Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524168EnglishN-0001November30General SciencesTHE EFFECT OF FEEDING TAKARA (SOY PULP) AND DAIRY COW FECES FOR LUMBRICUSRUBELLUS English0103Heni Setyo PrayogiEnglishThe production of earthworm biomass is one of the means to provide nutritive feed source for animal especially for cheap protein feedstuffs. Feeding earthworm with animal’s feces leads to low biomass production. Takara is a waste product of tofu industry. It canbe used to speed up the production of earthworm. Therefore, this study was conducted to evaluate the combination of takara and diary feces as earthworm’s feed toward the biomass production of Lumbricusrubellus. This experiment was carried out based oncompletely randomized design with five treatments of feed combination between takara and dairy cow feces. The treatments were performed in four replications within three weeks. The result on this study indicates that 75% of takara combined with 25 % of dairy cow feces significantly increases the biomass production of Lumbricusrubellus. It is not suggested to use 100% of takara as earthworm’s feed. Englishtakara, dairy cow feces, earthworm, biomass production, LumbricusrubellusINTRODUCTION Since 1997, earthworm was a new commodity started to develop by Indonesian farmer. In its development, there were many researchesdone to see the potency of earthworm as animal feed and the further product thereof as medication. Prayogi (2011) revealed that adding 10% of earthworm meal in quail feed provide good growth preformance indicated by low feed conversion and high body weight gain. In the production of earthworm, feed for earthworm is the most important part instead of media for their life. Giving a good quality of feed leads to growth of the biomass of the earthworm as well as the number of the cocoon produced. Basically, the feed of earthworm comes from the organic matter had been well decomposed mechanically or biologically, because earthworm has no teat and absorb the nutrition as simply system. Therefore, the given feed should contain 20% of dry matter and 80% of water. Generally, the farmer use dairy feces as the natural feed for earthworm, because of economical reason and the availability of source. However, the effect of using this feed toward the biomass production continuously had not been elaborated yet. On the other hand, there are still many waste products from industry having better organic source used as earthworm’s feed such as takara (soy pulp). It has high organic content such as protein, fat, and carbon source. To be compared with dairy feces, takara is much more better. Ideally, giving a variety source of feed for earthworm would be better for their growth as well as cocoon production. Based on the direct observation, earthworm more prefere to consume takara than dairy feces. To see the effect by combining these two sourceof feeds, it is necessary to do a research to prove that takara is better as earthworm feed than dairy feces or the combination in between would be the best. MATERIALS AND METHOD Preparation of media and cultivation:The media used for cultivation was serutankayu had beed well fermented for 35 days. The indicator of well done fermentation is the smelt and the texture of the serutankayu. The earthworms were cultivated in the box with 30 x 20 x 15 cm in dimension. Before cultivation, some of the earthworms were put in the media to see whether the media was properly ready to use. Feed preparation: The diary feces were fermented for 3 days and the soy pulp was fermented aerobically for 1 day using sealed chamber. Before using these feeds, both were opened for five hours to let the feed being cool. Erathworm and treatment: The earthworm used for cultivation was the Lumbricusrubellus at the age of two months obtained from the local farmer. Before the cultivation, ten of earworm weighed and defines as the early weight. The treatment was given for three weeks and then the earthworms were collected and weighed. There were five combinations of feed for the treatment; 100 % of diary feces (T1), 75% of dairy cow feces combined with 25% of takara (T2), 50% of diary feces combined with 50% of takara, 25% of dairy cow feces combined with 75% of takara (T4), and 100% of takara (T5). All the treatments were repeated 4 times. Data collection and analysis: This research was conducted experimentally using completely random design. The data was collected once at the end of the cultivation. The data was analyzed using analysis of variancesingle factor followed by Duncan test to see the different between the treatments. RESULTS AND DISCUSSIONS Combination between takara and dairy feces really affect the growth of the earthworm. Using 100 % of dairy feces gave poor growth performance of the earthworm as it was only 11.34 gr. More percentage of the takara added, higher biomass production was achieved. However, the using 100% of takara slows the growth of the earthworm (see tabel 1). It was look like that using 75% of takara combined with 25% of dairy feces would be the best combination as it gave highest mass production. A better picture of the growth among the treatments was presented on picture 1. Based on the analysis of variance, It was found that combination between takara and dairy feces give a significantly affect the growth performance of earthworm which mean that combination between takara and dairy cow feces give significant different to the biomass production. The Duncant test showed that T1 was different with T2, T3, T4, T5. However, there was no difference between T3 and T4. This indicates that using 50% and 75% of takara as earthworm feed would give almost the same performance. This study showed that takara was a better feed source for feeding earthworm up to 75% in combination with 25% of dairy cow feces. Using 100% of takara as feed are going to decline the biomass production and are not suggested. Although takara is more nutritious than dairy cow feces but it acidifies the earthworm’s habitat. Furthermore, using more takara, consequently, are going to add more water to the artificial habitat that make uncomfortable for the earthworm. Based on the protein content, takara has more value as 30,2 % from dried matter (Sutardi, 1997). This protein is going to be degraded by microorganism during the decomposition process (Achmad, K.T.B, at all, 2010). However, Protein content is not the one parameter for better biomass production. It isalso assumed that the combination would influence the porosity and the C/N ratio of the artificial life media that make the earthworm become more comfortable. Therefore, It would be more interesting to study the composition of organic matter on the combination these two waste products. CONCLUSION Combination between 75% of takara with 25% of dairy cow feces as earthworm feed gives the best performance of biomasproduction. Adding more procentase of takara in combination with dairy cow feces could improve the biomas production. However, Feeding with100% of takara could decline dramatically the biomas production. ACKNOWLEDGEMENT The Author is greatful to 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, and journals and books from where the literature for this article has been reviewed and discussed. The author is also grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript. Englishhttp://ijcrr.com/abstract.php?article_id=898http://ijcrr.com/article_html.php?did=898REFERENCES 1. Achmad, K.T.B., et al, 2010, The effect of Lumbricusrubellus seedling density on earthworm biomass and quality as well as quality of kascing in vermicomposting of cattle and bagasse mix. LucrariStiintifice Journal, Vol. 54 (15); 54-59 2. Prayogi, H.S., 2011, The effect of earthworm meal supplementation in the diet on quail’s growth performance in attempt to replace the usage of fish meal. International Journal of Poultry Science, 10 (10): 804-806 3. Sutardi, T., 1997, Peluangdantantangandanpengembanganilmuilmunutrisiternak. OrasiIlmiah Guru BesarTetapIlmunutrisiTemak.Fapet IPB, Bogor.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524168EnglishN-0001November30HealthcareCOMPARATIVE STUDY OF DIFFERENT DOSES OF EPIDURAL BUTORPHANOL FOR POSTOPERATIVE ANALGESIA IN ORTHOPAEDIC PATIENTS English0413Sanjeev B. BirajdarEnglish Vaishali A. GawandeEnglish Ramchandra G. LattiEnglish Bhagyashri R. LattiEnglishIntroduction: Previously studied epidural narcotic agonist such as fentanyl and morphine are capable of producing post-operative analgesia with undesirable side effects such as pruritis, nausea and respiratory depression that have limited their use. The objective of our study was to compare the duration and quality of postoperative analgesia offered by two different doses of epidural butorphanol. Methods: Our study comprised of Group A and B of 30 patients each, receiving 1mg and 2mg of butorphanolrespectively, diluted upto 10ml of normal saline and given by epidural catheter. Results: The study was a prospective randomized double blind study.In bothgroups A and B, epidural butorphanol in doses of 1mg and 2mg, both provided good quality of postoperative analgesia as determined by the Visual Analogue Scale scores in the postoperative period. Conclusion: The duration of postoperative analgesia provided by 2mg of epidural butorphanol is slightly longer than that provided by 1mg, but the difference is statistically not significant EnglishPain, Epidural Butorphanol, Postoperative analgesia, Orthopaedic, Visual Analog Scale (VAS) score, Hemodynamic effects, SedationINTRODUCTION Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage as defined by the International Association for Study of Pain. Surgical trauma causes severe tissue damage.Intraoperative and postoperative pain management should be an essential and integral part of the care given to the patient. Severity of postoperative pain varies with site of operation, age, sex, premedication employed, anaesthetic agent used, psychological makeup of the patient and quality of postoperative care given. Attenuation of postoperative pain, especially using certain type of analgesic regimens may decrease peri-operative morbidity and mortality. Anaesthesia administered for orthopaedic lower limb surgery is quite frequent and a routine practice for anesthesiologist.The importance of such intervention and effective pain control for ambulation of operated patients is essential. Epidural anaesthesia, has become a safe technique with advancement in procedures as well as in equipments (needle, catheter) etc. It is particularly preferred to administer intraspinal or epidural narcotic along with local anaesthetic. The addition of opioid to an epidurally administered local anaesthetic has been suggested to improve the quality of analgesia provided by a local anaesthetic like bupivacaine alone. A drug such as butorphanol a mu-agonist / antagonist and S / K agonist might be expected to be useful in the management of post-operative pain. Our aim was to study and compare the duration of postoperative analgesia offered by two different doses (1mg and 2mg) of epidurally administered butorphanol; to compare the hemodynamic changes and the incidence of side effects of two different doses of epidural butorphanol. And our objective was to compare the duration and quality of postoperative analgesia offered by two different doses of epidural butorphanol. MATERIALS AND METHODS The study was a prospective randomized double blind study conducted in orthopaedic operation theatre ofGrant Medical College, Mumbai. It comprised of 60 patients, aged 20- 70 years, of either sex and of ASA grade I and II posted for elective orthopaedic surgery of lower limb and hip. Patients were evaluated preoperatively. Detailed history was taken and the procedure of spinal/ epidural and visual analogue scale was explained to the patients. Thorough physical examination was carried out. Patients’ height and weight were recorded.All routine investigations such ashaemoglobin, complete blood count, blood sugar, kidney and liver function tests, coagulation profile, Echocardiography (ECG) and Chest X-ray were done. The study was approved by the Ethical committee anda written valid informed consent was taken from all the patients. Patients with ASA grade III, IV,V; those with age 70 years; those with co-existing systemic diseases like Hypertension, Asthma, Diabetes, Heart disease, renal and hepatic diseases, and psychiatric diseases; those undergoing surgery with operative time more than 3 hours; and uncooperative patients were excluded from the study. Baseline pulse rate, blood pressure, respiratory rate and oxygen saturation were recorded. Intravenous access with 18 gauge cannula was established.Preloading was done with Ringer lactate at the rate of 10 ml/ kg. Under all aseptic precautions epidural catheter was inserted through 16 G epidural needle at L3-L4 / L4 - L5 space and spinal anaesthesia was given with 3 ml of 0.5% heavy bupivacaine one space below (i.e. two level spinal – epidural) in sitting position.Patients were made to lie supine on the table. The sensory level by pin prick, Bromage scale and subjective pain score were recorded. Intraoperative pulse rate, blood pressure, respiratory rate and oxygen saturation were recorded for every 2minutes for first 10minutes and every 10 minutes for next 20minutes and there after every 30minutes. Also intravenous fluids, blood given were recorded. On completion of surgery duration of surgery were evaluated. Postoperatively the patients were observed in the recovery room. Patients complaining of discomfort or pain (Visual Analog Scale score of 1) were administered study drug. GROUP A: 30 Patients receiving 1mg of butorphanol diluted upto 10 ml of Normal saline and given by epidural catheter. GROUP B: 30 Patients receiving 2mg of butorphanol diluted upto 10 ml of normal saline given by epidural catheter for pain relief. The patients were observed in the recovery room and later in their respective wards for 8 hours with written instructions to withhold any analgesic or sedative. The patients were monitored for Pulse rate, Blood pressure (Systolic and Diastolic), Oxygen saturation (SpO2), Respiratory rate and Duration of analgesia. Patients were assessed for pain by 0 – 10 cm linear Visual Analogue Scale (VAS). It is a 10 cm long  scale of which 0 end is marked as no pain while other end as worst possible pain. The patients were asked to point out the intensity of pain as experienced by them on the scale. Duration of postoperative analgesia was calculated from the time of first dose of epidural Butorphanol to the time upto when patient again experienced pain (i.e. VAS score of 1). Rescue analgesia was given in the form of 75 mg of Diclofenac Sodium given intramuscularly whenever the patients experienced visual analogue pain score ≥ 4. The following parameters were noted in the postoperative period. 1. Pain score and duration of analgesia. 2. Vital parameters like pulse rate, systolic and diastolic blood pressure, respiratory rate and oxygen saturation. 3. Side effects like nausea, vomiting, pruritis, respiratory depression and urinary retention. Patients were also observed post operatively for sedation caused by epidural Butorphanol for 8 hours by simple sedation score. Sedation Scores 0 = Alert, conversant; 1 = mildly sedated; 2 = moderately sedated and drowsy; 3 = Asleep but arousal; 4 = Asleep and not arousal At the end of study, all data were compiled and analyzed statistically using paired and unpaired statistical difference between the two groups. A P value of 1mg compared to doses of 1mg. Our results correlated with the study conducted byCatherine. O. Hunt et al (1989)1 , Q.T. Palacios, M. M. Jones (1991)19 , J. L. Howkins et al(1991)19 Pramila Malik et al (2006)18, according to which it was evident that in both groups i.e. 1mg and 2mg butorphanol administered epidurally provided effective longer duration of analgesia..Slightly longer duration of analgesia in group B i.e. 2 mg group but the difference is statistically not significant (p value < 0.05). In our study, the VAS score of 1-3 was considered as mild painandscore of 4 or >4 was considered as moderate painandrescue analgesia was given at this point of time. On comparing the VAS scores of two groups(Table 3), which shows the number of patients at different time intervals and number of patients requiring rescue analgesia, at the end of 2 hours 30 minutes, 3 hours, 4 hours, 5 hours, 6 hours,were similarandresults were not statistically significant. The findings in our study correlated with the studies conducted by D. Lawhorn et al (1991)2 , Q.T. Palacios, M. M. Jones et al (1991)19, David R. Gambling et al (1994)3 , Pramila Malik et al (2006)18 , according to which there was no statistical significant difference in VAS scores at varying time intervals in patients receiving 1mg and 2 mg of epidural butorphanol. In our study, pulse rate, systolic blood pressure and diastolic blood pressure remained stable in the post operative period and difference between the 2 groups was not statistically significant (p > 0.05), which were well supported by the studies conducted by Catherine O’ Hunt et al (1989)1 , Q.T. Palacios, M. M. Jones et al (1991)19, Pramila Malik et al (2006)18 . In our study, the incidence of nauseaandvomiting in both groups was minimalandstatistically not significant (Table 4). The incidence of prutitis in patients who received 2mg of butorphanol was 3.3% which correlated with studies conducted by Ackerman et al (1988) 28 - 6.7%, Palacios et al(1991)19 - 1.4 %, Pramila Malik et al(2006)18 - 3% respectively. According to our study (Table 5), the sedation scores at varying time intervals of 30 mins, 1 hour, 1hour 30 mins and 2 hrs were higher in patients receiving 2mg of butorphanol as compared to those receiving 1mg. Thus, the sedation scores were higher in group B when compared to group A, but none of the patients developed respiratory depression i.e. respiratory rate 2mg compared to those receiving 1mg SUMMARY AND CONCLUSION The present study comprised of 60 patients of ASA class I or II, aged 20 – 70 years, weighing between 40-80Kgs and undergoing elective lower limb orthopaedic surgery and were randomly assigned to one of the two groups of 30 patients each to receive either. Group A – 1mg of Butorphanol diluted up to 10ml of Normal saline and given by epidural catheter. Group B – 2mg of Butorphanol diluted up to 10ml of Normal saline and given by epidural catheter. The duration of postoperative analgesia was calculated from the time of first dose of epidural butorphanol to the time when patient again experienced pain (VAS score of 1). Epidural Butorphanol, in doses of both 1mg and 2mg are effective means of providing postoperative analgesia. The duration of analgesia with 1mg of epidural Butorphanol is 187 ± 29.14 minutes and the duration of analgesia with 2mg of epidural Butorphanol is 201 ± 33.56 minutes. The duration of analgesia provided by 2 mg of epidural butorphanol is slightly longer than 1mg of epidural Butorphanol, but the difference is statistically not significant. Epidural Butorphanol in doses of 1mg and 2mg, both provide good quality of postoperative analgesia as determined by the Visual Analogue Scale scores in the postoperative period. Haemodynamic changes i.e. Pulse rate, Systolic B.P, Diastolic B.P. were comparable throughout the study period. On comparing the changes in these parameters in each group at various time intervals with the preoperative value, it was found that the difference is statistically not significant in both the groups. Therefore it can be concluded that the haemodynamic changes in both the groups were acceptable. Epidural Butorphanol in doses of 1mg and 2mg had minimal incidence of side effects and the difference between the two groups was statistically not significant. Sedation scores in 2mg Butorphanol group i.e. Group B were higher after 30 minutes, 1 hour, 1 hr 30 mins and 2 hours interval than in 1mgButorphanol group i.e. Group A. The difference is statistically significant.