Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524166EnglishN-0001November30HealthcareA STUDY OF MUSCULAR BRANCHES OF RADIAL NERVE: SIGNIFICANCE IN TREATMENT OF HUMERAL FRACTURE
English0108Bharati Prabhakar NimjeEnglish P. S. BhuiyanEnglishThe most common indications for surgical exposure of the radial nerve, along its course from axillary fossa to proximal part of forearm is repair of its open or closed traumatic injuries, surgical removal of nerve tumors and for treatment of entrapment neuropathies. Purpose of this work was to analyze topographical relations of radial nerve in the arm with reference to easily detectable anatomical landmarks. 114 upper limbs from 57 formalin-fixed cadavers were dissected meticulously to expose the radial nerve from its origin to its termination. The distance of origin of radial nerve and origin of branch to long head of triceps brachii and branch to medial head of triceps brachii originating in axilla is measured from tip of coracoid process of scapula. The distance of origin of branch to lateral head of triceps brachii and branch to medial head of triceps brachii originating in radial groove were measured from medial epicondyle of humerus. Distance of origin of branch to brachioradialis, branch to extensor carpi radialislongus and branch to anconeus were measured from the lateral epicondyle of humerus. Although efforts have been made by several authors to obtain precise anatomical data regarding the course of radial nerve and its topographical relations, measurements of radial nerve position with reference to reliable anatomical landmarks in the arm are seldom reported.This data will be useful for understanding the effect of entrapment or traumatic lesions along the course of radial nerve, for choosing the correct procedures and for allowing safe positioning of fixation implants.
EnglishRadial nerve, triceps brachii, radial groove, medial epicondyle, topography, entrapmentINTRODUCTION
Nature created the radial nerve to enable us to perform a variety of tasks with our arms, ranging from riding a scooter to performing complicated surgical procedure, not to mention various day to day activities. Anatomical knowledge is required for performing physical examination and diagnostic tests, interpreting their results and instituting treatment, particularly surgical procedures1 . Radial nerve is the one which comes in direct contact with humerus and that is why it is prone to get damaged in fracture of shaft of humerus2 . As a treatment of humeral fracture, either a closed manipulation or open reduction with internal fixation is done2 .Often, in orthopedic surgery, the radial nerve has to be exposed in order to permit the positioning of fixation implants for humeral fractures. The common operative exposure of the radial nerve in this area is the posterior approach, with the patient in lateral decubitus or in prone position.For open reduction, it is mandatory to know all the branches of radial nerve so as to save the movements of elbow and wrist. As Dr. Bergman indicates, it is only through human dissection that gross anatomical variation is really appreciated3 . Although bony structures may be altered in some pathological conditions like fractures and dislocations, anatomical landmarks may be useful for allowing surgeons to accurately identify the radial nerve, at least when normal anatomy is preserved, thus decreasing the likelihood of iatrogenic damage. Anatomical landmarks used in this study were tip of coracoid process of scapula, lateral and medial epicondyles of humerus. The parameters included in this study analyzed the topographical relationship of the radial nerve and its branches with that of the bony landmarks. In the arm, the radial nerve can be frequently injured due to fractures of the distal half of the humerus or iatrogenically after posterior surgery for open reduction and internal fixation of humeral fractures4, 5. Early exploration is advised by many authors for humeral shaft open fractures, spiral fractures and longitudinal fractures of the distal third of the humerus. Chronic radial nerve compressions at different sites at the arm are less frequently noted4 . MATERIALS AND METHODS The present study was done on 114 upper limbs of 57 cadavers. The cadavers were embalmed with 10% formalin.The upper limb in each supine cadaver was abducted and laterally rotated. Skin was incised from manubrium sterni to both xiphoid process of sternum as well as acromion process of scapula. Further, the skin was incised from xiphoid process extending upwards and laterally, along the floor of axilla, to the middle of the arm. Incision was further extended from middle of the arm up to apex of cubital fossa. The skin and superficial fascia were reflected from the deep fascia by blunt dissection. The deep fascia was then incised to expose muscles. The pectoralis major and minor muscles were reflected laterally to expose axilla. The axilla was dissected by removing loose connective tissue and fat. The axillary fascia was then incised and lymph nodes were removed to expose the cords of brachial plexus. The coracobrachialis and short head of biceps brachii muscle were then exposed. Radial nerve was identified. The long head of triceps brachii was exposed. Branches of radial nerve in axilla were identified and measured from the tip of the coracoid process by bisector and scale. (Figure 1) The cadaver was then pronated to expose the posterior aspect of the arm. The skin and superficial fascia were reflected from deep fascia by blunt dissection. The deep fascia over triceps brachii was incised. The lateral and medial heads of triceps brachii were identified. The radial nerve passes in between the two heads. To expose the radial nerve, the lateral head of triceps brachii was cut and reflected. Muscular branches of radial nerve were identified and the origin of each branch was measured from medial epicondyle by thread and scale. Radial nerve pierces the lateral intermuscular septum to come into anterior compartment of arm. (Figure 2) The cadaver was again put in supine position with arm abducted to 90o . The radial nerve was identified in-between brachialis and brachioradialis.The branches to brachioradialis, extensor carpi radialislongus muscles were identified and their origin from lateral epicondyle was measured by bisector and thread. (Figure 3)
RESULTS
1. Branch to the long head of triceps brachii (Table 1)
The mean distance of the origin of first branch to long head of triceps from the tip of the coracoid process in all 57 specimens of left side was found to be 69.4mm ranging from 46mm to 96mm and that of right side was found to be 75.9mm ranging from 51mm to 99mm
2. Branch to the medial head of triceps brachii
The mean distance of the origin of first branch to medial head of triceps from the tip of the coracoid process in all 57 specimens of left side was found to be 77.2mm ranging from 9mm to 104mm and that ofright side was found to be 77.8mm ranging from 50mm to 108mm. (Table 2 a) The mean distance of the origin of first branch to medial head of triceps from the medial epicondyle in all 57 specimens of left side was found to be 189.1mm ranging from 139mm to 220mm and that of right side was found to be 192.8mm ranging from 153mm to 225mm. (Table 2 b)
3. Branch to lateral head of triceps brachii(Table 3)
The mean distance of the origin of first branch to lateral head of triceps from the tip of the coracoid process in all 57 specimens of left side was found to be 199mm ranging from 148mm to 246mm and that of right side was found to be 201mm ranging from 152mm to 225mm. 4. Branch to brachialis (Table 4)
The mean distance of the origin of first branch to brachialis from lateral epicondyle in 7 specimens of left side was found to be 51.4 mm ranging from 43mm to 59mm and that in 6 specimens of right side was found to be 55.5 mm ranging from 49 mm to 63 mm.
5. Branch to brachioradialis (Table 5)
The mean distance of the origin of first branch to brachioradialis from lateral epicondyle in all 57 specimens of left side was found to be 44.4mm ranging from 24mm to 89mm and that of right side was found to be 45.1mm ranging from 28mm to 72mm.
6. Branch to extensor carpi radialislongus (Table 6)
The mean distance of the origin of first branch to extensor carpi radialislongus from lateral epicondyle in all 57 specimens of left side was found to be 41mm ranging from 20mm to 85mm and that of right side was found to be 42mm ranging from 22mm to 78mm. 7.
Branch to anconeus (Table 7)
The mean distance of the origin of branch to anconeus from lateral epicondyle in all 57 specimens of left side was found to be 67.2mm ranging from 34mm to 124mm and that of right side was found to be 68.3mm ranging from 42mm to 171mm.
DISCUSSION As per Sunderland, all the branches to triceps brachii were distributed through axilla and radial groove, in all the specimens6 . The motor branches to triceps brachii did not originate only in the axilla or only in the radial groove. The present study also confirms the same findings. As per the study done by de Seze et al., branch supplying the long head of triceps brachii arose from the axillary nerve but not from the radial nerve unlike in the present study, the branch to long head of triceps brachii arose from the radial nerve only7 . As per Sunderland, anconeus was supplied by the branch to medial head of triceps brachii which descended in the substance of that muscle6 . In the present study a branch to medial head of triceps was given from the radial nerve in the radial groove which descended in the substance of medial head of triceps brachii. This branch then divided into two branches nearer to the elbow joint one of which supplied the anconeus muscle and the other one supplied the elbow joint. According to the present study, branch given to the medial head of triceps divided 50- 100mmproximal to the lateral epicondyle of humerus. According to Sunderland, in half of the specimens, the lateral head of triceps brachii was innervated before its medial head regardless of the order of branching6 . In majority of these cases, the branch to the lateral head left the nerve before that to the medial head6 .Contradictory to it in the present study, branch to the medial head of triceps brachii arose before that of the lateral head; in the axilla. But if only radial groove was considered; Sunderland’s statement was comparable to the present study in which branch to the lateral head of triceps brachii arose from radial nerve trunk proximal to that of the medial head in the radial groove. Both of them ran along the sides of the parent trunk of radial nerve in radial groove as collaterals6 . As per Sunderland; in half of the specimens, the lateral head of triceps brachii were supplied by branches leaving the nerve in radial groove. In one third of the specimens, the medial head of triceps brachii were supplied by branches leaving the nerve in radial groove. Majority of them were in contact with the bone6 . As per Linell, other than the branch to medial head of triceps brachii which arose at the upper limit of radial groove, no other muscular branch arose while the main trunk of radial nerve was in the groove6 . In the present study, the branch to the medial head and lateral head of triceps brachii arose in the radial groove. Findings in the present study matched with Sunderland’s findings but it differed from the findings of Linell. According to Sunderland, the muscle innervated by the nerve in the furrow commonly received several branches. No branch from the radial nerve in the furrow left at a higher level than 60mm above the lateral epicondyleexcept for the branch to brachialis6 . In the present study, it was seen that branches to brachioradialis arose at a distance more than 60mm above the lateral epicondyle of the humerus in 7% of specimens. Branches to extensor carpi radialislongus arose at a distance more than 60mm above the lateral epicondyle of the humerus in 2% of specimens. As per Sunderland, multiple branches were present in the intermuscular furrow; highest and lowest were destined for brachioradialis and extensor carpi radialisbrevis respectively6 . Observations of the present study showed that though the highest branches were destined for brachioradialis, lowest were destined for extensor carpi radialislongus and not extensor carpi radialisbrevis. According to the study done by Sunderland, the mean distance between the site of origin of branch to brachialis muscle and lateral epicondyle of humerus was 59 mm which matched with the present study which observed it to be 54 mm6 . According to the study done by Blackburn et al, the mean distance of origin of the branch to brachialis muscle was 69 mm with a range of 45- 100 mm8 . The present study observations differed from his study with findings of the mean of the distance being 54 mm and the range being 43-63 mm. The present study matched with the study of Frazer et al who stated the mean distance between the site of origin of branch to brachialis muscle and lateral epicondyle of humerus to be 61 mm with a range of 21-72 mm9 . (Table 8)
CONCLUSIONS The average distance between the site of origin of the branch to long head of triceps brachii and the tip of the coracoid process of scapula was found to be 69.4mm +/- 12.56 mm on left side while 75.9mm +/- 10.48 mm on right side. The average distance between the site of origin of the branch to medial head of triceps brachii given in the axilla and the tip of the coracoid process of scapula was found to be 77.2mm +/- 16.11 mm on left side while 77.8mm +/- 11.83 mm on right side. The average distance between the site of origin of the medial head of triceps brachii and the medial epicondyle of the humerus was found to be 189.1mm +/- 18.7 mm on left side while 192.8mm +/- 16.33 mm on right side. The average distance between the site of origin of the branch to lateral head of triceps brachii and the medial epicondyle of the humerus was found to be 198.6mm +/- 18.73 mm on left side while 201.1mm +/- 16.03 mm on right side. The average distance between the site of origin of the branch to brachialis and the lateral epicondyle of humerus was found to be 51.4mm +/- 5.32 mm on left side and 55.5mm +/- 4.97 mm on right side. The average distance between the site of origin of the branch to brachioradialis and the lateral epicondyle of the humerus was found to be 44.4mm +/- 11.17 mm on left side while 45.1mm +/- 9.3 mm on right side. The average distance between the site of origin of the branch to extensor carpi radialislongus and the lateral epicondyle of the humerus was found to be 41.4mm +/- 12.31 mm on left side while 41.7mm +/- 10.26 mm on right side. Bharati Prabhakar Nimje et. al. A STUDY OF MUSCULAR BRANCHES OF RADIAL NERVE : SIG The average distance between the site of origin of the branch to anconeus and the lateral epicondyle of the humerus was found to be 67.2mm +/- 16.44mm on left side while 68.3mm +/- 19.75 mm on right side. The present study provides reliable and objective data for surgical anatomy of the radial nerve, obtained from dissection of embalmed cadavers, which should always be kept in mind by surgeons approaching to the surgery of the arm, in order to avoid iatrogenicinjuries. Awareness of the position of the branches of radial nerve would assist the surgeon to better orientate during surgery and thus reduce the surgical complications. Thus this study could be of help for various surgical approaches of open reduction of humeral fracture like anterolateral approach and posterior approach.
Englishhttp://ijcrr.com/abstract.php?article_id=923http://ijcrr.com/article_html.php?did=923REFERENCES
1. Sinnatamby C S. In: Sinnatamby C S, editor. Last’s anatomy: regional and applied. 11th ed. London: Churchill livingstone; 2006, vii.
2. Maheshwari J. Injuries around shoulder, fracture humerus. In: Maheshwari J, editor. Essential orthopedics. 3rdEd. New Delhi: Mehta publishers; 2002; 72-78.
3. Bergman R A. Thoughts of human variations. Ciln. Anat. 2011; 24: 938-40.
4. Artico M, Telera S, Tiengo C, Stecco C, Macchi V, Porzionato A, Vigato E, Parenti A, De Caro R. Surgical Anatomy of the Radial Nerve at the Elbow. J. Surg. Radiol. Anat. 2009; 31: 101-106.
5. de Seze M P, Rezzouk J, de Seze M, Uzel M, Lavignolle B, Midy D, Durandeau D. Does the motor branch of the long head of triceps brachii arise from the radial nerve? An anatomic and electromyographic study. SurgRadiol Anat. 2004; 26:459-46.
6. Sunderland S. The Radial Nerve- Anatomical and Physiological Features. In: Sunderland S, editor. Nerve and Nerve Injuries, Second ed. Edinburgh: Churchill Livingstone; 1978; 802- 819.
7. Guse T R, Osrtum R F. The surgical anatomy of the radial nerve around the humerus. Clin. OrthopRelatRes. 1995; 320:149-153.
8. Blackburn SC, Wood CPJ, Evans DJR, Watt DJ. Radial nerve contribution to brachialis in the UK Caucasian population: position is predictable based on surface landmarks. Clin. Anat. 2007; 20:64-67.
9. Frazer E A, Hobson M, McDonald S W. The distribution of the radial and musculocutaneous nerves in the brachialis muscle. Clin. Anat. 2007; 20: 785-89.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524166EnglishN-0001November30HealthcareUSAGE OF PROTEIN/CREATININE RATIO IN SPOT URINE SPECIMEN FOR EARLY IDENTIFICATION OF PRE-ECLAMPSIA
English0913Jaya ChoudharyEnglish Vineeta Garg English Abhilasha Bansal DepartmentEnglishObjective: To evaluate the diagnostic usage of spot urine protein-creatinine (P/C) ratio for quantification of proteinuria for predicting pre-eclampsia. Methods: A spot mid stream urine sample were collected for estimation of P/C ratio and the 24- hour urine sample for protein estimation was collected. The correlation between the spot P/C ratio and 24-hour urine proteinuria was done. Logistic regression analyses have been used to analyse data. Results: The spot P/C ratio and 24-hour urine protein excretion have well correlated (pearson’s correlation coefficient r = 0.70; P < 0.0001). Conclusion: Spot urine P/C ratio is an easy, rapid and useful test for assessment of proteinuria for diagnosis of pre-eclampsia.
Englishspot urine specimen, Protein/creatinine ratio, 24 Hour urinary protein, pre-eclampsia.INTRODUCTION
Obstetricians should be aware about early diagnosis of pre-eclampsia, the hypertensive disorder of pregnancy results in sever maternal and perinatal complications that affects 5% - 10% of pregnancy. (1) Preeclampsia is multisystem disorder related with pregnancy that is characterized by progressively elevation of blood pressure and proteinuria after 20 weeks of gestation. Some time blood pressure and proteinuria become significantly high and causing symptoms of end-organ damage which further results in fetal growth restriction. Preeclampsia is consequences in cerebrovascular and cardiovascular complications, acute renal failure, disseminated intravascular coagulation, placental abruption and maternal death. (2) It is very crucial for pregnant woman. Proteinuria of 0.3 g/day or more is gold standard for diagnosis of pre-eclampsia.(3) The measurement of proteinuria in pregnancy is done by collection of 24 hour urine.(4) The collection of urine is time consuming and uncomfortable for women and ward staff. It requires refrigeration and can create confusion if collected inaccurately. The collection of the urine cannot possible in case of delivery occurs, which lead to uncertainty of diagnosis of pre-eclampsia because proteinuria cannot be measured. (5) A long process in collection and estimation in 24 hour urinary protein causing expanded hospital stay of pregnant women in work up for pre-eclampsia thereby increasing risk of nosocomial infection, anxiety and unnecessary costs to patient. There is requirement an early diagnostic tool for it. The International Society for the Study of Hypertension in Pregnancy has proposed use of protein: creatinine ratio in random urine sample instead of 24 hour urine collection. (6) A rapid and sensitive test which should give equivalent results of 24 hours urine is required. Protein-creatinine ratio in spot urine sample is a substitute to estimation for proteinuria which is convenient, fast method and not influenced by changes in urinary solute concentration.(7) This study was carried out to evaluate the diagnostic accuracy of spot urine proteincreatinine ratio for the detection of significant proteinuria in patients with pre-eclampsia.
MATERIAL AND METHODS
A prospective study was designed which include 115 pregnant women of >20 weeks of gestation period and suspected pre-eclampsia (>140/90 mm hg Blood pressure), admitted in, Dept. of Gynecology, MGM medical college, Jaipur, over a period of 6 months. Pregnant women with chronic hypertension, diabetes mellitus, or preexisting renal disease were excluded. A detailed history with thorough clinical examination and routine investigations, liver function test, renal function test was done to select women. A protein/creatinine ratio was estimated, which was followed by the commencement of a 24-hour urine protein assessment. The relationship between protein-creatinine ratio and 24-hour protein excretion was assessed by Pearson correlation coefficient. Total urine protein quantification was done by well established, Biurate calorimetric assay and urine-creatinine estimation was done by modified Jaffe’s method. The urine P/C ratio was calculated by dividing the urinary protein concentration in mg/dl by the urine creatinine concentration in mg/dl. P value of 0.05 was considered to be significant.
RESULTS
A total of 125 pregnant women with preeclampsia were included according to diagnostic criteria of pre-eclampsia and exclusion criteria.3 women were delivered before proper collection of 24 hour urine, 5 had chronic hypertension and in 2 women, pregnancy had to terminate because of severe preeclampsia, and in another because of placental abruption. Table 1 shows maximum number (65.21%) of subjects of age group 21 to 30 years. Most of the women were nulliparous (54.78%), followed by primipara (45.21%). Majority of pre- eclampsic women were belong to group 33 to 36 weeks gestational age (37.39%), followed by group 28 to 32 week gestational age (35.65%).Most of women (54.78%) were having systolic blood pressure between 140 to 160 mm of Hg and 58 % of women were having diastolic blood pressure between 90 to 110 mm of Hg. Majority of women were detected with proteinuria between > 3 and < 5 gm/24 hrs.
DISCUSSION
Early diagnosis and confirmation of preeclampsia is very crucial for the management of it. For severity Assessment and diagnosis of preeclampsia, estimation of proteinuria is essential. Spot urine sample for urinary protein creatinine ratio is easy and more suitable than 24h urine collection for screening preeclampsia. It is hassle free, rapid and economical for patients. Results are not affected, if collected inaccurately.(8,9) It is very useful when there is less time to collect 24h urine in case of severe hypertension and since delivery is commenced (10) In this study we included 115 pregnant women induced hypertension. The young age group (21 - 30 yrs) showed highest incidence (65.21%) of PIH. J. O. Eigbefoh et al also found the same results and support our data that young age (age group 20 - 29 years (75.6%)) women are affected more with PIH (10) Mostly nulliparous women were affected with PIH in present study. J. O. Eigbefoh et al also showed that most of pregnant women were nullipara (54.7%) followed by primipara (15.15%). (10) Preponderance of preeclampsia were found in group 33 to 36 weeks gestational age (37.39%), followed by group 28 to 32 week gestational age (35.65%), showing that these gestational age range are more prone to PIH. Most of women (54.78%) were having systolic blood pressure between 140 to 160 mm of Hg and 58 % of women were having diastolic blood pressure between 90 to 110 mm of Hg. Majority of women were detected with proteinuria between > 3 and < 5 gm/24 hrs. The study of Amita et al is well correlated with our study. (11) We found an acceptable correlation between Protein/creatinine ratio in spot urine and 24hr urinary protein. Previously some researcher also has been done studies to establishing spot P/C ratio as an indicator for pre-eclampsia. Leonos – Miranda described a significant correlation (r= 0.8 ) (12) Durnwald and Mercer found lower correlation coefficients of 0.56 and not agreed for replacing spot P/C ratio for the 24 hour urine protein collection.(13) But an another study showed a significant relationship between random protein-creatinine ratio and 24-hour protein with higher correlation coefficients (r = 0.56, P < 0.01).(14) Wheeler et al gave the value of the P/C ratio with their corresponding 24 proteinuria values. The value of P/C ratio 0.46, 0.82 and 3.0 corresponded to 1000 mg/ 24 h 2000 mg/ 24 hr and 3000 mg/24 hr, respectively. The proteinuria for 24 hour was represented by the urine P/C ratio of 0.21. (15) The present study proposed that the spot urine protein creatinine ratio can used an alternative method for taking clinical judgment about proteinuria in preeclampsia. This investigation can be used on outdoor basis for fast clinical decision instead of time consuming process 24 hr urine collection. There are some limitation of our study that is small sample size and some false negative results. Further studies can overcome this issue including a larger study population and usefulness of this test in rapid and easy management of preeclamptic patients.
. CONCLUSION
The spot urine P/C ratio and the 24 hour proteinuria were well correlated. Spot urine protein-creatinine ratio can be used to predict the amount of 24 hours urine protein excretion with high accuracy. But the 24 hr urine collection remains the gold standard for evaluation for preeclampsia. So, spot urine protein-creatinine ratio can be used for detection of significant proteinuria in pregnant women with suspected preeclampsia with high accuracy, which is more rapid than 24 hour urine protein excretion. Thus this is a very useful and easy investigation to check the maternal morbidity.
Englishhttp://ijcrr.com/abstract.php?article_id=924http://ijcrr.com/article_html.php?did=924REFERENCES
1. Majhi, A.K., Mondal, A. and Mukherjee, G.G. (2001) Safe motherhood—A long way to achieve. Journal of Indian Medical Association, 99, 132-137.
2. Mackay AP, Berg CJ, Atrash HK. Pregnancyrelated mortality from preeclampsia and eclampsia. Obstet Gynecol 2001;97:533-8.
3. BrownMA, HagueWM, Higgins J, LoweS, McCowanL, Oats J, et al. The detection, investigation and management of hypertension in pregnancy: executive summary. Aust N Z J Obstet Gynaecol 2000;40: 133-8.
4. BrownMA, LindheimerMD, de Swiet M, Van Assche A, Moutquin JM.The classification and diagnosis of the hypertensive disorders of pregnancy: statement from the International Society for the Study of Hypertension in Pregnancy (ISSHP). Hypertens Pregnancy 2001;20:IX-XIV.
