseases.Apolipoproteins are the protein moieties of lipoproteins. The various functions of apolipoproteins are 1) theycan form part of the structure of the lipoprotein. 2) They are enzyme cofactors.eg A-1 for lecithin: cholesterolacyltransferase, or enzyme inhibitors.eg A-II for lipoprotein lipase. 3) They act as ligands for interactionwith lipoprotein receptors in tissues.eg, Apo B for LDL receptor, apo A-1 for the HDL receptor1,2 . ApoB is the major protein in VLDL, IDL and LDL,with one protein per particle of lipoprotein. ApoA-I is the major protein in HDL particles. The apoB level indicates the total number of atherogenic particles, while apoA-I
reflects the anti-atherogenic potential in HDL particleswhich has anti-inflammatory and anti oxidativeproperties. The apoB/apoAI ratio indicates the balance between atherogenic and anti-atherogenic particles. Thus higher the ratio, higher the cardiovascular risk in hypothyroidism8,9,10. There are some methodological advantages of using these apoB/apoA1 ratio 1) direct measurement of apo B and apo A-1 by internationally standardized methods. 2) Fasting sample is not required for the analysis. 3) Apo B and apo A-1 can be analysed on frozen samples8,9 . Considering these facts, present study was conducted to find theeffectiveness of this Apo B/ApoA1 ratio over conventional LDL/HDL and TC/HDL ratios in hypothyroidism. Objectives: 1) To estimate levels of TC, LDL, HDL, ApoB and ApoA1. 2) To find out ratiosLDL/HDL, TC/HDL and apo B/apoA1. 3) To check the effectiveness ofapoB /apoA1 ratio as a marker of cardiovascular risk in patients with hypothyroidism.
MATERIALS AND METHODS
This study was carried out after approval from the Institutional Ethics Committee and prior consentfrom all participants.Study design: case control study consists of total 60 subjects they were dividedin two groups. Group A: consists of 30 clinically diagnosed and biochemically confirmed casesof hypothyroidism. Group B: consists of 30 age and sex matched healthy controls with normal thyroid function tests. Exclusion criteria - patients suffering from diabetes, obesity, polycystic ovarian diseases, liver, renal disease, congestive cardiac failure, taking oral contraceptive pills, statins, and other medications that alter thyroid function were excluded from this study. Research methods-Venous blood samples were obtained from each participant after 12 to 14 hour fasting period.TC and HDLwere measured by
enzymatic kitmethods,LDL was estimated by theFriedewald equation, and apo B, apoA-1, measured by using immuno -turbidimetric method11. The assays were performed in the clinical laboratory of the institute. Statistical analysis SPSS software was used to analyze all statistical data. The continuous data was expressed as Mean ± SD and a comparison was done by using an unpaired t test. P value Englishhttp://ijcrr.com/abstract.php?article_id=869http://ijcrr.com/article_html.php?did=869REFERENCES
1. Harper’s Illustrated Biochemistry, 29th Edition [Hypothyroidism-Page No. 145, 745, 746 Lipoproteins- Page No. 238-249,]
2. Teitz Textbook Clinical Chemistry And Molecular Diagnosis-4 th Edition- Lipids, Lipoproteins, Apolipoproteins, and other cardiovascular risk factors. [Page No. 942- 960] [Hypothyroidism-Page No.2057-2059]
3. Unnikrishnan AG, menon UV. Thyroid disorder in India: an epidemiological perspective. [Indian J Endocr metabolism 2011;15:78-81]
4. Evagelos N Liberopoulos, moses S Elisaf, dyslipidemia in patients with thyroid disorders. [Hormones 2002,1(4):218-223]
5. O’ Brien T, Dinneen SF, O’Brien PC, PalumboPJ. Hyperlipidemia in patients with primary and secondary hypothyroidism.[mayo Clinproc 1993;68:860- 6]
6. Cappola AR and Ladenson P W. Hypothyroidism and Atherosclerosis.[Journal of clinical Biochemistry and Metabolism 2003/ 88(6): 2438-2444]
7. Hueston WJ, Pearson WS, subclinical hypothyroidism and the risk of hypercholesterolemia.[Ann Fam Med 2004;2:351-5]
8. Marcovina S, Packard CJ, measurment and meaning of apolipoproteinA1 and apolipoprotein B plasma levels. [journal of internal med 2006;259:437-44]
9. Wallidus G and Junger I: The apoB/apoA-I ratio: a strong, new risk factor for cardiovascular disease and a target for lipid-lowering therapy– a review of the evidence. [Journal of Internal Medicine 2006; 259: 493–519]
10. Wallidus G, Junger I. Rationale for using apolipoprotein B and apolipoprotein A-I as indicators of cardiac risk and as targets for lipid-lowering therapy.[ European Heart Journal. February 2005; 26(3): 210-212.]
11. Teitz Textbook Clinical Chemistry And Molecular Diagnosis-5 th Edition- measurment of apolipoproteins by immunoturbidimetric method [page No.785-88]
12. C.V Rizos, M.S Elisaf and E.N Liberopoulos Effects of Thyroid Dysfunction on Lipid Profile.[ Open Cardiovasc Med J.2011; 5: 76- 84]
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241610EnglishN-0001November30HealthcareMALE BREAST LESION PROFILE IN A TERTIARY CARE HOSPITAL IN WESTERN INDIA ON FINE NEEDLE ASPIRATION
English9095Raajul JainEnglish Smita A. ShahEnglish Tarang B. KadamEnglish R. N. GonsaiEnglish Karan ValaEnglishBackground: Male breast lesions are not very common. Usually male breast lesions are benign and affect the young male. Most common lesion is gynaecomastia. Male breast cancer accounts for a small proportion of breast cancers.Male breast cancer usually presents at an advanced stage. Objective: The aim of the study is to find out the incidence of male breast lesion in our setup and knowing the various pathologies afflicting male breast. Research and methodology:This is a retrospective study in which the computerised records in the department of cytopathology were analysed between January 2013 and October 2013.All breast lesions were analysed and male breast lesions were evaluated further for size, cytological diagnosis and histopathology work-up where available. Result: Most male breast lesions were benign. The most common lesion was gynaecomastia. Pre-operative diagnosis of male breast lesion in males is as desirable as in females. Cytology provides a reliable methodology for differentiating between benign and malignant lesions.
EnglishMale breast cancer, Fine Needle Aspiration Cytology (FNAC).INTRODUCTION
Male breast develops like a female breast till puberty. Due to absence of per- pubertal estrogenic stimulation, the normal male breast development ceases at this stage. Thus normal male breast mimics immature female breast1 . Breast lesions in males is relatively uncommon. A wide variation in the incidence range is seen in different geographical areas varying from 3.4 cases per 100,000 man years to 0.1 per 100,0001 . This study was undertaken to observe the prevalence and spectrum of lesions afflicting the male breast. In men, breast cancer is very rare. There are about 370 men diagnosed each year in the UK, compared with around 48,400 cases of breast cancer in women. That's about one man for every 130 women diagnosed2 . Like all cells of the body, a man's breast duct cells can undergo cancerous changes. But breast cancer is less common in men because their breast duct cells are less developed than those of women and because they normally have lower levels of female hormones that affect the growth of breast cells. The Surveillance, Epidemiology, and End Results (SEER) registry contains a total of 5,494 cases of male breast cancer and 835,000 cases of female breast cancer diagnosed from 1973 through 2005 (Anderson WF, submitted for publication).
MATERIALS AND METHODS
A retrospective study was conducted in which the computer records were collected from January 2013 to October 2013 for the patients who came to the Cytology section of
the department of Pathology of B. J. Medical College, Civil hospital, Ahmedabad, Gujarat for breast lesions. Ours is a teaching post graduate institute which also serves as a referral centre for nearby states. Data was evaluated for male patients with respect to age,site of lesion, cytology report and follow upbiopsy reports where available. Follow up biopsy was not availablein all cases as many cases were conservatively managed or were operated at a different institute.Most of the malignant cases diagnosed in our centre are referred to the Gujarat Cancer Research Institute (GCRI) and were lost to follow up. Fine needle aspiration was done with the help of 22 or 23 gauge needle, fixed in absolute alcohol and stained with haematoxylin and Eosin and Pap smears were made.The biopsy specimens were fixed in 10 % buffered formalin and paraffin embedded sections were stained with routine haematoxylin and eosin stains. No special stain or imunohistochemistry was used.
RESULTS AND OBSERVATIONS
Of the total of 473 cases 30 were cases of male breast lesions. Male breast lesions comprised 6.34% of the total breast lesions. The age group of presentation was between 13-100 yrs. Most common age group is 30-50 yrs. Majority of lesions were benign.The most common lesion was gynaecomastia (46.67%). Mean age of presentation was 41.5yrs. Median age of presentation was 40 yrs.
DISCUSSION
Diagnosis of breast lesions by fine needle aspiration cytology has gained worldwide recognition3 . The present study evaluated 30 male breast lesions. 6.34 % cases of breast lesions in our study were found to be in males. The incidence reported byRanbeer etal.3 is 5.8 %. In the study by Joshi et al. 4 incidence is 3.9%. Mansoor et al. 5 (Saudi Arabia) reported an incidence of 6%, Gupta et al. 6 reported an incidence of 1.4% while Das et al. 7 reported an incidence of 7.3%
Gynaecomastia is the predominant benign lesion in both the other studies and also in the studies by Joshi4 , Mansoor5 , Gupta6 , Das7 and Bannayan8 .The study by MS Gill et al. did not classify diseases as benign breast lesion which may be responsible for its such a high incidence. In our institute gynaecomastia was seen in the age group of 30-50 yrs. Gynaecomastia is caused by transitory hormone changes, as in puberty, often regresses after 1- 2 yrs. These factors share
in common increased estrogenic activity or decreased testosterone activity or both8 . The aetiopathological factors causing the gynaecomastia in adolescents are weight gain and fat deposition in the breast area, estrogen androgen imbalance in puberty, psychological stress, hypogonadism or abnormalities of pituitary(loss of blood supply, infection, steroid producing tumours), systemic causes such as adrenal genital syndrome, cirrhosis, renalfailure, thyrotoxicosis(estrogen and testosterone binding changed) or congenital (Klinefelter syndrome, androgen resistance etc.) or idiopathic8 . Causes of gynaecomastia in later years may be hormonally active tumours(Leydig cell tumour of testes, hCGsecreting germ cell tumours, lung carcinoma or others), cirrhosis, medications (digitalis, reserpine, dilantin and others) or idiopathic9 . Fine needle aspirates of gynaecomastia can have variable cellularity ranging from virtually acellular to richly cellular smears. Virtually acellular smears were seen in more mature lesions, where sclerosis had over taken proliferation. Duct cell clusters, myoepithelial cells and stromal cells were the three main components found in the smears7 . One very important clue is epithelial cohesiveness in these clusters which differentiate highly cellular smears with atypia from malignant lesions10,11 . The lesions where only benign cells were seen in a dispersed manner were termed as benign breast disease not otherwise specified. Male breast or chest wall lipoma is also seen which is similar to lipoma at any other location with variably cellular smear with fat cells. Schwannoma in breast is rare, accounting for 2.6% of schwannomas12. There are less than 30 cases reported in literature. Male breast schwannoma is rarer. Schwannoma is characterized cytologically by Antoni A areas which are fragments of cohesive cells. Samples from Antoni B areas often show mainly dispersed cells and myxoid at times cystic background. The most typical characteristicis the fibrillary appearance of the intercellular stroma. Nuclei tend to be long andslender with pointed ends often with a curved appearance11 . The male breast cancer were easily distinguished on cytology from gynaecomastia on the basis of high cellularity, dyscohesive cell groups with nuclear piling and anisonucleosis10.The absence of bipolar nuclei is an important clue in diagnosis of malignant lesions. In our study the follow up could not be possible in all cases because of the patients being referred to the cancer hospital.
