Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Warning: SimpleXMLElement::addChild(): unterminated entity reference foot. in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 205
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Warning: Cannot modify header information - headers already sent by (output started at /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php:142) in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 234
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524161EnglishN-0001November30General SciencesUSE OF CHROMOGENIC MEDIUM FOR SPECIATION OF CANDIDA ISOLATED FROM CLINICAL SPECIMENS
English0105Dharmeswari T.English Sheela Devi ChandrakesanEnglish Nagaraja MudhigetiEnglish Anitha PatriciaEnglish Reba KanungoEnglishAim: To explore the usefulness of chromogenic medium in speciating clinical isolates of Candida and to determine their antifungal susceptibility. Methodology: A total of 50 Candida isolated from various clinical specimens were included in the study. Speciation of Candida was done based on the growth on chromogenic medium and other conventional methods. Antifungal susceptibility testing was performed against fluconozole and amphotericin B. Results: Among the 50 clinical Candida isolates, 45 could be speciated with the help of chromogenic medium. Only 30% of the Candida isolates were identified as Candida albicans and the rest were non albicans Candida species. Among the non albicans species Candida tropicalis was the commonest isolate followed by C. glabrata and C. parapsilosis. None of the strains were resistant to amphotericin B or fluconazole. Conclusion: Use of chromogenic medium with the morphology on corn meal agar provides rapid identification of commonly isolated Candida species from clinical specimens. This will be useful to initiate appropriate antifungal therapy thereby reducing morbidity and mortality.
EnglishCandida albicans, Chromogenic medium, Antifungal susceptibility, speciation, Non albicans CandidaINTRODUCTION
The incidence of various fungal pathogens has increased dramatically over the past few decades. Candida species are the most common of these pathogens and have emerged as important opportunistic pathogens in the last decade. Infections by this group are often severe, rapidly progressive and refractory to therapy. Suppressed host defense and exposure to multiple risk factors are responsible for their emergence. Use of newer and broad spectrum antibacterial agents, increasing patient population living with AIDS, haematological malignancies or solid organ transplantation have been the contributory factors for the emergence of Candida species as important pathogens (1,2) Though Candida albicans is considered to be the commonest species causing human diseases, there are increasing reports of non-albicans Candida species emerging as important pathogens. (1,3) A rise in less common Candida sp. has been associated with significant morbidity and mortality. (4) The emergence of drug resistant Candida sp. which is largely attributed to use of prolonged and irrational empirical therapy has further complicated patient management. Some of the non-albicans Candida sp. are known to have varied susceptibility pattern to the routinely used antifungal agents especially the azoles. Conventional methods available to speciate the non albicans Candida sp. are time consuming and cumbersome. (5) To overcome this problem CHROM agar, a chromogenic differential culture medium was introduced. The manufacturers claimed that this chromogenic agar can facilitate the isolation and presumptive identification of certain clinically important Candida species. With the current scenario where non albicans Candida species are frequently isolated from clinical specimens, an early identification and speciation of positive Candida cultures is important . The present study was undertaken to explore the usefulness of chromogenic medium for speciation of Candida isolated from clinical specimens and to determine their drug susceptibility patterns.
MATERIALS AND METHODS
Isolation and identification of yeast
A total of 50 Candida isolated from various specimens (blood, clean-voided mid stream urine, pus, broncho-alveolar lavage and tracheal aspirates) submitted to the clinical microbiology laboratory from different clinical units of Pondicherry Institute of Medical Sciences (PIMS), a tertiary care hospital, were included in the study. All suspected yeast colonies on sheep blood agar were confirmed by Gram staining. All such yeast isolates that grew on sheep blood agar (HiMedia, Mumbai, India) were sub cultured on chromogenic medium (HiChrom agar Candida; HiMedia, Mumbai, India) and incubated at 37o C. The isolates grew well and developed distinctive colored colonies after overnight incubation. The plates were further incubated for 24 h to observe well distinguished colonies. Presumptive identification was made by n o t i n g t h e color of the colonies as per the manufacturer's Instructions. All isolates were further inoculated on corn meal agar (CMA) by slide culture method to determine microscopic morphological features of various Candida species. (6) Antifungal susceptibility testing by disc diffusion method was performed as per CLSI M44A (7) document against fluconazole discs (Hi Media, Mumbai, India) for all the 50 isolates. Briefly the yeast suspension was prepared in 5ml of sterile normal saline and turbidity was adjusted to 0.5McFarland standard. Modified Muller Hinton agar (Muller-Hinton agar + 2% glucose + 0.5 µg/ml of Methylene blue, pH 7.2) plates were inoculated and fluconazole (25 µg) discs (Hi Media, Mumbai, India) was placed on each plate. Results were obtained after 24 hours of incubated at 37 o C. MIC of Amphotericin B was determined by agar dilution method for 37 isolates. Amphotericin B (Hi Media, India) stock solution and working concentration were prepared as per CLSI guidelines. (8) As the study did not involve human subjects, obtaining informed consent was waived by the Institute Ethics Committee. Throughout the study C.albicans (ATCC90028), C.parapsilosis (ATCC90018), and C.krusei (ATCC6258), ATCC standard strains were used as Quality controls.