5. Wongkitisophon K, Phupong V, Yamasmit W, Pansin P, Tannirandorn Y, CharoenvidhyaD. Correlation of 4- and 24-hour urine protein in women with initially diagnosed hypertensive disorders in pregnancy. J Med Assoc Thai 2003;86:529-34.
6. Ginsberg JM, Chang BS,Matarese RA, Garella S. Use of single voided urine samples to estimate quantitative proteinuria.N Engl J Med 1983;309:1543-6.
7. Al, R.A., Baykal, C., Karacay, O., Geyik, P.O., Altun, S. and Doten, I. (2004) Random urine protein creatinine ra-tio to predict protenuria in new onset mild hypertension in late preganncy. Obstetrics and Gynecology, 104, 367- 371.
8. Chitalia VC, Kothari J, Wells EJ, Livesey JH, Robson RA, Searle M, Lynn KL. Cost-benefit analysis and prediction of 24-hour proteinuria from the spot urine protein creatinine ratio. Clin Nephrol 2001;55(6):436-47.
9. Menzies J, Magee LA, Macnab YC, Ansermino JM, Li J, Douglas MJ, Gruslin A, Kyle P, Lee SK, Moore MP, Moutquin JM, Smith GN, Walker JJ, Walley KR, Russell JA, von Dadelszen P. Current CHS and NHBPEP criteria for severe preeclampsia do not uniformly predict adverse maternal or perinatal outcomes. Hypertens Pregnancy 2007;26(4):447-62.
10. Eigbejoh, J.O., Abebe, J., Odike, M.A. and Isabu, P. Protein/creatinine ratio in random urine specimen for quantitation of proteinuria in pre-eclampsia. Internet Journal of Gynecology and Obstetrics, 2007; 18:1.
11. Sharma A, Kiran P, Ajai B. Spot urine protein/creatinine ratio—A quick and accurate method for diagnosis of pre-eclampsia. Open Journal of Obstetrics and Gynecology, 2013, 3, 609-612.
12. Leaños-Miranda A, Márquez-Acosta J, Romero-Arauz F, Cárdenas-Mondragón GM, Rivera-Leaños R, Isordia-Salas I, UlloaAguirre A. Protein: creatinine ratio in random urine samples is a reliable marker of increased 24-hour protein excretion in hospitalized women with hypertensive disorders of pregnancy. Clin Chem 2007; 53(9):1623-8.
13. Durnwald, C. and Mercer, B. (2003) A prospective comparison of total protein/creatinine ratio versus 24-hour urine protein in women with suspected preeclampsia. American Journal of Obstetrics and Gynecology, 189, 848- 852.
14. Al, R.A., Baykal, C., Karacay, O., Geyik, P.O., Altun, S. and Doten, I. (2004) Random urine protein creatinine ratio to predict proteinuria in new onset mild hypertension in late pregnancy. Obstetrics and Gynecology, 104, 367- 371.
15. Wheeler 2nd, T.L., Blackhurst, D.W., Dellinger, E.H. and Ramsey, P.S. (2007) Usage of spot urine protein to creatinine ratios in the evaluation of pre-eclampsia. American Journal of Obstetrics and Gynecology, 196, 465e1-4.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524166EnglishN-0001November30HealthcareISOLATED MEDIASTINAL LYMPHADENOPATHY - ETIOLOGICAL ANALYSIS
English1419Mandal A.English Pan K.English Maity P. K.English Panchadhyayee S.English Sarkar G.English Chakraborty S.English Choudhury R.English Chakrabarti S.EnglishBackground: The etiology of isolated mediastinal lymphadenopathy (without lung involvement or peripheral lymph node enlargement) is difficult to approach. Though various methods are available for histopathological confirmation, few literatures are there regarding the etiological diagnosis of isolated mediastinal lymphadenopathy. Aims and objective: This study was taken up with the aim to investigate the pattern of involvement of isolated mediastinal lymphadenopathy and to analyze the etiology among the adult patients presenting to a tertiary care institution in Eastern India. Materials and methods: A total of 50 patients were subjected to our study. Non-invasive investigation such as x-ray, CT scan, mantoux test etc. were done and these investigations established only a indirect evidence of etiological diagnosis. For definitive diagnosis, fine needle aspiration biopsy cytology ( FNABC) or biopsy from peripheral lymph node( if any) or various invasive investigations such as CT guided biopsy from mediastinal lymph node, bronchoscopy with transbronchial biopsy, mediastinoscopy or endobronchial ultrasound-guided transbronchial needle aspiration were done wherever feasible. Results: Overall tubercular lymphadenopathy was the most common (45 among 50 patients; 90%) followed by sarcoidosis (3 among 50 patients; 6%), lymphoma (1 among 50 patients; 2%) and carcinoma of lung ( 1 among 50 patients; 2%). Conclusion: So tuberculosis is the leading cause of isolated mediastinal lymphadenopathy.
EnglishMediastinal lymphadenopathy.INTRODUCTION
Common causes of mediastinal lymphadenopathy include tuberculosis, sarcoidosis, lymphoma, metastatic lymph node, fungal infections, etc. In 1959, Lyons and coworkers1 reported lymphoma as a group was the most common (26%) followed by sacoidosis (20%), nonlymphomatous neoplasm including metastatic disease (16%), histoplamosis ( 7%) and Tuberculosis. Tubercular mediastinal lymphadenopathy is common in pediatric age group. However, isolated tubercular mediastinal lymphadenopathy without a parenchymal lung lesion in adults is unusual. The reason why different individuals respond differently to infection with mycobacterium tuberculosis had been reviewed by Crofton J et all2 . The prevalence of the tubercular mediastinal lymphadenopathy is encountered as high as 49% in children below the age of 3 years3 and the prevalence decreases with age4 . The prevalence of tubercular mediastinal lymphadenopathy has been reported to be from 4% to 67% in adults5-10 . Sarcoidosis has been reported from all over the world. It is prevalent in western countries. In India, the first proven case of sarcoidosis was described by Ghose andChakraborty in1956. In reported study, Gupta (1985) observed an incidence of 150 per100,000 among the hospital population in south Calcutta, while Chakraborty in Delhi found the incidence to be 61.2 per 100,000 population11 . In carcinoma lung, a mass lesion with or without collapse of lung is the most common finding , the chest skiagram is normal only in rare occasion. Though the finding of mediastinal widening in carcinoma of lung was 16.7% seen in a large Indian series of 1009 patients12 . In Hodgkin, s lymphoma, most patients present with palpable lymphadenopathy in the neck, supraclavicular area and axilla. More than half of the patients will have mediastinal adenopathy at diagnosis, and this is sometimes the initial manifestation13 . The aim of the study was to investigate the pattern of involvement of the isolated mediastinal lymphadenopathy and to analyze its etiological diagnosis in adult patients attending this tertiary care institution.
STUDY DESIGN AND
METHODS This is a prospective study carried out over a period of two years (January 2010 –January 2012) at the Institute Of Post Graduate Medical Education And Research, Kolkata. Those patients having mediastinal lymphnode enlargement demonstrated by chest x-ray without presence of other organ involvement like lung, liver, bone, spleen other than cervical lymphnode were included in this study. Besides routine investigations including complete haemogram, liver function tests, mantoux tests, chest x-ray, the following investigations were done accordingly – 1) Contrast enhanced computed tomography (CECT) of chest 2) Fine needle aspiration biopsy cytology (FNABC) and/or cervical lymph node biopsy . 3) Mediastonoscopy guided biopsy from mediastinal lymphnode 4) CT guided FNABC from mediastinal lymph node and bronchoscopy were done 5) Sputum for AFB (3 times) 6) HIV serology was done by ELISA with consent
RESULTS
A total of 50 patients with isolated mediastinal lymphadenopathy diagnosed by chest X Ray were subjected to this study. Age at presentation ranged from 14-62 years. In this study population, 37 out of 50 patients were male. CECT scan was done in all 50 cases, It is evident that most common site of lymphadenopathy in tubercular group was right paratracheal nodes. Peripheral rim enhancement with low attenuation at the centre of the node was the most frequent pattern in tubercular group. Homogenous enhancement, inhomogenous enhancement and calcification of the involved lymphnodes were also seen in the same group. In sarcoidosis, both hilar and right paratracheal lymphnode involvement were seen. More than one site was involved in all cases. The distribution of lymphadenopathy and the pattern of nodal involvement have been depicted in table-1 and table-2 respectively. CECTscan revealed—lung infiltration in 16 cases, consolidation in 4 cases, retro-peritoneal lymphadenopathy in 4 cases, hypodense lesion in spleen in 2cases and in liver in 1 case in tubercular group. In sarcoidosis, lung involvement including peribronchial thickening and subpleural reticulo-nodular changes were seen in all 3 cases. Retro-peritoneal lymphadenopathy was seen in lymphoma. In carcinoma lung, lung involvement was seen. For confirmation of the diagnosis, peripheral lymph node biopsy from cervical region was done in 21 cases, CT guided mediastinal lymphRESULTS A total of 50 patients with isolated mediastinal lymphadenopathy diagnosed by chest X Ray were subjected to this study. Age at presentation ranged from 14-62 years. In this study population, 37 out of 50 patients were male. CECT scan was done in all 50 cases, It is evident that most common site of lymphadenopathy in tubercular group was right paratracheal nodes. Peripheral rim enhancement with low attenuation at the centre of the node was the most frequent pattern in tubercular group. Homogenous enhancement, inhomogenous enhancement and calcification of the involved lymphnodes were also seen in the same group. In sarcoidosis, both hilar and right paratracheal lymphnode involvement were seen. More than one site was involved in all cases. The distribution of lymphadenopathy and the pattern of nodal involvement have been depicted in table-1 and table-2 respectively. CECTscan revealed—lung infiltration in 16 cases, consolidation in 4 cases, retro-peritoneal lymphadenopathy in 4 cases, hypodense lesion in spleen in 2cases and in liver in 1 case in tubercular group. In sarcoidosis, lung involvement including peribronchial thickening and subpleural reticulo-nodular changes were seen in all 3 cases. Retro-peritoneal lymphadenopathy was seen in lymphoma. In carcinoma lung, lung involvement was seen. For confirmation of the diagnosis, peripheral lymph node biopsy from cervical region was done in 21 cases, CT guided mediastinal lymph node biopsy was done in 2 cases, bronchoscopy was done in 9 cases (bronchoalveolar lavage and transbronchial lung biopy were done), mediastinoscopy with mediastinal lymphnode biopsy was done in 2 cases, cold abscess aspiration in cervical region was done in 1 case. Diagnosis was made in 30 cases by isolation of organism( acid fast bacilli) or by presence of caseating granuloma as tubercular lymphadenopathy. Diagnosis of sarcoidosis was made by bronchoscopy (broncho-alveolar lavage and trasbronchial lung biopsy was done) in 3 cases. 1 case of carcinoma lung and 1 case of lymphoma were diagnosed by cervical lymph node biopsy. Investigation procedure required for diagnosis is shown in table-3. In the remaining 15 cases, the Mantoux reaction, presence of necrosis in mediastinal lymphnodes on CT scan finding and response to anti-tubercular treatment were the only evidence of tuberculosis and included in tubercular group. Tuberculin test - it is observed that 36 patients were positive in tubercular mediastinal lymphadenopathy group. So, among randomly taken 50 cases, tubercular lymph-adenopathy was the most common finding (45 cases) followed by sarcoidosis (3 cases), lymphoma (1 case) and carcinoma of lung (1 case).
DISCUSSION
We are prompted to undertake this study on account of several number of patients having isolated mediastinal lymphadenopathy are found in our outpatient department(O.P.D). Most of the patients had isolated mediastinal lymphadenopathy without any significant pulmonary parenchymal lesion, at least on plain x-ray of chest. CECT of chest is the standard investigation in patients with mediastinal lymphadenopathy. Radiologically, right paratracheal lymphnodes were most commonly involved in tubercular mediastinal lymphadenopathy5 . In our study, it is observed that in tubercular group, right paratracheal nodes was the most common site (89%) of involvement followed by subcarinal (66%) , pretracheal (55%) and hilar nodes in decreasing order of frequency. In tubercular mediastinal lymphadenopathy, peripheral rim enhancement with relative low attenuation at centre was the commonest pattern of nodal involvement 14-16 . In our study, it is observed that peripheral rim enhancement was the commonest pattern 53% followed by inhomogenous enhancement 24%. Homogenous enhancement was seen in 22% and nodal calcification was seen in 08%. Distribution of lymphadenopathy in tubercular group has been depicted in table-4.Pattern of nodal involvement in tubercular group of patients is shown in table-5.Determining the presence peripheral rim enhancement with relative low attenuation at centre of lymphnodes and location of lymphnodes in young adults with appropriate clinical setting is very helpful in differentiating tuberculosis from other causes of mediastinal lymphadenopathy. In sarcoidoisis, low density in mediastinal nodes is unusual. Lymphadenopathy in sarcoidosis is usually bilateral and hilar. Calcification is also described in sarcoid glands16. The associated reticulonodular pattern of lung parenchymal disease if present, may be a additional help. In our study, bilateral hilar lymphadenopathy was seen in all 3cases. Calcification of lymph nodes and reticulonodular pattern of lung involvement were seen in all 3 cases. In lymphoma group, the typical CT appearance of a nodal mass in a patient with Hodgkin , s disease is usually that of homogenous soft-tissue mass with sharply defined and often lobulated borders. Occasionally the centre of the nodal mass contains an area of decreased attenuation due to necrosis.17 In patient with metastatic lymphnode from lung cancer, the primary lung lesion is usually visible on CT scan. Visible low density within the metastatic nodes are not unusual15 . The granuloma in sarcoidosis may sometimes caseate, where in tuberculosis there may be absence of caseation. In view of above, diagnosis of tubercular mediastinal lymphadenopathy in present series of patients can only be considered to be a provisional one, except in those few in whom the AFB could be demonstrated. In area of high endemicity of tuberculosis, response to antituberculosis treatment may also consider to be diagnostic criteria for tubercular mediastinal lymphadenopathy. This is specially important, as methods for obtaining tissue diagnosis are sparingly available in developing countries where the disease is prevalent. CT scan is useful tool for diagnosis of mediastinal lymphadenopathy. The morphology of lymphnode on CT scan may help in diagnosing etiology, however, it is not specific. All efforts should be made to attend a cytological, microbiological, and histological diagnosis18. Invasive diagnostic tests including mediastinoscopy19 , bronchoscopy20,21 and endobronchial ultrasound- guided transbronchial needle aspiration22 should be undertaken for definitive diagnosis of mediastinal lymphadenopathy where facilities are available. CONCLUSION To conclude, though various differentials are there, tuberculosis is the leading cause of isolated mediastinal lymphadenopathy in our country. CECT of chest is the initial standard investigation to assass the pattern and characteristics of involved lymph nodes. Right paratracheal nodes was the most common site and peripheral rim enhancement with relative low attenuation at centre was the commonest pattern of nodal involvement in tubercular group.
Englishhttp://ijcrr.com/abstract.php?article_id=925http://ijcrr.com/article_html.php?did=925REFERENCES
1. Lyons HA, Calvy GL, Sammons BP. The diagnosis and classification of mediastinal mass. A study of 782 cases. Ann Intern Med 1959;51: 897-932.
2. Crofton J, Douglas A. Respiratory disease. The incidence of scrofula (tubercular lymphadenitis) in mediaeval Europe. Second edition. Oxford. Blackwell Scientific Publications,1975;chapter 11.
3. Lamont AC, Cremina BJ, Pelteret RM: Radiological patterns of pulmonary tuberculosis in pediatric age group. Pediatr radiol 1986;16:2-7.
4. Leung AN, Muller NL, Pindia PR, Fitz Gerald JM. Primary tuberculosis in childhood: Radiographic manifestation. Radiology 1992;182:87-91.
5. Amorosa JK, Smith PR, Cohen JR, Ramsy C, Leons HA. Tuberculous mediastinal lymphadenitis in adults. Radiology 1978;126:365-368.
6. Miller WT, MacGregor RR. Tuberculosis: frequency of unusual radiographic findings. AJR 1978; 130:867-875.
7. Stead WW,Kerby GR, Schlueter DP, Jodahl CW. The clinical spectrum of primary tuberculosis in adults. Confusion with reinfection in the pathogenesis of chronic tuberculosis. Ann Intern Med 1968;68:731-45.
8. Muller NL. Pulmonary tuberculosis. In : Sperber M, (ed): Radiographic diagnosis of chest disease. Springer- verlag, New York 1990;188-199.
9. Krysl J, Korzeniewska-Kosela M, Muller NL, Fitz Gerald JM. Radiologic feature of pulmonary tuberculosis: an assessment of 188 cases. Can Assoc Radiol J. 1994;45:101-108.
10. Moon WK, Im J, Yeon KM, Han ML. Mediastinal tuberculous lymphadenitis: CT finding of active and inactive disease. AJR 1998, 170:715-718.
11. Gupta SK. Pande JN. Sarcoidosis. In : Pande JN.(ed).Respiratory Medicine In The Tropics. Oxford University Press :1998, p.366.
12. Jindal. S.k. Pulmonary neoplasm. In: Pande JN. (ed). Respiratory Medicine In The Tropics. Oxford University Press: 1998, p.443.
13. Longo .DL. Malignancies of lymphoid cells. In : Longo, Fauci, Kapser, Hauser, Jameson,Loscalzo (eds): Harrisons Principles Of Internal Medicine: 18th ed. Mc Graw Hill Medical.2012. p.934.
14. Pombo F, Rodriguez E,Mato J, Perez-Fontan J, Rivera E, Valuena L. Patterns of contrast enhancement of tuberculous lymph nodes demonstrated by computed tomography. Clin Radiol 1992;46:13-17.
15. Im JG, Song KS, Kang HS, Park JH, Yeon KM, Han ML. Mediastinal tubercular lymphadenitis: CT manifestation. Radiology 1987;164: 115-119.
16. Gulati M, Suri S, Kaur G, Jindal SK, Behera D. CT manifestations of tuberculous madiastinal lymphadenopathy. Indian J Chest Dis Allied Sci. 1994jan-mar;36(1) : 3-7
17. Graham R Cherryman, Bruno Morgan. The lymphatic system. In :Sutton D.(ed). Textbook of Radiology And Imaging. Elsevier Churchill livingstone.2012, p.527.
18. Tiwari M, Aryal G, Shrestha R, Rauniyar SK, Shrestha HG. Histopathologic diagnosis of lymph node biopsies. Nepal Med Coll J. 2007 Dec;9(4): 259-61.
19. Nalladaru ZM, Wessels A. The role of mediastinoscopy for diagnosis of isolated mediastinal lymphadenopathy. Indian J Surg. 2011 Aug; 73(4): 284-6.
20. Straddling P (ed). In : diagnostic bronchoscopy a teaching manual. Churchill Linvinstone 6 th edition,1991,p.72.
21. Trisolini R, Anevalvis S, Tinelli C, Orlandi P, Patelli M. CT pattern of lymphadenopathy in unteated patients undergoing bronchoscopy for suspected sarcoidosis. Respire Med. 2013 jun; 107(6):897-903.
22. Navani N, Lawrence DR, Kolveker S, Hayward M, McAsey D, Kocjan G, Falzon M, Capitanio A,Shaw P, Morris S, Omar RZ, Janes SM; REMEDY Trial Investigators. Endobronchial ultrasound- guided transbronchial needle aspiration prevents mediastinoscopies in the diagnosis of isolated mediastinal lymphadenopathy : a prospective trial. Am J Respir Crit Care Med. 2012 Aug 1; 186(3): 255-60.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524166EnglishN-0001November30HealthcareASSOCIATION OF HbA1c WITH SERUM LIPID PROFILE AND LIPOPROTEIN (a) IN TYPE 2 DIABETES MELLITUS
English2025Mahantesh PatilEnglish Nirmal KumarEnglish Aliya NusrathEnglish Shubha JayaramEnglish Rajeshwari A.EnglishBackground: Diabetes mellitus (DM) is a group of metabolic disorders of carbohydrate metabolism. Also it is proposed thatunderutilization of glucose is associated with changes in lipid profile. Lipoprotein (a) [Lp (a)] is regarded as an independent indicator of risk development of vascular disease which is also a diabetic complication. Changes in lipid profile are also well related with severity of DM as adjudged by glycated Hb (HbA1c). Objectives: The study intends to find the association between Lipid profile, Lp (a) and HbA1c levels in type 2 diabetic patients. Methods: A case-control study was conducted in Adichunchanagiri Institute of Medical Sciences, B.G.Nagara, Karnataka from 1st Jan to 15th June 2012. Study involved 80 participants of which 40 were patients admitted with diagnosis of DM and other 40 were healthy controls. Blood samples were collected in fasting state and analyzed for FBS, PPBS, HbA1c, TAG, VLDL, HDL, LDL and Lp(a) and values were tabulated for statistical evaluation. Results: In DM patientssignificant changes in the following parameters were observedcompared to controls. FBS, PPBS, HbA1c &Lp (a) levels increased significantly (PEnglishDiabetes Mellitus, Glycated hemoglobin (HbA1c), Lp (a)INTRODUCTION
Diabetes mellitus (DM) is an iceberg disease. The metabolic dysregulation associated with DM causes secondary pathological changes in multiple organ systems that impose a tremendous burden on the individual with diabetes and on the health care system. In the United States, DM is the leading cause of end-stage renal disease (ESRD), no traumaticlower extremity amputations, and adult blindness. It also predisposes to cardiovascular diseases. With an increasing incidence worldwide, DM will be a leading cause of morbidity and mortality for the foreseeable future.[1]The number of adults with diabetes in the world will rise from 135 million in 1995 to 300 million in the year 2025. Presently, India, China, and the United States are the countries with the largest number of people suffering from diabetes and this trend is expected to continue till the year 2025,.[2, 3]In India alone, diabetes is expected to increase from 40.6 million in 2006 to 79.4 million by 2030.[4] Most of the longstanding macro and micro vascular complications are also more common among Indian diabetics as compared to other races and ethnic groups. Recent studies have shown that the prevalence of coronary heart disease (CHD) in Indian diabetics may be as high as in the migrant population. [4] Changes in lipid-profile are a consequential event in DM. Due to these changes distribution and function of various fractions of lipids are affected. Many Studies have evaluated the risk factors for CHD in DM patients and observed high fasting blood sugar (FBS) and post prandial blood sugar (PPBS), total cholesterol (Chol), low density lipoproteins (LDL), triglycerides (TAG) levels and low high density lipoproteins (HDL) levels when compared to controls. [5] Glycated heamoglobin (HbA1c) is considered a gold-standard measure of chronic glycemia in diabetic patients. In the Rancho Bernardo study, HbA1c was a better CHD predictor than fasting or 2-h glucose.[6]HbA1c was strongly associated with atherosclerosis as measured by carotid IMT (intima-media thickness). [7, 8]The ADA recommends measurement of HbA1c in patients with both type 1 and 2 diabetes, first to document the degree of glycemic control, then as part of continuing care.[9] Changes in lipid profile is also well related with severity of DM as adjudged by HbA1c. Lipoprotein (a) [Lp (a)] is a distinct class of lipoprotein that is structurally related to LDL, because both lipoprotein classes possess one molecule of Apo B-100 per particle and have similar lipid compositions. However, unlike LDL, Lp (a) contains a carbohydrate rich protein [Apo (a)]. Apo (a) is a unique component and has significant homology with plasminogen. [10] The serum level of Lp (a) is an independent indicator of risk development of vascular disease.[11] A clear correlation was found between the serum level of Lp(a) and its accumulation in the vessel wall.[12] Recently much interest has been focused on Lp(a) as an important marker of CHD.The level of Lp (a) is genetically determined, and when elevated, cannot be lowered by alterations in food intake or by most of the cholesterol lowering agents. Diabetic patients are reported to have higher Lp(a) values than nondiabetic persons and levels are still more significantly elevated in patients with diabetic complications.[13] The data on relationship between Lp(a) and diabetes is scarce and the data on Lp(a) in Asian Indian diabetics is still meagre.[14] Therefore the present study has been undertaken to assess the serum concentration of Lp(a) in patients with diabetes mellitus and to study any association of HbA1C with lipid profile and Lp(a) levels.