CONCLUSION
Cytology provides good pre operative methodology for diagnosis in male breast cancer. Judicious use of cytology can minimise biopsies and frozen sections in case of male breast lesions.
\
Englishhttp://ijcrr.com/abstract.php?article_id=870http://ijcrr.com/article_html.php?did=870REFERENCES
1. Gill MS, Kayani N, Khan MN, Hasan HS. Breast diseases in males- A morphological review of 150 cases.J Pak Med Assoc 2000;50;177-179.
2. “Breast Cancer in Men”. Cancer Research UK. 2007. Retrieved 2010-05-14.
3. RanbeerSingh, Anshu, Satish M. Sharma, NitinGangane. Spectrum of Male Breast lesions Diagnosed by Fine Needle aspiration Cytology: A 5- Year Experience at a Tertiary Care Rural Hospital in central India.DiagnCytopathol,Vol 40(2):113-117.
4. Joshi A, Kapila k, VermaK.Fine Needle Aspiration Cytology in the Management of Male breast Masses-Nineteen years of experience.ActaCytologica 1999;43:334-338.
5. MansoorI, Jamal A. The value of fine needle aspiration cytology in the diagnosis of male breast lesions. Kuwait Med J 2001;33:216- 219.
6. Gupta RK,Naran S, Dowle CS, Simpson JS. The diagnostic impact of needle aspiration cytology of the Breast on decision making with an emphasis on the aspiration diagnosisof male breast masses. DiagnCytopathol 1991; 7:637-639.
7. Das DK, Junaid TA, Mathews SB, Ajrawi TG, Ahmed MS, Madda JP. Fine needle aspiration cytology diagnosis of male breast lesions: A study of 185 cases. ActaCytol 1995; 39:871-876.
8. Bannayan GA, HajduSI.Gynaecomastia: Clinicopathologic study of 351 cases. Am J ClinPathol 1992; 57:431-437.
9. Coen P, Kulin H. Ballantine T, etal.An aromatase producing sex cord stromal tumour resulting in prepubertalgynaecomastia.NEngl J Med 1991; 324:317-322.
10. Bibbo M, Lang WR, Silverman JF.Breast. In: Bibbo M, editor.Text book of comprehensive cytopathology. 2nd ed. Philadelphia: W B Saunders Company; 1997.p 750-752.
11. Orell SR, Sterrett GF, Walter Max N-I, Whitaker D.Breast. In: Orell SR, Sterrett GF, Walters M N-I, Whitaker D, Lindholm K, editors. Manual and atlas of fine needle aspiration cytology.3rd ed. London: Churchill Livingstone; 1999.p 188-189.
12. VandanaDialani,Neely Hines, Yihong Wang, Priscilla Slanetz.Breast Schwannoma. Case Reports in Medicine;2011.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241610EnglishN-0001November30HealthcareORAL HEALTH KNOWLEDGE AND PRACTICES AMONG THE SCHOOL STUDENTS IN RURAL AREA OF JALGAON DISTRICT OF MAHARASHTRA
English9699Shubhadarshini PawarEnglish Rahul BogamEnglish Kalpak SaneEnglish Sujata MurarkarEnglishBackground: Improving oral health in the rural children is still a dream come true in a developing countries like India. The children especially from these countries are most susceptible to dental diseases due to social, economic and demographic factors like lack of awareness, lack of transportation, limited access to professional dental care, lack of perceived need for dental care. Objective: to assess the oral health knowledge and practices among the school students in rural area of Jalgaon District of Maharashtra. Material and Methods: A cross sectional survey was performed across one of the randomly selected primary schools in Jalgaon District of Maharashtra State. A total of 101 children belonging to 3rd and 4th class were included as study participants. A pre-tested questionnaire consisting of 15 questions in local language was used to collect information about oral health knowledge and practices among the students. Entire information was entered in Microsoft Office Excel Sheet and data was analyzed. Results: Out of total 101 school students from 3rd and 4th class, there were 58 females while the other 43 were males. The age bracket of all participants was between 9-10 years. Forty percent participants had fear of dental treatment. Only 1.98% of the participants said that they cleaned their teeth more than once in a day. Conclusion: The present study reported low level of oral health awareness among school children in Jalgaon District of Maharashtra., India.
Englishknowledge, oral health, rural area, school studentsINTRODUCTION
Oral health is an essential aspect of general health and well being of an individual. The American Academy of Pediatric Dentistry has also given recommendation i.e. ‘first visit by first birthday and then at intervals’ in order to ensure oral health and hygiene.1 A study in the ‘Journal Pediatrics’ showed that children who have their first dental visit before age one have 40% lower dental costs in their 5 years than children who do not, due to the cost of dental and medical procedures that may be necessary as a result of poor oral health.1 Even though the past fifty years have witnessed a reduction in the severity and prevalence of oral disease among the population of the developing Countries, 2-4 improvement in oral health of rural children is still a dream come true in a developing country like India.5 The children especially from developing countries like India are more susceptible to dental diseases due to social, economic and demographic factors like lack of awareness, lack of transportation, limited access to professional dental care, lack of perceived need for dental care.4 Therefore there is a need to impart education about oral health especially in high-risk communities and population groups in such countries. Several studies have shown that the proportion of children aged 5 to 10 years with any known dental decay was higher among low social class in countries like India. A very few studies have been conducted so far in rural areas of Maharashtra State to assess the knowledge and practices about oral health amongst school children. The present study was undertaken to assess the awareness levels about oral health among school students in rural area of Maharashtra.
OBJECTIVE
To assess the oral health knowledge and practices among the school students in rural area of Jalgaon District of Maharashtra
MATERIAL AND METHODS
A cross sectional survey was performed across one of the randomly selected primary schools in Jalgaon District of Maharashtra State. Written
informed consent was obtained from the school authorities before commencement of the study. A total of 101 children belonging to 3rd and 4th class were included as study participants. A pretested questionnaire consisting of 15 questions in local language was used to collect information about oral health knowledge and practices among the students. A questionnaire was divided into four sections namely personal information, practice of oral hygiene, pattern of practices for dental treatment and knowledge and awareness of oral health. The surveys were conducted personally with one to one interaction with students by trained teachers of respective school. Entire information was entered in Microsoft Office Excel Sheet and data was analyzed.
RESULTS
In present study, there were a total of 101 participants from 3rd and 4th Class. Out of these 101 participants, 58 were females while the other 43 were males. The age bracket of all participants was between 9-10 years.
DISCUSSION
The present study explored a comprehensive overview about awareness levels and practices of primary school students regarding oral health. Table 1 presents the knowledge of participants about dental health problems. Most of the participants (28.71%) Stated ‘tooth decay’ is common problem associated with mouth and disease. In present study, 40% participants had fear of dental treatment; this corroborates with study findings among school children in North Jordon 6 where 48.8% of children had fear to visit dentist to seek dental treatment. This may be attributed to the lack of proper oral health education programs for school children. Only 1.98% of the participants said that they cleaned their teeth more than once in a day.However Mehta A and Kaur G 7 reported in their study that 25% of school children were cleaning teeth more than once a day. Majority of participants i.e. 99% used toothbrush while only one participant used finger as a tool to clean his teeth. This study finding is comparable with the study conducted by Amrita Mehta et al. 8 where only 62.96% of students were brushing their teeth with brushes. The awareness amongst the participants in present study about the preventive ways of dental problem was found to be poor as only 6 (5.94%) participants stated that dental problems can be prevented by brushing twice a day. Forty six (45.54%) participants said ‘brushing of teeth once’ and 38 (37.62%) said ‘avoiding chocolates and sweets’ as a preventive way for dental problems. The present study revealed poor knowledge of participants about effect of fluoride on teeth. Only 6 (5.94%) participants rightly reported that excess fluoride is lethal to teeth. A study conducted by Archana J. Sharda et al. 9 reported that only 12.6% of students were aware about the effect of fluoride on teeth. However, high level of knowledge was reported in the study by Al Omiri et al. 6 where 77% of students had knowledge about fluoride and teeth.
CONCLUSION AND RECOMMENDATIONS
The present study reported low level of oral health awareness among school children in Jalgaon District of Maharashtra., India. It emphasizes the need for the oral health education of the school children in order to improve the oral health knowledge and sustained and effective implementation of school oral health promotion programs.
ACKNOWLEDGEMENTS
We are thankful to Dr. Lalit Sarode and Dr.Rahul Raj for their valuable help in conduction of this study. Authors acknowledge the immense help received from scholars whose articles are cited and included in references of this manuscript. Theauthors 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=871http://ijcrr.com/article_html.php?did=871REFERENCES
1. Get It Done In Year One, American Academy of Paediatric dentistry, Chicago. Available at: http://www.aapd.org/assets/2/7/GetItDoneInYea rOne.pdf.
2. Downer MC. The improving oral health of United Kingdom adults and prospects for future. Br Dent J 1991; 23:154-8.
3. Burt BA. Trends in caries prevalence in North American children. Int Dent J 1994; 44:403-13.
4. Marthaler T, O’Mullane DM, Vbric V. The prevalence of dental caries in Europe 1990-1995. Caries Res 1996; 39:237-55.
5. Oral Health Status in rural child population: Promotional and Interventional Strategies. A GOIWHO Collaborative Programme 2006-07. www.whoindia.org/en/.../Section 30_1453.htm.