RESULTS
Only 15/50 (30%) of the strains were identified as C. albicans. Nearly half of the remaining 35 strains were C. tropicalis (43%), followed by C.glabrata (25%) and C.parapsilosis ( 17%). Candida species identified by the color on the chromogenic medium is shown in fig 1. Out of 50 isolates, 45 isolates showed characteristic morphology for that particular Candida species identified by CHROM agar. Three Candida isolates did not correlate with morphology on corn meal agar and hence did not fit with any Candida species. However on CHROM agar t h e s e were identified as Candida glabrata, Candida albicans and Candida krusei. One Candida albicans which showed green colored colonies on CHROM agar and was positive for Germ tube test (GTT) did not show any chlamydospores on Corn meal agar, but only elongated yeast cells. The other two isolates, one identified as Candida glabrata on CHROM agar resembled Candida parapsilosis in morphology on corn meal agar (short pencil shaped yeast cells) and the one identified as Candida krusei on CHROM agar gave a typical morphology of Candida tropicalis (oval blastoconidia and long pseudohyphae) on corn meal agar. Two other isolates did not produce any color on Chrom agar and showed round to oval yeast cells on corn meal agar. Antifungal susceptibility of all the 50 Candida isolates for fluconazole was performed by disc diffusion method. None of the isolates in the study were resistant to fluconazole. Only 3 Candida isolates were intermediately susceptible showing that they were dose dependent susceptible (two Candida glabrata and one Candida tropicalis). The two Candida glabrata strains were isolated from high vaginal swab and one Candida tropicalis was isolated from blood. All the other Candida isolates were sensitive to fluconazole. Minimum Inhibitory concentration (MIC) was performed by agar dilution method for amphotericin B for thirty seven Candida isolates. It ranged from Englishhttp://ijcrr.com/abstract.php?article_id=972http://ijcrr.com/article_html.php?did=972REFERENCES
1. David Trofa, Attila Gácser and Joshua D. Nosanchuk. Candida parapsilosis, an Emerging Fungal Pathogen. Clin. Microbiol. Rev. 2008; 21(4):606.
2. Jacqueline M. Achkar and Bettina C. Fries. Candida Infections of the Genitourinary Tract. Clin. Microbiol. Rev. 2010; 23(2):253.
3. Wingard JR. Importance of Candida species other than Candida albicans as pathogens in oncology patients. Clin. Infect. Dis.1995;20:115-125.
4. Chakrabarti. A, Singh. S and Das. S. Changing pace of nosocomial candidemia. Indian. J.Med. Microbiol.1999;17:160-166.
5. Li-Ung Huang,Chi-Hsiang Chen,Chu –Fang Chou, Jang- Jih Lu,Wei-Mingchi, Wei-Hwa Lee. A comparison of methods for yeast identification including CHROM agar Candida , Vitek system YBC and a traditional biochemical tests. Chinese Medical Journal (Taipei.).2001;64:568-574.
6. Agarwal S, Manchanda V, Verma N, Bhalla P. Yeast identification in routine clinical microbiology laboratory and its clinical relevance. Ind J of Med Microbiol 2011; 29 : 2:172-177.
7. Wayne Pa. National committee for antifungal disk diffusion susceptibility testing yeast: approved guidelines; CLSI;M-44A;2004.
8. Wayne Pa. Clinical and laboratory Standards Institute Reference method for broth dilution antifungal susceptibility testing of yeasts; approved standard-third edition; CLSI document M27-A3;2008(a)
9. Malini R Capoor, Deepthi Nair, Manorama Deb, Pradeep Kumar Verma, Lakshmi Srivastva and Pushpa Aggarwal. Emergence of Non albicans Candida species and antifungal resistance in a tertiary care hospital. Jpn J Infect Dis.2005; 58:344- 348.