METHODOLOGY
This case control study was conducted at Adichunchanagiri Institute of Medical Sciences, Karnataka, India. A total number of 80 subjects participated in the present study. Forty controls and 40 clinically diagnosed cases of diabetes mellitus patients attending out- patient and inpatient departments of ShriAdichunchanagiri Hospital and Research Center (SAH&RC) were included in the study. Age and sex matched healthy individuals are taken as control group. The study was approved by ethical and research committee of SAH&RC. Patients with signs and symptoms of obstructive jaundice, hypothyroidism, hypopituitarism, epileptic patients, psychiatric disorders & nephrotic syndrome were excluded from study. Non-probability convenient sampling method was adopted for sample selection. After obtaining informed consent from patients and controls the data was collected using semi structured questionnaire. The questionnaire included the following information like, socio demographic data, detailed medical historyand relevant clinical examination data.
Collection of blood sample
Under aseptic precautions,7ml of Blood sample in fasting state was drawn from controls and clinically diagnosed cases of DM.Then the blood sample was divided into 3 test tubes, marked as 1, 2 and 3 and analyzed respectively for blood glucose (FBS & PPBS), Lp(a) & other lipid parameters (TAG, Chol, HDL, VLDL & LDL) and HbA1c. 1. Test tube 1 containing 2ml of blood with anticoagulant was used for estimation of blood glucose by Glucose Oxidase method. [15] 2. Test tube 2 containing 3ml of blood with no anticoagulant was allowed to clot and serum was separated. Serum was used for measurement ofTAG by GPO-Trindermethod[15,16], Cholesterol by CHOD-POD method[17], HDL by Phosphotungstic acid method[18], VLDL was calculated by formula (TG/5)[8], LDL was derived by FredricksonFriedwald formula [(TC-HDL) – TG / 5] [8] & [Lp(a)] was estimated by Immunoturbidometric method.[19] 3. Test tube 3 containing 2ml of whole blood was used for estimation of HbA1c by Affinity Chromatography. [20, 21] The chemicals and reagents used for the procedures were of analytical grade. Descriptive statistical analysis has been carried out in the present study. Results on continuous measurements are presented as Mean ? SD and results on categorical measurements are presented in Number (%). Significance is assessed at 5 % level of significance.Statistical significance between two groups (Inter group analysis) was studied using Student t-test (two tailed, independent). Chi-square/Fisher Exact test has been used to find the significance of study parameters on categorical scale between two groups.
RESULTS
The results of the study parameters FBS, PPBS, HbA1c, TAG, Chol, HDL, LDL, VLDL, Lp (a), are depicted in tabular form. Table 1 shows the demographic distribution between control group and patient group. Samples are age and gender matched with P=0.113. Table 2 gives the results of FBS, PPBS & HbA1c levels of patients and control group presented as Mean±SD. There is increase in all 3 parameters in patients compared to controls which is statistically strongly significant (pEnglishhttp://ijcrr.com/abstract.php?article_id=926http://ijcrr.com/article_html.php?did=926REFERENCES
1. Fauci AS, Kasper DL, Braunwald E, Hauser SL, Longo DL, Jameson JL Et al. Harrison’s Principles of Internal Medicine. 17th Ed. United States of America: McGraw-Hill Medical publishing division; 2008. Chapter 338,Diabetes Mellitus: p. 2275-304.
2. Hilary King, Ronald Aubert E, William Herman H. Global Burden of Diabetes, 1995- 2025: Prevalence, numerical estimates, and projections.Diabetes Care 1998;21:1414–31.
3. Ramachandran A, Snehelatha C, Latha E, Vijay V, Viswanathan M. Rising prevalence of NIDDM in an urban population in India. Diabetologia 1997;40:232–37.
4. Lt Gen SR Mehta, VSM, Col AS Kashyap, Lt Col S Das. Diabetes Mellitus in India: The Modern Scourge. MJAFI 2009;65:50-4.
5. Surekha Rani. H, Madhavi G, RamachandraRao V,Sahay B.K, Jyothy A. Risk Factors for Coronary Heart Disease in Type II DM. Indian Journal of Clinical Biochemistry 2005;20(2):75-80.
6. Zachary T,Bloomgarden. Cardiovascular Disease, Neuropathy and Retinopathy.Diabetes care 2009;32: e64- e 68.
7. Chambless LE, Heiss G, Folsom AR, Rosamond W,Szklo M, Sharrett AR, Clegg LX. Association of coronary heart disease incidence with carotid arterial wall thickness and major risk factors: the Atherosclerosis Risk in Communities (ARIC) Study, 1987– 1993. Am J Epidemiol 1997;146:483–94.
8. Burtis Carl A, Ashwood Edward R, Bruns David E.Tietz Textbook of clinical chemistry and molecular diagnostics. 4th Ed. New dehli: Elsevier publishers; 2008. Chapter 26,Lipids, lipopropteins, apolipoproteins and other cardiovascular risk factors: p. 903-83.
9. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care 2000;23(Suppl 1):S32–42.
10. Berg K. A new serum in man. The Lp system. ActaPatholMicrobiolScand 1963; 59:369-82.
11. Fijino A, Watanabe T. Kunii H, Yamaguchi N, Yoshinara K, Watanabe Y et al. Lipoprotein(a) is a potential coronary risk factor. JpnCirc J 2000;64(1):51-6.
12. Rath M, Ncendorf A, Reblin T, Dietel M, Knebber HJ. Detection and quantification of lipoprotein(a) in the arterial wall of 107 coronary bypass patients. Atherosclerosis 1989; 9:579-92.
13. KhareKC, Raman PG, Bhatnagar AD, ReemaBhavsar. Serum Lp(a) levels in patients of diabetes mellitus. Int. J. Diab. Dev. Countries 2000;20:79 – 83.
14. Clodi M, Oberbauer R, Bodlay G, Hoffman J, Maurer G, Kostner K. Urinary excretion of apolipoprotein (a) fragments in type I diabetes mellitus patients. Metabolism 1999; 48(3):369-72.
15. Trinder P. Determination of Glucose in Blood Using Glucose Oxidase with an. Alternative Oxygen Acceptor. Ann. Clin. Biochem 1969;6:24.
16. Product data sheet, triglyceride-G code no.997-69801,WAKO Pure Chemical Industries Ltd., Dallas,TX.
17. Allain CC, Poon LS, Chan CS, Richmond W. and Fu P., Clin.Chem 1974;20(4):470-5.
18. Burstein M, Scholnic H.R., Morfin RJ.Rapid method for the isolation of lipoproteins from human serum by precipitation with polyanions. J Lipid Res 1970;11(6):583-95.
19. Poulik, MD, Weiss ML. in F.W. Putman, Editor,"The Plasma Proteins", second Edition, Academic Press, New York, vol2;52-108.
20. Trivelli, LA, Ranney PH, Lai HT. Haemoglobin components in patients with diabetes mellitus. N Engl J Med 1971;284:355–8.
21. Gonen B, Rubenstein AH. Determination of glycohemoglobin.Diabetologia. 1978;15:1–5.
22. Robert McCarter J, James Hempe M, Ricardo Gomez, Stuart Chalew A. Biological Variation in HbA1c Predicts Risk of Retinopathy and Nephropathy in Type 1 Diabetes. Diabetes Care 2004;27:1259–64.
23. Christian Wilde (2003). Hidden Causes of Heart Attack and Stroke: Inflammation,Cardiology's New Frontier.Abigon Press. pp. 182–183. ISBN 0- 9724959-0-8.
24. Elizabeth Selvin, Josef Coresh, Sherita Golden H, Lori L. Boland,Frederick Brancati L, Michael Steffes W. Glycemic Control, Atherosclerosis, and Risk Factors for Cardiovascular Disease in Individuals with Diabetes. Diabetes Care. 2005;28(8):1965–73.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524166EnglishN-0001November30HealthcareEFFECTIVENESS OF MITOMYCIN-C APPLICATION AS AN ADJUNCT IN SURGERIES FOR RECURRENT PTERYGIUM - A META ANALYSIS
English2632Narendra P. DattiEnglish Nagesha C. K.English Rashmi N. R.English ShaliniEnglishBackground: Recurrent pterygium poses distinct problem like high postoperative recurrences and many surgical approaches have been tried to decrease recurrences. Currently, mitomycin C (MMC) application and amniotic graft are used as adjunct apart from the standard limbal-conjunctival autograft. Aim of study: Aim of this study is to determine through meta-analysis, the risk of recurrences and frequency of post operative complications associated with MMC application over bare sclera or along with amniotic graft for recurrent pterygia. Method: A thorough search of online resources for randomised controlled clinical trials comparing bare sclera technique with or without MMC and amniotic graft with or without MMC application was done. The purpose was to determine the pooled odds ratio and 95% confidence interval for post operative pterygium recurrence. Results: Among 5 studies, 2 studies comparing bare sclera technique with or without MMC showed pooled odds ratio of 0.105 with 95% CI 0.0131 to 0.847. Study comparing amniotic graft with or without MMC showed odds ratio 0.298 with CI of 0.0817 to 1.089. Conclusion: Application of MMC on bare sclera reduced recurrence rate to 10% and on amniotic graft it reduced to 30% with no added serious complications.
EnglishMitomycin-C, Amniotic graft, Bare sclera, Recurrent pterygia, Meta-analysis.INTRODUCTION
Pterygium is a fibrovascular growth arising from the conjunctiva onto the cornea. A number of surgical techniques have been described for primary pterygium excision including bare sclera technique1 , bare sclera resection with mitomycin-c (MMC) application2 , conjunctival autograft3 and recently amniotic membrane grafts4 . The treatment with these adjuncts have significantly reduced but not eliminated the problem; as far as the recurrent pterygium is concerned, there are greater challenges associated with treatment5 . Added to high recurrence rate, is the problem of deciding on the best approach of its surgical excision, since a recurrent pterygium is usually associated with subconjunctival fibrosis and/or corneal thinning and scarring. Mitomycin-C is an antitumor agent that acts by inhibiting DNA synthesis. The mechanism of action seems to be inhibition of fibroblast proliferation at the level of episclera6 . Adjunct MMC for pterygium surgery was first described by Kunitomo and Mori7 in Japan in 1963 and in US by Singh et al8 in 1998 as postoperative topical MMC with concentration of 0.4-1mg/ml. At present, MMC is being mainly used after pterygium excision as an intraoperative application to bare sclera for the management of both primary and recurrent pterygium.9 In order to further reduce the recurrence and postoperative complications, an intraoperative MMC treated sclera is normally covered with a conjunctival or amniotic membrane graft4 . Despite the fact that studies on MMC have shown rare but significant conjunctival, scleral, and corneal toxicity10, its use as an adjunct in primary or recurrent pterygia surgeries seems to be beneficial in few randomised clinical trials11-15 . We conducted a Meta-analysis of published randomised clinical trials analysing the recurrence rates and frequency of postoperative complications with MMC application over bare sclera or along with amniotic graft for recurrent pterygia. The purpose of this study was to determine the pooled odds ratio and 95% confidence intervals for postoperative pterygium recurrence.
MATERIALS AND METHODS
Selection strategy and selection criteria Following an established protocol, a survey of published studies comparing at least two of the three surgical techniques in the treatment of recurrent pterygium – bare sclera resection, bare sclera resection with MMC application and amniotic membrane transplantation with MMC – was conducted through an electronic search. We have not analysed technique of limbalconjunctival autograft with MMC here, because of paucity of Randomised Controlled Trials analysing its effect with or without MMC for recurrent pterygium surgery. Randomised controlled trials (RCTs) that compared above mentioned techniques and reported recurrence rates and post operative complications were included. Exclusion criteria included non-randomised, non-controlled trials, studies with other adjunct techniques and unpublished data. Clinical trials were identified through (1) Electronic search of PUBMED, Science direct, MD consult, Google scholar, MEDLINE and EMBASE. (2) Manual searches of the reference list of original article reports through electronic search. Searches were conducted using the keywords “recurrent pterygium”, “Mitomycin-C”, “Amniotic membrane”. The computerised search covered the period from 1980 to October 2013. Two reviewers (N.D and C.K.N) confirmed study eligibility and extracted data independently, and data were pooled using standard Meta-analysis techniques.
RESULTS
Total five eligible studies were identified, two that compared bare sclera resection with or without MMC application11,12, three studies that compared amniotic graft placement with or without MMC13,14,15. For statistical analysis and to maintain homogenicity in studies, 5 studies were divided into 2 groups. 1st group consisted of two studies of bare sclera technique with or without MMC and 2nd group with three studies consisting of amniotic membrane transplantation with or without MMC. Table 1 provides characteristics of clinical trials comparing mitomycin C on bare sclera and on amniotic graft. Table 2 provides a description of the population characteristics of studies included, follow-up periods and recurrence definition. Table 3 and 4 show recurrence rates and complications encountered in different surgical techniques. 3 studies were from English literature and 2 studies from Chinese literature. Full text was available in 3 studies and in 2 studies, only abstract was available. The results of meta-analysis showed that recurrence rate of bare sclera with MMC were 8% which was lower than bare sclera alone group with 47% recurrence rate. Amniotic Membrane Graft with MMC group was associated with lower recurrence rate (9%) compared to AMG group alone (25.5%). Heterogenecity was found between the studies in group 1 and group 2. In group 1, Q=5.2422 with significant P value (p=0.0220) and in group 2, Q=5.9912 with significant P value (p=0.05). The heterogenecity between the studies were taken into consideration and analysed with due care by random effect analysis of raw data. Narendra P. Datti et. al. EFFECTIVENESS OF MITOMYCIN-C APPLICATION AS AN A
DISCUSSION
Pterygium, a worldwide degenerative corneal disease with multifactorial etiology, is particularly common in tropical and subtropical countries.16 Although different treatment regimens have been proposed for the treatment of pterygium, the main complication of pterygium treatment is recurrence.17,18 Recurrent pterygium is more difficult to control, and various treatment modalities including radiotherapy19, antimetabolite or antineoplastic drugs2 , conjunctival flap3 , and conjunctival or limbal autograft transplantation have been proposed. 4 Now a days, conjunctival10 or limbal autografts and amniotic membrane transplants5 have been commonly used alone or combined with MMC11 as adjuvant treatment for recurrent pterygium. Use of antimetabolites, especially intraoperative administration of MMC, may be performed in conjunction with amniotic membrane transplantation.13,14 Covering bare sclera with amniotic membrane may decrease the risk of scleral ulcer formation as a late complication with the use of antimetabolites.20,21 This study provides evidence of the inherent risk of pterygium recurrence after excision of recurrent pterygium with or without mitomycin C application over bare sclera or amniotic graft. Analysis of group 1 studies showed that for every 100 recurrences in bare sclera alone group, there were only 10 recurrences with application of MMC with a 95% confidence interval of 0.0131 to 0.847 (Pooled OR=0.105). These results show dramatic change in recurrence rate with MMC application.(Graph:1) Analysis of group 2 studies showing role of MMC on amniotic grafts in preventing recurrences, showed pooled odd’s ratio of 0.298 with 95% confidence interval of 0.0817 to 1.089. This implies for every 100 recurrences in Amniotic Membrane Graft alone group, there were only 30 recurrences if MMC was added in AMG. Only one study13 revealed no difference with addition of MMC compared to Amniotic Membrane Transplant alone. The association between exposure (MMC) and control group (AMG alone) was less strong compared to group 1 studies but still carried high significant value in terms of recurrence rates.(Graph:2) We have found that bare sclera or AMG augmented with MMC was associated with a lower recurrence rate than either of it alone in recurrent pterygium surgeries. An interventional prospective case series comparing limbal-conjunctival autograft (L-CAT) with or without MMC showed least recurrence rate in MMC group.16 L-CAT theoretically is a natural substitute to cover bare sclera and hence associated with low recurrences but recurrent surgeries on conjunctiva pose difficulties in harvesting healthy conjunctival graft. We have not analysed this technique here because of paucity of RCTs analysing its effect with or without MMC for recurrent pterygium surgery. As per complications are concerned, Superficial punctate keratitis was found in only one study in MMC group. Otherwise the mentioned complications (table 4) are nonspecific and do not seem directly related to the effects of MMC. Moreover these complications are more in control group than treatment group suggesting protective role of MMC in preventing complications other than recurrences. There are many case series, prospective studies and reports of complications arising from MMC application21-24; no such serious complications like scleral or corneal melt were reported in our study group. The reason could be difficult to analyse but needs more data to conclude these findings. As per quality assurance and strength of studies is concerned, heterogenecity was found, which do weaken the result. Things like unpublished data, research in langauge other than English, Chinese and publication bias might appear like an island in a sea of darkness which may partly make the analysis incomplete. Hence, we tried doing a good home work before interpreting the findings.
CONCLUSION
To summarise, this is the first ever Meta analysis done, analysing the surgeries for recurrent pterygium using MMC as adjuvant. From above analysis, it is clear that MMC application over bare sclera stood highly scientific and rationale. So, we should strongly discourage bare sclera technique alone in a recurrent pterygium surgery. This fact is more or less well established from other meta analyses which tested MMC effectiveness on primary pterygium surgery.25,26 With respect to the surgeries with amniotic graft concerned, addition of MMC as an adjunct overweighs advantages compared to complications per se due to MMC. Hence, MMC is strongly recommended in high risk groups. There appears to be low magnitude of recurrence both in control and cases of group 2 studies. Here, amniotic graft has major contribution in low recurrence but addition of MMC makes the figures encouraging. In this regard, new research should focus on long term effects of mitomycin-C in recurrent pterygium surgeries.
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=927http://ijcrr.com/article_html.php?did=927REFERENCES
1. D’Ombrain. The surgical treatment of pterygium. Br J ophthalmol 1948;32:65-71.
2. Singh G, Wilson CS, Foster CS. Mitomycin eye drops as treatment for pterygium. Ophthalmology1998;95:813-21.
3. Kenyon K, Wagoner MD, Heltinger ME. Conjunctival autograft transplantation and recurrent pterygium. Ophthalmology1985;92:1461-70.
4. Katrircioglu YA, Altiparmak VE, Duman S. comparison of three methods for the treatment of pterygium: amniotic membrane graft, conjunctival autograft, and autograft plus mitomycin C. orbit.2007;26:5-13.
5. Shimazaki J, Shinozaki N, Tsubota K. transplantation of amniotic membrane and limbal autograft for patients with recurrent pterygium associated with symblepharon. Br J.ophthalmol.1998;82:235-240.
6. Donnenfeld ED, Perry HD, Wallerstein A, et al. Subconjunctival mitomycin c for the treatment of ocular cicatricial pemphigoid. Ophthalmology.1999;106(1):72- 8;discussion79.
7. Kunitomo N, Mori S. studies on pterygium. Report N. A treatment of pterygium by mitomycin C instillation. Acta Soc ophthalmol Spn.1963;67:601-607.
. Singh G, Wilson MR, Foster CS. Mitomycin eyedrop as treatment for pterygium. Ophthalmology.1998;95(6):813-821.
9. Ang LP, Chau JL, Jan DT. Current concepts and techniques in pterygium treatment. Curr opin ophthalmol.1998;82:235-240.
10. Muthu FM, Sobaei G, Jatar T, Yildirim E. A comparitive study of recurrent pterygium surgery:limbal conjunctival autograft transplantation versus mitomycin C with conjunctival flap. Ophthalmologgy.1998;106(4):817-821.
11. Leonardo Mastropasqua, Paolo Carpineto, Marco Ciancaglini, Pier Enrico Gallenga. Long term results of intraoperative mitomycin C in the treatment of recurrent pterygium. British Jounal of Ophthalmology 1996; 80: 288-291.
2. Nitin verma1 , Jambi arringa garap1 , Rosilyn marisi and Apisai kerek1 . Intraoperative use of mitomycin C in the treatment of recurrent pterygium. PNG Med J 1998 Mar;41(1):37-42.
13. Ma DH, See LC, Hwang YS, Wang SF. Comparison of amniotic membrane graft alone or combined with intraoperative mitomycin C to prevent recurrence after excision of recurrent pterygia. Cornea. 2005 Mar;24(2):141-50.
14. Shi CN, Zhou GL. Application of mitomycin C in amniotic membrane traansplantation to treat recurrence pterygium. Cuangzhou Med J (chin)2006;37(5):37-39.
15. Li SZ. Effect analysis of amnion membrane transplantation combined with mitomycin C in the treatment of pterygium. J bethune military medical college (chin)2007;10(5):290-291.
16. Mohamed A Fakhry. The use of mitomycin C with autologous limbal-conjunctival autograft transplantation for management of recurrent pterygiumClinical Ophthalmology 2011:5 123–127.
17. Starck T, Kenyon KR, Serrano F. Conjunctival autograft for primary and recurrent pterygia: surgical technique and problem management. Cornea 1991;10:196 –202.
18. Mahar PS, Nwokora GE. Role of mitomycin C in pterygium surgery. Br J Ophthalmol 1993;77:433–5.
19. MacKenzie FD, Hirst LW, Kynaston B, Bain C. Recurrence rate and complications after beta irradiation for pterygia. Ophthalmology 1991;98:1776–80; discussion 1781.
20. Rubinfeld RS, Pfister RR, Stein RM, et al. Serious complications of topical mitomycin-C after pterygium surgery. Ophthalmology 1992;99:1647–54.
21. Dunn JP, Seamore CD, Ostler HB, Nickel BL, Beallo A. Development of scleral ulceration and calcification after pterygium excision and mitomycin therapy. Am J Ophthalmol 1991;112:343–4.
22. Rubinfeld RS, Pfister RR, Stein RM, Foster CS, Martin NF, Stoleru S et al. Serious complications of topical mitomycin-C after pterygium surgery. Ophthalmology 1992 Nov;99(11):1647-54.
23. Shabbir Saifuddin, Alaa El Zawawi. Scleral changes due to mitomycin C after Pterygium excision: A report of two cases. Indian J Ophthalmol 1995;43:75-6.
24. B Safianik, I Ben-Zion, and H J Garzozi. Serious corneoscleral complications after pterygium excision with mitomycin C. Br J Ophthalmol2002March;86(3):357-8.
25. Yin-Wei Song, Ai-Hua Yu, Xiao-Jun Cai. Effectiveness of amniotic membrane transplantation combined with mitomycin C in the treatment ofpterygium: a meta-analysis. Int J Ophthalmol2010;3(4):352-355.
26. Juan Camilo Sánchez-Thorin, Guillermo Rocha, Julie B Yelin. Meta-analysis on the recurrence rates after bare sclera resection with or without mitomycin C and conjunctival autograft placement in surgery for primary pterygium. Br J Ophthalmol 1998 82: 661- 665.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524166EnglishN-0001November30HealthcareTUBERCULOSIS OF THE BREAST, AN UNCOMMON DISEASE-A CASE REPORT
English3335N. MurugesanEnglish K. NatarajanEnglish V.S. AnanthanEnglishThe aim of studying this patient with tuberculosis of the breast is to highlight the diagnostic difficulties posed by this rare disease which mimics many other serious conditions because of its multifaceted presentation. The patient under study presented with a firm mass in her right breast. Biopsy of the lump confirmed the diagnosis of tuberculosis, as it is important to rule out carcinoma of the breast. Finding the typical tubercular granuloma on histopathological examination settled the issue. Tuberculosis of the breast is more common in young women and it usually presents as a mass, recurrent chronic abscess, ulcer or a sinus. A high index of suspicion and awareness of the varied presentation of the disease will help not to miss the diagnosis.