(p value < 0.05).But the duration of sedation in the two groups was comparable and the difference was not statiticallysignificant.  ACKNOWLEDGEMENT Our sincere thanks to the post graduate students and attendants of Dept of Anaesthesiology and HOD Dr C. B. Upasani. We are thankful to all the patients for their co-operation. 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 the article has been reviewed and discussed. Englishhttp://ijcrr.com/abstract.php?article_id=899http://ijcrr.com/article_html.php?did=899REFERENCES 1. Catherine O Hunt, J Stephen Naulty, Andrew M Malinow, Sanjay Datta and Gerard W Ostheimer. Epidural Butorphanol – Bupivacaine for analgesia during labour and delivery.AnaesthesiaandAnalgesia 1989:68:323-7. 2. C. D. Lawhorn, J. D. McNitt, E. E. Fibuch, J. T. Joyce, and R. J. Leadley. Epidural Morphine with Butorphanol for postoperative analgesia after caesarean delivery.AnaesthesiaandAnalgesia 1991; 72:53- 7. 3. David R Gambling, Paul Howell, Christopher Huber and Sharon Kozak. Division of obstetric Anaesthesia, University of British Columbia and Grave Hospital, Vancouver, British Columbia, Canada.Epidural Butorphanol does not reduce side effects from epidural Morphine after caesarean birth.Anaesthesiaand Analgesia June 1994;78(6):1099-1104. 4. David A Scott, David S. N. BeilbyCalumMcClymontPost operative analgesia using epidural infusion of fentonyl with bupivacaine a prospective analysis of 1014 patients. Anesthesiology 1995;83:727- 737. 5. F.S.Rucci, M. Cardamone and P. Migliori. Fentanyl and Bupivicaine Mixtures for extradural Blockade.British Journal of Anesthesia 1985;57:275-284. 6. Laurence Brunton, Bruce Chabner, Bjorn Knollman, Goodman and Gillman’s The Pharmacology Basis of Therapeutics, 4th Edition. 7. J.W. Dundee, R.S.J. Clarke, W. McCounghey.Clinical Anesthetic Pharmacology, 2nd Edition. 8. J.S. Naulty, S. Weintraub, J. McMohan, GW Ostheimer, C Hunt, R Chantigain. Epidural Butorphanol for post caesarean delivery pain Management. Anaesthesia 1984:61:A415. 9. M. J. King, M. I. Bowden and G.M. Cooper. Epidural fentanyl and 0.5% Bupivacaine for elective caesarean section. Anesthesia 1990, 45.285-288. 10. Michael R Bond. Pain, its Nature, Analysis and Treatment, 2nd Edition, Churchill Livingstone. 11. Martin P. Gaffud, PratibhaBansal, Charles Lawton Norma Velasquez, William A. Watson. Surgical Analgesia for caesarean delivery with epidural bupivacaine and Fentanyl. Anaesthesiology 1986;65:331-334. 12. Morgan M. The rationale use of intrathecal and extra thecal opioids. British Journal of Anaesthesia. 1989; 63: 165-88. 13. Neil H Badner, RakeshBhyandan, Wendy, E Komar.Bupivacaine 0.125% improves continuous postoperative epidural fentanyl analgesia after abdominal or thoracic surgery. Canadian Journal of Anaesthesia .1994:41:387-92. 14. Neil H Badner, Eleanor J Reimer. Wendy E. Komar. Low dose bupivacaine does not improve postoperative fentanyl analgesia in orthopaedic patients. Anaesthesia – Analgesia 1991-72:337-41. 15. Nunn JR, Utting TE and Brown BR. General Anaesthesia, 5th edition. 16. P.M. Halonen, H Paatero, HJ. Hovorka, J. Haasio, and K. Korttilla .Comparisonn of two fentanyl doses to improve epidural anaesthesia with 0.5% bupivicaine for caesarean section. ActaAnaesthesiologica Scandinavia. 1993: 37:774-779. 17. PR Bromage, Enrico Comporesi and David Chestnut. Epidural Norcotis for postoperative Analgesia.AnaesthesiaandAnalgesia 1980;59:473-480. 18. Pramila Malik, Chaavi, Manchanda, Naveen Malhotra Comparative Evaluation of Epidural fentanyl and Butorphanol for postoperative analgesia. Journal of Anaesthesia for clinical Pharmacology 2006;22(4):277-382. 19. QT Palacios, MM Jones, JL Hawkins, JN Adenwala, S Longmire, KR Hess, BS Skjonsby, DH Morrow and JH Joyce 3rd.Post Caesarean Section Analgesia: A comparison of epidural Butorphanol and Morphine.Canadian Journal of Anesthesia 1991 Jan;38(1):24-30. 20. Ronald D. Miller.Miller’s Anaesthesia, 6th Edition, Elsevier Science Health Science Division. 21. R.K. Stoelting, Pharmacology and physiology in Anaesthesia practice, Lipincott Williams and Wilkins, 3rd Edition. 22. Sheila E. Cohen, Shirley Tan, George A. Albright, Gerry Halpern. Epidural fentanyl bupivacaine mixture for obstetric analgesia. Anaesthesiology 1987;67:403-407. 23. Smith .G. Pain after surgery. British Journal of Anaesthesia 24. Tan P.H., Chou A.K., Perng J.S., Chung H.C., Lee C.C. Mok M.S.Comparison of epidural butorphanol plus clonidine with butorphanol alone for postoperative pain relief.ActaAnaesthesiology Scandinavia. 1997 Jun 35(2):91-6. 25. T A Torda, P.Hann.GMillis,G.Deleon and D Penman. Comparison of extradural fentanyl, bupivacaine and fentanyl-bupivacaine mixture for pain relief after abdominal surgery.British Journal of Anaesthesia 1995;74:35-40. 26. Theresse K Abboud, M Moore J Zhu K, Murakawa M Minehert M Longhitano, J. Terrasi, J. D. Klepper, Y Choi SKimball and G Chu. Epidural Butorphanol or Morphine for relief of postoperative caesarean section pain: Ventilatory responses to Carbon Dioxide.Anaesthesia Analgesia 1987;66:887- 93. 27. Toshiharu Kasaba, GogtaroYoshikawa, TomkoSeguchi Mayumi Takasaki. Epidural fentanyl improves the onset and spread of epidural mepivacaineanalgesia. Canadian Journal of Anaesthesia 1996;43:1211-5. 28. W.E. Ackerman, M. M Juneja, G W Colclough. A comparison of epidural funtanyl, Buprenorphine and Butorphajol for the management of post caesarean section pain. Anaesthesiology 1988;69:A401. 29. Vinita Singh, Lokeshkumar Gupta, G.P. Singh. Comparison among intrathecal fentanyl anButorphanol in combination with Bupivicaine for lower limb surgeries. Journal of Anaesthesia for Clinical pharmacology 2006; 22(4):371-375. 30. Woolf. C.Recent advances in pathophysiology of acute pain.British Journal of Anaesthesia. 1989;63:139-46. 31. Wylie and A.C. Churchill Davidsons.A practice of Anaesthesia, 7th Edition, Fundamentals of regional Anaesthesia, H. B. J. Fischer, C. A. Pinnock, Cambridge University Press.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524168EnglishN-0001November30HealthcareCHRONIC HEMIFACIAL SPASM - A MASQUERADER OF EPILEPSIA PARTIALIS CONTINUA English1417Manigandan GopiEnglish Sunny D.A.N.English Aashish AarumugamEnglishHemi Facial Spasm (HFS) is commonly caused by compression of seventh cranial nerve by dolichoectatic arteries of posterior circulation though genetic and idiopathic causes to be considered1. Here we report a case of chronic HFS, A 55 years old female previously diagnosed to be HFS due to aberrant vascular loop compressing the facial nerve, on treatment for the past five years with no improvement in the symptoms. Patient EEG showed electrical activity in the right frontal lobe suggesting each spasm was due to partial seizure and diagnosis of Epilepsia Partialis Continua (EPC) was made. Patient symptoms resolved completely after starting newer anti convulsant medication suggesting that the facial spasms are due to EPC. Even though EPC is arising from cerebral cortex or sub cortical region it may present and to be mistaken as HFS - a peripheral movement disorder when it affects the face alone as in this case. EnglishHemifacial spasm, Epilepsiapartialis continuaINTRODUCTION Hemi facial spasm represents myoclonus of the muscles innervated by seventh cranial nerve. As the name suggests it occur unilaterally but bilateral involvement can also occur rarely. Though the ephaptic transmission theory2 and kindling theory3 suggests facial nerve dysfunction as the cause of hemifacial spasm the compression of facial nerve by posterior circulation vessels is considered to be the wide accepted cause of hemifacial spasm. Here we report a case of hemifacial spasm which on evalvuation showed epileptic discharge from right cerebral cortex as its cause which is unusual and reported very few in literature4-6 . CASE REPORT A 55-year-old-female was admitted and evaluated for an acute onset of Generalized tonic clonic seizure (GTCS) with post ictal confusion and 5 years history of facial twitching in left side (fig-1) with discomfort without pain. She had no prior illnesses. No history of head injury, meningitis / encephalitis or other precipitating events. There were no other abnormalities on the neurological or general examination. Brain MRI performed before 5 years at the onset of spasms and showed aberrant vascular loop from posterior circulaton causing compression over the exit of the facial nerve (fig- 2) and started on clonazepam as patient was allergic to carbamazepine. Inspite of therapy for one year patient symptoms didn’t resolve and she underwent botulinum toxin injection. Patient did not improve and advised for micro surgical decompression of facial nerve at the site of compression but patient was not willing for surgery and continued on clonazepam and baclofen. Patient now presented with GTCS and evalvuated for the same and repeat MRI brain did not reveal any new finding and EEG was taken which showed frequent epileptiform discharges from right frontal and temporal lobe (fig-3, 4) for every facial twitching which the patient had experienced and discharges from both the cortex when patient had GTCS suggesting secondary generalized seizure. Patient was allergic to carbamezipine, newer antiepileptics like levetiracetam and lacosamide provided almost complete resolution of facial twitching. When she temporarily discontinued the drugs due to sleepiness there was subsequent recurrence of these abnormal movements. The diagnosis of Epilepsiapartialis continua was confirmed by the finding of irregular epileptiform discharges from right cerebral hemisphere and rhythmic / semirhythmic focal slowing during prolonged video / EEG monitoring while the patient was experiencing Hemi facial spasm. DISCUSSION Epilepsiapartialis continua manifest as focal motor clonic seizures, which remain localized to the part of the body in which they originate (face / limbs) and the motor activity is persistent lasting for minute, hours, days, weeks or even years together7 . EPC can be considered the status epilepticus equivalent of simple partial motor seizures7 . In most cases of EPC the seizure focus lie on cerebral cortex eventhough subcortical foci have also been reported8 . Hemi facial spasm (HFS) is defined as unilateral, involuntary, irregular, clonic or tonic movement of facial muscles innervated by seventh cranial nerve.. Although most cases of hemifacial spasm are idiopathic and probably caused by vascular compression of facial nerve other etiologies like bells palsy, facial nerve injury by demyelination, vascular insult and hemifacial spasm mimickers should be considered. The hemifacial mimickers are classified as psychogenic, tics, dystonia, myoclonus and hemi masticatory spasm9 . In our case the mimicker has been identified as EPC. The ictal etiology for hemifacial spasm is evident from our case by the presence of electrical activity from the right frontal lobe for each facial twitching witnessed when EEG was taken and the prompt response to the antiepileptic drugs. It is further substantiated by the recurrence of twitching on withdrawl of the drug. The presence of aberrant vascular loop causing compression of the facial nerve made the previous clinician to think and treat as hemifaciaal spasm caused by vascular compression of facial nerve as it is the most widely accepted cause of hemifacial spasm. But the presentation of hemifacial spasm with GTCS made us to evalvuate for seizure and found that epileptic discharge from the right frontal lobe (partial seizure) present as facial twitching of the left side of face which is mistaken as hemifacial spasm due to clinical similarity and by the anatomic finding of aberrant vascular loop causing compression of the facial nerve. Since this partial seizure in our patient was persisitent for 4 years it is considered as Epilepsia partials continua. The EPC nature of HFC reported already in literature10 has a normal facial nerve course. In our case the patient had vascular compression of facial nerve and the cause for the facial twitching was not because of the compression but because of the Seizure activity is evidenced by the response from anticonvulsant medication and failure to respond for botulinumtox injection which is the commonest treatment for HFS of vascular compression of facial nerve11. Hence we hypothesize and emphasize that the prompt response of this patient with chronic HFS to newer antiepileptic drugs possibly indicate that HFS can occur sometimes as a manifestation of EPC with focal epileptiform discharge from the brain rather than due to facial nerve hyperexcitability. CONCLUSION We conclude that, Even though Hemifacial spasm is of neuropathic or idiopathic of origin, this case report should alert the physicians about the seizure activity from the cerebral cortex presenting as hemifacial spasm and EEG should be advised for all the cases of HFS irrespective of the MRI finding     Englishhttp://ijcrr.com/abstract.php?article_id=900http://ijcrr.com/article_html.php?did=900REFERENCES 1. Rahman, M.D. Ersalan; Jonathan D. Trobe, and Stephen S. Gebarski (June 2002). "Hemifacial Spasm Caused by Vertebral Artery Dolichoectasia". American Journal of Ophthalmology 133 (6): 854–855 2. Gardner, J.W.; Sava, Gerard A. (1962). "Hemifacial Spasm - A reversible pathophysiologic state". Journal of Neurosurgery 27 (3): 240–47. 3. Eby, Joesph; Sung Tae Cha,Hrayr K. Shahinian (2002). "Fully endoscopic vascular decompression of the glossopharyngeal nerve".The Journal of Craniofacial Surgery 13 (1): 90–95 4. Hogan RE, Rao VK. Hemifacial motor and crying seizures of temporal lobe onset: case report and review of electro-clinical localisation. J NeurolNeurosurg Psychiatry. 2006;77(1):107–10. 5. Arzimanoglou AA, Salefranque F, Goutieres F, Aicardi J. Hemifacial spasm or subcortical epilepsy? Epileptic Disord. 1999;1(2):121–5. 6. Chae JH, Kim SK, Wang KC, Kim KJ, Hwang YS, Cho BK. Hemifacial seizure of cerebellar ganglioglioma origin: seizure control by tumor resection. Epilepsia. 2001;42(9):1204–7. 7. Bancaud J, Bonis A, Trottier S, Talairach J, Dulac O. [Continuous partial epilepsy: syndrome and disease].Rev Neurol (Paris). 1982;138(11):803-14. 8. Juul-Jensen P, Denny-Brown D. Epilepsiapartialis continua. Arch Neurol. Dec 1966;15(6):563-78. 9. Yaltho TC, Jankovic J. The many faces of hemifacial spasm: differential diagnosis of unilateral facial spasms. MovDisord. 2011 Aug 1;26(9):1582-92 10. Espay AJ, Schmithorst VJ, Szaflarski JP. Chronic isolated hemifacial spasm as a manifestation of epilepsiapartialiscontinua.EpilepsyBehav. 2008 Feb;12(2):332-6 11. Singh S. Botulinum toxin in hemifacial spasm: Revisited.Indian J Plast Surg. 2013 Jan;46(1):159-60