10. J.E. Hoppe, P.Frey: Evaluation of six commercial tests and the germ tube test for the presumptive identification of Candida albicans. Eur. J. Clin. Microbiol. Infect. Dis.1999; 18:188-191.
11. Odds, F. C., and R. Bernaerts. 1994. CHROM agar Candida, a new differential isolation medium for presumptive identification of clinically important Candida species. J. Clin. Microbiol. 32:1923-1929.
12. Ann P Koehler, Kai Cheong Chu, Elizabeth T S Houang and Augustine F B Cheng. Simple, reliable and cost effective yeast identification scheme for the clinical laboratory. J. Clin. Microbiol.1999;37(2):422- 426.
13. Pfaller M A, Houston A and Coffmann S. Application of CHROM agar Candida for rapid screening of clinical specimens for Candida albicans, Candida tropicalis, Candida krusei and Candida glabrata. J Clin Microbiol.1996;34:58-61.
14. L Srinivasan and J Kenneth. Antibiotic susceptibility of Candida isolates in a tertiary care hospital in Southern India .Indian J Med Microbiol.2006;24(1):80-81
15. Adikary.R. Joshi.S. Species distribution and anti-fungal susceptibility of candidemia at a multi- super specialty center in southern India. Indian J Med Microbiol.2011; 29(3):309- 311.
16. Rizvi MW, Malik A, Shahid M, Singhal S. Candida albicans infections in a North Indian tertiary care hospital: Antifungal resistance pattern and role of SDS-PAGE for characterization. Biology and Medicine 2011; 3(2):176-181.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524161EnglishN-0001November30HealthcareUSE OF LOCKING PLATES IN FRACTURE MANAGEMENT
English0620Raza A.English Kailash K.English Mahalingam S.EnglishThe history of fracture management can be traced back to the prehistoric times. It was not until the late nineteenth and early twentieth century that operative treatments of fractures were contemplated. However operative treatment of fractures at that time was associated with devastating results secondary to infection with high morbidity and mortality. As a result, the mainstay of treatment of fractures remained traction and closed reduction within plaster of Paris. On the other hand, non-operative treatment of fractures was associated with the development of joint stiffness, disuse osteopenia and muscle atrophy, collectively described as „Fracture disease?. During 1950s, the Swiss AO group standardized the use of plating systems. The AO group revolutionized the concept of rigid stable internal fixation with early functional mobilisation which resulted in a positive impact on fracture disease. With time, surgeons started gaining more confidence in the operative management of fractures when better results were obtained while adhering to the principles of strict asepsis and using antibiotics. The article describes the use of modern locking plates in the management of fractures in different areas. Overall, the literature supports using locking plates for fixation of periarticular fractures of long bones, multifragmentary fractures of diaphysis and metaphysis and periprosthetic fractures. Locking plates are not the panacea for all type of fractures. As clinical experience with locking plate broadens, new indications and applications will emerge.
EnglishLocking plate, Internal fixation.INTRODUCTION
The history of fracture management can be traced back to the prehistoric times. Analysis of bones of Neolithic man shows both successful and unsuccessful attempts in fracture fixation [16]. It was not until the late nineteenth and early twentieth century that operative treatments of fractures were contemplated. Later, devices were developed that could be applied to the broken bone either externally or internally to hold the fracture and let it heal in the required position. External fixation was first attempted by Albin Lambotte in 1902 [49] and Gerhard Kuntscher developed his intramedullary nail in 1938. However operative treatment of fractures at that time was associated with devastating results secondary to infection with high morbidity and mortality. As a result, the mainstay of treatment of fractures remained traction and closed reduction within plaster of Paris. On the other hand, nonoperative treatment of fractures was associated with the development of joint stiffness, disuse osteopenia and muscle atrophy, collectively described as „Fracture disease?.During 1950s, the Swiss AO group standardized the use of plating systems [24]. The AO group revolutionized the concept of rigid stable internal fixation with early functional mobilization which resulted in a positive impact on fracture disease. With time, surgeons started gaining more confidence in the operative management of fractures when better results were obtained while adhering to the principles of strict asepsis and using antibiotics. The contribution by AO group in the understanding of fracture healing, management and internal fixation is undisputedly enormous.