EnglishTuberculous mastitis, Acid fast bacillusINTRODUCTION
Tuberculosis of the breast is not very rare (1). The presentation of this disease is variable. Most often it can be mistaken for carcinoma, fibrocystic disease or abscess of the breast. The confirmatory test is the demonstration of the acid fast bacilli or typical granuloma in the lesion. As HIV infection is on the rise globally tuberculous mastitis may also correspondingly increase in incidence.
CASE REPORT
A 27 year old female patient presented with a two month history of a painless lump in the right breast which was gradually increasing in size. She had evening rise of temperature. There was no discharge from the nipple. She gave no history of loss of weight or loss of appetite. There was no history of similar complaints in the past. She had no previous history of tuberculosis. On examination she was not anemic, no generalized lymphadenopathy. Blood pressure and pulse were normal. Respiratory and other systems were normal. Examination of the right breast revealed a non tender firm lump 3 x 2 cm size in the upper half just above the areola at 12 o clock position. It was freely mobile and not attached to skin or the deeper structures. Her left breast was normal. There was no axillary or cervical lymphadenopathy. Blood Investigations revealed normal haemoglobin, and normal white cell count and differential count. ESR was 45mm at half hour 85mm in one hour. Mantoux skin test was negative. Sputum for AFB was negative. Blood Sugar was - Fasting 88mg, Post prandial 178mg. Chest x-ray was normal. FNAC of the breast lump revealed inflammatory cells and was negative for AFB and fungus mycelia. It did not produce any growth on culture. She had no relief after a prolonged course of Broad spectrum Antibiotics. The breast lump became semi fluctuant and hence incision and drainage of the abscess were done. She developed multiple sinuses in and around the area of incision and drainage and the swelling further increased in size (Fig 1). Then, under GA, excision of the breast lump and surgical debridement were done. Histopathology of the right breast lump was reported as TB granuloma. She was started on Anti Tubercular Treatment with 4 standard drugs namely HREZ. She had excellent response after 2 months of intensive phase treatment. The discharge from the sinuses stopped and all sinuses healed after six months of anti tuberculosis treatment.
DISCUSSION
Sir Astley Cooper was the first to describe tuberculous mastitis as "scrofulous swelling in the bosom of young women" in 1829(2). Tuberculous mastitis is not very rare. The mammary tissue is relatively immune to tuberculous infection like skeletal muscle and spleen (3). India has a high incidence of tuberculosis (4). Even though tuberculosis of the breast is not uncommon in the developing world, it is becoming common in the developed world due to increase in the number of immunocompromised patients (5). In spite of this, the disease is not often reported. The reason may be that this condition presents in a variety of ways. It is usually confused with fibroadenoma or carcinoma (6). This may also present as an abscess, a chronic sinus, fistula or a fungating ulcer. It may or may not be associated with pulmonary or other extra pulmonary tuberculosis. It is postulated that the route of infection to the breast might be retrograde spread from the axillary or mediastinal nodes. It is also possible that the disease may directly spread from a suckling infant. Gupta et al. found a correlation between prevalence of tuberculosis in the faucial tonsils of suckling infants and higher incidence of tuberculosis in lactating women (7). Definitive diagnosis can be made by a positive culture or presence of AFB bacilli on staining. In our patient, even though AFB was not demonstrated in FNAC, typical granuloma was seen on histopathological examination (Fig 2). The patient had an excellent response to anti tuberculosis therapy (Fig 3).
CONCLUSION
India has a very high incidence of pulmonary and extra pulmonary tuberculosis. Tuberculosis of the breast is not uncommon. It poses diagnostic difficulties because of its varied presentation and similarities to various other conditions. When it presents as a mass then malignancy has to be excluded by excision biopsy. Presence of tubercular granuloma will clinch the diagnosis.
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. The 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=928http://ijcrr.com/article_html.php?did=928REFERENCES
1. Kalac N, Ozkan B, Bayiz H, Dursun AB, Demirag F. Breast tuberculosis. Breast 2002; 11: 346-9.
2. Cooper A. Illustrations of the diseases of the breast. Part I. Longmans. Orme, Brown and Green. London:1829; 73
3. Mukerjee P, George M, Maheshwari HB, Rao CP. Tuberculosis of the breast. J Indian Med Assoc 1974;62 : 410-2.
4. WHO global tuberculosis report 2013 www.who.int/tb/data
5. Kervancioglu S, Kervancioglu R, Ozkur A, Sirikci A. Primary tuberculosis of the breast. Diagn Interv Radiol 2005; 11:210-2.
6. Graunsman RI, Goldman ML. Tuberculosis of the breastreport of nine cases including two cases of co-existing carcinoma and tuberculosis. Am J Surg 1945; 67 : 48.
7. Gupta R, Gupta AS, Duggal N. Tubercular mastitis. Int Surg 1982; 67:422-4
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524166EnglishN-0001November30HealthcareA STUDY OF ANTHROPOMETRIC INDICES BETWEEN HYPERTENSIVE AND NORMOTENSIVE ADULTS
English3643Ramya K.English Jai Ganesh K.English Mukundan A.EnglishBackground: Hypertension is the most common cardiovascular disorder affecting 20% of adult population worldwide. Obesity is considered as the main risk factor for hypertension .Simple clinical anthropometric measurements of obesity may be conveniently used to assess regional adiposity, which serves as indicators for Hypertension. Aim: To establish the correlation of Waist Hip Ratio, Body Mass Index and Waist Circumference between Hypertensive and Normotensive status in adults between the age group of 45-55 years of both genders. Methods: This is a clinical based case control study. The subjects were selected according to the inclusion and exclusion criteria with a sample size of 100, using a pretest proforma. Blood Pressure, weight, height, waist circumference and hip circumference were measured for each participant, using standard methods. Then the data obtained was analyzed using Fisher’s exact test and Chi Square Test. Results: BMI and Waist Circumference were found to have significant association with hypertension, with a p value of 0.006 and 0.032 respectively, irrespective of the gender. BMI and Waist Circumference showed significant association in women (p=0.003) and in men (p=0.015) respectively. Conclusion: Association between these anthropometric measures and hypertensive status proves obesity to be a major pathological factor in the development of hypertension.
EnglishHypertension; Obesity; Anthropometric indicesINTRODUCTION
Hypertension is one of the most prevalent cardiovascular disorders affecting 20% of adult population worldwide, with a myriad of health complications that might lead to fatal consequences. Normal systolic blood pressure is 100-120 mm of Hg and the diastolic blood pressure is 70 -90 mm Hg and those readings above these are graded into pre hypertensive (120- 139 /80-89)and hypertensive conditions(140/90) 1 . In India, prevalence of hypertension ranges from 20-40% in urban adults and 12-17% among rural adults. The number of people with hypertension is projected to increase from 118 million in 2000 to 214 million in 2025, with nearly equal numbers of men and women.2 Even though hypertension results in many complications, it is considered as the primary risk factor for stroke, ischemic heart disease and cardiovascular disease mortality2,3. Hypertension can either be essential type or may occur secondary to many diseases. But age and obesity are considered as the main risk factors 4 .The above fact is supported by the data from the Framingham Cohort study, which states that obesity accounts for 78% and 65% of essential hypertension in men and women, respectively.5 Obesity is first of the “disease of civilization” to appear 6 , which has increased rapidly by urbanization, westernization, rapid economic development and unhealthy lifestyles. Based on data from the 2007 National Family Health Survey.19.8% of males and 24.4% of females are obese. Thus the past few decades had witnessed the soaring rates of obesity and its co morbid consequences7 .A study conducted by the World Health Organization has estimated the presence of more than 1 billion overweight and at least 300 million adults worldwide who are clinically obese and they are estimated to increase further by the year 2015 8 . It is one of the major modifiable risk factors for hypertension; and the relationship between Hypertension with body fat distribution has been demonstrated by various studies5 . So, obesity should no longer be simply considered only as a marker of cardiovascular risk but should be regarded as an important and primary contributor to the pathophysiology of hypertension9 . Especially, the central obesity plays a major role in triggering complications of Hypertension10 . Even though assessment of obesity is done by various clinical tests accurate quantification of body fat compartments requires imaging techniques, which are relatively expensive and impractical for routine clinical settings or largescale studies11 . Therefore, simple clinical anthropometric measurements such as waist circumference (WC), waist-to-hip ratio (WHR) and body mass index (BMI) may be conveniently used to assess regional adiposity, which correlates reasonably well with some of adiposity measures using imaging techniques 12. And these anthropometric measures have been used by many epidemiological studies to define obesity 13 . Though controversies exist for their reliability, the above mentioned parameters served as effective epidemiological equipment in assessing the relationship between obesity and hypertension for many researchers. Therefore, this study was structured with the intent to establish the relationship existing between obesity and hypertensive individuals and it is also compared with normotensive individuals.
MATERIALS AND METHODS
This study was conducted at Mahatma Gandhi Medical College and Research Institute, Pillaiyarkuppam, Pondicherry. The subjects were chosen from the Outpatient Medicine department and Master Health Check-up during January 2010 to May 2011. Sample size of this study was 100 including both male and female. Among which 50 are cases (hypertensive) and 50 are controls (normotensive), selected between the age group of 45 to 55years.Individuals with history of smoking, intake of drugs which influences lipid metabolism, upper abdominal surgeries, Diabetes Mellitus, Cardiovascular Disorders, Endocrinological Disorders and family history of hypertension were excluded from the study. Institutional Ethical Committee clearance was obtained before conducting the study. The purpose of the study was explained to the individuals and written consent was taken from the participants who had willingness, in both English and Regional languages. Following which, all the participants of the study were interviewed by using pre-test proforma. And the subjects were selected according to the inclusion and the exclusion criteria of the study. Then the following procedures were done: After giving a supine rest of 5 minutes to the subject, blood pressure was measured in supine position by using Mercury Sphygmomanometer. The pressure at which korotkoff’s sound was first heard [phase-I] was taken as systolic blood pressure and the pressure at which the sound disappeared [phase V] was taken as diastolic blood pressure11. Blood pressure was measured 3 times. The average of second and third reading was taken as systolic and diastolic blood pressure 11 . Height was measured to the nearest 0.1 cm, while the subject was standing in erect position with bare feet on flat floor against a vertical scale and with heels touching the wall and head straight at the OPD 11. Body Weight was measured using Bathroom weighing scale, while the subject was minimally clothed and without shoes, standing motionless on a weighting scale and it was recorded nearest to 0.1 Kg, at the OPD 11. Body Mass Index was calculated using the Quetlet’s index14 .Then the participants of the study were classified into normal and obese, according to the BMI. Revised WHO Criteria for Asian Indians 14 was used for this categorization. Waist Circumference (in cms) was measured at a point mid-way between the lower rib and iliac crest with the measuring tape centrally positioned at the level of the umbilicus 14.It is the average of two measurements one taken after inspiration and the other taken after expiration in standing position. Hip Circumference was measured (cms) over light clothing at the trochanter major of the Head of femur 14. And Waist Hip Ratio is taken as the ratio of waist circumference to the Hip Circumference.
Statistical analysis
Statistical analysis was done using Fisher’s exact test and Chi Square Test. They were analyzed using the p-value obtained.
RESULTS
From the analysis done, it was found that no association exists between Waist Hip Ratio and Hypertensive status. According to Waist Hip Ratio, individuals are classified into normal and obese. In this study all the subjects inclusive of 50 hypertensive and 50 normotensive individuals were found to be obese, irrespective of the gender.
DISCUSSION
Obesity is considered as a primary contributor to the pathophysiology of hypertension. Clinically, Obesity is evaluated clinically by anthropometric indices like BMI, Waist Circumference and Waist Hip Ratio. Observation similar to our results was found by Jung C, who established that BMI was a good predictor of Hypertension 15.In addition, two other previous studies conducted by Kaur P during 2008 and Koh-Banerjee P during 2004 has similar findings. They showed that increased BMI and waist circumference are strongly associated with cardiovascular disease risk factor such as hypertension in many populations 16, 17 . In contrary, Theodore A K during 2008 conducted a study on the Africans and Americans; found that the indices of obesity correlated well with normotensive than with hypertensive18 . Unlike the above parameters, WHR had no significance in establishing the relationship between hypertensive status and obesity in our study which is in accord with the findings of Kaur P during 2008 and Koh-Banerjee P during 2004 16, 17. Whereas, association was observed for WHR, in the studies of Mohan V and Tiffany G during 2004 which contradicted our study results 19, 20. Esmaillzadeh A in 2004 found a similar contradictory observation with WHR serving a better predictor for cardiovascular risk factors than BMI, WC and WHtR 21 . It was also observed that, parameters individually had gender selective significance rates. Body Mass Index and Waist Circumference correlated significantly among female and male Hypertensive respectively. The above mentioned result was supported by a study conducted in Japan, which showed, waist Circumference to have strongest association with BP and its prevalence in men and BMI had the strongest association with BP and its prevalence in women 22.And Esmaillzadeh A in his study during 2004 observed WHR to be a better predictor in male 21, which contradicted our study result. The anthropometric studies conducted by Rocchini, 2002 demonstrated, that Central obesity is often referred to as android obesity and gynoid obesity in males and females respectively; where there is preferential fat accumulation in the gluteal and femoral distribution, which can be measured by Waist Circumference and Waist Hip Ratio11. This study supported our result of Waist Circumference to be good predictor in male and contradicted our result of BMI to be good predictor in females. Majority of all the studies, which showed observations inclusive of both the supportive and contradictory facts were targeted with the same aim. The aim was nothing but the proven fact that, the obesity leads to hypertension and the various indices of obesity have greater predilection for hypertension. And this is clinically evident by many factors, which act together to promote vasoconstriction and sodium retention 23. Increased levels of leptin, free fatty acids and insulin in obesity enhances the sympathetic activity in a mutual way resulting in vasoconstriction due to increased vasoconstrictor tone. In addition, obesity-induced insulin resistance and endothelial dysfunction acts in a combined manner to magnify the vasoconstrictor response. Finally, increased renal tubular reabsorption of sodium may also occur, caused by an increased renal sympathetic nerve activity, the direct effect of insulin, hyperactivity of the renin-angiotensin system and possibly by an alteration of intrarenal physical forces. All together, these factors will lead to sustained hypertension. Variations in the results when compared with other studies that have assessed cardio metabolic risk factors in relation to the indices of adiposity may be attributable to differences in ethnicity, age, and gender distributions of participants across study populations. The above fact about the role of obesity in the development of hypertension was supported by a study conducted in Chennai by Mohan V during 2006 19 and various other studies. In our study, it is observed that majority of hypertensive were obese when compared to normotensive, which stresses the fact that hypertension could have resulted from obesity, as the other predisposing factors such as smoking, personal habits, family history and other medical, surgical and Endocrinological causes were excluded. Therefore, it could be established that obesity is one of the most common causes of the multi etiologic condition, “the hypertension”. The unequal recruitment of male and female subjects was due to the short available recruitment time and subject unavailability. Findings of the present study, suggests the need for larger population and increased duration for accurate results.
CONCLUSION
Our study serves as a reaffirmation, for the proven fact that obesity leads to hypertension. Body Mass Index and Waist Circumference were found to have significant association with hypertensive adults in the present study. Thus, these parameters in all their variations have proved themselves effective in establishing the linear relationship between Obesity and Hypertension. Personal habits, socioeconomic status and psychosocial factors play a major role in the development of complications of hypertension, when compared with other causes like race, ethnicity, or genetics. Obesity being a modifiable factor, life style modifications including increased physical activity and dietary modifications can decrease the incidence of hypertension and its outcomes
ACKNOWLEDGMENT
I acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. I am also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. And I also thank Dr.Tamilselvan, Assistant professor, Department of Physiology, Sri Venkateswaraa Medical College, Hospital & Research Center, Pondicherry, for his immense help during the work.
Englishhttp://ijcrr.com/abstract.php?article_id=929http://ijcrr.com/article_html.php?did=929REFERENCES
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10. Roopakala MS, Suresh A, Ashtalakshmi, Srinath, Ashok, Giridhar, Anand, Silvia WD. Anthropometric measurements as predictors of intraabdominal fat thickness. Indian J Physiol Pharmacol. 2009 Jul-Sep;53(3):259-64.
11. D.B. Tambe, A.V. Phadke, J.S. Kharche, A.R. Joshi. Correlation of blood pressure with Body Mass Index and Waist to Hip Ratio in middle aged men. Journal of Medical Update : July, 2010.
12. D.C. Chan, G.F. Watts, P.H.R. Barrett and V. Burke.Waist circumference, waist-to-hip ratio and body mass index as predictors of adipose tissue compartments in men. An International Journal of Medicine.2003 Jun ; 96(6): 441- 447.
13. Zhou Z, Hu D,Chen J.Association between obesity indices and blood pressure or hypertension: which index is the best? Public Health Nutrition. 2009; 12:1061-71.
14. World Health Organisation Expert Committee 1995. Physical Status: The Use and Interpretation of Anthropometry. Technical Report Series No. 854, World Health organisation, Geneva 427-438.
15. Jung C, Fischer N, Fritzenwanger M, Figulla HR. Anthropometric indices as predictors of the metabolic syndrome and its components in adolescents. Pediatr Int. 2010 Jun;52 (3):402- 9.
6. Kaur P, Radhakrishnan E, Sankarasubbaiyan S, Rao SR, Kondalsamy-Chennakesavan S, Rao TV, Gupte MD.A comparison of anthropometric indices for predicting hypertension and type 2 diabetes in a male industrial population of Chennai, South India. Ethn Dis. 2008 Winter;18 (1):31-6.
17. Koh-Banerjee P, Wang Y, Hu FB, Spiegelman D, Willett WC, Rimm EB: Changes in body weight and body fat distribution as risk factors for clinical diabetes in US men. Am J Epidemiol 2004, 159:1150-1159.
18. Theodore AK, Clarence EG, Jane MK, Shanthi K, Hongyan Y, Raymond GH and Emily LM. Altered Relationship of Blood Pressure to Adiposity in Hypertension. American Journal of Hypertension (Feb 2008).
19. Mohan V, Deepa R. Obesity and Abdominal Obesity in Asian Indians. Indian J Med Res. 2006; 123: 593-596.
20. Tiffany G , Catherine C, Anne T, Richard R, David W and Patrick P. Body mass index, waist hip ratio, and waist circumference: which measure to classify obesity? Journal Social and Preventive Medicine 2003, June:48 (3).
21. Esmaillzadeh A, Mirmiran P and Azizi F. Waist-to-hip ratio is a better screening measure for cardiovascular risk factors than other anthropometric indicators in Tehranian adult men. International Journal of Obesity.(2004) 28, 1325–1332.
22. Masaru Sakurai, Katsuyuki Miura, Toshinari Takamura, Tsuguhito Ota,Masao Ishizaki, Yuko Morikawa, Teruhiko Kido, Yuchi Naruse and Hideaki Nakagawa.Gender Differences in the Association between Anthropometric Indices of Obesity and Blood Pressure in Japanese. Hypertension Research (2006) 29, 75–80.
23. Keith SW, Redden DT, Katzmarzyk PT, et al. (2006)."Putative contributors to the secular increase in obesity: Exploring the roads less traveled". Int J Obes (Lond) : 2006:30 (11): 1585-94.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524166EnglishN-0001November30HealthcareUNILATERAL ACCESSORY RENAL ARTERY- ITS EMBRYOLOGICAL BASIS - CASE REPORT
English4447Janardhana Rao M.English Reshma MohammadEnglish Sirisha V.EnglishUnambiguous information of vascular variation and planning of conducting surgical and radiological procedure is important during renal transplantation. During the routine dissection of a male cadaver we discovered unilateral accessory renal artery (UARA). It originated from the antero-lateral aspect of the abdominal aorta, at the level of inferior mesenteric artery (IMR) and below the renal artery (RA). The evolutionary history of kidney and renal artery is recapitulated during embryonic development. The reminding of this type of variation is also important while performing the surgeries or dissections.
EnglishKidney, Abdominal aorta, Renal artery, Accessory renal artery, Unilateral, Inferior mesenteric arteryINTRODUCTION
The main right and left renal arteries are originated from the antero-lateral or lateral aspect of the abdominal aorta at the level of L1-L2 origin of the superior mesenteric artery [1]. Usually one renal artery supplies each kidney which enters through its hilum [2]. Variations in the pattern of renal arteries have been reported more frequently than other large vessels in the literature. The most common variation of renal artery is the presence of an accessory renal artery, which may enter through the hilum or through the surfaces of the kidney. Alternative nomenclatures have been used to describe the accessory renal artery as supernumerary, multiple, aberrant, additional etc. According to Graves (1956) [3], any artery arising from the aorta in addition to the main renal artery should be named ‘accessory’ and the renal arteries arising from sources other than the aorta should be called ‘aberrant’[4]. Accessory renal arteries (ARA) are common 30- 35% of individuals, usually arising from the aorta above or below the main RA and following it to the renal hilum. Higher or lower origins are not uncommon, an accessory artery or leash of arteries passing to the superior or inferior renal pole. They are regarded as persistent embryonic lateral splanchnic arteries. ARA passes to the inferior pole of the kidney and crosses the anterior to the ureter and may, by its obstruction, cause hydronephrosis [1]. ARA commonly derived from the abdominal aorta [2,5,6,7]. Renal transplantation is one of the most common surgical procedures require good knowledge of arteries supplying it and the possible variations, then surgeon can avoid intra and post-operative complications like haemorrhage. Therefore, a thorough knowledge of normal and abnormal anatomy, arterial supply of the kidney is very important to surgeon performing surgeries in adults, children and infants.
CASE REPORT
During the routine medical undergraduate educational dissection of 65-years-old male cadaver in the Department of Anatomy, Mamata Medical College, Khammam. We identified the presence of unilateral accessory renal artery to the right side kidney directly coming from the lateral aspect of the abdominal aorta and at the level of inferior mesenteric artery below the main renal artery (Fig.1).
DISCUSSION
The findings of the present case report have been compared with those of previous workers on the subject. According to authors Nayak, Harvey, Kara and Pestemalci [2,5,6,7] accessory renal arteries are common and mainly derived from the abdominal aorta as well as our case. Lacout A, Gesase AP [8,9] has been reported the origin of an ARA from either superior or inferior mesenteric artery. In our case report stated that ARA originated at the level of inferior mesenteric artery. According to study of Vrinda Ankolekar [10] the percentage of unilateral ARA was 11.67%, the inferior polar artery at hilum was 10%, the ARA from main renal artery 8.33%, the prevalence of ARA in 25%, the right and left RA at same level was 26.7% as well as our report stated that unilateral ARA was entering into the hilum at inferior pole of the kidney, we observed the another ARA from the main RA and right, left RA artery at same level. In the present case reported that the renal arteries entered the renal cortex at one of the poles. ARA generally represented the inferior polar artery and usually derived directly from the aorta and passes anterior to the ureter it was general agreement with the reports of Kumar MP, Alper Atasever, H, S. Saritha, Kocab?y?k N [11,12,13,14]. Embryological explanation for the accessory renal arteries are not uncommon they are derived from the persistence of embryonic vessels that formed during the ascent of kidney. Kidneys develop in three stages of development pronephros, mesonephros and metanephros during this process the kidneys ascend from pelvic to the lumbar region and there was error in fusion of the dorsal and ventral vessels which appeared in distribution of these vessels at the hilum [15].
CONCLUSION
Although an accessory renal artery can be responsible for reno-vascular hypertension. Everyaccessory renal artery is related to segmental arteries, so the risk of bleeding during urological surgery or renal transplantation, segmental ischemia and postoperative hypertension increases and the urosurgeon should take care into account the origin of accessory renal artery when operating the lower pole of the kidney and segmental resection.
Englishhttp://ijcrr.com/abstract.php?article_id=930http://ijcrr.com/article_html.php?did=930REFERENCES
1. William PL, Bannister LH, Berry MM, Collins P, Dyson M, Dussek JE (1995): Gray,s Anatomy. Cardiovascular system.38th Ed. Churchill Livingstone Edinburg: P.1826.