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524168EnglishN-0001November30HealthcareA CROSS SECTIONAL STUDY ON RISK FACTORS OF TYPE 2 DIABETES AMONG SEDENTARY MALE OFFICE WORKERS English1827Muhil S.EnglishIntroduction: Although many studies have focused on studying risk factors of diabetes, this study has highlighted the presence of modifiable risk factors of type 2 diabetes (T2DM) among young adults whose age range from 30 and so on. In addition to other possible risk factors, the current study has thrown a light on unhealthy waist stature ratio among office workers who spend more time as couch potatoes. Objectives • To describe the proportion of various modifiable and non-modifiable risk factors of T2DM among sedentary male office workers • To explore the distribution of diabetic risk factors with respect to HbA1c categories Material and Methods: After considering the non-modifiable risk factors such as age, gender, ethnicity and family history, the current study has addressed all possible modifiable risk factors of T2DM. Based on selection criteria, 146 office workers with the age of 30 years and above were considered for this cross sectional study. Statistical Methods: Simple percentage and confidence interval (for large proportion) were used to describe the data. Results: After grouping the subjects’ data based on their extent of risk factors, they were categorized under HbA1c level such as normal (13%), prediabetic (65.8%) and diabetic (13%) groups. The high proportion of prediabetes (65.8%) in younger age group than older adults (8.2%) isan unusual startling finding. While considering the anthropometric factors of office workers, 73.9 % showed their waist circumference in high risk zone, 44.5% had risky waist hip ratio, 78.1% of subjects with abnormal waist stature ratio and 93.2% were above the recommended cut off value of body mass index (?23 kg/m²). Conclusion: The current study concluded that there were 73.97% of young prediabetic subjects among sedentary male office workers which is of paramount importance as a critical health risk to the community. With a concomitant hike in sedentary lifestyle, younger adults are in the serious development of debilitating lifestyle diseases such as T2DM, heart attack, stroke and so on. Hence this study recommends a systematically designed, effective and economically feasible approach to reverse these risk factors in order to prevent or delay T2DM. EnglishCross sectional study, type 2 diabetes, risk factors, sedentary and office workersINTRODUCTION Every mankind wishes to be in a comfort zone within which human feels an anxiety-neutral state. Unbelievable growth of science and technology has put forth a not an invisible but a visible trap, if it is not for all, at least for those in sedentarism. By seeking calm and stress-free environment, our physique strives hard for comfort position. Undoubtedly, people spend more time in sitting and sleeping which is really a predisposing factor of many detrimental lifestyle diseases such as diabetes, stroke, heart attack and so on. World Health Organization (WHO) and International Diabetes Federation (IDF) state that “Diabetes is a life-threatening condition, a major threat to global public health that is rapidly getting worse and its frequency is dramatically rising all over the world. The biggest impact is on adults of working age in developing countries and in many cases, diabetes can be prevented”1 . Although many studies have focused on prevalence of diabetic risk factors2-4 , the current study had explored the proportionate distribution of T2DM risk factors under the categories of glycosilated hemoglobin levels (HbA1c) among young adults whose age range from 30 years. According to IDF, in South East Asia (SEA), the proportion of mortality due to diabetes in people under 60 years of age is 55% (for the year 2013) and out of 382 million of total diabetic people in the world, SEA has 72 million which urges us to think seriously about the silently killing disease diabetes5 . Moreover, out of this 72 million, 46% are undiagnosed and as of 2013, being the second of top ten countries having diabetic citizens (20 to 79 years), India has 65.1 million diabetic people5 . Whilst considering the Tamilnadu state of India, the prevalence of total diabetes (known and unknown) is around 10.4% and 8.3% of prediabetic subjects6 . While comparing with other ethnic groups, Indians have a strong genetic susceptibility of getting diabetes and lower cut-off values of demographic and anthropometric risk factors such as 30 years of age, 90 cms of waist circumference (WC), and 0.90 cms of waist-hip ratio (WHR) and with ≥ 23 kg /m² of body mass index (BMI)7 . Surprisingly, diabetes is no longer considered as rich people’s disease; rather it has now received a notation, ‘the disease of poor’8 . Due to the impact of rapid urbanization and sedentary lifestyle, even the people from lower economic status are quietly getting into the dreadful morbidity of life style diseases like diabetes and other9 . Thus it is wise to think of reversing the modifiable risk factors since it is feasible than to treat it once it has already affected a person10. In such contemplation, as a first move to trigger primary prevention, the current study has described the proportionate existence of T2DM risk factors among office workers who spend more time in sitting posture i.e. as couch potatoes11. Objectives • To describe the proportion of various modifiable and non-modifiable risk factors of T2DM among sedentary male office workers • To explore the distribution of diabetic risk factors under HbA1c categories MATERIALS AND METHODS An awareness campaign was conducted for the office workers in and around Dharapuram urban area of Tamilnadu state, India who were in sitting posture in their office hours (6 to 8 hours). In order to emphasize the emerging life style diseases such as diabetes, stroke and heart attack, this study specifically targeted the employees who are being engaged in clerical and administrative work called office workers. In the current study, excluding the age, sex (male), ethnicity (Asian) and family history, all other factors considered were non modifiable risk factors12,13. Since it is well known that the males are highly susceptible to type 2 diabetes than females, the author focused 273 male office workers and they were screened for baseline assessment14. Based on the selection criteria, about 127 subjects with known history of hypertension, diabetes and regular physical activity (>2 days consecutively) were excluded and 146 office workers with the age of 30 years and above were considered for the study. The current study adopted single group cross sectional study design and the formula (Zα/2)²pq)/dwas used to calculatethe sample size (n) of the study15. Although the estimated sample size was 117, since there was a plan of administering interventions and conducting an experimental study with the same subjects in future, 146 office workers were randomly selected and analyzed for the current study. Since the study used glycosilated haemoglobin (HbA1c) level to categorize the subjects, they were grouped based on the specifications of American Diabetic Association (ADA) such as those with ≤ 5.6% were considered under normal group, 5.7% to 6.4% were in prediabetic group and diabetic group included those with 6.5% and above16. In addition to HbA1c level, all 146 subjects were screened for demographical, anthropometrical, physiological, familial and behavioral risk factors of T2DM. The anthropometric measures such as WC, hip circumference (HC), WHR and waist stature ratio (WSR) were taken based on WHO standards17. A digital weighing scale (Camry ® EF432, ISO 9001:2008 certified by SGS) was used to measure the weight of the subjects and the Blood Pressure was measured by a digital blood pressure monitor (OMRAN HM 780). Moreover details regarding family and behavioral history were noted by one to one interaction between researcher and the subjects. Subjects who had Englishhttp://ijcrr.com/abstract.php?article_id=901http://ijcrr.com/article_html.php?did=901REFERENCES 1. World Health Organization and International Diabetes Federation. Diabetes Action Now: An Initiative of World Health Organization and the International Diabetic Federation. ISBN 924959151 X. 2. V. Mohan, S. Sandeep, R. Deepa, B. Shah and C. Varghese Epidemiology of type 2 diabetes: Indian scenario. Indian J Med Res 125, March 2007, pp 217-230. 3. Ambady Ramachandran, Simon Mary, Annasami Yamuna, Narayanasamy Murugesanand Chamukuttan Snehalatha. High prevalence of diabetes and Cardiovascular risk factors associated with urbanization in India. Diabetes Care 31:893–898, 2008. 4. Vipin Gupta. Type 2 Diabetes Mellitus in India. South Asian Network for Chronic Disease, New Delhi. 5. International Diabetes Federation, IDF Diabetes Atlas, Sixth Edition-2013, Page 11 – 13. 6. R. M. Anjana, R. Pradeepa, M. Deepa, M. Datta, V. Sudha, R. Unnikrishnan, A. Bhansali, S. R. Joshi, P. P. Joshi, C. S. Yajnik, V. K. Dhandhania, L. M. Nath, A. K. Das, P. V. Rao, S. V. Madhu, D. K. Shukla, T. Kaur, M. Priya, E. Nirmal, S. J. Parvathi, S. Subhashini, R. Subashini, M. K. Ali and V. Mohan. Prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in urban and rural India: Phase I results of the Indian Council of Medical Research–INdiaDIABetes (ICMR– INDIAB) study. Diabetologia (2011) 54:3022–3027 DOI 10.1007/s00125-011- 2291-5 7. V. Mohan. Why are Indians more prone to diabetes? JAPI Vol. 52 June 2004. 8. Upendra Bhojani. The Hindu.And You Thought Diabetes is a Rich Man’s Disease. August 31 2013. 9. Steven AllenderBen Lacey, Premila Webster, Mike Rayner, Mohan Deepa, Peter Scarborough, CarukshiArambepola, ManjulaDattaandViswanathan Mohan. Level of urbanization and non-communicable disease riskfactors in Tamil Nadu, India.Bull World Health Organ 2010; 88:297–304, doi:10.2471/BLT.09.065847. 10. Sailesh Mohan, K. Srinath Reddy and D. Prabhakaran. Chronic Non Communicable Diseases in India: Reversing the Tide. September 2011  11. Pronk NP, Katz AS, Lowry M, Payfer JR. Reducing Occupational Sitting Time and Improving Worker Health: The Take-a-Stand Project, 2011. Prev Chronic Dis 2012;9:110323. 12. Aravindalochanan V, Kumpatla S, Rengarajan M, Rajan R, Viswanathan V.Risk of diabetes in subjects with sedentary profession and the synergistic effect of positive family history of diabetes.Diabetes TechnolTher. 2014 Jan;16(1):26-32. doi: 10.1089/dia.2013.0140. Epub 2013 Oct 11. 13. ICMR Guidelines for Management of Type 2 Diabetes. Section 2.Individuals for Screening, 2.1. Asymptomatic Individuals, page 5, 2005 14. Alex SF Doney, Bettina Fischer, Joanne E Cecil, Patricia TW Cohen, Douglas I Boyle, Graham Leese, Andrew D Morris and Colin NA Palmer. Male Preponderance in Early Diagnosed Type 2 Diabetes is associated with the ARE Insertion/Deletion Polymorphism in the PPP1R3A locus. BMC Genetics 2003, 4:11 15. JaykaranCharan and TamoghnaBiswas. How to calculate sample size for different study designs in medical research? Year: 2013, Volume: 35, Issue: 2, Page. 121-126. 16. American Diabetes Association. Standards of Medical Care in Diabetesd2014. Diabetes Care Volume 37, Supplement 1, January 2014 17. World Health Organization, Waist circumference and waist–hip ratio: report of a WHO expert consultation, Geneva, 8–1, December 2008, ISBN 978 92 4 150149. 18. Chockalingam K, Vedhachalam C, Rangasamy S, Sekar G, Adinarayanan S, et al. (2013) Prevalence of Tobacco Use in Urban, Semi Urban and Rural Areas in and around Chennai City, India. PLoS ONE 8(10): e76005. doi:10.1371/journal.pone.0076005 19. Vishal Khosla, K.R. Thankappan, G.K. Mini and P.S. Sarma.Prevalence and predictors of alcohol use among college students in Ludhiana, Punjab, India.Indian J Med Res 128, July 2008, pp 79-81. 20. Pratima Murthy, N. Manjunatha, B.N. Subodh, Prabhatkumar Chand and VivekBenegal. Substance Use and Addiction Research in India. Indian J Psychiatry 2010; 52:SI 89 - 99 21. American College of Sports Medicine (ACSM) Editorial, The Science of Sedentary Behavior: Too Much Sitting and Too Little Exercise 22. Jessica Goldsmith. Walla Walla UnionBulletin.Pre-diabetes a precursor, not a curse. February 2014 23. Ram Weiss, Sylvie Dufour, Sara E Taksali, WillViaTmamborlane, Kitt F Petersen, RiccardCoBonadonna, Linda Boselli,GinaBarbetta, Karin Allen, Francis Rife, Mary Savoye, James Dziura, Robert Sherwin, Gerald I Shulman and Sonia Caprio. Prediabetes in obese youth: a syndrome of impaired glucose tolerance, severe insulin resistance, and altered myocellular and abdominal fat partitioning. Lancet Vol 362 September 20, 2003; 362: 951–57 24. Manisha Chandalia, Nicola Abate, AbhimanyuGarg, James Stray-Gundersen Scott m. Grundy. Relationship between Generalized and Upper Body Obesity to Insulin Resistance in Asian Indian Men.J ClinEndocrinolMetab84: 2329–2335, 1999 25. Alok K Gupta and William D Johnson. Prediabetes and prehypertension in disease free 26. Obese adults correlate with an exacerbated systemic proinflammatory milieu. Journal of Inflammation 2010, 7:36 27. RekhaGovindan, Vikas Kumar, Dolly, Imran ShaikhGouseBasha, Rahul Kumar V and RanaRanvijay Singh.Prevalence of Prehypertension and Hypertension in Rural Tamil Nadu Populations – A Pilot Study Report from Pandithamedu of Paiyanoor Village of Kancheepuram, Tamil Nadu, India.International Journal of Emerging Trends and Technology in Computer Science (IJETTCS) -Special Issue, 2013.ISSN 2278- 6856. 28. Helaine E. Resnick, Susan Redline, EyalShahar, Adele Gilpin, Anne Newman, Robert Walter, Gordon A. Ewy, Barbara V. Howard and Naresh M. Punjabi. Diabetes and Sleep Disturbances.Diabetes care, volume 26, number 3, March 200328. Peter m. 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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524168EnglishN-0001November30HealthcareTHE LEVEL OF KNOWLEDGE AMONGST SMALL AND MEDIUM ENTERPRISES OF THE QUALITY AND SAFETY ISSUES IMPACTING ON THE RE-USE OF COOKING OIL English2836Cavus O.English Sheward E.EnglishObjective: This study was designed to examine the level of knowledge, amongst small and medium enterprises, of the quality and safety issues impacting on the re- use cooking oil. Method: Interviews were conducted within 20 catering establishments in the Crayford and Dartford areas of London. The questionnaire was used to collect data from respondents via face-to-face interviews and comprised 21 questions. In order to evaluate the level of knowledge of food operators regarding the topic, each question was prepared based on the outcomes from the literature review. Result: The findings of the research showed that the majority of respondents have lack of knowledge regarding the safety and quality issues related to the re-use cooking of oil. The level of knowledge of the food businesses surveyed regarding the safety and quality of cooking oil needs to be improved, in key areas such as; selection criteria of cooking oil for their purpose, safe frying temperatures, segregation of different product before and during frying, frying of wet foods and assessing the quality and safety cooking oil during frying operations. However in other key areas such as storage of cooking oil knowledge and practice was good. Conclusion: Most respondents interviewed lack adequate knowledge regarding the safety and quality of re-used cooking oil. Englishsafety and quality issues, interviews, cooking oil, food businessesINTRODUCTION The consumption of vegetable cooking oil has been raising rapidly in the catering industry in the past decade within the UK small and medium catering businesses (Bou et al., 2012; McSavage and Trevisan 2001). Vegetable cooking oil is used by caterers for frying processes, frying operations are fast, convenient and an essential method of food preparation typically producing products with a specific flavour, colour, taste, and crispy surface, that is acceptable to many consumers (Tabee et al., 2008). During the frying process new compounds are formed resulting in a change in fried oil both physically and chemically; for example prolonged heat and high temperatures lead to some chemical reactions such as polymerization, oxidation, and viscosity (Wai 2007). These chemical reactions affect oil quality and safety (colour becomes darker, smells like smoke, and has an acidic taste), and these changes finally result in deterioration of the oil affecting the quality and safety of fried products (Lioumbas et al., 2013). The frying process is also open to atmospheric oxygen and high temperature and, during frying operations the amount of oil absorbed by the fried foods can affect consumer safety (Kochhar 1998). For these reasons, measures should be taken during the frying process to ensure that the quality and safety of reused oil is maintained (McSavage and Trevisan 2001). Due to the environmental impact of waste oil importance of oil, governments at all levels have regulations guiding the management and reuse of oil but little which examines the food safety issues (Dobarganes and Marquez-Ruz 1998). This study is aimed at determining the level of understanding of caterers on the food safety and quality issues of the use and re-use of cooking oil, within Dartford and Crayford, United Kingdom. MATERIALS AND METHODS Study designThe study was conducted to gather data appropriate information from small and medium sized catering businesses in respect of their knowledge level relating to the quality and safety issues associated with the use and re-use of cooking oil. Respondents were asked about the use of reused oil, the temperature used in frying their product, their understanding of the factors which effects quality and safety of reused oil, types of oil they use for frying operation and, how long they use reused oil, as well as different products they fry in the reused cooking oil, how often they clean the fryer and their source of information regarding the handling of reused oil. Design of questionnaire Questions were developed to understand the level of knowledge amongst small and medium enterprises. The questionnaire comprised 21 questions. In order to evaluate the level of knowledge of food operators regarding the topic, each question was prepared based on the outcomes from the literature review. Location and sample size This study was conducted through interviewing 20 small catering businesses that use cooking oil in their respective establishments in Crayford and Dartford) in London, United Kingdom. The questionnaire was used to collect information from respondents in face-to-face interviews. Respondents gave verbal informed consent that they were willing to take part in the survey. Although, some food operators initially expressed concerns assurances were provided that the information collected from them would be treated with absolute confidentiality. Analysis of survey data The results of the survey were analyzed using the statistical package of Microsoft Office Excel 2010. Descriptive analysis was also conducted to evaluate food operators’ understanding of the safety and quality of reused cooking oil used for frying operations. Also, tables and charts were prepared to present results. Respondents were asked about what they think could be quality and safety issues associated with oil used for frying. Twenty five percent of the respondents made mentioned of contamination that from food sources in the oil to constitute a food safety and quality issue, 10% suggested cleaning of frying equipment would be quality and safety issue associated with oil, 15% stated that they believed that design and maintenance of equipment and cleaning of frying equipment could be quality and safety issue associated with oil, 30% responded to suggest that all of these constituted quality and safety issue in respect of frying oil, as opposite 20% stated that they believed that none of these would be a food quality or food safety issue. Respondents were asked on the source they might obtain further information regarding the safe use and reuse of frying oil. Seventy of respondents would obtain information from the Local Authority EHO, while 15% would not obtain any information. Ten percent got information