6. Mohmoud K. Al-Omiri, Ahed M. Al-Wahadni, Khaled N. Saeed. Oral health attitudes, knowledge, and behavior among school children in North Jordan. J. Dent. Educ; 2006; 70(2): 179-87.
7. Mehta A and Kaur G. Oral health-related knowledge, attitude, and practices among 12- year-old schoolchildren studying in rural areas of Panchkula, India. Indian 2012 Mar-Apr; 23(2):293.
8. Amrita Mehta, Siddhant Pradhan, Samved Pradhan, Suchetan Pradhan. Oral Hygiene habits and general oral awareness in public schools in Mumbai. International Journal of Laser Dentistry 2013; 3(2):60-67.
9. Archana J. Sharda , Srinath Shetty , Dr. Ramesh N , Jagat Sharda , Nagesh Bhat, Kailash Asawa. Oral Health Awareness and Attitude among 12- 13 Year Old School Children in Udaipur, India. International Journal of Dental Clinics 2011; 3(4):16-19.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241610EnglishN-0001November30HealthcareORAL CANDIDIASIS IN HIV INFECTED PATIENTS
English100107Ramya ChellammalEnglishOral candidiasis is a general opportunistic infection of the oral cavity caused by an over growth of Candida genus,the most common being Candida albicans.The prevalence varies depending on certain predisposing factors and age.There are three extensive groupings consisting of acute candidiasis, chronic candidiasis, angularcheilitis.Risk factors comprise impaired salivary gland function,drugs, dentures, high carbohydrate diet, and extremes of life, smoking, diabetes mellitus, Cushing's syndrome and immunosuppressive conditions.Fluconazole oral suspension as a systemic therapy was used to treat oral candidiasis in HIV-infected patients and provided a longer disease-free interval before relapse
EnglishCandidiasis, Candida albicans, HIV infected.INTRODUCTION
Oropharyngeal candidasis is a common manifestation in immunocompromised patients, including individuals undergoing immuno suppressive therapy for cancer or organ transplantation and those exposed to broad-spectrum antibacterial therapy [1,2,3]. Most notably, oropharyngeal candidasis is a major problem in indiviuals affected with the human immunodeficiency virus [4,5,6]. Candida albicans the species most commonly isolated from patients with these infections. Colonization of the mouth by Candida species has a long recorded history. Hippocrates,as early as 37BCE,reported oral lesions that were probably caused by Candida [7]. Although C. albicans survives poorly on dry surfaces [7], it can remain viable for some time on moist objects. Candida often colonizes the human epidermis, especially moist webs of skin between fingers or toes, but the gastro-intestinal tract is considered to be the major reservoir [7]. The existence of such reservoirs ensures regular seeding of the oral cavity. Oropharyngeal candidiasis is an important disease of immunocompromised individuals such as organ transplant recipients, cancer patients [8], and individuals with AIDS [9].Oral candidiasis is one of the earliest indicators of the progression from HIV sero- positive status to AIDS. Esophageal lesions in AIDS patients can be extensive, requiring systemic Fluconazole therapy [10], and these lesions can be a source of infection for other forms of oral candidiasis that are often seen in AIDS patients[11]. The high frequency of oral Candida carriage [12] No single factor appears to be responsible for the pathogenicity of C. albicans. It has been proposed that a combination of different factors contributes at each stage of infection[13,14,15,16]Candida cells adhere to several hostcelltypes, including epithelia [17], endothelia [18], and phagocytic cells [19] C. albicans expresses adhesions that recognize extra cellular matrix proteins, including laminin, collagen, fibrinogen, fibronectin, and entactin [20,21] Several studies have shown that patients with acquirkedimmunodeficiency syndrome (AIDS) have
one predominant strain of C albicans,” but others have found multiple strains. The incidence of C albicans isolated from the oral cavity has been reported to be 45% in neonates,[22] 45%–65% of healthy children,[23] 30%–45% of healthy adults,[24,25]50%–65% of people who wear removable dentures,[26] 65%– 88% in those residing in acute and long term care facilities,[26,27,28] 90% of patients with acute leukemia undergoing chemo- therapy,[29]and 95% of patients with HIV.[30] C albicans is a normal commensal of the mouth and generally causes no problems in healthy people . Pathogenesis Candida albicans is the most common and most invasive fungal organism present in the oral cavity and causes both systemic and superficial infections. C. albicans is more adherent to human buccal epithelial cells than are other Candida species; a relationship has been suggested between the adherence of C. albicans and its ability to colonize and cause disease[31].The pathogenic significance of the yeast vs. the filamentous form of the organisms not clear[33].The blastospore form appears to be necessary for colonization and subsequent disease to occur[31].The filamentous form of C. albicans develops under suboptimal conditions invitro; however, the stimuli for its formation invivo are not known. The yeast form of most dimorphic fungi is considered the pathogenic but an association between the presence of the filamentous forms of C. albicans and candidiasis has been noted[33].The significance of the surface antigen city of the filamentous forms in oral candidiasis requires further study[33,34].Simonetti and Strippoli[32]have present evidence indicating greater pathogenicity of the yeast form. The yeast form of C. albicans may be the pathogenic form, and with clinical infection, the altered micro environment favors change to the filamentous form[32,35,36,and 37].The pathogenic effects of c. albicans in candidiasis are uncertain. It has been suggested that C. albicans produces an endotoxin[38],and immunity to the endotoxin may
confer immunity to the disease[39,40].However, the levels of endotoxin found invivo may not be sufficient to produce toxic effects[41].Alternatively, the organisms may produce enzymes that allow penetration of the mucous membranes[42-44].Pugh and Cawson[43,44]state that invasion of epithelial cells by C. albicans depends on hydrolytic enzyme activity and mechanical force. Some evidence suggests that toxic products of the organism do not initiate candidiasis is but act as irritants, aggravating tissue lesions[45].Immediate or delayed hypersensitivity may have a role in pathogenesis[46,47];up to 80% of the population without evidence of infection possess cellular hypersensitivity to C. albicans and others[48]not cell mediated hypersensitivity to Candida in pathogenesis and suggest that enzymes and toxins may aggravate immune-related lesions. Several reports indicate that specific immune imbalance in response to C. albicans plays a role in the pathogenesis of oral candidiasis [49,50,51]. Mackieetal.[50]described eight patients with candidiasis is due to resistant C. albicans and reported humoral antibody formation with poor cell-mediated immunologic activity. Similar findings were noted in patients with acute pseudomembraneous esophageal candidiasis[52]. Inpatients with candidiasis, excess humoral antibodies may inhibit a cell-mediated response .General abnormalities of host immunity have not been described; however, specific deficiencies of the cell-mediated response to Candida antigen have been reported[52,51].The specific abnormality of cell-mediated immunity may be reversible following successful treatment of acute candidiasis[49].Deficient serum or salivary IgA, abnormal complement function, and auto antibodies to various tissues are described. Antibody for Candida (antimannan) is present in serum, andlevels increase in chronic disease[40].However, the significance of cellmediated immune deficiencies in localized oral candidiasis is uncertain
HIV-Related Oral Candidiasis
Candida infections, with oral thrush and esophagitis as frequent clinical manifestations, are the most widespread opportunisticinfections encountered in AIDS [53, 54, 55]. Ever since the first clinical definition of AIDS (1981), the CDC/WHO have recognized candidasis of the mouth, esophagus, trachea, bronchi, and lungs as "major" opportunistic infections and important indicator diseases. Subsequently, in 1986 the Walter Reed Army Institute of Research [56] adopted a staging classification of HIV infection, applicable to adults only, based on HIV-antibodies and virus isolation, chronic lymphadenopathy, Thelper cells/mm3, delayed hypersensitivity, appearance of thrush, and other opportunistic infections [57]. Also, it has been shown in prospective studies of HIV-infected patients that the occurrence of an otherwise unexpected mycosis (typically oral candidasis) in an HIVinfected individual can be predictive of the subsequent development of full blown AIDS [53, 58]. Retrospective studies have shown that at least 58 to 81% of all AIDS patients contract a fungal infection at some time, and 10 to 20% die as a direct consequence [54].Clearly, Candida infections appear to be the most common fungal infection, occurring in at least 75% of HIVinfected patients [59] have shown that 92% of patients with a diagnosis of AIDS had oral candidasis, compared with only 24% of HIV infected patients who had not developed AIDS.