2. Nayak B.S (2008):- Multiple variations of the right renal vessels. Singapore Med J. 49(6):153–5.[PubMed]
3. Graves FT. (1956):- The aberrant renal artery. J Anat; 90: 553-58.
4. Anupma Gupta, Raman Gupta, Rajan Kumar Singhla (2011):-The Accessory Renal Arteries: A Comparative Study in Vertebrates with Its Clinical Implications October, Vol- 5(5): 970-973.
5. Harvey RW (1914):- A case of multiple renal arteries. Anat Rec.; 6(8):333–9.
6. Kara A, Kurto?lu Z, O?uz Ü, Öztürk AH, Uzmansel D (2006):- Two Accessory Renal Arteries with Histological Properties. Turk J Med Sci; (36):133–8.
7. Pestemalci T, Mavi A, Yildiz YZ, Yildirim M, Gumusburun E (2009):- Bilateral triple renal arteries. Saudi J Kidney Dis Transpl; 20:468– 70.
8. Lacout A, Thariat J, Marcy P-Y. (2011):- Main right renal artery originating from the superior mesenteric artery. Clin Anat. doi: 10.1002/ca.22002.
9. Gesase AP. (2007):- Rare origin of supernumerary renal vessels supplying the lower pole of the left kidney.Ann Anat. ;189(1):53–8.
10. Vrinda Ankolekar, Ratnabali Sengupta. (2013):- Renal artery variations: Acadaveric
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524166EnglishN-0001November30HealthcareABNORMAL LEFT VENTRICULAR RELAXATION IN YOUNG PREHYPERTENSIVES: A CASE CONTROL STUDY
English4854Santha KumariEnglish Jaiganesh K.English Amirtha GaneshEnglishBackground: Prehypertension predicts established hypertension. The structural and functional alteration of the heart caused by prehypertension is unclear. Aims and Objectives: The present study was designed to compare the diastolic function in young normotensive and prehypertensive subjects between the age group of 18–35 years. Subjects and Methods: Pulse wave transmitral Doppler echocardiographic data was assessed in 100 subjects. Of which, 50 were normotensives (systolic EnglishPrehypertension, E/A ratioINTRODUCTION
Hypertension is one of the major cardiovascular risk factor and is reported to be the fourth contributor to premature death in developed countries and seventh in developing countries (1). Hypertension is defined as persistent elevation of blood pressure equal to or more than 140 mm Hg systolic and equal to or more than 90 mm Hg diastolic in adults. The Seventh Report of Joint National Committee on Prevention, Detection, Evaluation and Treatment of high blood pressure (JNC-7) introduced a new category, prehypertension where systolic blood pressure was 120-139 mm Hg and diastolic blood pressure 80 - 89 mm Hg(2). The overall prevalence of prehypertension in our general population is almost comparable with that of United States (31%). Prehypertension was highest in the age group of 30 - 39 years (36%)(3,4). Prehypertension predicts established hypertension. A number of structural changes in the heart which eventually leads to systolic and diastolic abnormalities is caused by hypertension per se. Left ventricular diastolic dysfunction has been reported to be the earliest manifestation of cardiac involvement in subjects with hypertension. Diastolic impairment is associated with significant morbidity and mortality (5, 6). Few studies show that diastolic dysfunction starts even at the prehypertensive stage(7) . Cardiovascular structure and function can be studied by non-invasive imaging methods like pulse wave Doppler echocardiography. Altered mitral inflow velocities indicating prolonged left ventricular relaxation can be detected by this method even before any clinical or electrographic abnormalities develop (8- 10). The aim of this study is to compare the left ventricular diastolic function in young normotensives and prehypertensives. To assess and compare the diastolic function parameters E- velocity, A- velocity and E/A ratio in young normotensive and prehypertensives subjects.
SUBJECTS AND METHODS
This study was conducted after receiving the approval from Research Committee and Institutional Human Ethical Committee (IHEC), of Mahatma Gandhi Medical College and Research Institute, Puducherry, India. 100 subjects between 18 to 35 years of age of both genders were recruited from outpatient medicine department and master health check up of our institution from January 2012 to June 2013. Among them, 50 subjects were cases (prehypertensives) and 50 were controls (normotensives).
Inclusion criteria:
? Subjects between the age group of 18 to 35 years. ? Normotensive individuals with systolic BP 100 - 119 mm Hg and diastolic BP 60 - 79 mm Hg ? Prehypertensive individuals with systolic BP 120 - 139 mm Hg and diastolic BP 80 - 89 mm Hg
Exclusion criteria
Stage I and II hypertensives ? Secondary hypertension including chronic kidney disease, hypertensives with target organ damage. ? History of coronary artery disease, congestive heart failure, cardiomyopathies, diabetes, pregnancy. ? Use of anti- hypertensives, steroids or cardio active medications. Age, gender, anthropometric measurements, occupation, personal history were collected.
Blood pressure measurement
(11): Subjects were asked to rest in supine position for about 5-10 minutes in a quiet, calm examination room. Based on accuracy and reliability blood pressure was measured using standard mercury sphygmomanometer. Appropriate cuff selection based on the circumference of the bare upper arm at the midpoint between the shoulder and the elbow was selected. The cuff is wrapped around the midpoint of the bare upper arm. The lower edge of the cuff should be 2.5 cm above the antecubital fossa where the head of the stethoscope is to be placed. Inflate the cuff rapidly to 70 mm Hg and then by 10 mm Hg increments while palpating the radial pulse. The reading at which the pulse disappears is noted. By inflating the cuff rapidly and steadily to a pressure 20 - 30 mm Hg above the level previously determined by palpation and then deflating at 2 mm Hg/sec. As the pressure in the cuff falls, the manometer readings at the first appearance of Korotkoff sounds (phase I) is noted as systolic blood pressure and the pressure at which the sound disappears (phase V) was recorded as diastolic blood pressure. The measurements were repeated after 30 seconds of rest. Three blood pressure readings were recorded. The average of second and third reading was taken as systolic and diastolic blood. Echocardiographic Methods(12, 13): Echocardiography was performed using iE Philips Sonos system with the subject lying down in left lateral decubitus position. Mitral flow velocities were recorded within the apical 4-chamber or apical long axis view to determine the left ventricular filling hemodynamics. Evelocity, A- velocity and E/A ratio, were measured. The Doppler cursor was placed parallel to mitral inflow and maximum velocity measured with the sample volume at the mitral valve leaflet tips. The mitral peak E- wave (early filling) and A- wave (inflow with atrial contraction) were measured offline and E/A ratio was calculated.
Statistical Analysis
Statistical analysis was carried out using SPSS version 16.0. The baseline characteristics of the Study population to the baseline blood pressure was investigated using the student’s t-test. For parametric data, the level of significance between normotensive and prehypertensives groups was tested by unpaired student’s t-test.
RESULTS
Our study group consisted of 100 subjects between 18- 35 years of age of both gender. Among fifty prehypertensives, 35 subjects (70%) were men and 15 subjects (30%) were women. Fifty normotensives were controls, 34 (68%) were men and 16 (32%) were women. The mean age was 24.6 years for normotensives and 28.38 years for prehypertensives. The mean body mass index (BMI) in prehypertensives and normotensives were 23.39 kg/m2 and 23.56 kg/ m2 respectively. In prehypertensives 58% were sedentary workers and 42% of them were non sedentary workers. In normotensives 54% were sedentary workers and 46% were non sedentary workers. There were 28% smokers in prehypertensive group compared to 20% smokers in normotensive group. 56% of prehypertensives and 45% of normotensives were alcoholic. The mean systolic and diastolic blood pressures in prehypertensives were 127.52 mmHg and 84.26 mm Hg respectively and mean systolic and diastolic blood pressures in normotensives were 112.46 mm Hg and 75.24 mm Hg respectively (Table 1). When compared with normotensives, in the prehypertensive group it is observed that E-velocity did not show significant difference between prehypertensives and normotensives with a p value of 0.785 (>0.05). The comparison of A- velocity between normotensives and prehypertensives shows a significant difference with p-value of 0.031 (Englishhttp://ijcrr.com/abstract.php?article_id=931http://ijcrr.com/article_html.php?did=931REFERENCES
1. Deepa R, Shanthirani CS, Pradeepa R, Mohan V. Is the ’rule of halves’ in hypertension still valid? Evidence from the Chennai Urban Population Study. J Assoc Physicians India 2003; 51: 153-7.
2. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, Jr, et al. National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: National High Blood Pressed Education Program coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 Report. JAMA. 2003;289:2560–72. [PubMed]
3. Yadav S, Boddula R, Genitta G, Bhatia V, Bansal B, Kongara S, et al. Prevalence and risk factors of pre-hypertension and hypertension in an affluent north Indian population. Indian J Med Res. 2008;128:712–20. [PubMed]
4. Anand Chockalingam AB, Patterns and predictors of prehypertension among health urban adults in India. Angiology 2005 sep-oct; 56(5):557-63.
5. Iriarte MM, Perez Olea J, Sagastagoitia D, Molinero E, Murga N. Congestive heart failure due to hypertensive ventricular diastolic dysfunction. Am J Cardiol.1995 Nov 2; 76(13):43D-47D
6. Fouad FM. Left ventricular diastolic dysfunction in hypertensive patients, Circulation, 1987:75 (Suppl.1) 148-155.
7. Ike SO, Ikeh VO, The prevalence of diastolic dysfunction in adult hypertensive Nigerian. Ghana Med.J.2006:40(2):55-60
8. Thomas JD, Weyman AE. Echocardiographic Doppler evaluation of left ventricular diastolic dysfunction. Physics and physiology. Circulation.1991; 84:997.-1002
9. Myreng Y, Smiseth OA. Assessment of left ventricular relaxation by Doppler echocardiography. Circ. 1990; 81:260.
10. Appleton C.P., Hatle L.K., Popp R.L., Relation of transmitral flow velocity patterns to left ventricular diastolic function. New insights from a combined hamodynamic and Doppler echocardiography study. J Am Cardiol.1988; 12:426-440.
11. Levey AS, Coresh J, Balk E, Kausz AT, Levin A, Steffes MW, Hogg RJ, Perrone RD, Lau J, Eknoyan G, National kidney foundation. National kidney foundation practice guidelines for chronic kidney disease: evaluation, classification and stratification. Ann Intern Med 2003; 139:137-147.
12. Elaine M. Urbina, Philip R. Khoury, Connie McCoy, Stephen R. Daniels, Thomas R. Kimball, and Lawrence M. Dolan, Cardiac and Vascular Consequences of Prehypertension in Youth. J Clin Hypertens (Greenwich). 2011 May; 13(5): 332-342. doi:10.1111/j.1751-7176.2011.00471.
13. Roelandt J.R.T.C., M. Pozzoli. Non-Invasive Assessment of Left Ventricular Diastolic (Dys) function and filling pressure.
14. M. Fischer, A. Baessler, H.W. Hense, C. Hengstenberg , M. Muscholl, S. Holmer, A. Doring, U. Broeckel, and H. Schunkert , Prevalence of left ventricular diastolic dysfunction in the community. Results from a Doppler echocardiographic-based survey of a population sample. Eur Heart J (2003) 24 (4): 320-328.
15. HartCY, Redfield MM. Diastolic heart failure in the community. Curr Cardiol Rep.2000; 2:461- 469
16. Kuch B, Hense HW, Gneiting B, et al. Body composition and prevalence of left ventricular hypertrophy. Circulation.2000; 102:405-410
17. Valocik G, Mitro P, Zapachova J, Majercak I, Mudrakova K. Relation of various body mass index to systolic abd diastolic dysfunction. Bratisl Lek Listy 2008; 109(2) 52-56
18. Stork T, Eichstadt H, Mmockel M , Bortfeldt R, Moller, R Hochrein H . Changes of diastolic function induced by cigarette smoking: An echocardiographic study in patients with coronary artery disease. Clin Cardiol. Vol. 15, February 1992
19. Ahmet Yilmaz, Kenan Yalta, Okan Onur Turgut, Mehmet Birhan Yilmaz, Alim Erdem, Filiz Karadas, Ali Ozyol and Izzet Tandogan. The effect of smoking on cardiac diastolic parameters including Vp, a more reliable and newer parameter Cardiology Journal 2007Vol. 14, No. 3, pp. 281-286
20. Lazarevic AM, Nakatani S, Neskovic AN, Marinkovic Y, Yasumura Y, Stojicic D, Miyatake K, Bojic M, Popovic AD. Early changes in left ventricular function in chronic asymptomatic alcoholics: relation to the duration of heavy drinking. J Am Coll Cardiol. 2000 May; 35(6):1599-606.
21. Louise Bennet, Charlotte Larsson, Marianne Söderström, Lennart Råstam, and Ulf Lindblad. Diastolic dysfunction is associated with sedentary leisure time physical activity and smoking in females only. Scand J Prim Health Care. 2010; 28(3): 172-178.
22. Kim SH, Cho GV, Baik I, Lim SV, Choi CU, Lim HE, Kim EJ, Park CG, Park J, Kim J, Shin C. Early abnormalities of cardiovascular structure and function in middle-aged Korean adults with prehypertension: The Korean Genome Epidemiology study. Am J Hypertens. 2011 Feb; 24(2):218-24.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524166EnglishN-0001November30HealthcareCASE REPORT OF SYNOSTOSIS OF FIRST AND SECOND RIB - A BRIDGED VARIETY
English5557Uttama U. JoshiEnglish N.R. MudirajEnglishCongenital anomalies of ribs are rare incidental findings. Structural malformations of first rib are common as compared to other ribs. When such anomaly is present, may lead to compression of neurovascular bundle at the root of the neck causing thoracic outlet syndrome (TOS). The reported case of a rare bone specimen was an incidental finding during routine sorting of bones from the department. The specimen displayed fusion of right sided first and second rib in the midshaft region with free anterior and posterior ends. Such skeletal abnormality may be associated with segmentation defects of bony tissues and variations in the disposition of neurovascular structures, thus making them vulnerable for compression at thoracic outlet. Thus the awareness and precise knowledge of such anomaly is important for the anatomists, radiologists and thoracic surgeons dealing with this region.
Englishcongenital anomalies, rib, synostosis, bridged, thoracic outlet syndrome.INTRODUCTION
Ribs are essential components of thoracic cage. Anomalous ribs are rare anatomical findings. Such ribs are usually discovered as an incidental observation on routine chest radiographs or as a part of systemic disorder or syndrome. Almost 22 syndromes are described which involve rib anomalies as one of their component, eg.Poland syndrome, Klippel-Feil syndrome, Jarco-Levin syndrome etc. Presence of cervical rib, hypertrophied scalenus anterior and other factors obliterating either interscalene space or costoclavicular space lead to thoracic outlet syndrome (TOS).6 Abnormal 1st and 2 nd ribs can present with TOS.7,1 These anomalies include fused cervical rib and first rib or fused first and second rib.6 First rib anomalies can cause compression of structures as it creates narrow space through which the brachial plexus and subclavian vessels pass.2 This report is an attempt to throw light on the morphological implications and clinical significance of the specimen.
CASE REPORT
During routine sorting of bones from the departmental collection, a rare bone specimen displaying fusion of right sided 1st and 2nd rib in midshaft region was detected. The specimen was examined in detail for relevant anatomical features and various measurements. The morphological examination revealed fusion of the two ribs in midshaft region with free anterior and posterior ends. Thus the common shaft formed by their junction made it a bridged variety. This has resulted in the obliteration of 1st intercostal space in the conjoint shaft region. But a small intercostal space was present in the anterior and posterior ends. This common shaft had a maximum width of 42.6mm and length of 34.8mm. The first rib presented a facet separately on head and tubercle. The head of second rib had two facets of equal size separated by a ridge. The neckportions of the ribs were directed backwards and laterally. The maximum gap separating the neck regions of the two ribs was 5.92 mm (vertical). The first rib presented inconspicuous scalene tubercle close to the anterior end. The superior surface of the rib (1st) specimen displayed grooves and ridges. It showed a ridge extending from inner border of neck of first rib to the middle of conjoint shaft. Behind this ridge a well-marked large and rough impression was observed on the 1st rib for the attachment of scalenus medius muscle. A prominent bossing was observed on the superior surface of common shaft close to the outer border of 2nd rib for serratus anterior. The inner surface of the conjoint shaft was smooth and featureless and showed few vascular foramina.
DISCUSSION
The ribs develop from the mesenchymal processes of the primitive vertebral arches in the thoracic region. Morphological anomalies of the ribs and vertebrae can occur if malsegmentation of axial skeleton takes place before 20th day. Malexpression of myogenic determination factors like Myo D, Myogenin, Myf 5 and MRF4 could be the potential cause of such anomalies. Errors in segmentation of body tissues during development may be associated with variations in the disposition of nerves and vessels.5 Rib anomalies are traditionally classified into numerical and structural. Numerical anomalies are common such as supernumerary (cervical / lumbar) and deficient pair of 11th rib. Structural abnormalities are quite rare and they can be further classified as bifid, short, fused ribs. The fusion anomalies can be classified in to 3 types: (1) Bicipital rib- fused anterior ends and shafts but free posterior ends; (2) Bridged rib – fused shafts but free anterior and posterior ends; (3) Forked rib – fused posterior ends but separate shafts as well as anterior ends. Such fusion anomalies due to errors in the segmentation of body tissues may be associated with variations in the disposition of nerves and vessels.4 Costal anomalies occur frequently at the thoracic outlet. The abnormal 1st and 2nd rib can present with thoracic outlet syndrome. In the present case report, this rare bone specimen displayed the synostosis of right sided 1st and 2nd rib in the midshaft region leading to the formation of bridged type of anomaly. The anomalous first rib instead of forming synostosis may remain floating in the soft tissue similar to those found in birds, or may be attached by a ligamentous band with sternum. In the present case, both the ribs displayed costal facets which confirmed their articulation with thoracic vertebrae. The separate anterior ends confirmed articulation with sternum. 1 st rib anomaly can cause compression as it creates narrow space through which the plexus and subclavian vessels pass. First rib malformations are commonly associated with postfixed brachial plexus with large contribution from second thoracic nerve.7 Thus, the well formed groove on the superior surface of the first rib may be due to extra pressure contributed by second thoracic nerve or due to greater stretching of the lower trunk of brachial plexus. This may result in the neurological symptoms of TOS. Significant vascular compression and symptoms are also reported with congenitally abnormal first rib and associated second rib synostosis.7, 1 This warrants early surgical intervention. Fusion anomalies of ribs can cause scoliosis and restriction of chest movements, which may require surgical correction. We as an anatomists opine that the precise knowledge and awareness of such fusion anomaly as encountered in the present study has clinical significance besides academic interest.
CONCLUSION
Such fusion anomalies should be kept in mind before surgical interventions for the cases of thoracic outlet syndrome (TOS) and scoliosis.
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in reference of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=932http://ijcrr.com/article_html.php?did=932REFERENCES
1. Baumgartner F, Nelson RJ, Robertson JM. The rudimentary first rib: A cause of thoracic outlet syndrome with arterial compromise. Arch Surg.1989;124: 1090–92.
2. Edrogan Atosy. Thoracic outlet syndrome: anatomy, Hand Clin.2004;20:7-14.
3. Hashimoto H, NikaidoY, Nagai S, Shimada K.A case report of thoracic outlet syndrome with acute arterial obstruction caused by abnormal first rib. Journal of the Japanese association for Thoracic Surgery 1997;45 (12):2026-29.
4. Rani Anita, Rani Archana,Chopra J,Manik P.J. Anat.Soc.India 2009;58(2):189-91.
5. Todd TW.Costal anomalies of the thoracic inlet, interpretation and significance. Anal Anz.1912;41:257-71.
6. Turner WM. Cervical ribs and the so called Bicipital ribs in man in relation to corresponding structures in the Cetacea. Journal of anatomy and Physiology.1883; 17(30):384-400.
7. White JC, Poppel MH, Adams R. Congenital malformations of the first thoracic rib: A cause of brachial neuralgia which simulates the cervical rib syndrome. Surg Gynecol Obstet.1945; 81: 643–59.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524166EnglishN-0001November30HealthcareMICROHARDNESS EVALUATION OF NANO- COMPOSITE DENTURE TEETH
English5861JyotiEnglish Ravinder Kumar English Shivam SeshanEnglishBackground: New types of artificial teeth are commercially available. However, evidence - based information with respect to their physicomechanical properties is lacking. Objective: The purpose of this study was to qualify and quantify relative micro hardness characteristics of three commercially available types of artificial teeth. Materials and Methods: Three brands of three types of artificial teeth were examined. Vickers hardness was determined for each of the polished cross-sectioned teeth. Results: Vicker hardness values ranged from 22.3 to 26.7 for microfilled composites,20.0 to 25.3 for dual cross linked acrylic & 15.9 to 19.6 for nano- composite teeth. Conclusion: Within the limitations of this study, microfilled composite denture teeth exhibited superiority in terms of microhardness among all the specimens evaluated.
EnglishHardness, nanocomposite denture teeth, Vickers hardness test.INTRODUCTION
Artificial teeth are often necessary for prosthodontic rehabilitation when natural teeth are lost. Acrylic resins and porcelains have been used for the fabrication of artificial teeth; however, neither type completely accomplishes the requirements for an ideal prosthetic tooth.1 The amount of filler content, the geometry and size of the filler particles,and the properties of the polymer matrix have been reported to influence the properties of polymer materials.5,8-16 A new type of denture tooth, fabricated of nanocomposite resin, has recently been developed as a highly polishable, stain and impact resistant material.22 Since recently introduced nanofilled composite denture teeth material contains PMMA, even cross-linked with UDMA and reinforced by inorganic fillers, excellent hardness might not be expected. Also, evidence-based scientific information regarding these new types of artificial teeth with respect to composition and physicomechanical properties is lacking. Therefore, studies critically discussing latest peerreviewed reports and evaluating properties of commercial artificial teeth become necessary.
MATERIALS AND METHODS
Three groups of teeth including nano- filled composite {Veracia ( Shofu, Kyoto, Japan) }, microfilled composite {Endura ( Shofu, Kyoto, Japan)} and Dual cross-linked acrylic { SRPostaris ( Ivoclar / Vivadent, Lichenstein) } were analysed for study
MICRO-HARDNESS ESTIMATION
For each type, fourteen maxillary first molars were prepared. A maxillary 1st molar was aligned to its tooth axis parallel to the horizontal plane in a brass cup and secured with an auto-polymerized acrylic resin14. The buccal surface of the cusp was wet abraded and finished with grit abrasive paper (600,1,000,2500 & 4000-grit SiC paper) under water irrigation and polished with wet alumina. TheVicker’s micro-hardness tester (HMV 2000, Shimadzu, Japan ) was used to determine the surface hardness of specimens. A diamond indenter was pressed into the specimens under a load of 50 g for 30 seconds14. The areas of indentation were then measured using a ruler under microscope. Vicker hardness number (VHN) was calculated as the load divided by the area of indentation. Fourteen specimens were evaluated for each material, and the mean values were calculated by averaging all results on each material
RESULTS
The surface hardness expressed in terms of VHN of the nano-composite tooth, Veracia, ranges from 15.9 -19.6 whereas microfilled composite tooth , Endura, was between 22.3- 26.7 & dual cross linked acrylic tooth was between 20.0 to 25.3. Table 1 shows mean & standard deviation of microhardness among three groups. Mean VHN values of Group 1 (NC), Group 2 (MC) & Group 3 (DCL) were 18.057, 25.220 & 22.040 respectively which were stastically significant as ‘p’ = 0.0001 (p < 0.001). Table 2 shows pair wise comparison of microhardness among three groups under 50 gm load by scheffe test analysis & significant difference in Vicker Hardness Number (VHN) (p.001 ( p=0.009 & p=0.051 respectively ).