from a consultant, and 5% of respondents obtained information from trade publications. Additionally, the result indicated that respondents use Food Hygiene Training, Health and Safety and HACCP training. All respondents have Health and Safety training. Ninety percent had Food Hygiene training in addition. Interestingly only 25% had undergone HACCP training. DISCUSSSION The study aimed at obtaining information on the quality and safety issues associated with the use and re-use of cooking oil, together with levels of knowledge of appropriateness of use, and management, and health aspects of specific oils. The results of the study indicated the types of work undertaken regularly by interviewees in relation to the use and re-use of cooking oil. The purpose of this was to identify those responsible for the purchase, storage, handling, management of oil usage. From this information it was possible to identify those interviewees who could reasonably be expected to have higher levels of knowledge of the use of cooking oil. The initial survey targeted Food Business Operators, Supervisors, Managers and Chefs, but the results indicated that (in the case of small and medium sized businesses) in the many cases the owner or manager was also the chef. The results of the survey in respect of which types of oil were being used were somewhat unexpected. The vast majority (80%) of businesses stated that they used vegetable oil for all frying operations. A minority of study participants (20%) used rapeseed oil, which may be as a result of its higher suitability and common association with particular types of cuisine (i.e. Chinese) it was, however, surprising to find that there were no businesses using other types of oil such as olive, Palm- kernel, sunflower, soya- bean. One further finding, of interest, from the survey was that a high proportion of the respondents cited health attributes as being an important factor in their choice of oil. They stated that they were of the opinion that vegetable oil was healthier than the other alternatives available to them. This indicates a lack of knowledge amongst participants as to the actual properties of varieties. The outcome of a volume of other research (McSavage and Trevisan 2001; GSFS 2008; CAC 2011; GEA Food solutions 2013) shows that there are many types of oil which are actually healthier than vegetable oil. Olive oil, for example is unique frying oil having low saturated fatty acids and many nutritional benefits. The results from the survey indicated a juxtaposition between what respondents reported the drivers behind choice of oil type were i.e. healthy attributes of the oil being the main driver and their evident lack of knowledge about the healthy attributes of vegetable oil. For a minority of respondents, due to specific culinary requirements, the prime selection criteria were cooking characteristics. There was a lamentably low level of knowledge of the actual health aspect of the use of various oils. The results of the study show that, of the businesses surveyed only 15% use appropriate frequency for re-use of oil and the remainder of them need to improve their knowledge on re-use frequency of oil. Respondents also showed a lack of knowledge of recommended oil re-use practices. The food operators in this survey were asked to state how they handle the used oil after frying operations and how the oil was prepared for the next frying process. The majority of respondents (65%) stated that they filtered used oil and topped up with fresh unused oil or they didn’t filter the oil. Many scientific findings CAC 2011; GEA Food Solutions (2013) have recommended that on completion of the frying process, the oil should be filtered in order to remove food particles and bread crumbs completely, because they accelerate oil deterioration. The survey results indicated that 65% of the respondents top up used oil with fresh unused oil, but 35% of respondents follows good practices. A comparison between responses to the question in respect of good practice in respect of re-use of oil and those in respect of the length of time the oil was used for delivered conflicting data, in that respondents appeared to indicate that they followed good practice in one area but not in another. Survey results gave an insight into respondent’s levels of concern regarding food quality and safety issues in relation to cooking oil. Interestingly, 80% of respondents agree that all of the factors (change in colour of oil, food particles in oil, bubbling and foaming of oil) can be quality and safety issues. They are correct in this opinion, because food particles in oil increase the polymerization and oxidation and that these, in turn, cause the oil to change colour (colour darkening, with black spots appearing). This entire factor can affect quality of oil and consequently safety of food being fried. In this study the majority of respondents were aware that changes of colour indicated a reduction in quality. Only 25% were aware that excessive heat could be a cause for the change in colour, but large minorities were not aware of the any of the factors which could affect quality of oil. None were aware of any factors which could affect the health of consumers Respondents were asked how they cooked different products in oil. The majority of them mentioned that they fried different products in separate fryers. This is good practice and prevents cross-contamination of allergens. Twenty percent of respondents stated that they cooked all products in the same fryer. Allergenic contamination may occur when different products are cooked in the same oil and this could be a health issue for people with allergies (FSA 2006). The participants in this study showed good levels of knowledge regarding storage of re-used oil. This may be a result of a number of new regulations coming into force (Water UK 2013), specifically the Environmental Protection Act 1990 (Duty of Care). These proved that the level of knowledge respondents regarding the segregation product and storage of re-used oil is high. This is result of regular inspection from the local authority and if cateress does not follow regulation requirement they must pay penalty. In this study the majority of respondents stated that they fried product above 2000 C. A group of researchers (McSavage and Trevisan 2001; GSFS 2008; CAC 2011; GEA Food solutions 2013) mentioned that the optimal frying temperature should be around 180-1850 C. Another researcher, Fellows (2000) and Wai (2007) reported that deep frying between the temperature range of 170 0 C and 200 0 C can lead to the formation of acrylamide when frying especially starchy foods such as potatoes, and there is also likelihood that oil will undergo hydrolysis, oxidation and thermal polymerization. A very large majority of the (80%) participants in this study stated they not aware that the temperature of heating affected oil quality and/or safety of the fried product. This results was similar to those obtain in a study by Lioumbas et al., in Malaysia ( 2012) which showed that the majority of their respondents were not aware that high temperature heating could lead to increased degradation of oil. A very surprising result was that a majority of respondents named their sole source of information regarding the matters investigated as been literature originating with the local authority EHO, although a large number of respondents and the employees had attended courses and obtained qualification and certification in food and hygiene training, health and safety and, HACCP training. Despite this, the food safety issues associated with the use and re-use of cooking oil were either not addressed by the training or respondents had not translated the acquired knowledge into good practices. It was apparent that the only\ CONCLUSIONS The findings of the research showed that the majority of respondents have lack of knowledge regarding the safety and quality issues related to the re-use cooking of oil. The level of knowledge of the food businesses in Crayford and Dartford UK regarding the safety and quality of cooking oil needs to be improved through integrated efforts between the relevant central and local government agencies and the catering businesses themselves. Businesses need to be informed and trained to be aware that for example, by segregation methods, they can avoid cross-contamination from allergenic products to non-allergic products. That the correct monitoring of oil quality can avoid the potential for a buildup of chemicals in the oil and that by making simple alterations to oil use and reuse practices they can do much to significantly reduce food safety problems associated with the misuse of oil whilst simultaneously improving the food quality attributes. The basis for recommendations in this study is that knowledge of other areas of oil handling such as storage and disposal showed high levels of knowledge and compliance amongst the survey participants and this was linked to regular enforcement and oversight by the local authority.   Englishhttp://ijcrr.com/abstract.php?article_id=902http://ijcrr.com/article_html.php?did=902REFERENCES 1. Bou R, Navas JA, Tres A, Codo R, Guardiola F. Quality assessment of frying fats and fried snacks during continuous deep-fat frying at different large-scale producers. Food Control 2012; 27:254-262. 2. Codex Alimentarius Commission (2011) Recommended international code of practice for the storage and transport of edible fats and oils in bulk (CAC/RCP 36). Available from: www.codexalimentariuscommission.com (accessed 10 March 2013). 3. Dobarganes MC, Marquez-Ruz G. Regulation of used frying fats and validity of quick tests for discarding the fats. Grasas Y Aceites 1998; 49: 331-335 4. Fellows PJ, Food Processing Technology: Principles and Practice. England: WoodHead Publishers Ltd 2009. p. 555-573. 5. Food Standards Agency. Guidance on Allergen Management and Consumer Information 2006. Available from: http://multimedia.food.gov.uk/multimedia/pdf s/maycontainguide.pdf (accessed 28 July 2013). 6. GEA Food Solutions. Effective Oil Management 2012. Available from www.gea.com (accessed 28 March 2013). 7. German Society for fat Science (2008) Optimum deep frying Brochure. Available from: http://www.dgfett.de/material/optimum_frying .pdf (accessed 5 March 2013). 8. Kochhar, S.P. Security in industrial frying process. Grasas y Aceites 1998; 49:296-302. 9. Lioumbas JS, Ampatzidis C, Karapantsios TD. Effect of potato deep-fat frying conditions on temperature dependence of olive oil and palm oil viscosity. Journal of food Engineering 2012; 113: 217-225. 10. McSavage J, Trevisan S. The use and abuse of frying oil. Food service Technology 2001; 1:85-92. 11. Tabee E, Damirrchi SA, Jagerstad M, Dutta PC. Lipids and Phytopsterol oxidation in commercial French fries commonly in Sweden. Journal of food composition and Analysis 2008; 21:169-177. 12. Wai T, N.K. Local repeatedly used deep frying oils are generally safe. IeJSME 2007; 1: 55-60. 13. Water UK. Disposal of fats, oils, grease and food waste: best management practice for catering outlets 2013.p.1-8. Available from: http://www.water.org.uk/home/policy/publicat ions/archive/recycling/fogbrochure/fog-bestpractice.pdf (accessed 5 March, 2013)

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524168EnglishN-0001November30HealthcareOSSIFIED TRANSVERSE ACETABULAR LIGAMENT - AN OSTEOLOGICAL STUDY English3741A. PerumalEnglish S. SathiyaEnglishBackground: The ossification of transverse acetabular ligament is a rare interesting anatomical variation which converts the acetabular notch into a foramen. The transverse acetabular ligament (TAL) contributes to the stability of the joint. Sometimes the ligament gets ossified which limits the movement of hip joint and also leads to the compression of the nutrient vessel and subsequently result in ischemia of the area supplied by it. Ossification of the ligament as found in the present study may be helpful for the clinicians for differential diagnosis. Literature regarding the incidence, cause and clinical implications of this variation is therefore essential for radiologists, orthopaedicians and surgeons operating in the hip replacement surgery. The presence of ossified transverse acetabular ligament was noted and analyzed statistically. The study throws light on the incidence of the ossification of transverse acetabular ligament and discusses its clinical implications. Materials and Methods: Two hundred (214) dry human hip bones (right- 100 and left- 114) were taken for the study. The presence of ossified TAL was noted by macroscopic examination with naked eye. Results were tabulated and statistical analysis was done. Results: 4.3% of bones showed complete ossification of TAL on the left side hip bones and 14% of bones showed incomplete ossification of TAL on the right side and 11.4% on the left side hip bones. Conclusion: The knowledge of incidence of ossified TAL is essential for surgeons, orthopaedicians in performing the hip replacement surgery. The present study may be helpful for clinicians, radiologists and surgeons for differential diagnosis. EnglishHip bone, transverse acetabular ligament, compression, incidence, clinical implication.INTRODUCTION The acetabulum of hip bone is a cup- shaped depression where the three components ilium, ischium, pubis meet and subsequently fuse. It receives the head of femur to form the hip joint. The peripheral margin of the acetabulum gives attachment to a fibro-cartilaginous rim. The two ends of the notch give attachment to the transverse acetabular ligament (TAL) and contribute to the stability of the joint. The gap between the ligament and the notch transmits acetabular branches of obturator and medial circumflex femoral vessels which supplies the acetabular fat and head of femur. But if the transverse acetabular ligament (TAL) gets ossified which converts the acetabular notch into a foramen. The ossified TAL limits the movement of hip joint and also leads to the compression of the nutrient vessel and subsequently results in ischemia of the area supplied by it1 . The ligamentum teres predominantly arises from the transverse acetabular ligament which is thickened, hypertrophied in patients with developmental dysplasia of the hip (DDH), in which repeated traction on the attachment of the ligament centrally leads to hypertrophy of transverse acetabular ligament, which in turn further decreases the size of the acetabular fossa and prevents reduction of the hip8 . The transverse acetabular ligament (TAL) can be used to orient the acetabular component during total hip arthroplasty10. Literature regarding the incidence, cause and clinical implications of this variation is therefore essential for radiologists, orthopaedicians and surgeons operating in the hip replacement surgery. The presence of ossified transverse acetabular ligament was noted and analyzed statistically. The study throws light on the incidence of the ossification of transverse acetabular ligament and discusses its clinical implications. MATERIALS AND METHODS Data for this study comprised of 214 hip bones (Right - 100 and Left - 114) irrespective of sex and age was conducted in the Departments of Anatomy, VMKVMC and VMHMC, Salem. Hip bone with acetabular damage will be excluded from the study. Each hip bone was examined macroscopically for the presence of ossified transverse acetabular ligament (complete or incomplete). The various parameters like length, breadth, thickness of the ossified TAL and incase of complete ossification of TAL the vertical and transverse diameters of the acetabular foramen were measured using the vernier caliper. The results were tabulated and analyzed statistically. RESULTS The results were presented in Table: 1, 2, 3 & 4. Complete ossification of the transverse acetabular ligament (Fig. 1, 2) was observed in 4.3% of bones (5 bones out of 114 hip bones) on the left side and on the right side no such ossification of ligament. Incomplete ossification of the transverse acetabular ligament (Fig. 3) was observed in 14% of bones (14 bones out of 100 hip bones) on the right side and on the left side it was 11.4% (13 bones out of 114 hip bones). DISCUSSION The labrum is a fibrocartilaginous rim which encompasses the circumference of the acetabulum, effectively deepening the socket and its basal surface attached to the acetabular bone and transverse acetabular ligament. The transverse acetabular ligament mainly gives stability and also it bridges the acetabular notch. The gap between the notch and the ligament transmits the acetabular branches of obturator and medial circumflex femoral vessels which supplies the acetabular fat and head of femur. When the ligament gets ossified leads to the compression of the nutrient vessel and subsequently results in ischemia of the area supplied by it1 . The incomplete ossification of TAL was more common on the right side hip bone than the left and the average values of length, breadth and thickness on the right were found to be 1.5cms, 0.9cms, 0.4cms respectively and on the left the average values were 1.6cms, 1.1cms, 0.5cms respectively (Table:2). The TAL ligament was completely ossified on the left side hip bone and the average value of length, breadth and thickness were found to be 2.8cms, 1.6cms, 0.4cms respectively (Table: 3). With complete ossification of the TAL the acetabular notch was converted into acetabular foramen and the average vertical, transverse diameters of the acetabular foramen were 1.2cms, 1.8cms respectively (Table: 4). Sharmila Bhanu et al2 described that one of the male pelvis showed bilateral ankylosis of sacroiliac joint, ossified sacrospinous ligament, sacrotuberous ligament and ossification of TAL on both sides. In their study, the length of the TAL was 3.6 cm on the right, 3.5 cm on the left side and maximum width of the ligament was 1.4 cm on the right and 2.1 cm on the left side hip bone. But in our study we observed 0.4% complete ossification of TAL on the left side bone and the average length, breadth was 2.8, 1.6cms respectively but no such variation was observed on the right side. The Anterior pelvic plane (APP) has been the cornerstone of image-based hip navigation technologies in which TAL was also used to predict the inclination and version of the acetabulum indirectly and when the ligament is ossified causing problems in registering bony land marks through the ossified ligament5,6. In open surgical hip dislocation the ligamentum teres capitis was separated at the level of its attachment into the transverse ligament and acetabular fossa9 . In case of ossified TAL there will be difficulties in performing this procedure. The present study reveals an incidence of ossification of TAL 4.3% of complete ossification on the left side and incomplete ossification of TAL 14% on the right and 11.4% on the left respectively (Table: 1). CONCLUSION Based on the present study, it was concluded that the ossified transverse acetabular ligament (TAL) interferes in the total hip replacement surgery. Hence the knowledge about the incidence of ossified TAL is essential for surgeons, radiologists, and orthopaedicians in performing the above procedure. The presence of ossified TAL can be revealed using Radiographic imaging which helps the surgeons to overcome the problems before performing the hip replacement surgery. ACKNOWLEDGEMENTS The authors sincerely wish to thank the management, administrators and the Professor and Head of the department of Anatomy of Vinayaka Missions Kirupananda Variyar Medical College, Salem for their whole hearted support and permissions to utilize their resources and conduct this study. The authors acknowledge the great help received from the scholars whose articles cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Authors are grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript. Englishhttp://ijcrr.com/abstract.php?article_id=903http://ijcrr.com/article_html.php?did=903REFERENCES 1. Standring S. Gray’s Anatomy: Anatomical Basis of Clinical Practice. 