Development of Locking plates
The fixation achieved by conventional plate-bone construct is based on friction between the plate and bone interface. As the plate is firmly pressed against the periosteum, it impairs the periosteal blood supply with subsequent poor and slower bone healing. With time surgeons and researchers recognised the importance of biological environment of the fracture. The principle of “Biological Internal Fixation” emphasized more flexible fixation to encourage the callus formation, with less precise direct reduction thus reducing surgical trauma [54]. As a result Zespol plates and Schuhli nuts were introduced to convert conventional plate into fixed-angle device with plate acting as internal fixator. Later, the point contact fixator (PC-Fix) and Less Invasive Stabilisation Systems (LISS) were developed by AO, which had even minimal contact areas on the bone with improved preservation of periosteal and endosteal blood supply [47]. Thus locking plates were developed to achieve biological internal fixation with relative stability, yet strong enough to allow early functional mobilisation.
How Locking Plates Work
Conventional plates owe their stability to firm contact with bone surface, and reducing this contact also reduces the stability of implant-bone construct. In order to maintain such low contact to allow for biological fixation and yet stay stable, locking plates are designed as „fixed angled devices?. „Fixed-angle device? means that when screws are placed in the plate and stress is applied, the angle between the plate and screws does not change. In order to achieve this, locking head screws were developed which can lock within the screw holes of the locking plate by virtue of their threaded heads. Once locked, these screws even under stress maintain their relative position with respect to the plate, thus providing both angular and axial stability. In a conventional plate, loosening of one screw renders instability by reducing the contact pressure between the plate and bone. Thus loosening of even one screw can potentially jeopardize the overall stability with rapid sequential loosening, as is seen in osteopenic and osteoporotic bones. This however is not seen in locking plates where stability is not based on interface friction as the plate-screw construct acts as a composite structure. Currently locking plates are being used for treating a wide variety of fractures. Let us briefly consider different areas of the body where these plates have been used while comparing them with other treatment modalities.
Proximal Humeral Fractures
Proximal humeral fractures are the third most common osteoporotic fractures after hip and distal radius with females having higher risk than men [5]. The large majority of these fractures are managed non-operatively as they are mostly stable and minimally displaced ( Englishhttp://ijcrr.com/abstract.php?article_id=973http://ijcrr.com/article_html.php?did=973REFERENCES
1. Apivatthakakul T, Phornphutkul C, Laohapoonrungsee A, Sirirungruangsarn Y. Less invasive plate osteosynthesis in humeral shaft fractures. Oper Orthop Traumatol 2009; 21(6):602-13.
2. Apivatthakakul T, Patiyasikan S, Luevitoonvechkit S. Danger zone for locking screw placement in minimally invasive plate osteosynthesis (MIPO) of humeral shaft fractures: a cadaveric study. Injury 2010; 41(2):169-72.
3. Bae JH, Oh JK, Oh CW, Hur CR. Technical difficulties of removal of locking screw after locking compression plating. Arch Orthop Trauma Surg 2009; 129(1):91-5.
4. Bagby GW. Compression bone-plating: historical considerations. J Bone Joint Surg Am 1977; 59(5):625-631.
5. Baron JS, Barrett JA, Karagas MR. The epidemiology of peripheral fractures. Bone 1996; 18(3 Suppl):209S-213S.
6. Biggi F, Di Fabio S, D'Antimo C, Trevisani S. Tibial plateau fractures: internal fixation with locking plates and the MIPO technique. Injury 2010; (11):1178-82.
7. Blatter G, Weber GB. Wave plate osteosynthesis as a salvage procedure. Arch Orthop Trauma Surg 1990; 109(6):330-3.
8. Blyth MJ, Macleod CM, Asante DK, Kinninmonth AW. Iatrogenic nerve injury with the Russell-Taylor humeral nail. Injury 2003; 34(3):227-8.
9. Boldin C, Fankhauser F, Hofer HP, Szyszkowitz R. Three-year results of proximal tibia fractures treated with the LISS. Clin Orthop Relat Res 2006; 445:222-9.
10. Bråten M, Terjesen T, Rossvoll I. Torsional deformity after intramedullary nailing of femoral shaft fractures. Measurement of anteversion angles in 110 patients. J Bone Joint Surg Br 1993; 75(5):799-803.