Diagnosis
Diagnosis of candidasis depends upon the presence of the organismin a direct smear, the culture of significant numbers of organisms indirectly, the effectiveness of antimycotic medication[lIS].Culturing of Candida from whole, unstimulated saliva may be the most accurate method of distinguishing the carrier from the non carrier state [60,61]. Quantitative culture. unstimulated saliva or imprint culture technique say aid in diagnosis of patients with oral candidiasis[60,62,63]. Oral candidiasis has been
grouped into the following descriptive categories[64,65,66]: (1)acute pseudomembranous candidiasis(thrush);(2)acute atrophiccandidiasis;(3)chronicatrohphic candidiasis(denturestomatitis,angularcheilitis);and (4)chronic hyperplastic candidiasis(candidal leukoplakia),which takes two forms-chronic, localized, mucocutaneous candidiasis(monilial granuloma)and endocrine candidiasis is syndrome (endocrine moniliasis syndrome. It is important for all physicians looking after older patients to be aware of the risk factors, diagnosis, and management of oral candidiasis. In a recent study 30% of doctors said they would prescribe in for oral candidiasis on the request of nursing staff without examination of the oral. [63] This is unfortunate as other pathology may be missed, the diagnosis maybe incorrect, and failure to address risk factors may lead to recurrence of the candidiasis. The diagnosis of oral candidiasis can serve as a diagnostic marker of HIV infection and also as a signal of disease progression in patients known to be HIV seropositive, as evidenced by the relationship of this infection to decreasing CD4 lymphocyte counts [67]
Treatment
Topical antifungal therapy is the recommended first line treatment for uncomplicated oral candidiasis and where systemic treatment is needed topical therapy should continue as this reduces the dose and duration of systemic treatment required.[68] Itraconazole has a wider spectrum of activity than Fluconazole and is therefore valuable in salvage treatment of the immunocompromised patients with Fluconazole resistant candidasis. Increasing resistance to antifungals has become increasingly common since the introduction of Fluconazole especially in patients with advanced HIV disease, and recurrent and long term treatment [69, 70] Nystatin: Nystatin, if swallowed, may lead occasionally to gastrointestinal side effects such as Nausea, vomiting, and diarrhea [71]
Clotrimazol: Clotrimazole are the most potent topical agent in this class of antifungals but is used as a topical agent only because of its gastrointestinal and neurological toxicity [72] Miconazole: Miconazole is used mainly for topical treatment of candidasis. It is available for parenteral use against systemic mycoses, but the injection contain polyethoxylate castor oil, which may provoke allergic reactions [73]. Ketoconazole: Ketoconazole was the first of the imidazole agents shown to be capable of achieving therapeutic Blood levels when given orally. This led to the drug being used in the treatment of CMC and Candidasis in immunocompromised patients, but adverse effects, including nausea, rashes, pruritus, and hepatotoxicity, have restricted its use [74] Fluconazole: Fluconazole is a recently introduced bistriazole antifungal that acts by inhibiting fungal ergosterol production essential in cell wall formation[75] Itraconazole: This is an orally active bis-triazole, similar to Fluconazole, which inhibits ergosterol biosynthesis in the fungal cell. It has a long halflife and fewer side effects than ketoconazole but is expensive [76] and is eliminated hepatically. Prognosis The prognosis is good for oral candidiasis with appropriate and effective treatment[77] Relapse when it occurs is more often than not due to poor observance with therapy, failure to remove and clean dentures properly, orinability to resolve the underlying/predisposing factors to the infection. Prophylaxis with anti fungal agents reduces the incidence of oral candidiasis in patients with cancer undergoing and fluconazole are more effective than topical polyenes.[78] Prophylaxis on either a daily or weekly basis with anti fungal reduces the incidence of oral candidiasis in patients with HIV with their ductions being most marked in those with low CD 4 counts and recurrent oral candidiasis.[79,80,81,82] .The use of a chlorhexidinerinse only in bone marrow transplantpatients as prophylaxis was found to be very effective [83]
CONCLUSION
A wide range of therapeutic approaches exists to treat patients with HIV infection or AIDS and even oropharyngeal or esophageal candidiasis. Although the more traditional anti fungal agents such as the topical polyenes and imidazole maybe satisfactory for the treatment of relatively mild and transient episodes of oropharyngeal candidiasis (e.g., thrush),the clinical utility of these agents ultimately can become promised by the numerous encumbrances imposed by a demanding dosing schedule and the need for extended contact with the oroesophageal mucosa. Although ketoconazole has a long history of use for the treatment of oropharyngeal and esophageal candidiasis, concerns about potentially serious side effects have favored the use of alternative antifungal agents instead. Moreover, oral solutions are better tolerated, with fewer drug-drug interactions and more convenient dosing schedules and are easier to administor than tablets or capsules to patients with severe oral lesions, restricted oral intake, or inability to swallow. Also that the development of these new oral solution formulations other turning point in the ongoing quest for optimal treatment strategies for oropharyngeal and esophageal candidiasis in immunocompromised patients
ACKNOWLEDGEMENTS
Authors acknowledge theimmense help received from the scholars whose articles are cited and included inreferences of this manuscript. The authors are also grateful to authors / editors /publishers of all those articles, journals and books from where the literature for thisarticle has been reviewed and discussed.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241610EnglishN-0001November30HealthcareSELF REPORTED MORBIDITY PATTERN AMONG THE COMPUTER AIDED EMBROIDERY MACHINE WORKERS
English108111Sartaj AhmadEnglish Gurmeet KaurEnglish Amir Maroof KhanEnglish Bhawana PantEnglish Abhimanyu KumarEnglishIntroduction: The small scale unorganized industrial workers are a neglected lot and hardly get the benefit from occupational health-and-safety related laws and other provisions. Computer aided embroidery machine workers is one such category and the morbidity profile associated with this group has hardly been documented. Objective: To assess the self reported morbidity profile and tobacco use among the computer aided embroidery machine workers. Material and Methods: It is a field based cross sectional study conducted by interviewing 224 embroidery workers of small scale industries of an urban slum in Meerut from November 2012-to August 2013. Results: Most (74.99%) of the subjects were less than 35 years of age. All were married males and 78.13% were either illiterate or educated less than primary school level. Majority (87.05%) were current users of some sort of tobacco. The most common self reported health problem was musculoskeletal (37.94%) and respiratory illnesses (33.04%). Conclusion: These workers belonging to unorganized sector should be imparted health education regarding the importance of physical activity and also tobacco cessation. More studies need to be conducted to highlight this issue in the national context.
EnglishSocio-economic status, Smoking behaviors, Morbidity profile.INTRODUCTION
Embroidery work is very much a part of our socioeconomic fabric for many years. In developing countries, great efforts are directed towards the advancement of small-scale industries as these are considered the engine for their economic growth. Computerized embroidery machines are specialized machines that can make embroidery from computerized designs. According to WHO, over 1000 million people worldwide are employed in small-scale industries. [1] The computer aided embroidery workers industry of India is one such industry. It is an unorganized sector, mostly run by private establishments. It provides employment, mainly to those from the lower socioeconomic classes. Being in the unorganized sector, the employees of this industry are marginalized from main stream with respect to the occupational health-and-safety provisions and as a result workers may suffer from various health problems and risk factors. This ill health may becompounded by various socio-economic factors such as poverty, addictions, poor diet, lack of education, poor working condition, and excess working hours etc. [2] Objectives: To assess the self reported morbidity status and tobacco use among the computer aided embroidery workers
MATERIALS AND METHODS
The present cross-sectional study was conducted among the computerized embroidery machine workers in Meerut District (UP) from November 2012-to August 2013. Consecutive sampling was used to select the workers (n=224) in the study. Verbal informed consent was taken from each respondent after explaining the purpose of the study. Face to face interview technique was used to collect information on a pre-designed Performa regarding socio-demographic characteristic, self reported current morbidity and current tobacco use status. Current morbidity referred to the health problems faced by the respondents within the last three months from the day of the survey. Current users of tobacco, that is those who used tobacco in the last six months from the day of interview were considered for the study. Local language i.e. Hindi was used to interact with the subjects. Data was complied and analyzed using Microsoft Excel and the results were expressed as simple proportions and percentages.
RESULTS
A total of 224 computer-aided embroidery machine (CAEM) workers were studied. All (100%) were males belonging to the Muslim religion. Most (68.03%) were less than 30 years of age, followed by 25.89% between 30 to 40 years and only 16.08% more than 40 years of age. Majority (62.50%) were educated up to primary school, whereas about one-fifths (21.87%) were educated up to middle school and 15.63% were illiterate. With respect to socioeconomic status, based on the modified Kuppuswamy scale (for 2012), majority(40.18%) belonged to lower class, 59.82% to lower middle class and none belonged to upper middle and upper class. The most common self reported morbidity was related to musculoskeletal system (37.94%), closely followed by respiratory illnesses (33.04%) and then visual disturbances (12.05%), skin problems (6.69%) and gastrointestinal disorders (5.35%). A large majority (87.05%) were current users of tobacco in the form of either smoking or chewing. Out of the tobacco users, it was found that most (43.59%) were only smokers, 18.46% were only tobacco chewers, while around two-fifths (37.95%) were using both forms of tobacco i.e. chewing and smoking.
DISCUSSION
In this study, most of the workers in this sector were young adults and married similar to that reported by other studies [3], [4] The overall prevalence of tobacco use was very high similar to that reported by Zaki A et al. [5] Tobacco use may be influenced by a variety of factors like lower socioeconomic status and lower educational levels. Musculoskeletal disorders were the commonest health problems and similar results were reported by studies from India and abroad. [6], [7], [8]. Respiratory illness has also been reported to be a common health problem among such subjects similar to those found by other studies. [9] Long sitting hours and an incorrect posture may be responsible for the musculoskeletal problems associated with these workers. Also tobacco use and smoking may have lead to the respiratory illnesses so prevalent in the study population.
CONCLUSION
A large proportion of these workers were found to be suffering from musculoskeletal disorders and respiratory illnesses and also current users of tobacco. Health education regarding the hazards of tobacco use and also physical inactivity isrecommended for this group of workers. Also more studies need to be done to highlight the health issues of this unorganized sector which is usually neglected in the studies on occupational healt
ACKNOWLEDGEMENTS
The authors are thankful to Mr Praveen Kumar ( Data Entry operator) , Mr Aleem Ansari, Mr Yaad Mohd, Mr Pawan Saini , Mr Mashrul Ahamd , Mr Anas and all embroidery workers for the help they rendered for carrying out this study.
Conflict of Interest: None Source of funding:
Nil Ethical Clearance: Permission taken
Permission taken
Englishhttp://ijcrr.com/abstract.php?article_id=873http://ijcrr.com/article_html.php?did=873REFERENCES
1. Occupational health: The work place health and Environment in sustainable development. Geneva: WHO; 1997. Available from http;//www.int/pch/occupational _health/ occupational_ health2.htm[last accessed on 2012 Feb. 26
2. ILO Encyclopedia . Occupational health and safety. 1998 ; 4th ed. pp. 89–90.
3. Tushar KS, Dasgupta A , Butt A, Chattopadhyay O, Health status of workers engaged in small scale garment Industry : How healthy are they? Indian Jour comm Med.2010 ; 35(1):179 -182.
4. Goel K, Ahmad S, Parashar P, Bansal R, Pant B, Goel P . Health Status and treatment seeking behaviour among power loom workers in an urban slum of Meerut city in U.P, Journal of advance Research in biological sciences, 2013,Vol 5 (1)67-71
5. ZakiAA, Bano SN, Zulkifle M. Prevalence of tobacco use among power loom workers-A cross sectional study. Indian Journal of Comm Med. 2010; 35(1):34-39
6. Ray A, Das A, Ghoshal G, Gangopadhya S. : A study on upper extremity cumulative Trauma Disorders in different unorganized sectors of West Bengal, India; Available on http://www.jstage.1st.go.jp/article/joh /45/6/45_351/_article/_charlen: accessed on 1/8/2013.
7. Anjali Nag A, Vyasi H, Nag PK. Gender difference ,work stressor and musculoskeletal disorders in weaving industries. Industrial Health. 2010;48:339-348.