39th Ed., London, Elsevier Churchill-Livingstone 2008; 1389– 1390. 2. Sharmila Bhanu P and Devi Sankar P. Bilateral ankylosis of sacro-iliac joint with ossified sacrospinous, sacrotuberous and transverse acetabular ligaments: a case report. International Journal of Anatomical Variations 2011; 4: 123–127. 3. Stefan Milz,Georgios Valassis, Andreas Buttner, Markus Maier, Reinhard Putz, James R. Ralphs, Michael Benjamin. Fibrocartilage in the transverse ligament of the human acetabulum. Journal of Anatomy 2001; 198: 223-228. 4. Archbold.B, Mockford.D, Molloy.J, McConway.L, Ogonda.D, Beverland. The transverse acetabular ligament: an aid to orientation of the acetabular component during primary total hip replacement. British Editorial Society of Bone and Joint Surgery 2006; 88: 883-886. 5. Sam Hakki, Victor Bilotta, Janiel Oliveira, Luis dordelly. Acetabular Center Axis: Is It the Future of Hip Navigation?. Orthopaedics 2010; 33: 43-47. 6. A. Narvani, E. Tsiridis, C. C. Tai, P. Thomas. Acetabular labrum and its tears: Br J Sports Med 2003; 37: 207–211. 7. Daniel.J, Abramson, Samuel Kamberg, Jefferson Barracks, Missouri. Spondylitis, pathological ossification, and calcification associated with spinal-cord. The Jounal of bone and Joint Surgery 1949; 31-A: 275-283. 8. Luis Cerezal, Ara Kassarjian, Ana Canga, María Carmen Dobado, Juan Antonio Montero, EvaLlopis, Alejandro Rolon, Luis Perez-Carro. Anatomy, Biomechanics, Imaging and Management of Ligamentum Teres Injuries. RadioGraphics 2010; 30:1637– 1651.  9. Rafael J. Sierra, Robert T. Trousdale. Labral reconstruction using the ligamentum teres capitis. Clin Orthop Relat Res 2009; 467:753– 759. 10. Noah J. Epstein, Steven T. Woolson, Nicholas J. Giori. Acetabular Component Positioning Using the Transverse Acetabular Ligament. Clin Orthop Relat Res 2011; 469:412–416. 11. Sudsriluk Sampatchalit, Lina Chen, Parviz Haghighi, Debra Trudell, Donald L. Resnick. Changes in the Acetabular Fossa of the Hip: MR Arthrographic Findings Correlated With Anatomic and Histologic Analysis Using Cadaveric Specimens. AJR 2009; 193:127– 133.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524168EnglishN-0001November30HealthcareSTUDY OF NOSOCOMIAL URINARY TRACT INFECTIONS WITH SPECIAL REFERENCE TO CANDIDURIA AT BLDEU&#39;s SHRI B.M.PATIL MEDICAL COLLEGE AND HOSPITAL, BIJAPUR, KARNATAKA English4251Raj Mohammed D. MalledEnglish Prashant K. ParandekarEnglish Annapurna G. SajjanEnglishBackground of the study: Nosocomial urinary tract infections are the most common of hospital acquired infections comprising about 40%. Majority are related to catheterization or other predisposing factors. Candiduria is rarely encountered in otherwise healthy people with structurally normal urinary tract. It is however of common occurrence in hospitalized patients. Candida spp. account for almost 10-15% of nosocomial urinary tract infections. Objectives: Present study was undertaken to identify various pathogens causing nosocomial UTI, and further study including identification of yeasts and to analyze the various risk factors associated with candiduria in hospitalized patients. Methodology: 195 urinary isolates of patients admitted in hospital ?3 days were screened. The bacterial and yeast isolates were identified by conventional methods. Results: Of the 195 samples from the cases of suspected nosocomial UTI screened, 131(67.17%) yielded growth, amongst which 17 (12.9%) were Candida species. Amongst the bacterial isolates, E.coli (38.16%) was the most common followed by Citrobacter spp. (16.0%), Klebsiella pneumoniae (12.2%) and others. Whereas, among the Candida isolates C. tropicalis (41.1%) was found to be predominant followed by C. guillermondi (23.5%), C. albicans (17.6%), C. krusei (11.7%) and C.glabrata (5.8%). Majority of the patients were having various predisposing factors. Conclusion: Non albicans species were predominant amongst the Candida isolates, majority of patients were having predisposing factors emphasizing the need of proper surveillance of nosocomial UTI for appropriate treatment. EnglishNosocomial UTI, Candiduria, non-albicans CandidaINTRODUCTION Urinary tract infections (UTIs) are the most common nosocomial infections which account for about 40% of all hospital – acquired infections and constitute a major source for nosocomial septicemia and related mortality in acute care hospitals.1 The vast majority of UTIs occur in patients with temporary indwelling catheters. 1,2,3,4 The microorganisms usually responsible for catheter – associated UTIs are derived from the fecal flora native to the patient or originate in the hospital environment.1 They include Escherichia coli, Enterococcus species, Pseudomonas aeruginosa, Klebsiella pneumoniae, Proteus mirabilis, Staphylococcus aureus, Staphylococcus epidermidis and Candida species.2,4 An increasingly important subgroup of nosocomial urinary tract infections are those due to fungi, and almost all fungal urinary tract infections are caused by Candida spp.5 The predisposing factors frequently associated with candiduria are urinary tract instrumentation, prior surgical procedures, recent use of antibiotics, prolonged hospital stay, extremes of age, diabetes mellitus, female sex and use of immunosuppressive therapy.6,7 Candiduria or presence of Candida spp. in the urine is a relatively rare finding in otherwise healthy people.8 The presence of Candiduria may reflect only colonization of the bladder, perineum, or indwelling urinary catheter.9 It is rarely encountered as a community acquired infection in a structurally normal urinary tract as they usually present as complicated nosocomial infections. Candida spp. accounts for almost 10-15% of nosocomial urinary tract infections.10 The recovery of Candida species from urine samples presents the clinician with a diagnostic dilemma as to whether the presence of candiduria in a patient represents contamination, colonization or true infection.8 Though contamination of urine sample is very common, it can be ruled out by obtaining a second sterile urine sample. But till date, there are no reliable methods of differentiating colonization of urinary tract from true UTI with Candida spp.8,10 The specific identification of Candida spp. is important as it provides information in the choice of treatment, because C.glabrata and C.krusie are naturally resistant to fluconazole.11 Though Candida albicans is the most frequently isolated species, few observers have emphasized the changing microbial trends towards non-albicans Candida species.10,12 Hence, the present study was undertaken with the objective of identifying various pathogens incriminated in nosocomial UTI, to speciate the yeasts isolated in these infections and to analyze the various risk factors associated with candiduria. METHODOLOGY The study was undertaken after clearance from institutional ethical committee at BLDEU’s Shri B.M.Patil Medical College and Hospital, Bijapur, Karnataka from March 2012 to January 2013. After taking informed consent from the patients, a total of 195 urine samples of patients admitted in hospital for ?3days were screened. Inclusion criteria Patients admitted in the hospital for more than 3 days. Pure growth from urine sample with significant colony count of 104 colony forming units (cfu)/ml for Candida and 105 cfu/ml in case of bacteria were included.8 The specimen yielding Candida isolates were further subjected to repeat urine cultures. The Candida species reisolated after repeat culture were included in the present study. Exclusion criteria Absence of pyuria / mixed growth in the culture. Duration of admission in hospital is less than 3 days. Candida species failed to be isolated on repeat culture. In the Patients with candiduria, demographic details such as age, sex, duration of hospital stay, duration of catheterization and other clinical details were noted. Presence of other associated risk factors like diabetes mellitus, history of antibiotic use, any urinary tract instrumentation, any surgical procedures carried out on the patient or use of immunosuppressive drugs were also recorded. Urine sample processing In case of non-catheterized patients a clean catch midstream urine samples were collected, whereas in catheterized patients sterile urine specimens were obtained via syringes after cleaning the catheters with an antiseptic solution.14 After direct microscopic examination in the form of wet mount and Gram stained smears, the urine samples were inoculated on Cysteine Lactose Electrolyte Deficient (CLED) and MacConkey’s agar using standard loop as per the semi quantitative culture technique. Moreover, the specimens showing budding yeast like cells on direct examination were inoculated on Sabourauds Dextrose Agar (SDA). The further incubation of these media was done at 370C temperature for 16-24 hours followed by identification by using conventional methods. The specimens yielding no growth after 16-24 hours were further incubated upto 48 hours and regarded as sterile if there is no growth.15 The Yeast cells identified on Microscopy are processed further for identification as follows a. Germ tube test – the Candida cultures were treated with human serum and incubated at 370C for 2-4 hours. A drop of the suspension is examined on the slide under the microscope. The germ tubes are seen as long tube like projections extending from the yeast cells.16 b. Chlamydospore formation - the Candida isolates were grown on the corn meal agar (CMA) plate and incubated at 250C for 2-3 days and later examined for microscopic morphology of the chlamydospores for identification of various Candida species.16 Statistical analysis The results wherever applicable were analyzed by Fischer’s exact test for statistical significance by using Graphpad In Stat 3. The P value was calculated for determining whether the results obtained were statistically significant. P value of ?0.05 was considered as statistically significant. RESULTS The present study includes 195 samples from the cases of suspected nosocomial UTI of which 131(67.17%) yielded growth amongst which 17 (12.9%) were Candida species. The most commonly isolated organism was Escherichia coli-50 (38.16%), followed by Citrobacter spp.-21 (16.03%), Klebsiella pneumoniae -16 (12.21%) and others (Table 1.) Demographic profile with regards to candiduria: Majority of the patients with candiduria belonged to age group ? 61 years (35.3%) followed by age group 46-60 years (29.4%). (Table 2.) Amongst 94 culture positive males 11 (11.7%) showed candiduria whereas out of 37 culture positive females 6(16.2%) cases revealed candiduria (fisher’s exact test, P value = 0.565). Other associated risk factors of the study group are shown in Table 3. The average length of hospitalization during which candiduria developed was 14.9±6 days. The risk of developing candiduria was high in patients after 11.6±6 days of catheterization. Antibiotic usage was seen with all the patients for the duration of 5 to 8 days. Whereas one patient of candiduria was on fluconazole for 10 days in which Candida krusei was isolated. Moreover one case was on corticosteroids. 7 of the 17 patients (41.1%) were diabetic, and 6 (35.2%) were having associated urinary tract abnormality such as benign hypertrophy of prostate, renal and ureteric calculi. In the present study, amongst the cases of candiduria, non-albicans Candida spp. were the predominant species recovered responsible for 82.3% of nosocomial UTI. Candida albicans accounted for only 17.6% of nosocomial UTI. Amongst Non albicans Candida species, Candida tropicalis accounted for majority of the cases (41.1%). Distribution of various Candida spp. is given in table 4. DISCUSSION In the recent past, medical and surgical advances in the areas of medical technologies, have markedly altered the hospitalized patient populations leading to survival of greater number of hospitalized patients who are severely ill. These patients are at increased risk of nosocomial infections. Nosocomial infections constitute a serious public health problem, as they are a major cause of morbidity and mortality, and cause an increased time of hospitalization with associated enhanced healthcare costs.12 Therefore we studied a spectrum of organisms causing nosocomial urinary tract infections with special emphasis on nososcomial candiduria. In the present study we observed that Escherichia coli was the most common organism isolated (38.16%) followed by Citrobacter spp (16.03%), Klebsiella pneumoniae (12.21%) and Candida spp.(12.97%). Whereas, Kamat U et al.17 showed E.coli (49.1%), as the most common pathogen followed by P.aeruginosa (12.72%), Klebsiella spp. (12.7%) and Candida albicans (10.9%) in a similar study. Another study by Savas et al.18 demonstrated E.coli (31.4%) as the most common pathogen followed by Candida spp. (21.3%), Klebsiella spp.(10.6%) and Enterococci (6.9%). Our study revealed 12.97% of the isolates to be Candida spp. Similar observation was noted by Kamat U et al.17 who reports 10.9%. Whereas, Savas et al.18 reported 21.3% of the UTIs caused by Candida spp. This may be perhaps because of difference in the sampling techniques and antibiotic prescribing trends in the hospital. Of the Candida isolates in our study, 17.6% were Candida albicans, whereas 82.4% were Candida non-albicans. Amongst overall isolation of Candida species, C.tropicalis was found to be the predominant Candida spp. accounting for 41.1%, followed by C.guillermondi 23.5%, C.albicans 17.6%, C.krusie 11.7% and C.glabrata 5.8%. Many previous studies reported Candida albicans as the predominant species such as a study conducted by Febre N et al.11 who showed that C.albicans was isolated in 46.1%. Similarly Sobel JD et al.19 reported C.albicans in 50% of the cases followed by non-albicans Candida spp. Whereas a study conducted by Paul N et al.20 which showed C.albicans in 19% and C.tropicalis in 43% of the cases and a study by Jain M et al.10 revealed C.albicans in 28.6%, C.tropicalis in 52.9% and C.glabrata in 1.4% of the cases which are in accordance with our study. These findings suggests that there is a changing trend towards Candida non-albicans which might be due to the selection of less susceptible species by antifungal agents such as fluconazole.7 Analogous observation was seen in one case in our study group on fluconazole therapy in which Candida krusei was isolated. We found that candiduria was apparently more common in females (16.2%). This finding is well in accordance with other researchers also.6,8,19 But this statistical analysis revealed that there is no significant association of candiduria in females by fisher’s exact test (P value = 0.565). There have been few other observers who did not find significant difference in terms of female sex having more chances of candiduria.14 This may be perhaps be explained by associated various risk factors such as age, immunocompromised status, antibiotic therapy, instrumentation etc. We observed that nosocomial UTI due to Candida spp. was more common in the age groups >61 yrs, which is well in accordance with other researchers.10 Diabetes mellitus was seen in 41.1% of the patients with candiduria in present study. This is in agreement with the study conducted by Kauffman CA et al.5 who noted diabetes mellitus in 39% of candiduria in their study. Patients with diabetes are at increased risk for UTIs due to candida spp. Diabetes may predispose patients to fungal candiduria by predisposing them to Candida colonization, by enhancing urinary fungal growth in the presence of glycosuria, by lowering host resistance to invasion by fungi as a consequence of impaired phagocytic activity, and by promoting stasis of urine in a neurogenic bladder.8 Previous history of antibiotic use was seen in all the patients with candiduria. In a study by Guler S et al.14 88.2% of the cases with candiduria were on the antibiotics, whereas Passos XS et al.7 noted antibiotic use in all the patients with candiduria. Our finding is well in accordance with latter. Antimicrobial treatment was reported to be a risk factor for candiduria in 70-100% in various studies. It has been reported that approximately 30% of the adults gastrointestinal tract is colonized by Candida species and the colonization rates approached to 100% in patients receiving antibiotics.8 Antibiotic use suppresses susceptible endogenous bacterial flora in the gastrointestinal and lower genital tract and favors the colonization of epithelial surface with fungal species, thus increasing the chance of introducing the organisms into the urinary tract specially in the presence