11. Buttaro MA, Farfalli G, Paredes Núñez M, Comba F, Piccaluga F. Locking compression plate fixation of Vancouver typeB1 periprosthetic femoral fractures. J Bone Joint Surg Am 2007; 89(9):1964-9.
12. Camden P, Nade S. Fracture bracing the humerus. Injury 1992; 23(4):245-8.
13. Catalano LW 3rd, Cole RJ, Gelberman RH, Evanoff BA, Gilula LA, Borrelli J Jr. Displaced intra-articular fractures of the distal aspect of the radius. Long-term results in young adults after open reduction and internal fixation. J Bone Joint Surg Am 1997;79(9):1290-302.
14. Chen F, Mont MA, Bachner RS. Management of ipsilateral supracondylar femur fractures following total knee arthroplasty. J Arthroplasty 1994; 9(5):521-6.
15. Citak M, Kendoff D, Gardner MJ, Oszwald M, O'Loughlin PF, Olivier LC, Krettek C, Hüfner T, Citak M. Rotational stability of femoral osteosynthesis in femoral fractures - navigated measurements. Technol Health Care 2009; 17(1):25-32.
16. Clark WA. History of fracture treatment up to the sixteenth century. J Bone Joint Surg Am 1937; 19:47-63.
17. Cole PA, Zlowodzki M, Kregor PJ. Treatment of proximal tibia fractures using the less invasive stabilization system: surgical experience and early clinical results in 77 fractures. J Orthop Trauma 2004; 18(8):528- 35.
18. Cooney WP 3, Linscheid RL, Dobyns JH. External pin fixation for unstable Colles' fractures. J Bone Joint Surg Am 1979; 61(6A):840-5.
19. Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal humeral fractures. Acta Orthop Scand 2001; 72:365-71.
20. Dabezies EJ, Banta CJ 2nd, Murphy CP, d'Ambrosia RD. Plate fixation of the humeral shaft for acute fractures, with and without radial nerve injuries. J Orthop Trauma 1992; 6(1):10-3.
21. Dennis DA. Periprosthetic fractures following total knee arthroplasty. Instr Course Lect 2001; 50:379-89.
22. Edwards GS Jr. Intra-articular fractures of the distal part of the radius treated with the small AO external fixator. J Bone Joint Surg Am 1991; 73(8):1241-50.
23. Edwards SL, Wilson NA, Zhang LQ, Flores S, Merk BR. Two-part surgical neck fractures of the proximal part of the humerus. A biomechanical evaluation of two fixation techniques. J Bone Joint Surg Am 2006; 88(10):2258-64.
24. Eggers GWN, Shindler TO, Pomerat CM. The Influence of the Contact-Compression Factor on Osteogenesis in Surgical Fractures. J Bone and Joint Surg 1949; 31A:693-716.
25. Egol KA, Su E, Tejwani NC, Sims SH, Kummer FJ, Koval KJ. Treatment of complex tibial plateau fractures using the less invasive stabilization system plate: clinical experience and a laboratory comparison with double plating. J Trauma 2004; 57(2):340-6.
26. Ehlinger M, Adam P, Moser T, Delpin D, Bonnomet F. Type C periprosthetic fractures treated with locking plate fixation with a mean follow up of 2.5 years.Orthop Traumatol Surg Res 2010; 96(1):44-8.
27. Ehlinger M, Adam P, Abane L, Rahme M, Moor BK, Arlettaz Y, Bonnomet F. Treatment of periprosthetic femoral fractures of the kneeKnee Surg Sports Traumatol Arthrosc 2011; 19(9):1473-8.
28. Ehlinger M, Adam P, Di Marco A, Arlettaz Y, Moor BK, Bonnomet F. Periprosthetic femoral fractures treated by locked plating: feasibility assessment of the mini-invasive surgical option. A prospective series of 36 fractures. Orthop Traumatol Surg Res 2011; 97(6):622-8.
29. Erhardt JB, Roderer G, Grob K, Forster TN, Stoffel K, Kuster MS. Early results in the treatment of proximal humeral fractures with a polyaxial locking plate. Arch Orthop Trauma Surg 2009; 129(10):1367-74.
30. Farragos AF, Schemitsch EH, McKee MD. Complications of intramedullary nailing for fractures of the humeral shaft: a review. J Orthop Trauma 1999; 13(4):258-67.