8. How-Ran Guo, Ya-ching, Chang, Wen-Yu Yeh: Prevalence of Musculoskeletal Disorders among workers in Taiwan : A national wide study : Journal of occupational Health.2004;46(1):26-36
9. Ahmad S, Parashar P, Bansal R, et al (2013) Musculoskeletal disorders and respiratory illness of workers in Meerut. Asian Journal of Pharmaceuticals Heal. Sci..2013;3:4.743-747
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241610EnglishN-0001November30HealthcareDYNAMIC BACTERIAL PROFILE OF ENDOTRACHEAL ASPIRATES AND ITS SENSITIVITY PATTERN -A CAUSE OF CONCERN
English112119N. Shanmuga VadivooEnglish Priya SantharamEnglish K. SudhaEnglish G. KalaiselviEnglish B.K. PadmavathiEnglish B. UshaEnglish Amar KumarEnglish Nitesh Kumar JaiswalEnglishAim: To analyse the changing spectrum of aerobic bacteria isolated from endotracheal secretions of Mechanically ventilated patients andto evaluate the antibiotic sensitivity pattern & Multi drug resistance of those isolates Materials and Methods: Endotracheal secretions received during the study period from Oct 2010 to Dec 2012 were processed & all the pathogenic isolates were identified as per the standard guideline. Antibiotic sensitivity was performed for the identified pathogens according to CLSI standards. Clinical condition of the ventilated & tracheotomised patients were recorded. Results: A total of 95 Endotracheal isolates were processed and 73 % of the aspirates were showing growth. The incidence of VAP was 33.3% and most frequently isolated pathogens were Klebsiella spp(36%), Pseudomonas(17%) &Acinetobacter spp(18%).Multidrug resistance was observed in 53% of Klebsiella spp, 26% in Pseudomonas and 56% in Acinetobacter spp.Most of the patients (33%)were ventilated for Trauma and hence most of the patients had prolonged hospital stay –average time being 25 days. Conclusion: In this study we observed that there was a gradual shift in the isolated aerobic bacterial profile. Initially in 2011 the frequent pathogen was Klebsiella spp(41%) &Pseudomonas spp(18%) when Acinetobacter was 10% . In 2012 Acinetobacter was found to be the most prevalent pathogen (30%) and klebsiella spp prevalence reduced to 28%. Multidrug resistant was also observed among the isolated pathogens. Prolonged hospital stay for trauma has resulted in multidrug resistance and change in bacterial profile. Empirical antibiotic therapy was recommended based on the antibiogram of the most prevalent pathogen in ICU.
EnglishDynamic, Bacterial profile, Endotracheal aspiratesINTRODUCTION
Uses of invasive drugs and therapeutic methods have saved many lives but on the other hand it has caused life threatening consequences due to severe persistent resistant infections [1]. Hence following these invasive therapeutic and diagnostic methods the incidences of nosocomial infections particularly in ICU’s and CCU’s have raised[2, 3, 4, 5]. There is much well documented evidence that hospital personnel and environment are the microbial source and prolonged hospital stay& overuse of antimicrobial agents has led to multidrug resistance of these microbes [6] . Intensive care patients on Mechanical ventilation/ orotracheal intubation arefrequently colonized with this microbial sourceof exogenous origin orendogenously from patients themselves [7, 8, 9] . These colonized bacteria cause eitherVentilation
associated Tracheo bronchitis(VAT)orVentilated associated Pneumonia (VAP)[10, 11] . Colonizationmay be caused by a wide spectrum of bacterial pathogens, which may be polymicrobial.Common pathogens include aerobic gram-negative bacilli, such as Pseudomonas aeruginosa, Escherichia coli, Klebsiellapneumoniae and Acinetobacterspecies[11- 14]Infections due to Gram-positive Cocci, such as Staphylococcus aureus, are more common in patients with diabetes mellitus and head trauma.The colonization of the enteric GNB is frequently observed in patients who have prolonged hospital stay as in the case of Trauma/head injury. As the traumatic patients stay longer, the type of infecting flora change in due course of therapy [15] Despite advances in patient care, these changing floras complicate therapy by acquiring drug resistance and altering their sensitivity pattern [16].Therefore updated knowledge of local epidemiological and susceptibility profile is recommended for guiding the clinicians regarding empirical choice of antibioticsand has become mandatory along with adequate clinical diagnosis and bacterial confirmation [17]Hence the aim and objective of the study is to retrospectivelyanalyze the spectrum of aerobic bacteria isolated from endotracheal aspirates of tracheostamised patients & Patients on Mechanical ventilation, to evaluate the antibiotic sensitivity pattern & Multi drug resistance of those isolates, to record the demographic details, Clinical diagnosis for which the patient was intubated, length of ICU stay and duration of ventilation
MATERIAL AND METHODS
The present retrospective study was conducted at the Microbiology Department of a teaching tertiary care hospital over a period of two years and three months (October 2010 – December 2012). Endotracheal secretions (ETS) were collected aseptically from the patients of all age groups and sex admitted to intensive care unit, who were on mechanical ventilation for at least 3 days and with clinical suspicion of VAP or VAT.All the specimens received were immediately plated on the blood agar and MacConkey agar by semi quantitativemethod and incubated aerobically overnight at 37°C. Organisms were identified as commensal or pathogen as per protocol. Single or mixed growth (two or more than two isolates per specimen) isolated from all the eligible single and consecutive samples were identified by observing the colony characteristic on the blood, MacConkey agar plate, and biochemical reactions using standard microbiological methods. Isolates from repeat culture of previously recruited patients and isolates identified as commensal or contaminants were excluded. The following antibiotics (Hi-Media Disc in μg) were tested for Gram negative bacilli: Ampicillin10(A), Piperacillin-100(Pi), Ceftazidime30(Ceftaz), Ceftazidime+clavulinic acid-30/10 (CaC), Cefaperazone-30(CPZ), Cefotaxime30(CTX), Cefotaxime +clavulinicacid30/10(CxC), Ceftriaxone-30(CFTR), Ampicillin/Sulbactum-10/10(AmpS), Piperacillin/tazobactum-100/10(PiT), Aztreonam30(Ao),Gentamicin -10(Gen), Amikacin-30 (Ak), Ciprofloxacin-5(Cip), Ofloxacin-5(Ofl), Imipenem-10(IPM) and Colistin-10(CL).Zone diameter was measuredand interpreted as per the Clinical and Laboratory Standards Institute guidelines.ESBL production was also detected by Phenotypic confirmatory method as per CLSI Guideline
RESULTS
During the study period of two years and three months (Oct 2010 – Dec 2012), laboratory data of 95 Endo tracheal aspirates specimens from 81 patients received in our laboratory were evaluated. The demographic data’sand Characteristics’ of ICU are described in Table 1 & Table-2.The most
frequent clinical condition needing mechanical ventilation was for Trauma(head injury) and the mean hospital stay was 25 days .The clinical conditions for mechanical ventilation and the mean hospital stay for each condition are discussed in Table-3. From 72 of the 81 patients (89%), single sample was received and from nine patients (11%) consecutive samples were received (Table- 4). Sixty six of 81 patients (82%) showed bacterial growth in their ETS. Out of 95 endotracheal aspirates received, 70specimens (73 %) were culture positive, whereas 25 (27%) specimens showed no growth. Eighty nine (89) bacterial isolates were recovered from 95 endotracheal aspirates and 18.6% of endotracheal aspirates had polymicrobial growth.Bacterial profile of 89 isolates is shown in Table-5.Out of the total 89 isolates identified, 92% were gram-negative bacilli (GNB) and 8% were gram-positive organisms. Aerobic gram negative bacilli remained the predominant pathogens from mechanically ventilated patients throughout the study period. Frequency of changing bacterial profile of the three prevalent pathogens and its sensitivity pattern are shown in Table-6 and from Table-7 to Table-9.
DISCUSSION
Health care associated infections (HCAI) continue to be a major cause of patient morbidity and attributable mortality and device associated infections contributes a maximum towards HCAI.The mechanically ventilated and Tracheostamized patients are colonized with bacteria of either endogenous or exogenous origin which might end up in VAT or VAP.The incidence of VAP at our center during the study period was 33.3% with Device utilization rate being 0.21. As mentioned before changing bacterial profile from ETS and its sensitivity pattern are analyzed and discussed below. Our study showed 73% bacterial growth from ETS received at our Microbiology lab. The percentage is less when compared to following studies which show bacterial growth of 92% [17], 90%[18], and 78% [19] but higher when compared to a study by Shalini S etal[20]where 67.3% of ETS showed growth . In our study the most frequent clinical conditions needing mechanical ventilation was Trauma (Head injury) accounting to 33 % followed by Poisoning at 22% as shown in Table-3. In a study by Arindam de Post operative condition was the most frequent clinical condition needing mechanical ventilation[13] and COPD patients were the most frequently ventilated patients in a study by Ramakrishna pai[14]. The mean hospital stay for Head Injury patients were 34 days and for poisoning 16 days. But the maximum mean hospital stay was for CVA with 41 days. Table -4 shows that 73% of (72/95) ETS was a single sample whilethe rest 27 % (23 /95) were consecutive sample. The eligible consecutive samples were from Head trauma and CVA patients who had more than a month of mean hospital stay. Bacterial growth was seen in 91% of Trauma/Head Injury patients followed by 83% of CVA patients. And as indicated before these patients had more than 30 days of ICU stay .This correlates with the fact that Head injury leads to prolonged hospital stay which ultimately results not only in increased bacterial growth rate but also changing bacterial spectrum of ETS [15] Among the bacterial profile of 89 isolates (Table5) Gram negative Bacilli were 92% among the 89 isolates and only 8% were Gram positive cocci.This result is supported by many studies and particularly as shown in one systematic review article where GNB’s range from 41-92% and Gram positives between 6-58%[21]. The most predominant pathogen of ETS during the two year study period was Klebsiellaat 35.9% followed by Acinetobacter spp at 17.9% and Pseudomonas at 16.8% (Table-5). This is in accordance with other
studies where in Klebsiella is the most prevalent one at 34% [14] and 38.4%[20] . Acinetobacter was the predominant in the following studies [3, 7, 13, 17, 19, 22]and Pseudomonas was 40.3 % in a study by Koirala.P[18] . E.coli (33.3%) was the predominant in a study by Tullaet al [12] .Gram positives were the predominant in the following study by Maryam etal [23]. In the study even though Staphylococcusaureus was the prevalent one, among the gram negatives Klebsiella(23.3%) was the foremost one followed by Acinetobacterspp at 20% which is similar to our study. Our review demonstrates that there is a change in microbial spectrum during the study period as in Table-6, which shows dynamic bacterial profile of the three most prevalent pathogens.Klebsiella species was the most prevalent one during 2011 at 41% followed by Pseudomonas 18% and Acinetobacter species at 10.2%.This profile altered during 2012, where in Acinetobacter prevalence rate increased to 30.1% followed by Klebsiella at 28.2% and Pseudomonas spp at 17%.This changing bacterial profile at our hospital could be attributed to Prolonged hospital stay among the study group patients .The changing bacterial profile of ETS was also described in a study by Maryam amini[23] . We reviewed not only the changing bacterial profile but also their sensitivity pattern during the study period. Similar to our study the changing antibiotic sensitivity pattern was also analyzed and discussed in a study by S.Kaulet al [16] .Analysis on changing sensitivity pattern of the three most prevalent pathogens of ETSKlebsiella spp, Acinetobacter spp & Pseudomonas sppat our tertiary care center is shown in Table-7, Table-8 and Table-9 respectively Analysis on changing sensitivity pattern of Klebsiella spp shows that there was an increase in percentage sensitivity for Imipenam, ciprofloxacin &Ceftazidime in 2012 when compared to 2011. Sensitivity towards Aminoglycosides &Cefotaxime decreased in 2012. There was relatively overall good sensitivity percentage (i.e.) more than 50% sensitivity forAmikacin (56.2%),Ofloxacin(64%) and Imepenam(72%). Other antibiotics showed less than 30% sensitivity with ciprofloxacin at 28%, Cefotaxime at 25% and Gentamicin at 28%.Multi drug resistance to Klebsiella at our hospital setting was at 53% and ESBL producing Klebsiella were 85%. Ina study by Santosh kanal et al [19], MDR to Klebsiellawas at 73% where in Klebsiella was 31% sensitive to Gentamicin, 21% to Cefotaxime and 45% to Ciprofloxacin. In a study by Mehta et al[2] Imepenam sensitivity to Klebsiellawas alarmingly low at 50%! In our tertiary care centre Acinetobacter species showedoverall good sensitivity to Imipenam at 94%, but there was a decrease in percentage sensitivity when compared to 2011. Aminoglycoside sensitivity drastically decreased in the year 2012 when compared to 2011 as shown in Table-8. There was an increase in sensitivity to Ciprofloxacin from 25% in 2011 to 33.3% in 2012. Piperecillin-Tazobactum sensitivity almost remained same during the study period at 70%.Multi drug resistance to Acinetobacter at our center was 56 % which is low when compared to following studies by Santosh khanal [19] and Werarek.P [22], where Acinetobacter was 85% & 92% MDR respectively.ESBL producing Acinetobacter was 80% Third most Prevalent pathogen Pseudomonas had overall very good sensitivity to many antimicrobial agents except Ciprofloxacin. Imipenam sensitivity was consistently at 100% throughout the study period. The other antibiotics started to show a decrease in sensitivity percentage as shown in Table-9. MDR percentage of Pseudomonas at our centre was 27% which is low when compared to other studies [19].Ina study by Koirala et al [18] , Pseudomonas had Zero percent sensitivity to Ceftazidime, Amikacin at 22% and Gentamicin at 18%. Sensitivity to ciprofl0oxacin was at 19% which is similar to our study.