of indwelling urinary devices.7 In the present study 58.8% of the patients with candiduria were catheterized and the mean duration of catheterization was 11.6±6 days. Similar results were obtained by Passos XS et al.7 who verified that 92.6% of the patients with candiduria had urinary catheter. Urinary catheters serve as a portal of entry and most catheters become colonized if left for longer duration. There is a direct relationship between the duration of catheterization, candidial colonization and of nosocomial candiduria.10 With short term catheterization (upto 7 days), 10-50% patients develop infections, whereas in long term catheterization (>28 days), usually all patients develop urinary tract infection. The risk of catheter associated infections increases by approximately 10% for each day.21 With this observation we recommend that catheterization should be conducted when it is dire essential and for short duration as early removal of the urinary catheters lessens the burden of UTIs. In the present study associated urinary tract abnormality was seen in 35.2% of the cases and previous surgery in 17.6% of the cases. According to literature,22 obstruction to urinary flow at all levels is a key factor in increasing host susceptibility to UTI. Obstruction inhibits the normal flow of urine and the resulting stasis compromises bladder and renal defense mechanisms. Stasis also contributes to the growth of bacteria in the urine and their ability to adhere urothelial cells. Perhaps the similar mechanisms may be playing role for the colonization and invasion of Candida species in the cases of candiduria in our study group. Although the number of Candida species studied were limited, the present study highlights the increasing importance of candiduria in hospitalized patients with various risk factors which should not be ignored. Careful vigilance and monitoring of such cases is of utmost importance. Appropriate diagnosis of causative agent is essential as it impacts the therapy of these patients. Moreover, changing trend of Candida species towards non-albicans Candida species is being increasingly reported. Thus appropriate speciation of Candida is crucial for further management of these cases. This is necessary as the non-albicans Candida species such as C.glabrata and C.krusie are resistant to fluconazole which is commonly prescribed drug for the treatment. CONCLUSION Escherichia coli is the most frequent uropathogen isolated from nosocomial UTIs. Candida spp. are more common in patients admitted in hospital for prolonged periods in presence of other risk factors such as urinary catheterization, diabetes, previous surgeries, associated urinary tract abnormality and older age groups. Our study emphasizes the fact that there is a change in trend with shift towards non-albicans Candida spp. as the predominant pathogen causing nosocomial UTI which are more difficult to treat. Thus speciation should be performed for appropriate management of such patients. ACKNOWLEDGEMENTS Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors  publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed./ Englishhttp://ijcrr.com/abstract.php?article_id=904http://ijcrr.com/article_html.php?did=904REFERENCES 1. Taher MT, Golestanpour A. Symptomatic nosocomial urinary tract infections in ICU patients: identification of antimicrobial resistance pattern. Iranian journal of Clin Infect Dis 2009;4(1):25-29. 2. Kyschi MF, Namias N. Nosocomial urinary tract infection. Surg Clin N Am 2009; 89: 475- 481. 3. Maldonado SIC, Luna JAC. Nosocomial Urinary Tract Infections In: Dr. Ahmad Nikibaksh, editors. Clinical management of complicated urinary tract infection, Croatia: InTech Europe; 2011:225-238. 4. Khan BA, Saeed S, Akram A, Khan FB, Nasim A. Nosocomial uropathogens and their antibiotic sensitivity patterns in a tertiary referral teaching hospital in Rawalpindi, Pakistan. J Ayub Med Coll Abottabad 2010;22 (1):11-12. 5. Kauffman CA, Vazquez JA, Sobel JD, Gallis HA, McKinsey DS, Karchmer AW et al. Prospective multicenter surveillance study of funguria in hospitalized patients. Clin Infect Dis 2000;30:14-8. 6. Bukhary ZA. Candiduria: A review of clinical significance and management. Saudi J Kidney Dis Transplant 2008;19(3):350-360. 7. Passos XS, Sales WS, Maciel PJ, Costa CR, Miranda KC,Lemos JA, et al. Candida colonization in intensive care unit patients’ urine. Mem Inst Oswaldo Cruz 2005;100(8):925-8. 8. Lundstrom T, Sobel J. Nosocomial candiduria: A review. Clin Infect Dis 2001; 32:1602-7. 9. Kauffman CA. Candiduria. Clin Infect Dis 2005; 41:S371-6. 10. Jain M, Dogra V, Mishra B, Thakur A, Loomba PS, Bhargava A. Candiduria in catheterized intensive care unit patients: Emerging microbiological trends. Indian J of Pathol Microbiol 2011;54(3):552-5. 11. Febré N, Silva V, Medeiros EAS, Wey SB, Colombo AL, Fischman O. Microbiological characteristics of yeasts isolated from urinary tracts of intensive care unit patients undergoing urinary catheterization. J Clin Microbiol 1999;37(5):1584-86. 12. Silva S, Negri M, Henriques M, Oliveira R, Williams D, Azeredo J. Silicone colonization by non-Candida albicans Candida species in the presence of urine. J Med Microbiol 2010;59: 747- 754. 13. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections. In: Olmsted RN, ed.: APIC Infection Control and Applied Epidemiology: Principles and Practice. St. Louis: Mosby; 1996: pp. A1-20. 14. Guler S, Ural O, Findik D, Arslan U. Risk factors for nosocomial candiduria. Saudi Med J 2006; 27(11):1706-10. 15. Forbes BA, Sahm DF, Weissfeld AS. Baily and Scott’s Diagnostic Mirobiology. 10th Ed. Mosby Elsevier, Missouri, US 1998:842-856. 16. Chander J. Textbook of Medical Mycology, 3 rd Ed. Mehta publishers, New Delhi, India 2011: p278. 17. Kamat US, Fereirra A, Amonkar D, Motghare DD, Kulkarni MS. Epidemiology of hospital acquired urinary tract infections in a medical college hospital in Goa. Indian J of Urology 2009; 25(1):76-80. 18. Savas L, Guvel S, Onlen Y, Savas N, Duran N. Nosocomial urinary tract infections: microorganisms, antibiotic sensitivities and risk factors. West Indian med J 2006; 55(3):188- 93. 19. Sobel JD, Kauffman CA, McKinsey D, Zervos M, Vazquez JA, Karchmer AW et al. Candiduria: A Randomized, Double-Blind Study of Treatment with Fluconazole and Placebo. Clin Infect Dis 2000;30:19-24.  20. Paul N, Mathai E, Abraham OC, Mathai D. Emerging microbiological trends in candiduria. Clin Infect Dis 2004;39:1743-4. 21. Bose S, Ghosh AK, Barapatre R. The incidence of Candiduria in an ICU – A study. Journal of Clinical and Diagnostic Research 2011; 5(2): 227-230. 22. Schaeffer AJ, Schaeffer EM. Infections of the Urinary Tract. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA editors. Campbell – Walsh Urology. 10th Ed. Vol 1. Elsevier Saunders, Philadelphia, USA 2012. P. 257-327.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524168EnglishN-0001November30HealthcareCOMPARATIVE STUDY OF HEALTH PROMOTING BEHAVIORS AMONG MANIPURI AND NORTH INDIAN STUDENTS IN CHANDIGARH, INDIA English5256Suraj S. SenjamEnglishBackground: Many students from north east India mostly from Manipur have migrated to Chandigarh for further studies. It is worthwhile to know how their health promoting behaviours is different from north Indian students in Chandigarh. Objective: To compare health promoting behaviours of migrant Manipuri students and north Indian students of Chandigarh. Material and Methods: A cross sectional study was conducted in four purposively selected colleges of Chandigarh during September 2007 to June 2008. Two hundred students (Manipuri=100 and north Indian=100 with equal proportion of male and female) were studied using a self administered questionnaires of health promoting lifestyle profile (HPLP). Results and Conclusion: Local students had significantly higher sense of health responsibility than Manipuri students (24.69 vs. 25.54; pEnglishINTRODUCTION In college life, students pass through in a dynamic transitional period of growth and development. As they grow, the adolescents gradually assume responsibility for their own health1 . Their health promoting practices and behaviors not only impact their immediate health status but also have long term health consequences. It is far more difficult for adults to change unhealthy habits adopted in their youth. Many of the factors that contribute to health risks in older adults are preventable if identified and changed at an early stage of life2 . College life, thus, offers opportunities for inculcating healthy lifestyle behaviors in students. Around 700 Manipuri students are presently pursuing higher studies in Chandigarh3 . Every year, approximately 100 Manipuri students migrate to the Union Territory Chandigarh for the purpose of higher studies. Generally migrant students are likely to be different in several aspects of life from their counterparts in the receiving state. Often, they suffer from nutritional deficiencies and communication problem, social exclusion, social inequality, poverty and lack of social support or protection etc. All these factors have direct adverse health effects on students? lives4 . Against this background, the present study was conducted with an objective to compare the level of engagement in health promoting behaviors among Manipuri and north Indian graduate students of Chandigarh. METHODOLOGY This cross sectional study was carried out during September 2007 to June 2008 among 1st year graduate Manipuri students (MN) and north Indian students (NI) in Chandigarh in four purposively selected colleges of Chandigarh where Manipuri students were enrolled. There were 126 Manipuri students (67 male and 59 females) who enrolled in the year 2007-08 in these four colleges of Chandigarh. Of these, convenience sampling of 100 Manipuri students (50 male and 50 female) students were done. Equal numbers of north Indian native students who were in the same college and year, were also selected randomly. The sample size (N=170) was estimated based on an alpha value of ≤0.05, and power level of 0.90 for two independent groups with medium effect size of 0.505 . To be on safer side, a sample size of 200 was taken with each group of 100 students. A selfadministered questionnaire „Health Promoting Lifestyle Profile? (HPLP) was used in this study which measures health promoting behaviors. In the original HPLP questionnaire, all 52 items are scored by a fixed 4-point Likert-type format where: 1 coded as “never”, "sometimes" as 2, "often" as 3, and "routinely" as 4. The term „routinely? was chosen to represent the most frequent response category because it suggests a regular pattern of behaviors or characteristic of life-style6,7 . For the present study, requisite minor language change was done from the original items to make it understand to study population. In addition, two items which were not suitable locally, were deleted from the original HPLP. Remaining 50 items were grouped into six different subscales as original: viz. health responsibility, physical activities, nutrition habits, stress management, interpersonal relationship, and spiritual growth. Face, content and consensus validity of the tool was done with experts. Pretest was also done in 10 each of Manipuri and north Indian Chandigarh students. In analyzing health promoting behaviors, only those who reported “often” or” routinely” or similar option or those who got 3 or 4 score in each items were considered as practicing health promoting behavior and those reported “never” or “sometimes” or got 1 or 2 score were considered as not practicing the particular health promoting behaviors. The internal consistency, reliability coefficients for total scale, and subscales ranged from 0.7- 0.85. The original HPLP had reliability with internal consistency for the total score and subscale ranging from 0.7-0.92. Data were analyzed with SPSS for Windows software, version 16 (Chicga, Illinois, USA). Descriptive statistics, Chi- square test and t-test were used in statistical analysis. Ethical clearance: Institute ethical clearance was sought before the study. A written permission was obtained from the Vice Chancellor of the Punjab University and respective colleges? principal before study. Consent of students was also taken. RESULTS Overall, 200 students were included in the study i.e. 100 Manipuri (50 male and 50 female) and 100 north Indian Chandigarh students (50 male and 50 female). HPLP questionnaires were filled by both groups of students without missing any item. Mean age of Manipuri students was higher as compared to local students (table 1). North Indian Chandigarh students had significantly higher sense of health responsibility than Manipuri students (p=0.04; table 2). While 49% of Manipur students consulted a doctor whenever they had any health problem, 64% native students did so (pEnglishhttp://ijcrr.com/abstract.php?article_id=905http://ijcrr.com/article_html.php?did=905REFERENCES 1. Terries M. Healthy lifestyle: The perspective of epidemiology. J Public Health Policy 1992;13(2):186-94. 2. Lee A, Wun Y, Chan K. Changing family medicine/general practice morbidity patterns in Hong Kong adults. Hong Kong Practitioner 1997;19(10):508-17. 3. Manipur Students? Association Chandigarh, available from http://www.msacmanipur.com (last accessed on August 2007) 4. Shaw M, Dorling D, Smith GD. Poverty, social exclusion, and Minorities: Marmot M and Wilkinson RG. Social determinant of health, 2 nd Edition. London, Oxford University Press, 2003;196-223. 5. Cohen J. Statistical power analysis for the behavioral sciences, 2nd edition. Hillsdale New Jersey, Lawrence Erlbaum Associate Publishers,1988. 6. Walker SN, Sechrist KR, Pender NJ. The Health-Promoting Lifestyle Profile: Development and psychometric characteristics. Nurs Res 1987;36(2):76-81. 7. Walker SN, Hill-Polrecky D. Psychometric evaluation of the Health-Promoting Lifestyle Profile II. In:Proceeding of the 1996 Scientific session of the American Nurse Association?s Council of Nurse Researchers 1996 June13-14 Washington (DC):p-110. 8. Martin JJ, Wardle J. Social patterning of individual health behaviors: the case of cigarette smoking. Marmot M and Wilkinson RG. Social determinant of health, 2nd Edition. London, Oxford University Press, 2003;224- 37. 9. History of Manipur –available from free encyclopedia: en.wikipedia.org/wiki/Manipur (last assessed on July 2010). 10. Haddad L, Kane D, Rajacich D, Cameron S, Al-Ma&#39;aitah R. A comparison of health practices of Canadian and Jordanian nursing students. Public Health Nurs 2004;21:85-90. 11. Duffy ME, Rossow R, Hernandez M. Correlates of health-promotion activities in employed Mexican American women. Nurs Res 1996;25:18–24. 12. Petlzer K. Health behaviors among Black and White South Africans. Perspect Public Health 2002;122:187-93. 13. Steven RH, Hala NM, Ray MM, Marylynn BG, Takeo M. A Cross-cultural comparison of health promoting behaviors among college students. The International Electronic Journal of Health Education 2002;5:84-92 14. Ahijevych K, Bernhard L. Health promoting behaviors of African American women. Nurs Res 1996;43:86-9. 15. Kerr MJ, Ritchey DA. Health-promoting lifestyles of English speaking and Spanishspeaking Mexican-American migrant farm workers. Public Health Nurs 1990;7:80-7

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524168EnglishN-0001November30HealthcareCLINICOPATHOLOGICAL STUDY OF BENIGN SOFT TISSUE TUMORS English5762Venkatraman J.English Rathna S..English Dhananjay S. KotasthaneEnglish Govindaraj T.EnglishObjective: “Soft tissue&#39; is a non epithelial extra skeletal tissue of the body exclusive of the reticuloendothelial system, glia and supporting tissue of the various parenchymal organs”[1]. Though they can occur anywhere in the body, most commonly they involve upper and lower extremities, trunk, retro-peritoneum and head and neck [1,7]. Biological activity of these tumors varies from benign localized tumors, to benign locally aggressive, to malignant metastatic types [4]. Diagnosis of soft tissue tumors are done by standard methods like Light microscopy, special stains and immune histo chemistry [7,8,9]. This study was conducted with the aim of studying gross and microscopic features of various benign soft tissue tumors and also to correlate them clinically. Materials and methods: The incisional and excisional specimens of various soft tissue tumors were fixed in 10% neutral formalin for 24 hrs and they were subjected for routine processing and reporting. Both gross and light microscopy of the tumors were studied that included the clinicopathological features of 109 cases of soft tissue tumors between the period of May 2008 to May 2012. Results: A total number of 109 cases of soft tissue tumors were studied. Benign soft tissue tumors constituted 79.8% with a peak age occurrence in the fifth decade and showed predilection for upper extremities and lower extremities. Conclusion: Benign soft tissue tumors out number malignant tumors and it is very important to make accurate diagnosis since it has a favourable clinical outcome. EnglishBenign tumors, microscopy, soft tissue, lipoma.INTRODUCTION “Soft tissue&#39; is a non epithelial extra skeletal tissue of the body exclusive of the reticuloendothelial system, glia and supporting tissue of the various parenchymal organs” [1]. Though they can occur anywhere in the body, most commonly they involve upper and lower extremities, trunk, retro-peritoneum and head and neck [1,7]. The incidence of soft tissue tumors are more when compared to the frequency of malignant ones. Benign soft tissue tumors out number malignant tumors by a margin of about 100:1 in a hospital population, and their annual incidence is approximately 300 per 100,000 population [2,3]. They can occur at any age and, like carcinomas they are more common in older patients; Malignant Soft tissue tumors occur more commonly in males than females, but gender and age-related incidences vary among the histologic types [1]. Biological activity of these tumors varies from benign localized tumors, to benign locally aggressive, to malignant metastatic types [4]. Clinical history, radiography and histopathology are the most reliable guides for making an accurate diagnosis and for predicting the clinical behaviour of the tumor. However grading of malignant soft