31. Fenichel I, Oran A, Burstein G, Perry Pritsch M. Percutaneous pinning using threaded pins as a treatment option for unstable two- and three- part fractures of the proximal humerus: a retrospective study. Int Orthop 2006; 30(3):153-7.
32. Fritz T, Wersching D, Klavora R, Krieglstein C, Friedl W. Combined Kirschner wire fixation in the treatment of Colles fracture. A prospective, controlled trial. Archives of orthopaedic and trauma surgery 1999; 119(3- 4):171-8.
33. Füchtmeier B, May R, Hente R, Maghsudi M, Völk M, Hammer J, Nerlich M, Prantl L. Proximal humerus fractures: a comparative biomechanical analysis of intra and extramedullary implants. Arch Orthop Trauma Surg 2007; 127(6):441-7.
34. Gosling T, Schandelmaier P, Muller M, Hankemeier S, Wagner M, Krettek C. Single lateral locked screw plating of bicondylar tibial plateau fractures. Clin Orthop Relat Res 2005; 439: 207-14.
35. Hakimi M, Jungbluth P, Windolf J, Wild M. Functional results and complications following locking palmar plating on the distal radius: a retrospective study. J Hand Surg Eur 2010; 35(4):283-8.
36. Hasenboehler E, Rikli D, Babst R. Locked compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture: a retrospective study of 32 patients. Injury 2007; 38(3):365-70.
37. Hazarika S, Chakravarthy J, Cooper J. Minimally invasive locking plate osteosynthesis for fractures of the distal tibia-- results in 20 patients. Injury 2006; 37(9):877- 87.
38. Helfet DL, Hotchkiss RN. Internal fixation of the distal humerus: a biomechanical comparison of methods.J Orthop Trauma 1990; 4(3):260-4.
39. Jiang R, Luo CF, Wang MC, Yang TY, Zeng BF. A comparative study of Less Invasive Stabilization System (LISS) fixation and twoincision double plating for the treatment of bicondylar tibial plateau fractures. Knee 2008; 15(2):139-43.
40. Joveniaux P, Ohl X, Harisboure A, Berrichi A, Labatut L, Simon P, Mainard D, Vix N, Dehoux E. Distal tibia fractures: management and complications of 101 cases. Int Orthop 2010; 34(4):583-8.
41. Kapoor H, Agarwal A, Dhaon BK. Displaced intra-articular fractures of distal radius: a comparative evaluation of results following closed reduction, external fixation and open reduction with internal fixation.Injury 2000; 31(2):75-9.
42. Kayali C, A?u? H, Eren A, Ozlük S. How should open tibia fractures be treated? A retrospective comparative study between intramedullary nailing and biologic plating.Ulus Travma Acil Cerrahi Derg 2009; 15(3):243-8.
43. Keener JD, Parsons BO, Flatow EL, Rogers K, Williams GR, Galatz LM. Outcomes after percutaneous reduction and fixation of proximal humeral fractures. J Shoulder Elbow Surg 2007; 16(3):330-8.
44. Kobbe P, Klemm R, Reilmann H, Hockertz TJ. Less invasive stabilisation system (LISS) for the treatment of periprosthetic femoral fractures: a 3-year follow-up. Injury 2008; 39(4):472-9.
45. Kralinger F, Gschwentner M, Wambacher M, Smekal V, Haid C. Proximal humeral fractures: what is semi-rigid? Biomechanical properties of semi-rigid implants, a biomechanical cadaver based evaluation. Arch Orthop Trauma Surg 2008; 128(2):205-10.
46. Kregor PJ, Hughes JL, Cole PA. Fixation of distal femoral fractures above total knee arthroplasty utilizing the Less Invasive Stabilization System (L.I.S.S.). Injury 2001; 32(3):64-75.
47. Kubiak EN, Fulkerson E, Strauss E, Egol KA. The evolution of locked plates. J Bone Joint Surg Am 2006; 88 Suppl 4:189-200.
48. Lam SW, Teraa M, Leenen LP, van der Heijden GJ. Systematic review shows lowered risk of nonunion after reamed nailing in patients with closed tibial shaft fractures. Injury 2010; 41(7):671-5.
49. Lambotte MA. Technique and indications of the prosthesis into the lost treatment of fractures. Presse med 1909; 17:321-323.
50. Mallina R, Kanakaris NK, Giannoudis PV. Peri-articular fractures of the knee: An update on current issues. Knee 2010; 17(3):181-6.