CONCLUSION
The frequency of specific MDR pathogens colonizing upper respiratory tract and causing Tracheobronchitis or VAP’s may vary by hospital, with in hospital in different units, type of ICU patient, patient population, exposure to antibiotics, and changes over time. Hence periodic surveillance to identify MDR pathogens and their antibiotic sensitivity pattern will allow appropriate empirical antibiotics followed by earlier targeted antibiotic treatment which could improve outcome in patients and prevent VAP. This emphasizes the need for timely periodic local surveillance data .Considering these important factors in to account, this Review has addressed the changing bacterial profile, changing AST pattern of most prevalent pathogens over the time &multidrug resistance among the three most prevalent pathogens isolated from Endotracheal aspirates at our center. Gram negatives were the predominant pathogens. High rate of resistance to Cephalosporin, Fluoroquionolone and Amino glycosides wasnoted for all the three prevalent pathogen. ButImipenam resistance was seen only in Klebsiella&Acinetobacter sppand not in Pseudomonas. Following this retrospective study, pipericillin-tazoactum, ampicillin-sulbactum, and imipenam were proposed as empirical antimicrobial choice for patients diagnosed with clinical VAP or VAT at our center. These empirical antibiotics were recommended to be given alone or in combination depending on severity of Patient’s clinical condition and renal parameters.Also recommendations were made such that antibiotic therapy should be changed and deescalated based on Culture identification report and a specific antibiotic should be chosen based on sensitivity pattern.An Active Surveillance for VAP was also initiated as a measure of Hospital Infection control at our tertiary care centre.
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=874http://ijcrr.com/article_html.php?did=874REFERENCES
1. Victor D. Rosenthal et al.Device-Associated Nosocomial Infections in 55 Intensive Care Units of 8 Developing Countries.Ann Intern Med. 2006; 145(8):582-591.
2. A. Mehta a, V.D. Rosenthal et al.Deviceassociated nosocomial infection rates in intensive care units of seven Indian cities. Findings of the International Nosocomial Infection Control Consortium (INICC). Journal of Hospital Infection (2007) 67, 168- 174.
3. SS Kanj, ZA Kanafani, N Sidani, L Alamuddin, N Zahreddine, and VD Rosenthal. International Nosocomial Infection Control Consortium Findings of DeviceAssociated Infections Rate in an Intensive Care Unit of a Lebanese University Hospital. J Glob Infect Dis. 2012 Jan-Mar; 4(1): 15–21.
4. SALOMAO, Reinaldo et al. Device-associated infection rates in intensive care units of Brazilian hospitals: findings of the International Nosocomial Infection Control Consortium. Rev PanamSaludPublica [online]. 2008, vol.24, n.3, pp. 195-202.
5. http://www.who.int/csr/resources/publications/ drugresist/en/whocdscsreph200212.pdf 6. Mukhopadhyay C, Bhargava A, Ayyagari A. Role of mechanical ventilation and development of multidrug resistant organisms in hospital acquired pneumonia. Indian J Med Res 2003; 118:229-35.
7. Joseph NM, Sistla S, Dutta TK, Badhe AS, Parija SC. Ventilator-associated pneumonia: role of colonizers and value of routine endotracheal aspirate cultures.Int J Infect Dis. 2010; 14(8):e723-9.
8. T.J.J.InglisE,W.Lim G,,.H.Lee,Cheong NG. Endogenous source of bacteria in tracheal tube and proximal ventilator breathing system in intensive care patients.British journal of Anaesthesia 1998; 80:41-45.
9. Fagon JY, Chastre J, Hance AJ, Montravers P, Novara.A, Gibert C. Nosocomial pneumonia in ventilated patients: A cohort study evaluating attributable mortality and hospital stay. Am J Med. 1993; 94:281–8. [Pub Med: 8452152]
10. Niederman MS, Ferranti RD, Zeigler A and Reynolds HY () Respiratory infection complicating long-term tracheostomy. The implication of persistent gramnegative tracheobronchial colonization. Chest 1984; 85(1): 39-44
11. Donald E. Craven and Karin I. Hjalmarson. Ventilator-Associated Tracheobronchitis and Pneumonia: Thinking Outside the Box. Clinical Infectious Diseases 2010; 51(S1):S59–S66. 12. MS Tullu, CT Deshmukh, SM Baveja .acterial profile and antimicrobial susceptibility pattern in catheter related nosocomial infections..JPGM, 1998: 44 : 1 : 7-13.
13. ArindamDey , Indira Bairy.Incidence of multidrug-resistant organisms causing ventilator-associated pneumonia in a tertiary care hospital: A nine months' prospective study. AnnThorac Med. 2007 Apr-Jun; 2 (2): 52–57.
14. Ramakrishna PaiJakribettu and RekhaBoloor.Characterisation of aerobic bacteria isolated from endotracheal aspirate in adult patients suspected ventilator associated pneumonia in a tertiary care center in Mangalore.Saudi J Anaesth. 2012 Apr-Jun; 6(2): 115–119.
15. Gotsman MS and Whitby JL .Respiratory infection following tracheostomy. Thorax 1964; 19:89-96
16. S Kaul, KN Brahmadathan, M Jagannati, TD Sudarsanam, K Pitchamuthu, OC Abraham.One year trends in the gramnegative bacterial antibiotic susceptibility patterns in a medical intensive care unit in South India.. Indian Journal of Medical Microbiology, (2007) 25 (3):230-5.
17. JoãoManoel da Silva Júnior, EderlonRezendeetal .Epidemiological and Microbiological Analysis of VentilatorAssociated Pneumonia Patients in a Public Teaching Hospital. BJID2007; 11(5):482-488.
18. PratirodhKoirala, Dwij Raj Bhatta, PrakashGhimire, Bharat Mani Pokhrel, UpendraDevkota.Bacteriological Profile of Tracheal Aspirates of the Patients Attending a Neuro-hospital of Nepal. Int J Life Sci 4:60- 65.
19. SantoshKhanal,Dev Raj Joshi, Dwij Raj Bhatta, UpendraDevkota,and Bharat Mani Pokhrel. β-Lactamase-Producing MultidrugResistant Bacterial Pathogens from Tracheal Aspirates of Intensive Care Unit Patients at National Institute of Neurological and Allied Sciences, Nepal. ISRN Microbiology.Volume 2013. Article ID 847569, 5 pages.
20. Shalini s, Kranthi k, Gopalkrishnabhat k. The Microbiological Profile of Nosocomial Infections in the Intensive Care Unit. Journal of Clinical and Diagnostic Research. 2010 October ;(4):3109-3112.
21. YaseenArabi a, Nehad Al-Shirawi a, ZiadMemish b, Antonio Anzueto. Ventilatorassociated pneumonia in adults in developing countries: a systematic review. International Journal of Infectious Diseases (2008) 12, 505—512.
22. Werarak P, Kiratisin P, Thamlikitkul V. Hospital-acquired pneumonia and ventilatorassociated pneumonia in adults at SirirajHospital: etiology, clinical outcomes, and impact of antimicrobial resistance. Med Assoc Thai. 2010 Jan; 93 Suppl 1:S126-38.