tissue tumors are much more important in predicting the biological behaviour as well in assessing the prognosis of the tumors [5,6]. The criteria used for grading soft tissue tumors include cellularity, mitotic count, tumor differentiation and necrosis [6,7]. Diagnosis of soft tissue tumors are done by standard methods like Light microscopy of Hematoxylin and Eosin tissue sections, special stains like Masson’s trichrome, PAS and if necessary immunohistochemistry [7,8,9]. Prognosis of soft tissue tumors mainly depend on tumor size, microscopic grade, location, margins, clinical staging, DNA ploidy and genetic alterations [1,6]. SUBJECTS AND METHODS This study was carried out during May 2008 to May 2012 in a tertiary care hospital in Pondicherry, India. All benign soft tissue tumors received in the department of pathology following surgeries are included in the study. A detailed clinical data of the patient including clinical history and histo-pathological examination of the specimen was carried out. The parameters included were the age, sex, anatomical location, clinical diagnosis and the histo-pathological features. Following surgery, the specimens were received in the Department of Pathology and gross findings like size, shape, colour and consistency were recorded. The specimens were fixed in 10% neutral formalin for 24 hrs and then 4 mm thick sections were cut from representative areas and submitted for routine processing. Sections were studied by light microscopy after H and E staining. Special stains such as periodic acid schiff, Masson’s trichrome and reticulin are done, wherever necessary. Immunohistochemical studies and the electron microscopical studies were advised in some of the soft tissue malignant tumors to support the diagnosis. The data was analyzed and compiled with help of tables, pie chart and bar diagrams. Histological subtypes were classified according to WHO classification of soft tissue tumors. RESULTS A total of 87 benign soft tissue tumors out of a total of 1010 tumors of all types were included in the present study for final analysis. Incidence Soft tissue tumors constituted 10.7% of all tumors. There were 109 soft tissue tumors in which 87 were benign. Benign soft tissue tumors constituted 79.8 % of all soft tissue tumors. The adipose tumors accounted for the majority of benign soft tissue tumors (53.2%) followed by vascular tumors (21.1%). Benign tumors of smooth muscle and tumor of skeletal muscle were not encountered in the present study (figure 1). Age and sex Benign STT’s were relatively equal in both females and males with a male to female ratio of 1:1.02(Table 1). The youngest patient in the present study was 7 months old while the oldest was 74 years old. Majority of the benign tumors occurred in the fourth, fifth and sixth decade with a peak occurrence in the fifth decade (Table 2). Size and location Benign soft tissue tumors showed a marked predilection for upper extremity followed by lower extremity and trunk in descending order of frequency (Table 3). On gross, Majority of the benign tumors (84 cases, 96.5%) were well circumscribed measuring less than 5 cm. Benign fibrous tumors The commonest benign fibrous tumor was Nodular fasciitis (3 cases, 3.4 %), which occurred, commonly in the adult age group with predilection for upper extremities. There were only one case of Fibroma and Angiofibroma and both of them occurred in females (Table 4). Venkatraman J. et. al. CLINICOPATHOLOGICAL STUDY OF BENIGN SOFT T Fibrohistiocytic tumors There were 4 cases of benign Fibrous histiocytomas (4.5%) involving commonly the upper extremity and all of them occurred in females. Adipose tissue tumors The commonest of adipose tumors were lipomas followed by lipomatosis, which showed a predilection for extremities. Benign adipose tumors are most common tumors of all STT’s (56 cases, 51.37%). Vascular tumors Benign vascular tumors were the second common tumor group (20 cases, 18.3%). Haemangiomas occurred in the first two decades thus accounting for the commonest benign soft tissue tumor of childhood. They showed a striking predilection for the head and neck region unlike other benign soft tissue tumors. Haemangioma of granulation tissue type otherwise called pyogenic granuloma occurred most commonly over the lips (Table 5). DISCUSSION Occurrence The commonest benign tumor type was the adipose tumor constituting 64.3 % of benign soft tissue tumors, which is in contrast to the study of Kransdorf [10] where the commonest tumor was fibrous tumor which constituted 20.6 % and the adipose tumor constituted only 16.1 % Age In the present study the age ranged from 7 months to 74 years. Which can be comparable to Tsujimoto[11] study where the age ranged from one month to 84 years. The average age in the case of benign tumors was 45 years which is comparable to the studies of M. Jensen [12]. The age range in the benign tumor group was 7 months to 73 years with a peak occurrence in the fifth decade. Size and anatomic site In the present study the commonest site was the upper extremity followed by lower extremity, which is comparable to the study of Kransdorf [10]. But in Geethadev’s study, the commonest site was the head and neck which constituted 32% followed by trunk (24.8%) [13]. The comparative analysis of anatomical site distribution of benign soft tissue tumors are shown in Table 6. On gross, Majority (96.5%) of benign soft tissue tumors were well encapsulated and presented with a size less than 5 cms while 81.3% of malignant soft tissue tumors measured more than 5 cms, which has been noted by Myhre Jensenwhere the comparative figures were 95% and 75% respectively[12]. Fibrous tumors There was one case of fibroma (1.1%) and 3 cases of nodular fasciitis (3.4%), which seem to be comparatively less than Kransdorf[10] study where they formed 2.6% and 11.3% respectively. Fibrohistiocytic There were 4 cases of benign fibrous histiocytomas, commonest site being upper extremity. The occurrence of benign fibro histiocytic tumors is less when compared to the studies of Myhre Jensenand Kransdorf[10,12]. Adipose In the present study, lipomas are the commonest of soft tissue tumors with a peak occurrence in the fourth, fifth and sixth decade, which is comparable to the studies of Myhre Jensen [12] and Kransdorf [10]. Vascular There were 20 cases of hemangiomas (11.4%) and 11 cases capillary hemangiomas (3.4%) which showed striking predilection for the Head and neck region, which was in favour of other studies [10,12,13]. Perivascular There was 1 case of benign glomus tumor with an occurrence of 1.1% of all benign soft tissue tumors. This was compared to the study of Rao et al [14] which showed female preponderance with an occurrence 1.6%. Tumors of uncertain origin There was 1 case of benign intramuscular myxoma (1.1%) occurred in 6th decade with a predilectionfor lower extremity which was comparable to the study of Theodorou et al [15] CONCLUSION Soft tissue tumor accounted for 10.7 % of all tumors (1010 tumors diagnosed during the study period). Benign soft tissue tumors formed 79.8 % of all soft tissue tumors. Benign soft tissue tumor showed a peak age occurrence in the fifth decade. The male to female ratio among benign soft tissue tumors was 1:1.02.The benign and intermediate soft tissue tumor showed predilection for upper extremities and lower extremities. The commonest benign tumor was lipoma (62%) of all benign tumors of soft tissue followed by vascular tumors (22.9%), fibrous tumors (5.7%) and fibrohistiocytic tumors (4.5%) in the decreasing order to frequency. The commonest benign soft tissue tumor in the first and second decade was haemangioma. From this study, it is concluded that the benign soft tissue tumors out number malignant tumors and it is very important to make accurate diagnosis since it has a favourable clinical outcome. ACKNOWLEDGEMENT Authors sincerely thank Dr Soumya S, Head, Dept of Pathology and DrAnand s Patil, Associate professor, Dept of Pathology, Sri Manakulavinayagar medical college, Puducherry for their constant support. Authors also acknowledge the immense help received from the scholars who 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=906http://ijcrr.com/article_html.php?did=906REFERENCES 1. Enzinger FM and Weiss SW. Soft tissue tumors. 3rd edn. Missouri: Mosby Company; 1995. 2. Rydholm A. Management of patients With soft tissue tumors: strategy developed at a regional oncology center. ActaOrthopScand Supp1203:13, 1983. 3. Rydholm A, Berg NO, Gullberg B, et al. Epidemiology of soft tissue sarcoma in the locomotor system: a retrospective population based study of the interrelationships between clinical and morphological variables. ActaPatholMicrobiolImmunol Scand 92A:363, 1984. 4. Espat NJ, Bilsky M, Lewis JJ, Leung D, Brennan MF. Soft tissue sarcoma brain metastasis-prevalence in a cohort of 3829 patients. Cancer 2002; 94:2706-11. 5. Hashimoto H, Daimaru Y, Takeshita S, Tsuneyoshi M, Enjoji M. Prognostic significance of histologic parameters of soft tissue sarcomas. Cancer 1992; 70:2816-22. 6. DreinhoferKE,BaldetorpB,AkermanM,Ferno M,RydholmA,Gustafson P.DNA ploidy in soft tissue sarcoma: comparison of flow and image cytometry with clinical follow up in 93 patients.Cytometry 2002,50:19-24 7. Fletcher CDM, Unni KK, Mertens F edn. WHO Classification of tumors of soft tissue and bone. Lyon: IARC Press 2002. 8. Espat NJ, Bilsky M, Lewis JJ, Leung D, Brennan MF. Soft tissue sarcoma brain metastasis-prevalence in a cohort of 3829 patients. Cancer 2002; 94:2706-11. 9. Tsujimoto M, Aozasa K, Ueda T, Morimura Y, Komatsubra Y, Doi T. Multivariate analysis for histologic prognostic factors in soft tissue sarcomas. Cancer 1988; 994-998. 10. Mark J Kransdorf. Benign soft tissue tumors in a large referral population: Distribution of specific diagnosis by age, sex and location. AJR1995; 164:395-402. 11. Tsujimoto M, Aozasa K, Ueda T, Sakurai M, Ishiguro S, Kurata A, et al. Soft tissue sarcomas in Osaka, Japan (1962-1985): review of 290 cases. Jpn. J. Clin. Oncol. 1988 Sep;18(3):231–4  12. Jensen M, A consecutive 7 year series 0f 1331 Soft tissue tumors-A clinicopathological data comparison with sarcomas.Actaorthopscand 1981;52:287-293. 13. Dev G, Banerjee AK, Aikat BK. Soft tissue tumors. Part I : Benign tumors. Ind J Cancer1974; 2: 336-343. 14. Rao AG, Indira D, Kamal J. Extra digital glomangioma. Indian J Dermatol. 2010 Oct;55(4):397–8. 15. Theodorou D, Kleidi ES, Doulami GI, Drimousis PG, Larentzakis A, Toutouzas K, et al. Intramuscular myxoma associated with an increased carbohydrate antigen 19.9 level in a woman: a case report. J Med Case Rep. 2011;5:184.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524168EnglishN-0001November30HealthcarePURE TONE AUDIOMETRIC EVALUATION IN NON-INSULIN DEPENDENT DIABETIC PATIENTS English6370S. VijayasundaramEnglish P. KarthikeyanEnglish V. Nirmal CoumareEnglishThe prevalence of hearing defects in the Indian population is estimated to be about 6%. The risk factors are age, noise, cardiovascular system disorders, Diabetes mellitus and social factors. Aims: The aims of the study were to find out the prevalence and type of hearing loss among diabetic subjects, to establish if there was a relationship between age, duration, severity and complications of Diabetes to the changes in hearing threshold and to establish if there was a relationship between height, weight, family history, diet, blood pressure, blood group and blood cholesterol. Materials and methods: This study included 100 diabetic patients (NIDDM) and 200normal subjects (controls) in the age group of 30 – 59 years, and the controls were matched for age and sex. A detailed clinical examination was performed using a diabetic proforma and screened for complications. The diagnosis was established with the help of tuning fork tests and audiometric analysis. Diabetic patients were categorized into groups and subgroups and were analyzed for statistical significance. Results: It was found that diabetics have an increased mean threshold of hearing at higher frequencies than non-diabetics. The type of hearing loss is typically bilateral and symmetrical, involving higher frequencies. The complications of the disease, sex, weight, height, family history, diet, blood pressure, blood group and blood cholesterol had no significant correlation with the type of hearing loss and with mean average hearing threshold. Conclusion: A relationship exists between the hearing impairment in diabetic patients and other aspects of the disease, which include age, duration and control of Diabetes mellitus. EnglishPure tone audiometry, Non-insulin dependent Diabetes mellitus, Hearing lossINTRODUCTION Diabetes mellitus is a chronic metabolic disorder with an incidence of 1-2% which is classified as non-insulin-dependent diabetes mellitus or insulindependent diabetes mellitus, which corresponds to the previous labels of adult onset diabetes mellitus (Type II) and juvenile onset diabetes mellitus (Type I). They are suspected to be two separate entities from the pathogenesis, with the non-insulin type probably the result of breakdown of interaction of regulatory mechanisms, while insulin-dependent diabetes mellitus may be related to partial destruction of B cells in the pancreas and may be modified by polygenic (suspected to be a specific HLA antigen) and environmental (thought to be a viral infection) factors. An autoimmune component is thought to be responsible for the destruction of the B cells. Pathologically it constitutes the triad of neuropathy, retinopathy and nephropathy.1 Complications from insulin-dependent diabetes are more commonly microvascular, resulting in small vessel disease of the kidneys, retina and the skin as well as neuropathy, and less commonly, macrovascular. Non-insulin-dependent diabetes is more common in obese and older patients with a strong genetic predisposition. Fewer microvascular complications are seen; there is a higher risk of large vessel atherosclerosis, coronary disease and peripheral vascular disease.2 The literature exhibits many contradictions concerning the correlation between hearing impairment and diabetic manifestations. It is evident that good control and regular surveillance for complications enables the patients to lead a normal life. The typical hearing loss described is a progressive, bilateral. Sensorineural deafness of gradual onset affects predominantly the higher frequencies and older patients. There is a decrease in auditory acuity which is similar to that of presbyacusis, but those affected show a hearing loss greater that that expected at that age.3,4 Worldwide the prevalence of hearing impairment is estimated at about 440 million people. Age is the primary risk factor in the population. Other risk factors include noise, cardiovascular disease, Diabetes mellitus and social factors. Non-insulin dependent Diabetes mellitus accounts for almost three quarters of all cases of diabetes. Angiopathy and peripheral neuropathy are well recognized complications. It is reasonable to expect these lesions to affect the inner ear leading to hearing impairment.8,9,10 The oculomotor, trochlear and facial nerve palsies seen in diabetic subjects further suggest that besides autonomic and peripheral neuropathy there is definitely some neuroendocrine defect which contributes to central neuropathy.5 MATERIALSAND METHODS This study was undertaken on patients who attended the outpatient departments of General Medicine and ENT of Mahatma Gandhi Medical College and Research Institute, Pondicherry, over a period of one year. The aims of the study were to find out the prevalence and type of hearing loss among diabetic subjects, to establish if there was a relationship between age, duration, severity and complications of Diabetes to the changes in hearing threshold and to establish if there was a relationship between height, weight, family history, diet, blood pressure, blood group and blood cholesterol.The inclusion criteria were: (i) diagnosis of Diabetes mellitus based on National Diabetic Data Group of the National Institute of Health (NDDG) criteria and (ii) cases receiving anti-diabetic treatment showing even a normal range of blood sugar. The exclusion criteria included: (i) history of congenital deafness in the family, (ii) history of head injury and intake of ototoxic drugs, (iii) history of chronic suppurative otitis media, (iv) history of previous ear surgery and (v) history of acoustic trauma and noise induced hearing loss. In this study, 200 age and sex matched healthy subjects formed the control group (Group I) and were evaluated along with 100 diagnosed cases of Non-Insulin Dependent Diabetes Mellitus (NIDDM) without (Group II) and with complications (Group III) such as peripheral neuropathy, non-healing ulcer, diabetic retinopathy, hypertension, nephropathy, congestive cardiac failure or ischaemic heart disease. All patients included in the study were subjected to a thorough systemic and ENT examination to rule out any organic pathology in the external and middle ear. Tuning fork tests were done using 256 Hz, 512 Hz and 1024 Hz tuning forks. All patients were screened for diabetic retinopathy in the retina clinic by direct and indirect opthalmoscopic examination of the fundus. Audiological evaluation was done by Pure Tone Audiometry (PTA) in the Department of ENT using Arphi Digital model 500 MK III audiometer. Both air and bone conduction were tested. Audiograms were recorded for each patient. Patients were examined by a neurologist to rule out peripheral neuropathy, which was confirmed by nerve conduction study. Biochemical estimation of blood urea and serum creatinine was carried out to rule out nephropathy. The patients were categorized into groups according to age, sex, duration, severity and complications of diabetes. Hearing loss was assessed purely based on tuning fork tests and audiometric readings only. Statistical data was analysed using epidemiological information package developed by WHO. To find out the statistical significance, Kruskal-Wallis H test (equivalent to Chi square test) was used since the observations were normally distributed and a large sample was taken. Mean, standard deviation and ‘p’ value were calculated and tests of significance carried out. The bone/air conduction thresholds were measured for both right and left ears in all patients and taken for each frequency 250 to 8000 Hz. The mean was further categorized according to the group and analysed statistically. RESULTS A total of 300 patients were included in the study, of which, 142 were male and 158 were female, with the age ranging from 30 – 59 years. Table I shows the distribution of hearing impairment among the study population. Hearing impairment among the diabetic population is 48% in comparison with non-diabetic population. Diabetes mellitus is the risk factor which contributes four times more risk of hearing loss in comparison with the control population. Table II shows the average hearing threshold for different frequencies for the study population. The mean threshold at each frequency of all control subjects and diabetic patients were calculated, tabulated and compared. The average thresholds in different frequencies were highly significant. The p value is Englishhttp://ijcrr.com/abstract.php?article_id=907http://ijcrr.com/article_html.php?did=907REFERENCES 1. Agarwal MK. Otorhinolaryngological studies in diabetics. IJO and  HNS 1998;50:116-121. 