51. Neer CS 2nd, Grantham SA, Shelton ML. Supracondylar fracture of the adult femur. A study of one hundred and ten cases. J Bone Joint Surg 1967; 49(4):591-613.
52. Orbay J. Volar plate fixation of distal radius fractures. Hand Clin 2005; 21(3):427-41.
53. Perren SM, Schlegel U. Surgical aspects of implants and infection: the effect of material, design and application on resistance to local infection. Nova Acta Leopoldina 2001; 84:65- 73.
54. Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br 2002; 84(8):1093-110.
55. Perren SM. Backgrounds of the technology of internal fixators. Injury 2003; 34(2):1-3.
56. Phisitkul P, McKinley TO, Nepola JV, Marsh JL. Complications of locking plate fixation in complex proximal tibia injuries. J Orthop Trauma 2007; 21(2):83-91.
57. Rizzo M, Katt BA, Carothers JT. Comparison of locked volar plating versus pinning and external fixation in the treatment of unstable intraarticular distal radius fractures. Hand (N Y) 2008; 3(2):111-7.
58. Sarmiento A, Kinman PB, Galvin EG, Schmitt RH, Phillips JG. Functional bracing of fractures of the shaft of the humerus. J Bone Joint Surg Am 1977;
59(5):596-601. 59. Schatzker J, Home G, Waddell J. The Toronto experience with the supracondylar fracture of the femur. Injury 1974; 6(2):113-28.
60. Schütz M, Müller M, Krettek C, Höntzsch D, Regazzoni P, Ganz R, Haas N. Minimally invasive fracture stabilization of distal femoral fractures with the LISS: a prospective multicenter study. Results of a clinical study with special emphasis on difficult cases. Injury 2001; 32( 3):48-54.
61. Smith TO, Hedges C, MacNair R, Schankat K, Wimhurst JA. The clinical and radiological outcomes of the LISS plate for distal femoral fractures: A systematic review. Injury 2009; 40(10):1049-63.
62. Strohm PC, Müller CA, Boll T, Pfister U. Two procedures for Kirschner wire osteosynthesis of distal radial fractures. A randomized trial. J Bone Joint Surg Am 2004; 86-A(12):2621-8.
63. Südkamp N, Bayer J, Hepp P, Voigt C, Oestern H, Kääb M, Luo C, Plecko M, Wendt K, Köstler W, Konrad G. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J Bone Joint Surg Am 2009; 91(6):1320-8.
64. Syed AA, Agarwal M, Giannoudis PV, Matthews SJE, Smith RM. Distal femoral fractures: long-term outcome following stabilisation with the LISS. Injury 2004; 35(6):599-607.
65. Thanasas C, Kontakis G, Angoules A, Limb D, Giannoudis P. Treatment of proximal humerus fractures with locking plates: a systematic review. J Shoulder Elbow Surg 2009; 18(6):837-44.
66. Theivendran K, Duggan PJ, Deshmukh SC. Surgical treatment of complex distal humeral fractures: functional outcome after internal fixation using precontoured anatomic plates. J Shoulder Elbow Surg 2010; 19(4):524-32.
67. Väistö O, Toivanen J, Kannus P, Järvinen M. Anterior knee pain after intramedullary nailing of fractures of the tibial shaft: an eight-year follow- up of a prospective, randomized study comparing two different nail-insertion techniques. J Trauma 2008; 64(6):1511-6.
68. Wood GC, Naudie DR, McAuley J, McCalden RW. Locking compression plates for the treatment of periprosthetic femoral fractures around well-fixed total hip and knee implants. J Arthroplasty 2011; 26(6):886-92.