DISCUSSION
New materials, even if they are proved excellent, often have one or the other limitation, because they may be associated with a re - evaluation of the established systems of use and may not readily be amenable for use. Furthermore, there is an unavoidable time lag in establishing the precise relationship between their properties and clinical performance. Thus, the introduction of nanofilled resin systems has led to considerable controversy, both from the standpoint of the dentist and within the scientific community. However, it is possible to evaluate newer composite resins systems on the basis of their microstructure. Results of this study clearly indicate that the hybrid (especially the nano-filled) resin composites are markedly superior to the traditional composites and acrylic resins in terms of hardness, surface smoothness and anti-staining tendency. Further, as the filler particle size is reduced, the polishability, permanence of surface smoothness, and esthetics of the nano-filled composites improve. It was hypothesized that the hardness of this material would be superior to the conventional acrylic. This hypothesis was totally confirmed as the results showed the hardness of nanocomposite teeth to be not significantly different from conventional acrylic counterparts. Over all, this material has hardness, stain resistance and surface finish equivalent to most micro-filled composites with improved impact resistance and wear resistance. The generation of such essential information will enable the clinicians to consider these physical characteristics in addition to the mold and shade of artificial teeth
CONCLUSION
Judging by these results, it can be authentically concluded that the original macrofilled systems are now almost obsolete. In the same vein, the profession has hailed the nanofilled resins for the superior esthetic results that are possible. Nanocomposite denture teeth may be one of the most promising and appropriate materials for denture teeth in near future. However, further investigation of other characteristics such as wear, impact resistance, and bonding to reparative autopolymerizing resins should be performed.
ACKNOWLEDGEMENT
We acknowledge to Geetanjali Medical College & Hospital, Udaipur and Indian Institute of Sciences, Bangalore for their immense support.
CONFLICT OF INTEREST
None declared
Englishhttp://ijcrr.com/abstract.php?article_id=933http://ijcrr.com/article_html.php?did=933REFERENCES
1. Zarb GA, Bolender CL. Eckert SE, Jacob RF,Fenton AH, Merickske-stern RM. Prosthodontic treatment for edentulous patients:Complete denture and Implantsupported prosthesis. 12th ed. St. Louis: Mosby; 2004. p. 195-8.
2. Zeng J, Sato Y, Ohkubo C, Hosoi T. In vitro wear resistance of three types of composite resin denture teeth. J Prosthet Dent 2005; 94: 453–457.
3. Huan lu,:leslie b. roeder,: Effect of Surface Roughness on Stain Resistance of Dental Resin Composites J Esthet Restor Dent 17:102–109, 2005.
4. Kim KH, Ong Okuno O. The effect of filler loading and morphology on the mechanical properties of composites.J Prosthet Dent 2002;87:642-9.
5. Condon JR, Ferracane JL. In vitro wear of composite with varied cure, filler level, andfiller treatment. J Dent Res 1997;76:1405- 11.
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8. Hashinger DT, Fairhurst CW. Thermal expansion and filler content of composite resins. J Prosthet Dent 1984;52:506-10.
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10. Schwartz JI, Soderholm KJ. Effect of filler size, water, and alcohol on hardness and wear of dental composites. Acta Odontol Scand 2004;62:102-6.
11. Turssi CP, Ferracane JL, Vogel K. Filler features and their effects on wear and degree of conversion of particulate dental composites.Biomaterials 2005;26:4932-7.
12. Miyasaka T. Effect of shape and size of silanated fillers on mechanical properties of experimental photo cure composite resins.Dent Mater J 1996;15:98-110.
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14. Suzuki S. In vitro wear of nano-composite denture teeth.J Prosthodont 2004; 13: 238– 243.
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16. Mandikos MN, McGivney, Davis E,Bush PJ, Carter JM. A comparison of the wear resistance and hardness of indirect composite resins. J Prosthet Dent 2001;85:386-95.
17. Kawano F, Ohguri T, Ichikawa T, Mizuno I, Hasegawa A. Shock absorbability and hardness of commercially available dentureteeth. Int J Prosthodont 2002;15:243-7.
18. Okada K, Tosaki S, Hirota K, Hume WR.Surface hardness change of restorative filling materials stored in saliva. Dent Mater 2001;17:34-9.
19. Leard A. Addy:The propensity of different brands of tea and coffee to cause staining associated with chlorhexidine.JClin Periodontol 1997:24:115-118.
20. Asher C, Read MJF: Early enamel erosion in children associated with the excessive consumption of citric acid.Br. HP.HI J 19X7; 162:384-387.
21. Mui S. Soh , Adrian U. J. Yap , Alan Sellinger (2007): Physicomechanical evaluation of low-shrinkage dental nanocomposites based on silsesquioxane cores .European Journal of Oral SciencesVolume 115, Issue 3, Pages 230-238
22. Paola G. Loyaga-Rendon, Hidekazu Takahashi,Iwao Hayakawa, c and Naohiko Iwasaki (2007) : Compositional characteristics and hardness of acrylic and composite resin artificial teeth. (J Prosthet Dent 2007; 98: 141-149.)
23. Muhamad Ghazal and Matthias Kern (2009) : The influence of antagonistic surface roughness on the wear of human enamel and nanofilled composite resin artificial teeth .J Prosthet Dent 2009;101:342-349.
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25. T. Stober , H. Gilde, P. Lenz (2001): Color stability of highly filled composite resin materials for facings. Dental Materials 17 (2001) 87±94.
26. JM Brady and RD Wood (1977) : Scanning microscopy of cervical erosion .J Am Dent Assoc, Vol 94, No 4, 726-729.1977.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524166EnglishN-0001November30HealthcareEFFECT OF AEROBIC EXERCISE ON CARDIOVASCULAR FUNCTIONS AND REACTIVITY IN NORMOTENSIVE OFFSPRINGS OF NORMOTENSIVE AND HYPERTENSIVE PARENTS
English6270Amruta ChauhanEnglishIntroduction: Hypertension is a major health problem and when untreated, predispose to cardiovascular morbidity and premature death. Cardiovascular reactivity is the pattern of an individual’s hemodynamic response to stress On the basis of genetic factor and environmental components, first degree relatives of essential hypertensive patients are known to be at risk of developing hypertension. Objective: The objective of the study is to compare the effect of aerobic exercise on response of cardiovascular functions and reactivity in normotensive offsprings of normotensive and hypertensive parents. Methodology: 30 individual with parental history of hypertension and 30 individual without parental history of hypertension were taken. At the beginning, baseline measures included body weights, heights were taken and BMI was calculated. After 5 minutes of rest, blood pressure reading was taken with mercury sphygmomanometer and heart rate reading was taken. Subjects performed aerobic exercise start with warm up in the form of slow walking for 5 minutes. Circuit training was given in the form of upper limb exercise, trunk mobility exercise, treadmill walking for 30 minutes. Subject performed exercise on RPE 6 and as much as can go above it on modified Borg scale with their maximum speed. Post parameter of heart rate and blood pressure was taken at immediately after, after 3 minute. Subjects performed cool down period in the form of slow walking for 5 minutes and again parameters were taken. Results: The result shows that there is statistically significant difference in the reactivity and cardiovascular functions in normotensive offsprings of hypertensive parents compared to normotensive offsprings of normotensive parents. Conclusion: The normotensive offsprings of hypertensive parents have increased reactivity and cardiovascular functions with delayed recovery compared to normotensive offsprings of normotensive parents.
Englishaerobic exercise, reactivity, offspringsINTRODUCTION
Hypertension is a major health problem and when untreated, predispose to cardiovascular morbidity and premature death.1 Seventh report of joint national committee on prevention, detection, evaluation, and treatment of high blood pressure (JNC 7 report) has introduced following classification for adults aged 18 and older 2 ? Normal: Englishhttp://ijcrr.com/abstract.php?article_id=934http://ijcrr.com/article_html.php?did=934REFERENCES
1. Allemann Yves, et al. increased central body fat deposition precedes a significant rise in resting blood pressure in male offspring of essential hypertensive parents: a 5 year follow-up study. 2001, vol. 19; 2143-2148 32
2. BR Widgen, et al. increased response to physical and mental stress in men with hypertensive parents. Hypertension 1992; 20; 606-611 36
3. Carmel M, et al. Endogenous endothelin-1 limits exercise-induced vasodilation in hypertensive humans. Hypertension.2002; 40; 202-206 31
4. D G Morton, Vollmer WM, Sacks FM, Ard J, Appel LJ, Bray GA, et al. Effects of diet and sodium intake on blood pressure: subgroup analysis of the DASH-sodium trial. Ann Intern Med. 2001; 135; 1019–1028 18
5. David Molineux, et al. Exaggerated blood pressure response to submaximal exercise in normotensive adolescents with a family history of hypertension. Journal of hypertension. 1988;
6; 361-365 37 6. Dunlap ED, Pfeifer MA. Autonomic function testing, In: Schneiderman N, editiors. Handbook of research methods in cardiovascular behavioural medicine.New York: 1989. p 91-106.40
7. Karen A, et al. Blood pressure reactivity to psychological stress predicts hypertension in the CARDIA study. Circulation 2004; 110; 74-78 28
8. Folkow BS et al. early structural changes in hypertension: pathophysiology and clinical consequences. J Cardiovasc Pharmacol 1994; 22; s1-s6.41
9. Nielsen JR, et al. plasma nor-adrenalin response to a multistage exercise test in young man at increased risk of developing essential hypertension. J Hypertension. 1997; 7; 377- 382 42
10. Noll G et al. increased activation of sympathetic nervous system and endothelin by mental stress in normotensive offsprings of hypertensive parents. Circulation. 1996; 93; 866-869.43
11. E G Ciolac, EA Bocchi, et al. Haemodynamic, metabolic, and neuro-humoral abnormalities in young normotensive women at high familial risk for hypertension. Journal of human hypertension 2010; 24: 814-822 23
2. Enrico Mangieri, MD, et al. Handgrip increases endothelian-1 secretion in normotensive young male offspring of hypertensive parents. J Am Coll Cardiol 1998; 31; 1362-6 34
13. Folkow BS. et al. cardiovascular structural adaptation: its role in initiation and maintenance of primary hypertension. Clin Sci Mol Med 1978; 55; 3s-22s 44
14. Song CK et al. Renal kallikrein excretion: role of ethnicity, gender, environment, and genetic risk of hypertension. J Hum Hypertens 2000; 14: 461–468 46
15. Wong CM et al. Diminished renal kallikrein responses to mineralocorticoid stimulation in African-Americans: determinants of an intermediate phenotype for hypertension. Am J Hypertens 2003; 16; 281–289 47
16. O’Connor DT et al. Early alteration in glomerular reserve in humans at genetic risk of essential hypertension: mechanisms and consequences.Hypertension 2001; 37: 898– 906;45
17. Nasakas S. modification of arterial baroreflex: obligatory roles in cardiovascular regulation in stress and post stress recovery. Jpn J Physiol 1996; 46:271-88 48
18. L R Davarath, et al. early autonomic malfunction in normotensive individuals with a genetic predisposition to essential hypertension. Am J Physiol Heart Circ Physiol 2003; 285; 290.49
19. M Hammer et al, cardiovascular and renal responses to mental challenges in highly and moderately active males with family history of hypertension. Journal of hypertension;2002; 16; 319-326; 50
20. Manuck SB et al. Absence of enhanced sympathoadrenal activity and behaviorally evoked cardiovascular reactivity among offspring of hypertensives. Am J Hypertens 1996; 9: 249-255; 51
21. GM Schneider, DW Jacobs et al. cardiovascular haemodynamic response to repeated mental stress in normotensive subjects at genetic risk of hypertension: evidence of enhanced reactivity, blunted adaption, and delayed recovery. Journal of human hypertension 2003; 17; 829-840; 12
22. De Visser DC et al. Cardiovascular response to mental stress in offspring of hypertensiveparents: The Dutch Hypertension and Offspring Study. J Hypertens 1995; 13; 901-908; 52
23. Sydeny B. Miller,PhD. et al. Parental history of hypertension, sodium loding, and cardiovascular response to stress. Psychosometic medicine. 1995; 57; 381-389 35
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524166EnglishN-0001November30HealthcareA STUDY OF FIBULAR PLANTAR MARGINAL ARTERY WITH ITS CLINICAL PERSPECTIVE
English7174Anupama K.English Saraswathi G. English Jyothi K. C. English Shanmuganathan K.EnglishIntroduction: The plantar arterial arch is formed by anastomosis of the deep plantar branch of the dorsalis pedis artery and the deep transverse branch of the lateral plantar artery. The plantar arch gives off three perforating and four plantar metatarsal branches. An additional lateral digital branch to the fifth toe arises directly from the lateral plantar artery near the base of the fifth metatarsal bone and this artery is named as Fibular Plantar Marginal artery or Lateral Marginal Artery. The study was undertaken because of its varied origin and clinical importance in reconstructive surgery, vascular surgery and auto graft transplantation. Objectives: To study the incidence, origin and variations of Fibular Plantar Marginal Artery. Materials and methods: 50 feet of the formalin fixed adult human cadavers were dissected and studied, in the Department of anatomy, JSS Medical College, Mysore. Results: The presence of fibular plantar marginal artery was observed in 14 specimens (28%) and absent in 36 specimens. In 12 specimens it was originating from Lateral plantar artery, in 2 specimens the origin was from Dorsalis pedis artery. Conclusion: Knowledge of the variations in the anatomy of plantar arteries and the presence of fibular plantar marginal artery are important for vascular surgeons to carry out reconstructive surgeries and to obtain neurovascular flap for auto graft transplantation.
EnglishPlantar Arch, Fibular Plantar Marginal Artery, Reconstructive Surgeries, Neurovascular flaps.INTRODUCTION
The human foot is a complex structure, adapted to allow orthograde, bipedal stance and locomotion. It is the only part to support the entire body weight during locomotion. The blood supply of the foot is rich and is derived from branches of the major arteries, namely the Dorsalis pedis, Posterior tibial and Peroneal.1 The plantar arch is formed by anastomosis of the deep plantar branch of the dorsalis pedis artery and the deep transverse branch of the lateral plantar artery. The plantar arch gives off three perforating and four plantar metatarsal branches and numerous cutaneous and muscular branches in the sole.2 An additional lateral digital branch to the fifth toe arises directly from the lateral plantar artery near the fifth metatarsal base. This artery is given the name Fibular Plantar Marginal artery or lateral marginal artery .3 In the present study the incidence, origin and variations of fibular plantar marginal artery were observed. This study was undertaken because of its clinical importance in reconstructive surgery, vascular surgery, and autograft transplantation.
MATERIALS AND METHOD
Dissection method
50 feet (25 right and 25 left) from 25 embalmed adult cadavers (21 male and 4 female, 35-70 years of age) were dissected and studied in the Department of anatomy, JSS Medical College, Mysore. The superficial and deep plantar regions of the foot were dissected carefully. The oblique head of adductor hallucis was dissected to visualize the full course of lateral plantar artery and plantar arterial arch. The plantar metatarsal branches were traced and cleaned. The presence of fibular plantar marginal artery and its origin was noted. The arterial arch and its branches were coated with acetone and quickfix solution, painted using synthetic enamel asian paints and photographed. In the present study, the incidence and origin of fibular plantar marginal artery was studied.
RESULTS
The fibular plantar marginal artery was observed in 14 specimens (28%) and absent in 36 specimens. In 12 specimens it was taking origin from lateral plantar artery (Fig 1); in 2 specimens the origin was from dorsalis pedis artery. (Fig 2, 3)
DISCUSSION
The lateral marginal artery may arise independently from lateral plantar artery or as a common trunk with a fifth superficial plantar metatarsal artery as described by Murakami. It pierces the lateral intermuscular septum and courses distally between the flexor digiti minimi brevis and adductor minimi muscles and its incidence being 22.5% 3 . In the present study it was found to be present in 28% of the specimens. The extrinsic circulation to the fifth metatarsal area is provided by the dorsal metatarsal artery, the plantar metatarsal arteries, and the fibular plantar marginal artery. These three source arteries supply branches to the metatarsal and adjacent joints. In the absence of fibular plantar marginal artery the dorsal and the plantar metatarsal arteries take over the vascularity in this region4 . The architecture of the skeletal and fibromuscular components is well designed to support the body weight in erect posture. The integrity of the structure invariably depends upon the blood supply5 . In the past few decades’ change in the lifestyle and increase in the use of vehicles have drastically increased the incidence of accidents and trauma all over the world. A thorough knowledge of topography and relations of the plantar arteries help the vascular surgeons in successfully performing microvascular surgeries of the foot. It helps in reconstructive surgeries of the foot, to avoid amputation in cases of trauma in industrial and automobile accidents. The knowledge of vascular variations are indispensable to the surgeons undertaking surgeries of the foot and ankle6, 7 . In diabetics and some non diabetics with atherosclerotic ischemic symptoms in the foot, the main occlusive process affects the pedal arteries. With the efforts of vascular surgeons restoring vascularisation by bypass surgery in patients with critical leg ischemia, the number of amputations as primary treatment has been greatly reduced8 . The neurovascular flaps are being utilized frequently in reconstructions in conditions such as burns, amputation following malignancy or due to accidents and in cosmetic correction of congenital defects. The dorsalis pedis artery was first used as the vascular basis for such neurovascular flap by O’Brien et al. Almost simultaneously it was found that the plantar vascular system involving first and the second intermetatarsal arteries can also be used for such reconstructions. The fibular plantar marginal artery when present can be an additional source of such neurovascular flap, without compromising the function of the foot 9, 10 . Angiographic investigations specially intraarterial digital arteriography and contrast enhanced magnetic resonance angiogram, not only indicates the pattern of the plantar arterial arch but also the presence of fibular plantar marginal artery, and helps to identify the site of occlusion of the arteries if any. This helps to determine the nature of treatment11 . In the year 1900, a pedicle graft of a toe to replace a missing digit in the hand was first described, but owing to the complicated nature of the operation this method for reconstruction of a digit had never been popular. The advent of microvascular surgery enabled one to use toes for free vascularised complex tissue grafts12, 13 . Hence the present work was undertaken which has relevance and significance for surgeons in the field of reconstructive surgeries.
CONCLUSIONS
The foot plays an important role in recreational, sporting and occupational activities, with the integrity of its component parts depending on its blood supply. Consequently knowledge of arteries of the foot is necessary for advances in arterial reconstruction. The study was undertaken because of its varied and important clinical application in reconstructive surgery, vascular surgery and autograft transplantation. Knowledge of the variations in the anatomy of plantar arteries and the presence of fibular plantar marginal artery are of immense help to the plastic surgeons while harvesting the neurovascular flaps and for vascular surgeons to carry out plastic and reconstructive surgeries. The purpose of this study is to draw the attention to this most exciting field and its ongoing developments. If accessory arteries are present in the foot they can be used as vascular autograft for surgeries in other parts of the body
ACKNOWLEDGEMENT
I sincerely thank all the editors /authors of all the articles, journals and books whose references I have quoted in this article. I also thank my Head of Department Dr Shailaja Shetty for her constant support and encouragement.
Englishhttp://ijcrr.com/abstract.php?article_id=935http://ijcrr.com/article_html.php?did=935REFERENCES
1. Pomposelli FB, Kansal N, Hamdan AD, Belfield A, Sheahan M, Campbell DR et al., A decade of experience with dorsalis pedis artery bypass. Analysis of outcome in more than 1000 cases. Journal of vascular surgery. 2003; 37: 307-315.
2. Mahadevan V. Pelvis and lower limb. Chapter 84 in Gray’s Anatomy 40th ed. Standring S. Churchill Livingston. Elsevier; 2008: 1455-1457.
3. Sarrafian SK. Anatomy of the foot and ankleDescriptive, topographic, functional. JB. Lippincott Company. Philadelphia; 1983: 281- 291.
4. Kitaoka HB, Holiday Jr AD, Metatarsal head resection for bunionette: Long term followup. Foot and ankle international, an official journal of AOFAS. 2004; 25: 521-525.
5. Gabrielli C, Olave E, Mandiola E, Rodrigues CFS, Prates JC. The deep plantar arch in humans. Constitution and topography. Surg radiol anat. 2001; 23(4): 253-258.
6. Strauch B, Sharzer LA, Brauman D. Innervated free flap for sensitivity and coverage, chapter 14 in Microsurgery for major limb reconstruction. Urbaniak JR. Mosby publication; 1990: 112- 116.
7. Ozer MA, Govsa F, Bilge O. Anatomic study of the deep plantar arch. Clinical anatomy. 2005; 18(6): 434-442.
8. Hughes K, Domenig CM, Hamdan AD, Schermerhorn M, Aulivola B, Blattman S et al., Bypass to plantar and tarsal arteries: An acceptable approach to limb salvage. Journal of vascular surgery. 2004; 40: 1149-1157.
9. Cobbett JB. Free digital transfer. Report of a case of transfer of a great toe to replace an amputated thumb. The journal of bone and joint surgery. 1969; 51: 677-679.
10. Papon X, Brillu C, Fournier HD, Hentati N, Mercier P. Anatomic study of the deep plantar artery: Potential bypass receptor site. Surg Radiol Anat. 1998; 20(4): 263-6.
11. Sebastien C, Douek P, Moulin P, Vaudoux M, Marchand B. Contrast-Enhanced MR Angiography of the Foot: Anatomy and Clinical Application in Patients with Diabetes. American Journal of Radiology. 2004; 182: 1435-1442.
12. Biemer E. Toe transfer for thumb and finger replacement in Textbook of Microsurgery. Lie TS. 3rdedition. International Congress Series 465 Excerpta Medica. Amsterdam; 1979: 17-19.
13. Foucher G, Merle M, Maneaud M, Michon J. Microsurgical free partial toe transfer in hand reconstruction: A report of 12 cases. Plastic and Reconstructive Surgery. May 1980; 65 (5): 616-626.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524166EnglishN-0001November30HealthcareCLINICALLY SIGNIFICANT UNILATERAL VARIATION OF MUSCULOCUTANEOUS NERVE
English7579Krishnendu BhowmikEnglish Arpita SarkarEnglishDuring routine dissection conducted for undergraduates study in the Department of Anatomy, Kolkata Medical College, variations in the course of musculocutaneous nerve was found in two cadavers.In normal individuals the Musculocutaneous nerve arises from the lateral cord of the brachial plexus, passes inferolaterally and then pierces through the coracobrachialis muscle after supplying it. Then it descends between the biceps and the brachialis muscle, sending branches to both the muscle and continues as the lateral cutaneous nerve of the forearm. In our cases we found that the musculocutaneous nerve did not pierce the coracobrachialis muscle and in the middle 1/3rd of arm, it communicates with median nerve. Knowledge about these variations helps surgeons during operation of brachial plexus lesions, arthoscopy of shoulder joints and repair of fracture humerus.
EnglishBrachial plexus, Coracobrachialis, Median nerve, Musculocutaneous nerveINTRODUCTION
Musculocutaneous nerve is the terminal branch of lateral cord of brachial plexus and it arises from lateral cord at the lower border of pectoralis minor. It leaves the axilla after piercing the coracobrachialis and then it passes downward between biceps brachii and brachialis muscle in arm. At the junction of middle third and lower third of arm, it appears at the lateral margin of biceps brachii tendon. Here it pierces the deep fascia and passes downward along the lateral aspect of the forearm as the lateral cutaneous nerve of forearm. It supplies three muscles in arm- coracobrachialis, bicep brachii and most of the brachialis. Usually the branch to coracobrachialis is given off before the musculocutaneous nerve pierces the muscle. The musculocutaneous nerve also supplies the shoulder joint and elbow joint. The distribution, course and branching pattern of the musculocutaneous nerve is important from the clinical point of view, especially for surgeons dealing with repair of brachial plexus lesions. Variation in the course and branching pattern of the musculocutaneous nerve is not uncommon and mentioned in many literature. In “Gray’s anatomy” the musculocutaneous nerve is described as having frequent variations like it may run behind coracobrachialis or pass behind biceps after adhering for some distance to the median nerve. Sometime few fibers of the median nerve may pass to the musculocutaneous nerve, and the median nerve sends a branch to the musculocutaneous nerve. Occasionally it supplies pronator teres and may replace branches of radial nerve to the dorsal surface of the thumb.