2. Verma A, Bisht MS, Ahuja GK. Involvement of central nervous system in diabetes mellitus. Journal of Neurology, Neurosurgery and Psychiatry 1984;47:414-416. 3. Axelsson A, Fagerberg SE. Auditory function in diabetics. ActaOtolaryngologica 1968;66:49-64. 4. Axelsson A, Fagerberg SE. Hearing in diabetics. ActaOtolaryngologica 1978;356:1- 23 (supplement). 5. Jorgensen MD, Buch NH. Studies on inner ear functions and cranial nerves in diabetics. ActaOtolaryngologica 1961;53:350-364. 6. Zelenka J, Kozak P. Disorder in the bloodsupply of the inner ear as an early symptom of diabetic angiopathy. JLO 1965;79:314-319. 7. Taylor IG, Irwin J. Some audiological aspects of diabetes mellitus. JLO 1978;92:9-13. 8. Gibbin KP, Davis CG. A hearing survey in diabetes mellitus. Clinical Otolaryngology 1981;6(3):345-350. 9. Robin PE. Deafness and Diabetes (Editorial). Clinical Otology 1981;6:309. 10. Miller JJ, Beck L, Davis A, Jones DE, Thomas AE. Hearing loss in patients with diabetic retinopathy. AJO 1983;4:342-346. 11. Kurien M, Thomas K, Bhanu TS. Hearing thresholds in patients with diabetes mellitus. JLO 1989;103:164-168. 12. Cullen JR, Cinnamond MJ. Hearing loss in diabetics. JLO 1993;107;179-182. 13. KrocsColloboration Study Group. Blood glucose control and the evolution of diabetic retinopathy and albuminuria. NEJM 1984;311:365-376. 14. Olsen S, Noffsinger D. Comparison of one new and three old tests of auditory adaptation. Archives of Otolaryngology 1974;99:94-99. 15. Friedman SA, Schulman RH, Weiss S. Hearing and diabetic neuropathy. Archives of Internal Medicine 1975;135:573-576. 16. Sieger A, White NH,Skinner MW, Spector GJ. Auditory function in children with diabetes mellitus. Annals of Otology, Rhinology and Laryngology 1983;92:237-241. 17. Wilson R, Soeldner JS. The relationship of idiopathic sudden hearing loss to diabetes mellitus. Laryngoscope 1982;92:155-160. 18. Snashall SE. Bakesey audiometry and tone and reflex decay tests in diabetes. Archives of Otolaryngology 1977; 103:342-343. 19. Costa OA. Inner ear pathology in experimental diabetes. Laryngoscope 1967;77:68-75. 20. Virtaniemi J, Laakso M, Nuutien J. Auditory brainstem latencies in type I (IDDM) diabetic patients. AJO 1993;14(6):413-418. 21. Rudolph. Inner ear damage secondary to Diabetes mellitus. Arch Otolaryngol Head Neck Surg 1990;117:635-640. 22. Wackym PA, Linthicum FH. Diabetes mellitus and hearing loss: clinical and histopathological relationship. AJO 1986;7:176-182. 23. Sharma R et al. Brain stem evoked response in patients with diabetes mellitus. IJO 2000;52:223-228. 24. Sharma R. Audiovestibular changes in diabetes mellitus. IJO and HNS 1999;51:40-43. 25. Kutty SR et al. Hearing loss in diabetes mellitus. IJO and HNS 1998;4:131-135. 26. Tay HL, et al. Diabetes mellitus and hearing loss. ClinOtolaryngol 1995;20(2):130-4. 27. Huang YM, Pan CY, Rui G, Cai XH, Yu LM, Chou CY. Study on the hearing impairment in diabetic patients. Chinese Journal of Otorhinolaryngology 1990;25:354-356. 28. Carmen RE, Svihovec DA, Gocka EF, Gay GC, House LR. Audiometric configuration as a reflection of low plasma glucose and diabetes. AJO 1989;10:372-379.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524168EnglishN-0001November30HealthcareNON-PHARMACOLOGICAL INTERVENTIONS IN ALGIATRY English7178Viral Ishvarlal ChampaneriEnglish Rajesh KathrotiaEnglish G. K. HathiEnglish J. M. HarsodaEnglishThis review presents and discusses an overview of the emerging non-pharmacological treatment options and strategies for managing pain.When medications are not satisfactory due to various causes e.g. compliance, side effects, cost effectiveness non-pharmacological management of pain comes in to picture. Although these interventions effectively manage pain they are overlooked and underused. If medical person is familiar with these therapies he or she can identify and educate patients who may benefit from it. They are providing effective analgesia, well accepted, simple measures and adjunct to pharmacological therapies. Non-pharmacological pain management utilizes ways to alter thoughts and focus concentration to better manage and reduce pain. These include physical modalities, mind-body therapies, behavioural modification, manual therapies, natural therapies, neurostimulation, static magnets, cannabinoids. EnglishPain, Algiatry, Alternative Therapies, Non-Pharmacological Management.INTRODUCTION Decline in the living quality, functional status, daily life activities, working capacity, social interaction, work force have been observed in the painful situations1,2,3,4 due to which in addition to the pharmacological treatment options for pain management, today, non-pharmacological treatment options and complementary medical attempts have started to be used.5, 6 Many patients still suffer from pain despite of progress in technology and knowledge regarding effective pain management. Medical drugs treat the somatic (emotional and physiological) aspect of pain while non-pharmacological interventions aim to treat affective, cognitive, behavioural and socio-cultural dimensions of the pain.7 Non-Pharmacological management of pain These therapies decrease the stress, anxiety, pain behaviour, feeling of weakness, needed dosage of analgesic drugs thereby decrease the side effects and improve functional level, individual control feeling.8They affect the pain transmission by Gate Control Theory of Malzek or by the release of natural opioids like endorphins and encephalin.4,5,7 Non-pharmacological management of pain is described below in nine groups such as physical modalities, mind-body therapies, behavioural modification, manual therapies, natural therapies, neurostimulation, bio-field therapies, static magnets and cannabinoids. Physical modalities Beds Prescribing different mattresses by physicians like fluidized, air, and foam overlays can improve patient comfort as bedding itself often can be wrinkled or irritating. Pillow can improve coughing effort, stabilize a joint, prevent deformity, help a splint and provide psychological support if brought from home. Heat Its application helps to reduce striated muscle spasm, relax smooth muscles andmoves the reflex arcs that inhibit the pain by means of heat receptors and reduces pain by vasodilatation effect.9 It can be provided by warm blankets, electric heating pads, moist hot packs. Cold Its application reduces muscle spasm and has longer lasting effect than application of heat. By vasoconstriction effect it causes reduction in inflammation, oedema and bleeding. It can be applied by ice-packs, ice- cubesand cool wash clothes. Massage Massage is manipulation applied on the soft tissue with tapotement, friction, percussion, vibration. It activates large diameter fibres (Aβ), inhibits pain messages carried by smaller fibres (Aδand C fibers), increase endorphins, and causes decreased sensitivity to pain, relieves the mind, muscles and increase the pain threshold.9 Exercise Exercise increases the movement, increasing the blood flow, preventing spasm and contractures of the muscles, muscle atrophy, deterioration of bones and joints and relieving the pain following orthopaedic injuries.10 Positioning Positioning provided by pillows, special beds and weight lifting, position changes increases blood flow, prevents muscle contraction and spasm and reduces acute pain.11It is the most common nonpharmacological method used in post-operative patients.12 Restriction of movement/ resting It can be used for fractures and back injuries patients who need certain bed rest and patients which are in traction. Mind Body Therapies Relaxation Relaxation techniques cause an increase in slow brain waves in EEG by decreasing O2 consumption, blood pressure, respiration amount and pulse rate and prevent the sensitivity developed against the pain.9 Appropriate for any type of pain which works by reducing muscle tension and anxiety. It can be provided by focusing on respiration and PMR (progressive muscular relaxation) techniques. Guided Imagery This is done by taking attention away from pain by guiding through an imaginary mental image of tastes, sounds, sights, smells and feelings especially for children as imagination is spontaneous and natural for them.13 Dreaming Patient is made to focus on stimulant that makes him happy e.g. pattern, sound, colour, light etc.for a short period of time.9 Pain can be effectively managed by guiding patient to dreaming for more than 4 days.13 Distraction It gets the attention away from the pain, decreases its severityand increases tolerance. Small babies can be distracted by use of colourful moving objects, singing songs while preschooler can be distracted by telling stories or looking at the books or videos. Watching TV, listening to music, reading books, dreaming are the other methods.14 Praying Praying relieves depression and anxiety that is caused by chronic pain in older people.9,15 Meditation Meditation is focusing on the moment and the present achieved by focusing on individual’s own respiration, a word or picture. It is effective in relieving pain as it helps relaxation.16It can last for few minutes to 30 minutes.16,178 weeks meditation is useful for relieving the pain of chronic lumbago.18 Yoga Yoga is useful against musculoskeletal pain because of physical stretching, moves and increasing strength.19Applying yoga for 16 weeks has cured the chronic lumbago, reduced functional insufficiency and use of pain killers due to it.20 Hypnosis Hypnosis is the deep physical relaxation state similar to sleep during which subconscious can be reached. It is used for analgesia in chronic pains such as cancer pain and effective in head and neck pain, phantom pain.7,21It has decreased pain and anxiety level in paediatric cancer patients.22 Behavioural Modification These therapies aim to increase the functional level of the patient, firstly reduce and then completely stop painkiller usage. They teach the patient to avoid the maladaptive behaviour such as remaining motionless, grimacing, moaning and reinforcement of well adaptive behaviour like physical activities.23 Cognitive Behaviour Therapy These therapies are a part of multimodal approach in pain management, which helps the patient to improve self-esteem and to develop management behaviour against pain. Study stated that they should be applied earlier and before the patient experiences the pain.24 Bio-feedback It is aimed to control of physiological reactions such as muscle tension, body temperature, heart rate, brain activity and other vital parameters for symptomatic improvement by mental and physical exercises, visualization and deep breaths.25Effective in treatment of many types of chronic pain.26,27 Manual Therapies Prolotherapy It is proliferation injection therapy, in which nonpharmacologicaland non-active irritant solution is injected in the region of tendons or ligaments to strengthen connective tissue and alleviating musculoskeletal pain. Examples of such solutions are hyperosmolar dextrose, sodium morrhuate, phenol and glycerine. Indicated in low back pain, knee osteoarthritis, achillestendinopathy, shoulder dislocation, neck strain, costochondritis, plantar fasciitis, lateral epicondylitis, pain from whiplash injury and fibromyalgia.28,29 Chiropractic It is neck pulling movement causes joint realignment and gentle manipulation used in treatment of the disorders in connective tissues and musculoskeletal system. It relieves the pain with application made on spine and joints which have positive effect on neural system and natural defence mechanisms.16Contraindications of this therapy are rheumatoid arthritis, tumours, infections and severe cervical disc hernia.9,30,31 Reflexology Pressure applied to reflex points on our feet corresponding to all parts of our body, organs and system causes the stress to be relieved and reduction in pain perception.8 Pressure is applied by five techniques - compressing move, putting move, rubbing move, thumb move, fingure move which is generally deep but not painful. Used for migraine pain, back pain, muscle pain, end stage cancer pain, side effects of chemotherapy.32,33,34,35,36 Natural Therapies Herbal Treatment Herbal medicine is the chemical materials obtained from inside, root, leave, seed and flower parts of the herbs.9 It is commonly used to treat lumbago and back pains.16,37 Aroma Therapy The use of scented oils can be relaxing and reduce pain. Study stated that the aroma oils reached the lymph system by means of blood circulation and provided recovery by means of intercellular fluids.30Lavender oil is used in treating migraine pain, osteoarthritis, rheumatoid arthritis, lumbago. Eucalyptus, black pepper, ginger, daisy, licorice, rosemary andmurrh oils are used in relieving pain.24 Hydro Therapy (Balneotherapy) Hydro therapy is using water for treatment by thermal spring and potable water resources. When it is used with temperature effect,it is known as hydrothermal therapy. Hydrothermal therapy stimulate the immune system, circulation, provides hormones that are suppressing the stress, increases the blood flow, relax the muscles and reduces the sensitivity developed against the pain.9 Effective while treating back pain and chronic lumbago.37,38 Neurostimulation Repetitive Transcranial Magnetic Stimulation (rTMS) It is based on a time-varying magnetic field that generates an electric current inside the skull, where it can be focused and restricted to small brain areas by appropriate stimulation coil geometry and size. Primary motor cortex corresponding to the painful area stimulated by rTMS treated the chronic pain due to trigeminal neuralgia, thalamic pain, brainstem lesion, brachial plexus injury, spinal cord lesion, post stroke, peripheral neuroma operation, caudaequina lesion, central supratentorial lesion.39,40Stimulation of Left Primary motor cortex corresponding to hand area treated pain due to trauma, spinal disc degeneration, arthritis, skull base fracture andcrohndisease.41When right secondary somatosensory cortex area is stimulated visceral pain due to chronic pancreatitis42 while stimulation of right dorsolateral prefrontal cortex and left dorsolateral prefrontal cortex treated finbomyalgiaand chronic migraine respectively.43,44 Transcranial Direct Current Stimulation (tDCS) It is based on the application of a weak direct current to the scalp that flows between anode and cathode electrodes.Primary motor cortexcorresponding to the painful area stimulated with 2 mA current for 5 sessions of 20 minutes treated chronic pain due to Spinal cord injury.45 Acupuncture Its works by Gate Control Theory of Malzek i.e. effect of sensory stimulant (e.g.chronic lumbago) can be suppressed with another stimulant (pricking a needle) within neural system. It causes production of endorphin, serotonin and acetylcholine within CNS.46 Effective in cure of patella-femoral pain, rheumatoid arthritis pain,post traumatic somatic painand idiopathic head pain.17 Acupressure Physical pressure is applied on selected points of body by fingers, hands, palms, wrists and knees in order to provide internal flow of energy. It reduces back pain, headache, osteoarthritis, musculoskeletal pain, neck pain, nausea, vomiting and sleeping problem.47It is non-invasive and safe. Both acupuncture and acupressure are component of traditional Chinese medicine. Transcutaneous Electrical Nerve Stimulation (TENS) It is electricalstimulation to the skin to manage the pain. Gate Control Theory is used to define how TENS affects the pain.48Thick and rapid transmitting nerve fibres are stimulated artificially with TENS and the pain transmission is tried to be stopped or reduced by electro analgesia method.49 TENS has reduced the narcotic drugs usage and pain level.14Most common use of TENS is for managing acute, chronic andpost operative pain with or without pharmacological agents. Study stated that post-operative pain management with TENS has reduced the needed analgesic drug dosage and pain level.50 Bio-field Therapies Bio-field is defined as energy that surrounds and penetrates the human body. These therapies aim to do modification of the patient`s bio-field and thereby stimulating the auto healing response. These therapies include Reiki, Healing touch,Therapeutic touch (TT). A systemic review stated that strong evidence for reducing pain intensity in pain population, moderate evidence for reducing pain intensity in hospitalized and cancer populations and a need for high-quality studies in this area.51 Cannabinoids Efficacy of the cannabinoids like canabidiol/delta- 9-tetrahydrocannabinol (THC) buccal spray has been proved for the treatment of neuropathic pain as in multiple sclerosis in a metaanalysis.53 CONCLUSION As a result, with the combination of pharmacological and non-pharmacological therapies the pain can be managed in a more effective manner. These techniques must be encouraged as a part of the comprehensive pain management efforts. They should be included to the care plan whenpatient is appropriate and willing, together with medical and pharmacological treatments. We need more study results that support the efficiency of these methods. 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