23. Maryam Amini , Ahmad Javanmard, Ali Davati ,GhasemAzimi . Bacterial Colonization in Tracheal Tubes of ICU Patients. Iranian journal of pathology. 2009; 4: (3).123-127.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241610EnglishN-0001November30HealthcareMALIGNANT PHYLLODES TUMOUR OF BREAST WITH LIPOSARCOMATOUS DIFFERENTIATION PRESENTING CLINICALLY AS FIBROADENOMA - REPORT OF A RARE CASE
English120125Vimal Chander R.English Sonti SulochanaEnglish Madhavan M.English Karuna Kumar K.English Chitra S.EnglishIntroduction: Malignant phyllodes tumor accounts for less than 1% of breast tumors and 2 to 3% of fibroepithelial tumors of the breast. They are derived from intralobular or periductal stroma and most of them are benign. The stromal component of phyllodes tumor has the potential to undergo metaplasia to cartilage, bone, smooth muscle and striated muscle as well as their respective malignant neoplasms. The liposarcomatous differentiation of the stromal elements of phyllodes tumor is extremely rare. Case Report: We report a 27 year old female with a history of a mobile lump in the left breast presenting clinically and cytologically similar to a fibroadenoma. Histopathological examination revealed features of Malignant phyllodes tumour with liposarcomatous differentiation. Conclusion: Malignant phyllodes tumour is very rare and represents less than 1% of breast malignancies. It presents in females more than 40 years of age as a large mass. Malignant transformation is rare and heterologous liposarcomatous differentiation is unusual. This case is presented to illustrate that in a small mobile nodule of the breast presenting in young women clinically as a fibroadenoma, the possibility of a malignant phyllodes tumour should also be considered. Hence a thorough histopathological examination is necessary to rule out a malignant component. A regular follow up is needed in such cases to monitor for recurrence.
EnglishPhyllodes tumour, Malignant, Breast tumour, LiposarcomatousINTRODUCTION
Phyllodes tumour of the breast is an uncommon biphasic fibroepithelial neoplasm accounting for less than 1% of all breast tumours, the median age at the time of diagnosis being 45 years.[1,2] Phyllodes tumours are thought to be derived from intralobular or periductal stroma and may develop de novo or from fibroadenoma. Though most of them are benign, they display a morphological spectrum lying between fibroadenomas and pure stromal sarcomas. The distinction between benign, borderline and malignant phyllodes tumour is based on the assessment of a number of histological features including stromal overgrowth and atypia, cellularity, mitotic activity and infiltrative margins. Malignant transformation is seen in about 6% of phyllodes tumours, usually in the form of malignant transformation of the stroma, often showing fibrosarcomatous differentiation and rarely heterologous sarcomatous elements.[3] We present a case of malignant phyllodes tumour with stroma showing an unusual heterologous liposarcomatous differentiation in a 27 year old female.
CASE REPORT
A 27 year old female presented with a palpable lump in the left breast 1 month duration. On examination, a firm mobile lump measuring 4x4 cm in the upper outer quadrant of left breast and moving freely within the breast. The overlying skin was normal. No axillary nodes were felt. A clinical diagnosis of fibroadenoma was made. Fine needle aspiration cytology showed cellular smears with benign ductal epithelial cells in monolayered sheets and clusters with interspersed myoepithelial cells and numerous scattered bare bipolar nuclei in a clean background. Occassional clusters showed cells with apocrine changes. An impression of fibroadenoma was given. [Figure 1] Later, excision biopsy was done and the specimen was sent for histopathologic examination. Macroscopic examination revealed an irregular globular soft tissue mass measuring 4x4x3 cm with cut surface showing a well circumscribed capsulated nodule which was gray white with numerous slit-like spaces. One area appeared solid and yellowish white in colour. [Figure 2] Microscopic examination showed a malignant tumour composed of both epithelial and mesenchymal components. The tumor had both solid and cystic areas with many leaf like projections lined by two layers of cells, the secretory epithelial cells and myoepithelial cells. The underlying stromal cells were spindled to highly pleomorphic containing many tumour giant cells. In some areas the tumour cells showed myxoid background with thin capillaries. Sections from the solid yellowish white areas showed few epithelial lined clefts with stromal overgrowth with sheets of univacuolated and multivacuolated lipoblasts with hyperchromatic, pleomorphic and scalloped nuclei and occassional wreath-like tumour giant cells. Mitosis was increased (more than 10 per 10 high power fields). Atypical mitoses were also seen. [Figures 3 and 4] A diagnosis of malignant phyllodes tumour with heterologous liposarcomatous component was then made. The patient is doing well and is on regular follow up for recurrence.
DISCUSSION
Malignant phyllodes tumours of the breast are rare fibroepithelial neoplasms with a potential for recurrence and metastases. They represent 1% of all breast malignancies and occur in middle aged and elderly and are relatively rare below the age of 40 years.[4] They form lobulated firm masses which may grow rapidly and cause breast enlargement with stretching of the overlying skin. In fine needle aspiration cytology, usually epithelial and stromal elements are seen. Occasionally only the epithelial component is represented in the smears, especially when there is tumour heterogeneity and hence may be mistaken for a fibroadenoma as in the present case.[5] Grossly, phyllodes tumours are relatively well circumscribed lobulated and firm with the cut surface showing a characteristic whorled pattern resembling a compressed leaf bud with visible clefts. Microscopically, they typically exhibit an enhanced intracanalicular growth pattern with leaf-like projections into dilated lumens. The epithelial element consists of clefts lined by secretory epithelial cells and myoepithelial cells. Focal epithelial hyperplasia and occasional apocrine or squamous metaplasia are known to occur in the epithelial elements, though malignant change is extremely rare. The stromal element is more cellular than a fibroadenoma and consists of spindle cells with infrequent mitosis. Occassional cases may show admixture of adipose tissue foci. It is graded into benign, borderline and malignant categories based on the histological characteristics given in Table 1.[6]
The stromal elements in malignant phyllodes tumours usually exhibit a fibrosarcomatous differentiation. Heterologous differentiation such as chondrosarcoma, osteosarcoma, angiosarcoma, leiomyosarcoma, rhabdomyosarcoma and liposarcima are rarely encountered in malignant phyllodes tumours.[7] Liposarcomatous differentiation is extremely rare and consist of well differentiated round cell, myxoid and pleomorphic liposarcomatous components. The finding of a malignant heterologous element places the tumour into a malignant category. The finding of tumour necrosis is associated with a worse prognosis.[8,9] The clinical behaviour of malignant phyllodes tumour is difficult to predict. Liposarcomatous differentiation of the stromal component, however, does not appear to correlate with aggressive clinical behaviour. Phyllodes tumour with liposarcomatous differentiation requires complete surgical excision to prevent local tumour recurrence.[10] Hence a thorough histologic sampling of the stromal tissue is necessary for a diagnosis of malignant phyllodes tumour.
CONCLUSION
Malignant phyllodes tumour is very rare and represents less than 1% of breast malignancies. It presents in females more than 40 years of age as a large mass. Malignant transformation is rare and heterologous liposarcomatous differentiation is unusual. In the present case, the age of the patient is of 27 years, the tumour size is small and the overlying skin was normal and microscopically showed features of malignant phyllodes tumourwith unusual liposarcomatous component. This case is presented to illustrate that in a small mobile nodule of the breast presenting in young women clinically similar to a fibroadenoma, a possibility of a malignant phyllodes tumour should also be considered. Hence a thorough histopathological examination is necessary to rule out a malignant component. A regular follow up is needed in such cases to monitor for recurrence.
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=875http://ijcrr.com/article_html.php?did=875REFERENCES
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2. Taira N, Takabatake D, Aogi K, Ohsumi S, Takashima S, Nishimura R, Teramoto N. Phyllodes tumor of the breast: stromal overgrowth and histological classification are useful prognosis-predictive factors for local recurrence in patients with a positive surgical margin. Jpn J Clin Oncol 2007;37:730-6.
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8. Uriev L, Maslovsky I, Vainshtein P, Yoffe B, Ben-Dor D. Malignant phyllodes tumor with heterologous liposarcomatous differentiation and tubular adenoma-like epithelial component. Int J Med Sci 2006;3:130-4.
9. Abdul Aziz M, Sullivan F, Kerin MJ, Callagy G. Malignant phyllodes tumour with liposarcomatous differentiation, invasive tubular carcinoma, and ductal and lobular carcinoma in situ: case report and review of the literature. Patholog Res Int 2010:501274.
10. Chen WH, Cheng SP, Tzen CY, Yang TL, Jeng KS, Liu CL, Liu TP. Surgical treatment of phyllodes tumors of the breast: retrospective review of 172 cases. J Surg Oncol 2005;91:185-94.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241610EnglishN-0001November30HealthcarePTERYGOSPINOUS BAR AND MULTIPLE CIVININI FORAMEN- A RARE ANATOMICAL VARIANT AND ITS CLINICAL IMPLICATIONS
English126133Thomson Jones EbenrajEnglish NagarajanVishaliEnglishObjectives: Our aim is to study the prevalence of Pterygospinous bar and analyzemorphometrically the homonyms foramen in a collection of existing skulls and discuss their clinical implications. Methods: 90 dried adult human skulls were used for the study. The base of the skull was examined both macroscopically and radiologically for the presence of abnormal osseous structures extending from the lateral pterygoid plate. Average diameter of the Civinini’s foramen, width of the lateral pterygoid plate, width of the extending bar from the pterygospinous process and sphenoid spine were measured using the vernier caliper. Results: Out of 90 skulls reviewed, only 5 skulls showed the presence of complete pterygospinous bar with enclosed Civinini’s foramen, in which 2 skulls showed the multiple Civinini’s foramen. 58 skulls showed the presence of incomplete pterygospinous bar. Conclusion: It is obvious from the results that the incomplete pterygospinous bar is more prevalent, which may lead to altered course of the structures passing through foramen ovale and foramen spinosum. Some of the structures may also be entrapped in the enclosed Civnini’s foramen there by resulting in neural and vascular complications. Hence, the vivid knowledge of such presence is highly beneficial to anaesthetists, dental and maxillo – facial surgeons in day to day clinical practice.
Englishpterygospinous ligament, pterygospinous bar, civinini’s foramen, lateral pterygoid plate, spine of the sphenoid.INTRODUCTION
The cranial base is an important region for it provides attachments to muscles of mastication, deep muscles of neck and also for the presence of foramina which provides the means by which vessels and nerves enters or leaves the cranial cavity. The abnormal bony growths such as spines, spurs, tubercles or bony plates may be due to abnormal ossification or overgrowths of surrounding parts of the bones around the foramen of base of the skull, which may lead to ischemia, necrosis and potential paralysis of the parts of the body being supplied, drained or innervated by its contents. There were many ligaments in the exocranial region. One such ligament is the pterygospinous ligament, described by Civinini in 1829 (1), that connects the spinous process of the sphenoid bone to the Civinini’s spine located in the posterior margin of the lateral pterygoid lamina of the sphenoid bone. Complete ossification of the pterygospinous ligament is known as pterygospinous bar (2).When completely ossified the pterygospinous ligament form the Civinini’s foramen. (3; 4;) Ossification of these ligaments can be important as to relate with the adjacent anatomic structures. In adults, these unique ossification leads to spoil the interrelationships of the anatomic configuration. Such abnormal osseous structures may alter the normal course of the mandibular nerve or its branches and they can cause serious implications in accessing the oval foramen in a therapeutic approach, in any surgical intervention in the region and may lead to false neurological differential diagnosis. Therefore, the anatomical knowledge of physician should be accurate to overcome the anatomic variations and diversity so as to provide success. Accordingly, the present study was designed to find out the osseous structure especially the pterygospinous bar in the available dry human skulls.