MATERIAL AND METHOD
This study was performed from August 2011 to September 2012, on cadavers allotted for routine dissection classes for undergraduate study in the Department of Anatomy, Kolkata Medical College. Cadavers were lying in supine posture and arms were extended and abducted to 90 degree. Dissections were performed as per standard incisions described in Cunningham’s manual of Practical Anatomy. The cords and the branches of the brachial plexus were dissected. The variations of the musculocutaneous nerve were noted. Cases were analyzed by comparing with normal standard gross origin, courses, and branches as stated in “Gray’s Anatomy” 17 .
RESULT
During routine dissection conducted for undergraduate study in the Department of Anatomy, Kolkata Medical College, variations in the course of musculocutaneous nerve was found in two male cadavers; both were aged around 50 years. The variations found were unilateral- one in right side and other in left side. In both cases, the musculocutaneous nerve arises from lateral cord, did not pierce the coracobrachialis muscle and in the middle 1/3rd of arm, it communicates with median nerve [Figure 1]. Later the course was normal. The nerve to coracobrachialis muscle was from the lateral border of the musculocutaneous nerve. In both the cases the nerve was lateral to the brachial artery through out its course in the arm.
DISCUSSION
The limb muscles develop from the mesenchyme of the paraxial mesoderm during the fifth week of intrauterine life. The axons of the spinal nerves grow distally to reach the muscles and skin19 . Thus, a lack of coordination between these two processes due to altered signaling may lead to the development of multiple variations. Mostafa M El-Naggar reported three cases where musculocutaneous nerve did not pierce coracobrachialis muscle. According his study the course of musculocutaneous nerve has greatly affected the morphology of the muscle. He identified the presence of two heads of origin for the coracobrachialis muscle, which are situated superficial (anterior) and deep (posterior) to the musculocutaneous nerve and it formed of a single head where the nerve was not piercing the muscle 7 . Studies by Nakatani et al. found three variations in which the musculocutaneous nerve did not pierce the coracobrachialis 15. Jamuna M also reported in one case where musculocutaneous nerve was not piercing coracobrachialis10. In another study by Jamuna M and Amudha G found three limbs out of fifty where musculocutaneous nerve was not piercing coracobrachialis11. Nayak reported in one case where the origin of the musculocutaneous nerve was very low and it was not piercing coracobrachialis16. Chitra observed in 2 cases, that the musculocutaneous nerve did not pierce the coracobrachialis4 . Various authors reported communicating branches between the musculocutaneous and median nerves at different levels. Le Minor13 described five types of variations: Type 1: There is no communication between the median nerve and musculocutaneous nerve. Type 2: The fibers of the medial root of median nerve pass through the musculocutaneous nerve and join the median nerve in the middle of the arm. Type 3: The lateral root fibers of the medial root of median nerve pass through the musculocutaneous nerve and after some distance, leave it to form the root of the median nerve. Type 4: The musculocutaneous nerve fibers join the lateral root of the median nerve and after some distance the musculocutaneous nerve arise from the median nerve. Type 5: The musculocutaneous nerve is absent and the entire fibers of musculocutaneous nerve pass through lateral root and fibers to the muscles supplied by a musculocutaneous nerve branch out directly from the median nerve Venieratos and Anagnostopoulou 21described three different types of communication between musculocutaneous nerve and median nerve in relation to coracobrachialis muscle - Type I: The communication was proximal to the entrance of the musculocutaneous nerve into coracobrachialis Type II: The communication was distal to the muscle Type III: The nerve as well as the communicating branch did not pierce the muscle Marios Loukas and Haqq Aqueelah 12classified the communication patterns as follows Type I (45%): the communications were proximal to the point of entry of the musculocutaneous nerve into the coracobrachialis. Type II (35%): the communications were distal to the point of entry of the musculocutaneous nerve into the coracobrachialis. Type III (9%): the musculocutaneous nerve did not pierce the coracobrachialis. Type IV (8%): the communications were proximal to the point of entry of the musculocutaneous nerve into the coracobrachialis and additional communication took place distally. The result of our study coincided with type III of Loukas and Aqueelah classification and type III of Venieratos classification, but did not correspond to any of the Le Minor’s classification. Choi et al reported variations in connections between the musculocutaneous and median nerves 64 cadavers (46.4%) out of 138, among which 9 bilaterally and 55 unilaterally (26 right and 29 left) 5 . Maheria, Pankaj Band et al. found two cases where musculocutaneous nerve gave a communicating branch to median nerve after piercing the coracobrachialis muscle 14 . Basar et al found a connecting branch between the musculocutaneous and the median nerves in one case 1 . Bhattarai and Poudel found 3.125% cases where musculocutaneous nerve terminated by joining with median nerve at the level of junction of distal and middle third of medial side of arm 2 .
CONCLUSION
It is very important to be aware of the variations of the musculocutaneous nerve and its relation to surrounding structures during repair of brachial plexus lesions, shoulder arthroscopy and various other surgical and investigation procedure of arm
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed
Englishhttp://ijcrr.com/abstract.php?article_id=936http://ijcrr.com/article_html.php?did=936REFERENCES
1. Basar, R., M. M. Aldur, H. H. Celik, M. Yüksel, and A. B. Tascioglu. "A connecting branch between the musculocutaneous nerve and the median nerve." Morphologie: bulletin de l'Association des anatomistes 84, no. 266 (2000): 25-27.
2. Bhattarai, C., and P. P. Poudel. "Unusual variation in musculocutaneous nerves." Kathmandu University Medical Journal 7, no. 4 (2009): 408-410.
3. Chauhan, R., and T. S. Roy. "Communication between the median and musculocutaneous nerve–a case report." Journal of the Anatomical Society of India 51, no. 1 (2002): 72-75.
4. Chitra R. Multiple bilateral neuroanatomical variations of the nerves of the arm. Neuroanatomy 2007; 6:43-5.
5. Choi, D., Rodríguez-Niedenführ, M., Vázquez, T., Parkin, I. and Sañudo, J. R. (2002), Patterns of connections between the musculocutaneous and median nerves in the axilla and arm. Clin. Anat., 15: 11–17. Doi: 10.1002/ca.1085
6. Eglseder Jr, W. A., and M. Goldman. "Anatomic variations of the musculocutaneous nerve in the arm." American journal of orthopedics (Belle Mead, NJ) 26, no. 11 (1997): 777-780.
7. El-Naggar, Mostafa M. "A study on the morphology of the coracobrachialis muscle and its relationship with the musculocutaneous nerve." FOLIA MORPHOLOGICA-WARSZAWAENGLISH EDITION- 60, no. 3 (2001): 217- 224.
8. Gümü?alan, Y., Fatih Yazar, and Hasan Ozan. "Variant innervation of the coracobrachialis muscle and unusual course of the musculocutaneous nerve in man." Kaibogaku zasshi. Journal of anatomy 73, no. 3 (1998): 269.
9. Guerri?Guttenberg, Roberto A., and Mariana Ingolotti. "Classifying musculocutaneous nerve variations." Clinical Anatomy 22, no. 6 (2009): 671-683.
10. Jamuna, M. "Clinically significant variations of the cords of the brachial plexus in relation to axillary artery." International Journal of Anatomical Variations 4 (2011): 9-11.
11. Jamuna, M., G. Amudha, and Jamuna Meenakshisundaram. "A Cadaveric Study on the Anatomic Variations of the Musculocutaneous Nerve in the Infraclavicular Part of the Brachial Plexus." J of Clinical and Diagnostic Research 5, no. 6 (2011): 1144-1447.
12. Loukas, Marios, and Haqq Aqueelah. "Musculocutaneous and median nerve connections within, proximal and distal to the coracobrachialis muscle." Folia Morphol (Warsz) 64, no. 2 (2005): 101-108.
13. Le Minor IM. A rare variation of the median and musculocutaneous nerves in man. Arch Annt Histol Embryul. 1990;73:33-42.
14. Maheria, Pankaj B., et al. "A study of anatomical variations of the musculocutaneous nerve." Int J Res Med. 2013; 2(2);1-4
15. Nakatani, Toshio, Shigeki Mizukami, and Shigenori Tanaka. "Three cases of the musculocutaneous nerve not perforating the coracobrachialis muscle."Kaibogaku zasshi. Journal of anatomy 72, no. 3 (1997): 191.
16. Nayak S, Samuel VP, Somayaji N. Concurrent variations of median nerve, musculocutaneous nerve and biceps brachii muscle. Neuroanatomy. 2006; 5: 30–32.
17. Prasada Rao, P. V. V., and S. C. Chaudhary. "Communication of the musculocutaneous nerve with the median nerve." East African medical journal77, no. 9 (2000): 498-503.
18. Sadler, Thomas W. Langman's medical embryology. Wolters Kluwer Health, 2011.
19. Williams PL, Bannister LH, Berry MM, Collins P, Dyson M, Dussek JE et al. Nervous system. In: Gray’s Anatomy. 38th edition. Churchill Livingston, Edinburgh, London I995: 1267-72.
20. Uzun, Ahmet, and Leonard L. Seelig. "A variation in the formation of the median nerve: communicating branch between the musculocutaneous and median nerves in man." FOLIA MORPHOLOGICAWARSZAWA-ENGLISH EDITION-60, no. 2 (2001): 99-102.
21. Venieratos, D., and S. Anagnostopoulou. "Classification of communications between the musculocutaneous and median nerves." Clinical Anatomy 11, no. 5 (1998): 327-331
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524166EnglishN-0001November30HealthcareSEVERE HYPOMAGNESEMIA, HYPOKALEMIA AND HYPOCALCEMIA ASSOCIATED WITH PULMONARY TUBERCULOSIS
English8083Baskaran S.English Gopi ManigandanEnglish Arumugam AashishEnglishWe report a case of severe hypomagnesemia, hypokalemia and hypocalcemia in a 55-year-old lady who defaulted her treatment twice for pulmonary tuberculosis and presented with tetany to the emergency room. Hypocalcemia and hypokalemia persisted despite adequate correction and improved only after the correction of hypomagnesemia. The biochemical abnormalities were further complicated by streptomycin therapy necessitating to modify the anti-tuberculous regimen. The association of hypomagnesemia with tuberculosis is reported earlier and this association is attributed to renal magnesium wasting following aminoglycoside containing anti tuberculous regimen. However, hypomagnesemia contributing to hypocalcemia and hypokalemia, occurring as a primary abnormality in patients with tuberculosis is reported rarely. Here we report a case of active pulmonary tuberculosis who presented with such rare manifestations. This report emphasizes the need to maintain a high index of clinical suspicion of hypomagnesemia in patients with tuberculosis and in those receiving aminoglycoside as a part of their anti tuberculous therapy (ATT).
Englishhypomagnesemia, hypokalemia, hypocalcemia, pulmonary tuberculosisINTRODUCTION
Magnesium is the second most abundant intracellular cation after potassium and plays a significant role in neuromuscular function. Though magnesium depletion may contribute to increased morbidity and mortality in hospitalized patients, it is most under diagnosed electrolyte abnormality in current medical practice.(1) Magnesium deficiency is strongly associated with other electrolyte deficiencies especially potassium and calcium, although phosphate and sodium deficiencies are also described.(2) We report a case of active pulmonary tuberculosis presented to us with clinical manifestations of hypomagnesemia and associated biochemical abnormalities.
CASE REPORT
A 55-year-old south Indian lady presented to the emergency room with numbness and paresthesia involving the extremities over the past two days and episodes of carpopedal spasm over the past twelve hours. She had no history of recent episodes of loose stools and vomiting. She reported occasional cough, poor appetite and undocumented weight loss over the past two years. Earlier, she was diagnosed to have pulmonary tuberculosis elsewhere and had defaulted her treatment twice within a period of two years. She had no history of diuretic or aminoglycoside use in the past. She had no other significant past, personal or family history. On examination, she was moderately built and poorly nourished. She was pale with pulse rate 96/min, BP 110/70mmHg and respiratory rate 18/min. Chevostek’s and Trousseau’s signs were present. Systemic examination revealed bronchial breath sound over the right axillary region. Initial laboratory evaluation showed Haemoglobin 8.6g/dl, total leukocyte count 12900/cu.mm, differential leukocyte count N90%, L8%, E2%, platelet count 3.05 lakhs/cu.mm, erythrocyte sedimentation rate 96mm/hr, urea 31mg/dl, creatinine 1mg/dl, sodium 130meq/L, potassium 2meq/L. Arterial blood gas showed metabolic alkalosis (pH-7.65, HCO3-40meq/L, PCO2- 41mmHg). Serum calcium was reported as 6.2mg/dl (NV : 8.7 – 10.2mg/dl). Her LFT including serum albumin was within normal limits. ECG showed QTc prolongation (Fig.1) and chest X-ray revealed a thin walled cavity over the right midzone and a small pleural effusion on the left. (fig.2) which was exudative but sterile on aspiration. Correction of hypokalemia and hypocalcemia initiated with intravenous infusion of KCl and calcium gluconate at recommended doses. However serial electrolytes and biochemical tests revealed persisting hypokalemia and hypocalcemia despite adequate correction. Magnesium level was reported as low at 1mg/dl (NV:1.5-2.3 mg/dl). Patient was administered magnesium 8gm (64mEq) infusion for 24 hours followed by 4gm (32mEq) infusion for next five days with simultaneous potassium and calcium replacement with necessary precautions and frequent monitoring of the serum magnesium, potassium and calcium levels. Electrolyte abnormalities, calcium level and metabolic alkalosis gradually improved with reduction of patient’s symptoms. Her further investigations revealed urinary spot magnesium as 0.9mg/dl(NV:0.9-1.9mg/dl), urinary spot potassium 15meq/L, urinary spot creatinine 67mg/dl(NV:25-400mg/dl), serum osmolality-278.1 mOsmol/kg serum water (NV:275-295 mOsmol/kg serum water), urine osmolality-328.5 mOsmol/kg water(NV:500-800 mOsmol/kg serum water), 24 hrs urinary calcium 0.27g (NV:0.15-0.35g/d), 25 – hydroxyl - vitamin D 38.8 ng/ml (NV:30-100 ng / ml), PTH 16.41 pg / ml (NV:15-65 pg / ml). She was found to be positive for sputum AFB, microcytic hypochromic picture on peripheral smear, low serum ferritin and no evidence of GI blood loss on stool examination and endoscopy. She was started on antituberculous treatment as per the WHO guidelines with isoniazid, rifampicin, pyrazinamide, ethambutol and Streptomycin. After five days of ATT, she again developed symptoms of tetany with carpopedal spasm and was found to have severe hypomagnesemia (0.8mg/dl), hypokalemia (3.2meq/L) and hypocalcemia (6.3mg/dl). Repeated urinary spot magnesium and creatinine showed 5.6mg/dl and 72mg/dl respectively. Streptomycin was discontinued. She was restarted on intravenous magnesium and calcium gluconate with continuing oral potassium. Patient improved symptomatically and biochemically and was discharged on modified ATT regimen including isoniazid, rifampicin, pyrazinamide, ethambutol and ofloxacin, oral magnesium, calcium and Iron supplements. One week later, she was reviewed in the OPD and was found to be doing better symptomatically. Her repeated values showed serum magnesium 1.4mg/dl, potassium 3.8meq/l and calcium 8.2mg/dl. Oral potassium was discontinued and was continued with ATT, magnesium and calcium supplementation. She was counselled for regular follow up.
DISCUSSION
Hypomagnesemia, though infrequently looked for, is present in up to 12 % of hospitalised patients.(3) Hypomagnesemia may present clinically as fatigue, cramps, nausea, irritability, tetany, seizures, lethal cardiac arrhythmias and sudden death.(2) Symptomatic magnesium depletion is often associated with multiple biochemical abnormalities such as hypokalemia, hypocalcemia and metabolic alkalosis.(4) Few studies(5,6, 7, 8) have documented the association of hypomagnesemia in patients with tuberculosis and is multifactorial in origin such as malnutrition, malabsorption, and therapy induced renal loss. Hypomagnesemia occurring as a complication of anti tuberculous therapy is reported by few authors (7, 8, 9), however, hypomagnesemia occurring as a primary complication of pulmonary tuberculosis is reported rarely. The above patient harbouring active pulmonary tuberculosis presented to us with symptoms of tetany secondary to hypomagnesemia and hypocalcemia. Hypomagnesemia contributed to Hypokalemia due to increased distal renal potassium secretion (10) as indicated by increased transtubular potassium gradient at 6.34. Hypocalcemia associated with hypomagnesemia is due to inappropriately low PTH level and PTH resistance (11, 12) which is consistent with the observations in our patient. Further, persistent hypocalcemia and hypokalemia despite adequate correction and had improved only after the correction of hypomagnesemia suggest that hypomagnesemia is the primary electrolyte abnormality contributing to other biochemical abnormalities in our patient. Hypomagnesemia in our patient prior to initiating antituberculous therapy in the absence of urinary magnesium wasting (fractional excretion of magnesium, FEMgEnglishhttp://ijcrr.com/abstract.php?article_id=937http://ijcrr.com/article_html.php?did=937REFERENCES
1. Limaye CS, Londhey VA, Nadkar MY, Borges NE. Hypomagnesemia in critically ill medical patients. Journal of associations of physicians of India 2011; 59:19-22.
2. Wong ET, Rude RK, Singer FR. A high prevalence of hypomagnesemia in hospitalized patients. Am J clin pathol 1983; 79: 348-352.
3. Ahsan SK. Metabolism of magnesium in health and disease. J Ind Med Assoc 1997; 95(9):507-10.
4. Zalman S.Agus. Hypomagnesemia. J AM Soc Nephrol 1999; 10:1616-1622.
5. Biswajit das, Prassanna Chandra, K.V Thimmaraju. A Comparitive study of serum magnesium in pulmonary tuberculosis and bronchial asthma. International Journal of Pharma and Bio Sciences 2011; 2(3): B 23-29.
6. Jain MK Khanuo sk, Chandre RD, Jain GC, Bisarya BN. Serum magnesium in pulmonary tuberculosis. IND.J.Tuber 1976; 23:177-181.
7. Shin S Furin J, Alcantra F et al. Hypokalemia among patients receiving treatment for multi drug resistant tuberculosis. Chest 2004; 125:974-80.
8. Aquinas M, Citron k. Rifampicin, ethambutol and capreomycin in pulmonary tuberculosis, previously treated with both first and second line drugs: the results of two years chemotherapy. Tubercle 1972; 53:153-65.
9. Vanasin B, Colmer M, Davis P. Hypocalcemia hypomagnesemia and hypokalemia during chemotherapy of pulmonary tuberculosis. Chest 1972; 61:496-99.
10. Chou-Long Huang, Elizabeth Kuo. Mechanism of hypokalemia in magnesium deficiency. J AM SOC Nephrol 2007; 18 (10):2649-2652.
11. Chase LR, Slatopolsky E. Secretion and metabolic efficiency of parathyroid hormone in patients with severe hypomagnesemia. J Clin Endocrinal Metab 1974; 38: 363-371.
12. Rude RK, Oldhan SB, Singer FR. Functional hypoparathyroidism and parathyroid hormone end organ resistance in human magnesium deficiency. Clin Endocrinol 1976 5:209-224.
13. Martin R.Pollak, Alan.S.L.Yu, Eric N.Taylor. Disorders of Calcium Magnesium and Phosphate imbalance. In: Barry M.Brenner. Brenner and Rector’s The Kidney. 8th(ed). vol 1; Philadelphia: Saunders, 2007:596-601
14. Avinash K Shetty, N Lymn Rogurs, Elizabeth E Mannick, Diego H. Aviles. Syndrome of hypokalemic metabolic alkalosis and hypomagnesemia associated with gentamicin therapy: case reports. CLIN PAEDIATR 2009; 39:529-533.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524166EnglishN-0001November30HealthcareBIFID RIBS - A RARE CHEST WALL DEFORMITY:A CASE REPORT
English8486Murali Krishna S.English Rajesh V.English Udaya Kumar P.English Kalpana T.English Chandra Mohan M.English Naveen Kumar B.EnglishAim: Aim of the present case is to report and describe a rare case of chest wall deformity in a 70 years old male cadaver. Case Report: Variations in the anterior chest wall are rare. Present case describes bifid ribs involving the right 3rd rib and 3rd costal cartilage, 5th rib and 5th costal cartilage which were observed during routine dissections for undergraduate medical students. When compared to the lower intercostal spaces, the upper intercostal spaces of the third and fifth bifid ribs were found to be narrow. Intercostal muscles were present in both the bifid spaces. They received their nerve supply and arterial supply from the 3rd and 5th intercostal nerves and arteries respectively. Conclusion: It is important to know about such anatomical variations, for clinicians during differential diagnosis with other diseases, such as a chest wall tumors or costal fracture and for counting the ribs.
EnglishBifid rib, intercostal spaceINTRODUCTION
Twelve pairs of ribs develop from costal processes in thoracic region during the 9th week of intrauterine life. The elongated cartilaginous costal arches get ossified to form the ribs. True ribs articulate to the sternum via the costal cartilages by 45th day and false ribs do not articulate with the sternum. Secondary ossification centers appear at 15 years. [1] A bifid rib is a congenital abnormality found in the anterior chest wall, with the sternal end of the rib cleaved into two, enclosing an additional intercostal space. The over all prevalence of bifid rib is 0.15% to 3.4% of the population. It is commonly unilateral and may be asymptomatic. This anomaly may be found incidentally on chest radiography [2].
CASE REPORT
During routine cadaveric dissection of the thorax of a man aged about 70 years, in Department of Anatomy, Mamata Medical College, Khammam, we observed variations of bifid appearance involving the right 3rd rib and 3rd costal cartilage and right 5th rib and 5th costal cartilage enclosing an additional circular intercostal space. On careful observation of the specimen we found that intercostal muscles were present in both the additional intercostal spaces but the 3rd additional intercostal space was too small space for the muscles to be distinguished. They were supplied by collateral branches of 3rd and 5th intercostal nerves. Arterial supply was by 3rd and 5th intercostal arteries. The dimensions of upper intercostal spaces were narrower than the lower intercostal spaces. The morphological measurements revealed that the distance from the lateral border of sternum to the bifid point in the 3rd intercostal space is 3.8 cm and in 5th intercostal space is 3.2 cm. The additional intercostal space of the 3rd bifid rib measured 1 cm in vertical distance and 0.7 cm in transverse distance and of 5th bifid rib is 2.5cm in vertical distance and 3.7 cm in transverse distance. The upper intercostal space between the 2nd and 3rd rib was narrowed and it measured 0.5 cm. The lower intercostal space between the 3rd (unusual rib) and 4th rib was widened measuring 2 cm. The upper intercostal space between the 4th and 5th rib was narrowed and it measured 0.1cm and the lower intercostals space between 5th and 6th rib measured 1.6 cm (Table No. 1).
DISCUSSION
Common congenital rib anomalies can be classified into numerical and structural. Numerical anomalies include supernumerary ribs like cervical, lumbar, pelvic or sacral and sometimes deficiency in total number of ribs. Structural abnormalities include short ribs, bifid ribs, fused or bridged ribs and pseudoarthrosis of first rib. [2, 3] Bifurcation of the rib and presence of additional intercostal spaces is a rare abnormality of thorax. Very few cases have been reported on such variations. Song et al., reported three cases of bifurcation of the right fourth rib [4]. Cristopher D Stickly et al., reported the presence of bifurcated 4th rib in one cadaver [5]. Development of intra thoracic rib is doubtful, however it may result from an incomplete fusion of cephalic and caudal segments of sclerotome during the development, occurring around the 4–6th week of foetal life [6]. The incidence of bifid ribs is more frequent in males than females. It is more common in the third and fourth ribs (degree of incidence - third > fourth > fifth > sixth > second) [5, 7]. Comparatively it is more prevalent on the right side of the chest than on the left side [8]. Some times bifid ribs can be present on both the sides. Presence of bifid rib may be associated with a syndrome called Basal cell nevus syndrome or Gorlin-Goltz syndrome. It is a hereditary multisystemic disorder that predominately affects the skeletal system, skin, eye and reproductive systems [9]. In the present case, bifid ribs were present in 3rd and 5th intercostal spaces on right side with narrowing of upper intercostal spaces.