MATERIALS AND METHODS
The study was carried out using 90 dried adult human skulls irrespective of age and gender, were obtained from Department of anatomy, Asan memorial dental college and Hospital and Karpaga Vinayaga institute of dental sciences. Skulls that are evident of abnormalities such as distress or obvious morphological asymmetries were expelled from this study. The base of the skull was examined both the sides macroscopically for the presence of anomalous osseous structures from the lateral pterygoid plate. The presence of a rare variant ossified ligament connecting the spine of the sphenoid and the lateral pterygoid plate was noted in all these bone specimens. As described by Suazo et al.,2010; the following descriptions are given for ossification of the ligament: Type I: Complete ossification of pterygospinous ligament: there is a bony bridge that leads from the pterygospinous process to the apex of the sphenoid spine. In this case, it is the pterygospinous foramen or Civinini’s foramen. Type II: Incomplete ossification of pterygospinous ligament: there is anexpansion of the pterygospinous process, but fails to contact the sphenoid spine. In this case, the pterygospinous foramen is partly formed. The specimen with ossified pterygospinous ligament was photographed and compared to that of the normal and the same was also subjected to radiological study. In case, there was complete ossification as in Type I the average diameter of its enclosed Civinini’s foramen was measured using a vernier caliper. The bar extending from the spine of the sphenoid and from the lateral pterygoid plate was also measured in Type II variety. Even the small gap left between the two bars making it incomplete pterygospinous bar was also noted using the Vernier Caliper. With the data obtained, prevalence rates of the two proposed types were estimated, differentiating the bilateral, left and right presentations.
RESULTS
Among the ninety skulls studied, twenty seven (30%) of the skulls did not have any abnormal osseous structures extending from the lateral pterygoid plate. Normal bone No bony projection from the plate of lateral lamina of the pterygoid process of the sphenoid bone. The lateral pterygoid plate was thin, flat and everted. The maximum width of the lateral pterygoid plate was measured to be 1.4 cm
Anomalous Osseous structure
from the Lateral pterygoid plate:pterygoid plate: The following osseous structures were observed macroscopically and morphometrically extending from the lateral pterygoid plate: Type I i. In three(3.33%) skulls,unilateral (right side) complete pterygospinous ligament was noted. Ossified Pterygospinous ligament are present medial to the Foramen Ovale. Since the bar is complete, it presented a complete Civinini’sforamen with an average diameter of 0.66mm (Fig.1). ii. In one (1.11%) another skull, unilateral (right side) complete pterygospinous ligament was noted. But it showed instead of a single Civinini’s foramen, it showed two variable foramen with an average diameter of about 0.7mm and 0.2 mm (Fig. 2) iii. In one another (1.11%) skull, unilateral (left side) complete pterygospinous ligament was noted. This skull also showed multiple Civinini’s foramen of variable size with an average diameter of about 0.6 mm, 0.4 mm and 0.3 mm (Fig. 3) Type II i. Rarely, in thirty one (34.44%) skulls, bilateral incomplete pterygospinous ligament was observed. The bony projection from the lateral pterygoid plate was pointing towards the spine of the sphenoid which we presume, is the ossified part of the pterygospinous ligament which is incomplete as there was asmall gap between the spine of the sphenoid
and the posterior border of the lateral pterygoid plate. ii. The nine (10.00%) skulls showed unilateral (right side) incomplete pterygospinous ligament, in which one skull showed their presence inferior to the foramen ovale so that it is divided into medial and lateral compartments. iii. In 18 (20.00%) skulls, unilateral (left side) incomplete pterygospinous ligament was observed. Of which 10 – 12% of the variety showed the presence of the bar overlying the foramen spinosum dividing it into medial and lateral compartments. iv. The projection from the lateral pterygoid plate measured 7 mm, while the projection from the spine measured 4.6 mm. Thus two projections from the lateral projection plate and the spine of sphenoid approached each other and left a deficit of 6 mm between them.
DISCUSSION
In the cranial base there are strings of intrinsic ligaments in relation to sphenoid bone: interclinoid, caroticoclinoid, pterygospinous and pterygoalar ligaments. Ossification process with different clinical implications has been reported for all. The incidence of pterygospinous bony bridges has beenreported by different authors with different results. Wood-Jones (1931) reported an 8% pterygospinous ligament ossification inHawaiian skulls. Nayak et al. (2007) indicated that such bridges were completelyossified in 5.76% of the cases analyzed by them. Pekeret al. (2002)reported the presence of this bridge in 8.8% skulls of an Anatolianpopulation. In this study, the prevalence of complete pterygospinousligament ossification was only 5.55%, lower than those reported by 6 and 7; and much closer to Nayak et al(2007) studies. The study also confirmed the presence of incomplete pterygospinous bar of a greater range (64.44%). This could be attributed to the age of this sample(average 52.4years), as the emergence of ossification process isassociated with increasing
age of subjects (8) and incomplete presence can be ascribed to the incomplete process of ossification. Although there are reports on the presence of ossified pterygospinous ligament, there is dearth of literature on the radiological study of the pterygospinous ligament. The earliest description of the ossified pterygospionous ligament radiologically was done by De Froe and Wagener,1935 (10) . The complexity of the pterygomaxillary region may not have prompted too many scientists to explore the region radiographically. The present study analyzed both morphologically and radiologically the presence of total or partial pterygospinous ligaments ossification and its enclosed Civinini’s foramen. The present study also exposed the presence of multiple Civinini’s foramen which may be involved in multiple complications involving both vascular and nervous compression. The present observation on unilateral presence of pterygospinous bar in 5 skulls out of 90 cases (i.e. 5.55 % incidence) makes the study clinically important. The maximum width of the lateral pterygoid plate in the anomalous bone was 2.1 cm, where as in the normal cases it was 1.4 cm. These results clearly state that the lateral pterygoid plate was very much wider in the anomalous bone specimen. Theosseous bar formations are present deep in the infra temporal fossa establishing important relationships with the two foramen and structures passing through it such as mandibular nerve and its branches through foramen ovale, the middle meningeal artery and vein passing through foramen spinosum, and other structures in the region include the otic ganglion, the chorda tympani nerve, the medial and lateral pterygoideus muscles. These structures are compressed against bone formations and are capable of generating clinically important alterations(11;12). It has been reported that the mandibular nerve has some of its branches passing through the Civinini’sforamen formed as a result of presence of such osseous bar (ossification of pterygospinous ligament) and may compress upon the branches of the mandibular nerve (13). In view of the close relationship of the chorda tympani nerve, it may also be compressed by the anomalous bar of bone (11). Involvement of the chordatympani nerve would then result in the impairment of the taste sensation to the anterior two – third of the tongue. This would lead to a clinical condition like lingual numbness, speech impairment and mandibular neuralgia (14). The incomplete bars formed are in relation to either foramen ovale or spinosum dividing it into medial and lateral compartments. The lingual nerve, the inferior alveolar branch of mandibular nerve and the middle meningeal vessels in the region of the infratemporal fossa are forced to take a long curved course in presence of a large pterygoid plate (12) and during contraction of the pterygoid muscles, these nerves and vessels are subjected to compression(15).Hence, the presence this large lamina of the lateral pterygoid plate causes clinical symptoms (12) It has to be remembered that while applying conductive anaesthesia on mandibular nerve by lateral subzygomatic route, one may encounter variable ossified formations at lateral pterygoidplates’s posterior border of pterygoid process thereby acing as an obstacle to high - quality conductive anaesthesia (13). Thus, lateral pterygoid plate forms an important landmark for mandibular anaesthesia and any anomalies in the lateral pterygoid plate is bound to confuse anaesthetists (16). A research study had also advocated that a distance of approximate 0.25 cm beyond the distance to the lateral pterygoid plate be taken, while performing maxillary block by the lateral extraoral approach (17). Its presence may also cause the failure of anaesthesia during the treatment of trigeminal neuralgia as reported by an earlier research (18). It is also been reported that thermo-coagulation of the trigeminal ganglion becomes difficult in the presence of this bar (16). The presence of the ossified pterygospinous ligament means that there would be less accessible
space to gain entry into para and retro pharyngeal spaces (12). The skiagram (Fig.3A, 3B and 4) obtained in the present case depicts that there is very little space for surgeons to gain entry into para and retropharyngal space.
CONCLUSION
The presence of ossified pterygospinous ligament is an unusual finding, which may not be detected unless indicative, the cause of which may be very difficult to establish. The incidence of the ossified pterygospinous ligament has been reported by different authors with different results. The disparity could be attributed to the age of the sample (avg. 50) as the emergence of ossification process is associated with increasing age of subjects. The awareness on the anatomical variations in this region is very important for surgeons, anaesthetists, radiologists and neurologists. As the ossified pterygospinous ligament which can be complete or incomplete, is a very rare finding and can produce various symptoms depending upon the nerve compression. The presence of such osseous bar can produce nerve entrapment syndrome and can interfere with surgical or anaesthetic procedures. The knowledge increases the successful rate of the surgical procedures and helps in curing painful conditions which results from nerve compression. The present study also reported the presence of multiple Civinini’s foramina which would result in many clinical complications relatively nervous or arterial as the structures compressed passing through such abnormal enclosed foramina. As per our knowledge such abnormal osseous variations with many such enclosed foramina were not reported in the modern medical literature. Thus, the anatomical knowledge of such ossified pterygospinous ligament may be beneficial for anaesthetists, dental and maxilla – facial surgeons in day – to - day clinical practice.
ACKNOWLEDGEMENT
Dr. GirijaSivakumar, Head of the Department, Karpaga Vinayaga Institute of Dental Sciences for providing us the additional study material. Dr. K. Jagannathan, Principal, Asan Memorial Dental College and Hospital for the constant support rendered during the proceeding of this work.
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