CONCLUSION
This is the first case reported in cadavers where two bifid ribs are present on right side of the chest wall. It is necessary for the clinicians to know about this malformation because this may cause confusion during counting the ribs for some surgical procedures and diagnostic procedures. It is also necessary for the differential diagnosis with other diseases, such as costal fractures and chest wall tumours.
Competing interests
The authors declare that we have no competing interests
Ethical committee clearance
As the study included only human cadavers, ethical committee clearance was not taken into consideration. Authors will take the responsibility of any further allegations regarding ethical clearance that arise from the study.
Englishhttp://ijcrr.com/abstract.php?article_id=938http://ijcrr.com/article_html.php?did=938REFERENCES
1 Ronald b.j glass,MD,Karen,I,Norton et al, paediatric ribs: a spectrum of abnormalities, Radiographics January 2002 22:1 87-104.
2 Anita R, Archana R, Jyoti C, Punita M. Synostosis of First and Second Rib – Case Report. Jornal of Anatomical Society of India. 2009; 58(2): 189- 191.
3 Deepak S, Dakshayani KR. An unusual Case of a Bicipital Rib – A Report. Anatomica Karnataka. 2011; 5(1): 50-52.
4 Song WC, Kim SH, Park DK, Koh KS. Bifid rib: anatomical considerations in three cases. Yonsei Med J. 2009; 50: 300–303.
5 Cristopher D Stickly, Kaori Tamuri, et al., bifurcation of fourth rib as possible indicator of Gorlin Syndrome in a 85 yr old female cadaver. International Journal of Anatomical variation (2013) 6 : 86 – 89.
6 Satheesha Nayak.B. A case of bifid rib and additional intercostals space. International Journal of Anatomical Variations .2012 ;5:128–129.
7 Schumacher R, Mai A, Gutjahr P. Association of rib anomalies and malignancy in childhood. Eur J Pediatr. 1992; 151: 432–434.
8 Osawa T, Onodera M, Feng XY, Sasaki N, Nagato S, Matsumoto Y, et al., Two cases of bifid rib observed in the fourth and the fifth rib. Dental Journal of Iwate Medical University. 2002; 27: 98–103.
9 Rai S, Gauba K. Jaw cyst-Basal cell nevusBifid rib syndrome: A case report. J Indian Soc Pedod Prevent Dent - September 2007, 25:137-139
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524166EnglishN-0001November30HealthcareROLE OF HUMAN PAPILLOMAVIRUS (HPV) IN ORAL PRECANCEROUS DISORDERS AND ORAL CANCER- A REVIEW OF LITERATURE
English8792Vaishali KeluskarEnglishOral cancer is a major global health problem andaffects more than 200000 people worldwide. These are often led by preexisting oral lesions termed as potentially malignant disorders of the oral mucosa. Oral cancer is associated with multiple risk factors. Though tobacco and alcohol consumption are the most common risk factors, studies have also revealed that DNA viruses, especially human papillomavirus (HPV) may be an important etiological factor for head and neck malignancy. HPV infection is a significant risk factor for cervical carcinoma; however the role of HPV in OSCC is less well defined. Hence this article throws a light on various studies which were done previously to show an association between HPV and potentially malignant disorders and oral cancers.
EnglishHuman papillomavirus (HPV), oral premalignant disorders, oral squamous cell carcinoma (OSCC).INTRODUCTION
Oral cancer is the 6 th most common malignancy in developed countries, representing almost 3% of all malignancies, accounting for 50% of all cancersespecially in India and other regions of Southeast Asia.. Besides the main risk factors of tobacco, smoking and alcohol, infection by human papillomavirus (HPV) and genetic alterations are likely to play an important role in these lesions. More than 90% of these malignancies are often preceded by preexisting oral lesions termed as potentially malignant disorders of the oral mucosa.1 In several epidemiological studies, the role of tobacco smoking and alcohol consumption as major risk factors for potentially malignant disorders and oral cancer is well documented.2 Literature reveals that oncogenic HPVs are main causative agent for cervical cancer, but its role in potentially malignant disorders and carcinomas of the oral cavity is less established.3Association of HPV with oral and pharyngeal carcinogenesis was first proposed in 1983 by Syrjanenet al. 4 HPVs are small (55 nm), nonenveloped, icosahedral, epitheliotropic DNA tumor viruses that are transmitted early in life. To date more than 75 different HPV genotypes have been cloned and characterized. 16 HPV DNA genotypes have been isolated from oral lesions among whichmajority are low risk HPVs (6, 11, 13, 32) associated with benign papillomatous lesions having little potential for malignant progression. Whereas highrisk HPV genotypes (16,18,31,32,33,35) are frequently associated with epithelial dysplasia and squamous cell carcinomaand have increasedmalignant potential.5
REVIEW
Various studies have been carried out to know the prevalence of HPV in the oral cavity, yetits role in oncogenic development is unclear. This could be attributedto varied studies carried out in diversepopulation, with different sample size and different assays to detect viral DNA.Hence a retrospective review of the existing epidemiologic data wascompiledto highlight the relationship of HPV in the development of potentially malignant disorders and OSCC. Syrjanen K and Syrjanen Set al. in 1983 assessed biopsies from 40 cases of OSCCand observedassociation of HPV with malignancy. Morphological signs of the flat-type HPV lesion were found in 4 cases (10%), inverted type in 3 cases (7.5%), and papillomatous type in 9 cases (22.5%). Epithelial cells (mostly koilocytes) showing HPV-positive nuclei were disclosed in 5 papillomatous lesions, in 2 inverted lesions and in 1 flat lesion. Thus according to them HPV could be the etiological factor for certain types of OSCC.4 Shroyer KR and Greer RO in 1991 compared the sensitivity of detection of HPV DNA in premalignant and malignant oral lesions by in situ hybridization (ISH) and polymerase chain reaction (PCR). As per his observations HPV DNA was found among 4 of 24 cases of epithelial dysplasia, 4 of 14 cases of verrucous hyperplasia, and 1 of 10 cases of squamous cell carcinoma. The 10 cases of smokeless tobacco keratoses and 3 cases of verrucous carcinoma were all negative for HPV DNA. According to them, PCR was an effective technique for identifying HPV 16 DNA from premalignant and malignant oral lesions.6 Young SK and Min KW et al. in 1991 evaluated potentially malignant and malignant lesions with biotinylated double-stranded DNA probesfor detection of HPV types 6/11, 16/18, and 31/33/35.According to his observations 62% (13/21) of oral squamous papillomas were positive for HPV DNA among which 6 and 11 HPV types demonstrated the strongest reactivity. Of the 13 cases, 10 also showed some reactivity with HPV- 16/18 and -31/33/35. This study thus confirmedthat HPV DNA is frequently found in oral squamous cell papillomas and may not be detected in keratotic, premalignant, or cancerous lesions of the oral mucous membranes.7 The studies by Chang et al in 1991, Yeudall in 1992 and Miller and Johnstone in 2001 detected many low risk types of HPV ( 6 and 11) with benign lesions and HPVs( 16,18 and 33) with malignant lesions.8-10 Shindoh Met al in 1992 studied an association of HPV DNAs in carcinomas of the oral cavity.According to their observations HPV-16 DNA sequences may have the capability to maintain the proliferative state of epithelial cells, and thus may contribute to the production of malignant phenotypes.11 Yeudall WA and Paterson ICet alin 1995 studied patients with tobacco history and their association with HPV. They suggested that though p53 mutation was a frequent genetic event in oral cancer, this does not preclude a papilloma viral etiology for these tumors. 12 Zhonghua Kou et. al. in1996 detected HPV 16 and 18 type DNA in OSCC and normal mucosa (NOM) by PCR, and thenanalyzed the PCR products using southern blot hybridization. They observed that the positive rates of HPV DNA were 47.8% (11/23) in OSCC, including HPV16 in 6 samples, HPV 18 in 3 samples and 16, 18 coinfection in 2 samples. Whereas HPV16 DNA was found to be 20% (2/10) in normal oral mucosa, thus suggesting that HPV may play a role in carcinogenesis of OSCC.13 Bustos D.A et al in 1999 studied association of HPV with cervical and oral cancer.According to their observations, HPV DNA in cancer biopsy specimens were detected less frequently among tobacco smokers and pan chewers and more frequently among heterosexuals or those who practiced oral sex.14 Martha Bouda et. Al. in 2000 conducted a study to examine HPV infection in oral hyperplasias, dysplasias and squamous cell carcinomas as well as in normal oral mucosa by nested polymerase chain reaction (NPCR) , type specific PCR (TS– PCR), restrictionfragment length polymorphism RFLP) analysis, dot blotting (DB), and nonisoropic in situ hybridization (NISH). They suggested that, association of high risk HPV types with oral carcinogenesis and high percentage in hyperplasias and dysplasias to be an indicator of an early involvement of HPV in oral neoplasia.15 Scully et. al. in 2000 also suggested that viral factors like HPV may contribute to the etiology of OSCC.16 Klussmann JP and Weissenborn SJ et. al. in 2001 reported 25 Head and Neck Squamous Cell Carcinomas (HNSCCs) (26%) to be HPV positive. The frequency of HPV positive lesions was 18% in the oral cavity, 45% for oropharynx, 25% for hypopharynx, 8% for nasopharynx, and 7% for larynx.17 Nagpal et. al. in 2002 analyzed the genetic predisposition of Indian population to HPV infection and oral carcinogenesis. They screened 110 patients of oral cancer, who were highly addicted to betel quid and tobacco chewing for HPV 16/18 infection and its association with polymorphism at p53 codon. Total 37 patients (33.6%) showed the presence of HPV 16 in 22.7%, HPV 18 in 14.5% and HPV 16/18 coinfection in 10%.18 Hansson BG and Rosenquist K et. al. in 2005 demonstrated a strong association between infection with high-risk types of HPV and oral and oropharyngeal squamous cell carcinoma (OOSCC), suggesting that high-risk HPV types play a key role in carcinogenesis.19 Syrjanen S. et. al. in 2005 were the first to present evidence on the involvement of HPV infections in both laryngeal and oral carcinogenesis. Until 2002, 4768 oral carcinomas had been analysed for HPV DNA, and 22% were reported to contain HPV. Tonsillar carcinomas appeared to have the highest prevalence of HPV among all non genital cancers. By the end of 2002, 422 cases of tonsillar carcinoma were analyzed for the presence of HPV DNA, with the overall detection rate of 51%. HPV 16 was the most prevalent type found in 84% .The role of HPV in laryngeal squamous cell papilloma and recurrent respiratory papillomatosis (RRP) is well - established, whereas the role of HPV in laryngeal carcinomatosis remains controversial. The molecular mechanism of HPV-associated carcinogenesis of the head and neck is still not understood.20 KoppikarP et. al. in 2005 studied HPV DNA in oral carcinoma by polymerase chain reaction (PCR) amplification and reported that HPV contributed to carcinogenesis. High risk HPVs are predominantly found in oral cancer and may play a role in its progression, while low risk subtypes are usually associated with oral precancerous lesions.21 Chen PC and Pan CC et. al. in 2006 analyzed the association of potentially malignant lesions with HPV. According to them HPV 16 and 18 were frequently identified with all potentially malignant lesions, whereas HPV 6 and 11 were found only in squamous papilloma. HPV 18, betel quid chewing and smoking were significantly associated with leukoplakia and squamous papilloma, while only betel quid chewing and smoking were significantly associated with oralsubmucous fibrosis (OSMF).22 Chen SL et. al. in 2007 suggested that the role of HPV infection is due to oncoproteins E6 and E7 which inactivate p53 and pRB respectively. The oncogene E5 has also been found to transform cells by modulating growth factor receptors, thus suggesting that several oncoproteins contribute in carcinogenesis.23 Katie M. Applebaum and C. Sloane Furniss et. al. in 2007 suggested HPV 16 seropositivity and alcohol and tobacco use to be associated with risk of Head and Neck Squamous Cell Carcinoma. According to them, the strongest risk factors by tumor site were smoking for laryngeal cancer, alcohol for cancer of the oral cavity, and HPV16 for pharyngeal cancer. For pharyngeal cancer, risk increased with increasing alcohol consumption and smoking among HPV16-seronegative subjects but not among HPV16-seropositive subjects. Among light drinkers or never smokers, HPV16 seropositivity was associated with a 30-fold increased risk of pharyngeal cancer. They concluded thatalcohol or tobacco use does not further increase risk of HPV16-associated paryngeal cancer and the risk of Head and Neck Squamous Cell Carcinoma associated with smoking, alcohol, and HPV16 differs by tumor site.24 Liang XH and Lewis J et. al. in 2008 carried out a study to examine the prevalence and significance of HPV infection and its clinical significance in patients with oral tongue cancer. They suggested that the incidence of HPV in oral tongue cancer was low and was unlikely to play a significant role in etiology, pathogenesis and clinical outcomes of oral tongue cancer, as there was a rising trend of oral tongue cancer in the young populations.25 Scapoli L and Palmieri A et. al. in 2008 carried out a study to evaluate the presence of high-risk tHPV in a large, well defined sample of oral squamous-cell carcinoma. Data obtained from 314 oral squamous-cell carcinoma, indicated that the prevalence of high - risk HPV was as low as 2% and thus did not support a major role of HPV in the etiology of oral squamous-cell carcinoma. 26 Jalouli J and Ibrahim SO et. al. in 2010 illustrated human simplex virus (HSV), HPV and Epstein Barr virus (EBV) infections to be common and may influence oral health and cancer development. According to them, there was a high prevalence of HPV in Oral Sub Mucous Fibrosis and the etiologic implication of this finding warrants further studies.27
CONCLUSION
The role of HPV in Oral Squamous Cell Carcinoma has gained attention due to biological similarities between the epithelium of the cervix and the oral cavity. HPV is an important risk factor for potentially malignant disorders and Oral Squamous Cell Carcinomas. HPV 16 and 18 were detected more frequently in Oral Squamous Cell Carcinoma than potentially malignant disorders and absent in the normal samples. This suggests an association of the virus with oral carcinogenesis. Data pertaining to prevalence of HPV in patients with Oral Squamous Cell Carcinomas. without history of smoking, alcohol or betel nut habit is limited. Hence, further studies need to be carried out to find the prognostic value of HPV infection as a biomarker for early diagnosis ofpotentially malignant disorders and Oral Cancer.
Englishhttp://ijcrr.com/abstract.php?article_id=939http://ijcrr.com/article_html.php?did=939REFERENCES
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15. Bouda M, Gorgoulis VG, Kastrinakis NG, Giannoudis A, Tsoli E, DanassiAfentaki D, Foukas P, Kyroudi A, Laskaris G, Herrington CS, Kittas C: "High risk" HPV types are frequently detected in potentially malignant and malignant oral lesions, but not in normal oral mucosa. Mod Pathol 2000;13:644-53.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524166EnglishN-0001November30HealthcareTUBERCULAR CERVICAL LYMPHADENITIS : EXPERIENCE OVER A FOUR YEAR PERIOD
English9399Vineet ChaudharyEnglish M. Abbas AliEnglish Ravi MathurEnglishObjective: This Study was done with the Aim to investigate various Clinico-pathological aspects of Tubercular cervical lymphadenitis. Material and Methods: Four hundred patients with cervical lymphadenopathy of all age group, out of which 220 males and 180 females who attended OPD of NIMS Medical college, Jaipur between March 2009 and Feb 2013 were included in study.FNAC of Cervical lymph nodes was done. The lymph node biopsy was done in selected patients. Mycobacterial culture was also done in selected patients. Total 218 cases of tubercular cervical lymphadenitis (proved by FNAC/Biopsy) were included in this study. Results: Most common cause of cervical lymphadenopathy was found to be tubercular in 218 patients (54.5%). Female/Male Ratio was 1:84. Younger Age Group (15-30 years) was most commonly affected, seen in 77 patients (35.32%). Diagnostic accuracy of FNAC in tubercular lymphadenitis was 95.41% .Concurrent pulmonary tuberculosis was seen in 33 patients (15%).Constitutional symptoms were present in 32 patients(14.67%).Montoux Test was positive in 100 patients(45.87%). Posterior Triangle of neck was most commonly involved.Commonest presentation of tubercular lymph nodes was multiple matted lymph nodes, seen in 110 patients (50.45%).In our study 150 patients (68.80%) presented as 2-4cms size lymph nodes. Conclusion: This study also emphasizes that complications can be minimized by regular anti tubercular treatment, good patient compliance and regular follow up especially for development of fresh complications.
EnglishTubercular cervical lymphadenitis, FNAC, ATT, Defaulters, Excisional biopsy, mycobacterium culture.INTRODUCTION
Cervical lymphadenopathy is one of the commonest clinical presentation of the patients attending hospital outdoor.Grossly cervical lymph node enlargement can be classified as Acute and chronic cervical lymphadenitis. Chronic cervical lymphadenitis usually presents as chronic painless enlargement of cervical lymph nodes. Etiology of chronic cervical lymphadenitis is either tubercular or due to secondary malignant deposits or lymphomas. Tubercular lymphadenitis (historically referred to as scorfula) is the commonest form of extrapulmonary tuberculosis reported in children from TB endemic areas ,present in 8-10% of children diagnosed with TB in India and South Africa (1,2). Lymph nodes become infected with mycobacterium tuberculosis following lymphatic drainage from local disease site or after haemetogenousdisiminetion .The aim of this study was to investigate various clinicopathological aspects of tubercular cervical lymphdenitis among patients presenting to Four hundred patients with cervical lymphadenopathy of age group,new born to s
our institute over a four year period.
MATERIALS AND METHODS
eventy five years,out of which 220 males and 180 females who attended OPD of NIMS Medical college, Jaipur between March 2009 and Feb 2013 were included in study .Written Informed consent was obtained from all study subjects. All patients were clinically assessed and a detalied history was taken regarding age , sex ,mode of onset ,duration, distribution, family history, presence or absence of pain, fever, weakness, loss of weight, night sweats, anemia, cough, progress of disease. All clinical records were maintained. After taking patient’s history, full clinical examination was done. Special emphasis was made to site/size/clinical stage of cervical lymph node. All patients were subjected to routine investigations CBC, ESR,MT, X-Ray chest PA view. FNAC of Cervical lymph nodes was done with help of 10cc disposable syringe and needle (22gauge). Half smears were dried in air and half were fixed by immersing in absolute alcohol for one hour .The lymph node biopsy was done in selected patients. Mycobacterial culture was also done in selected patients.Total 218 cases of tubercular cervical lymphadenitis (proved by FNAC/Biopsy) were included in this study.
OBSERVATIONS
Out of total 400 patients, 220 (55%) were males and rest 180(45%) were females. Tubercular lymphedentis was the most common FNAC finding in 208 patients (52%) followed by Reactive hyperplasia in 100 patients (25%).
DISCUSSION
Lymphadenitis is the most frequently occurring form of pulmonary TB, with cervical Nodes being most commonly involved in adults. Although inguinal, mesenteric and mediastinal Nodes may be involved (1, 2.) It has been found that by FNAC alone, 208 patients (52%) were found to have tubercular cervical lymphadenitis followed next by Reactive Hyperplasia in 100 patients (25%). These 100 patients with Reactive Hyperplasia group were also subjected to Excisional Biopsy. It has been found in our study that 10 patients of Reactive Hyperplasia group proved to be Tubercular by Excisional Biopsy. So overall by Excicional Biopsy overall 218 (54.5%) patients proved to be tubercular in our study. This study emphasises that Tubercular cervical lymphadenitis is one of the most common clinical presentation of Extra pulmonary tuberculosis. In our study, FNAC of cervical lymph Node Biopsy was positive for Tubercular lesion in 208 patients, out of 218 patients. So, Diagnostic accuracy of FNAC in Tubercular Cervical lymphadenitis was 95.41% in our study. This study emphasises importance of FNAC in diagnosis of Tubercular Cervical Lymphadenopathy. Fine Needle aspiration is suggested as an initial investigation if lymph node Tuberculosis is suspected. (3) FNAC constituted main diagnostic tool, with positive yield in 90% on Patients, TB cervical lymphadenitis can be readily diagnosed by FNAC as a simple and cost-effective test. (4) Fine needle aspiration is simple, cheap and may be of value in the diagnosis of Tuberculosis, especially in developing countries with limited diagnostic and therapeutic resources.(5) In our study, 77 patients(15.32%) were found to have Tubercular Cervical Lymphadenitis in 15-30 year age group, followed by 67 patients (30.73%) patients in children age group (0-15 yr); 42 patients (19.20%) in 30-45 years age group and 32 patients (14.60%) in >45 age group. Our study shows maximum incidence of Tubercular Cervical Lymphadenitis in younger and children age group.Tuberculosis was found to be common in young patients who are in accordance with local data as well as international data. (6)In another study, Tuberculosis found to be commomest in young adult females (15-24yrs) age group and rare above age of 45yrs. (7) It has peak incidence in 20-40 age groups. (8) In our study. Tubercular Lymphadenitis was found in 118 (54.12%) female patients as compared to 100 (45.87%) male patients. So in our study, M: F was 0.84:1. TB lymphadenitis is showing some atypical characteristics for its distribution according to age and sex as it is more common in females and in younger age groups, in compare to pulmonary TB which is more commonly affects males and older age group.(9) Family History of any form of Tuberculosis in our study was found in 55 patients (25%). Concurrent Pulmonary tuberculosis was found in 33(15%) patients in our series. Constitutional symptoms were found in 32 (14.67%) patients. Fatigue, Bodyache was commonest symptom in 10 patients (4.58%) followed by loss of weight, failure to thrive (children) in 7 patients (3.21%), cough in 6 patients (2.75%), fever in 5 patients (2.29%), Night sweats in 4 patients (1.83%).Most physicians agree that Tubercular Cervical Lymphadenitis is a local manifestation of systemic infection but a striking feature of many reports in infrequent occurrence of systemIc features and specifically of pulmonary involvement. (10) Constitutional symptoms were not present in most patients in few series. In several series, in approximately 80% (11) patients, the chest films were normal so there is continuous debate whether Tubercular Cervical Lymphadenitis is a localized disease or a part of systemic disease. (12) Post Traingle of Neck was found to be most common involved in 98 patients (44.95% ) followed by upper deep cervical lymph nodes in 66 patients(30.27%) , submandibular lymph node in 20(9.17%) patients ,supraclavicular in 18(8.25%),preauricular lymph node in 16 patients(7.33%). In a study by Pameraetal (15) regarding distribution of enlarged lymph nodes, the upper jugular, submandibular and supraclavicular groups were found involved more often and occipital group less often. Montoux Test was positive in Tubercular Cervical Lymphadenitis in 100 patients (45.87%). Among 100 Tubercular cases (M.T. positive), 48 patients were below 15 years age. Hence Montoux Test was positive in 48 patients, out of 67 patients (71.64%) in 2cm, upto 4 cm) was found in 150 patients (68.80%), followed by LN size (>4cm) in 41 patients (18.80%), LN (Englishhttp://ijcrr.com/abstract.php?article_id=940http://ijcrr.com/article_html.php?did=940REFERENCES
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1 6. Peripheral L.Node Tuberculosis: A review of 80 cases BJS vol. 77, Issue 8, pages 911-912 Aug 1990 professor M.C.Dandapat, BM Mishra , S.P. Dash, P.K.Kar.
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