69. Xue H, Tu Y, Cai M, Yang A. Locking compression plate and cerclage band for type B1 periprosthetic femoral fractures preliminary results at average 30-month follow-up. J Arthroplasty 2011; 26(3): 467- 471.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524161EnglishN-0001November30HealthcareA POSTMORTEM STUDY ON THE WEIGHT AND MORPHOLOGY OF ADRENAL GLANDS IN VICTIMS OF SUICIDE
English2127Arpita SarkarEnglish Manjari ChatterjeeEnglish Suddhodhan BatabyalEnglishObjective: Stress plays an important role in affecting adrenal gland anatomy and structure which may have connection with suicidal behaviour in depressed patients. The increase in adrenal cortical function is paralleled by increased adrenal weight and zone specific cortical width. Method: Adrenal glands from persons aged 20-85 years who died unexpectedly either from road traffic accident or committed suicide and died immediately, were obtained from mortuary of Medical college and Hospital, Kolkata, within 48 hours of death and without any gross sign of putrefaction. After overnight fixation, the adrenals were carefully cleaned of adherent fat, blotted dry, weighed on electronic weighing machine having the accuracy of ± 0.1gram. After proper fixation, paraffin blocks were prepared, sectioned and stained with haematoxylin and eosin. Widths of cortical zones were measured by means of a calibrated eyepiece micrometer under light microscope. Result: The weight of right and left, both adrenal glands are significantly higher for suicide group than the control group. The width of zona fasciculata of right and left, both adrenal glands are significantly higher for suicide group than the accident group. The total cortical width of right and left, both adrenal glands are significantly higher for suicide group than the accident group. Conclusion: Increased weight of adrenal glands in suicide victims is mainly due cortical hypertrophy with increased width of zona fasciculata.
EnglishAdrenal gland, suicide, weight, width of zona fasciculata, cortical widthINTRODUCTION
Suicide has taken lives around the world and across the centuries. It is one of the world’s largest public health problems and has multiple causes among which mood disorders contribute over 90% of suicide attempt and 60% of completed suicides (15). In India, 127151 and 134599 persons ended their life by a suicidal act in 2009 and 2010 respectively. This indicates an increase of 5.9% over the previous year's figure. West Bengal reported the highest number of suicidal deaths in 2008, and the second highest number of such deaths in 2010 accounting for 11.9%, while 11.4% of total such deaths in the country in 2009. (Source: National Crime Records Bureau, Accidental deaths and suicides in India, Ministry of Home Affairs, New Delhi, Government of India, 2010). Studies have shown that stress plays an important role in affecting adrenal gland anatomy and structure. In particular, adrenal gland size has been shown to be partially regulated by adrenocorticotropic hormone (ACTH) stimulation (3), which is known to regulate stress corticosterone levels during the hypothalamopituitary-adrenal (HPA) axis activation due to an acute physical or psychological stressor (26) . Elevated plasma cortisol levels and adrenal enlargement have been found individuals suffering from chronic stress, such as depressed patients (1, 17), and increases in adrenal weight have been found in individuals who have committed suicide (9, 11, 27). During acute stress, the elevated levels of corticosteroids induce a negative feedback loop to the pituitary gland, where they bind to glucocorticoid receptors to regulate the responsiveness of the stress system (6, 7). Chronic stress can lead to hypercortisolism or constant high levels of circulating glucocorticoids and dysregulation of the HPA axis, which can further affect the regulation of corticotropin-releasing hormone, catecholamines, and serotonin that are associated with the precipitation of depression (5, 8) . Previous studies showed that many patients with depression have increased basal plasma cortisol and enlarged adrenals (1, 4, 9, 10, 18, 19, 22, 27) . Depression is a chronic stress-related disorder and it is one of the most common causes of suicide. Many depressed patients have altered HPA axis function that is generally characterized by increased HPA axis activity (4, 19, 22) and enlarged adrenal glands (1, 9, 11, 24, 27) . Many studies showed that this increase in adrenal weight is associated with increased size of the adrenal cortex (27, 29) , and many depressed patients have exaggerated cortisol responses after ACTH administration (1, 13, 14) . Furthermore, increased glucocorticoid levels have been linked with the onset and severity of depression (6, 12) , suggesting that alterations in peripheral HPA axis structure and function may also be clinically relevant. Collectively, these works suggest that chronic stress-induced adrenal growth produces alterations in adrenal function that may have connection with suicidal behaviour in depressed patients (28) . The present work addresses the hypothesis that adrenal responses to ACTH are augmented after chronic stress and that this increased responsiveness is associated with increased weight and cortical hypertrophy and hyperplasia of adrenal glands.
MATERIAL AND METHOD
A cross-sectional descriptive type of study was designed and done in the Department of Anatomy, Kolkata Medical College, Kolkata, from April 2011 to October 2012, based on collection of human adrenal glands from 100 dead bodies that were under examination in the Department of Forensic Medicine, Kolkata Medical College, Kolkata from April 2011 to October 2012. This study was approved by the Ethical Review Committee of Kolkata Medical College, Kolkata. Both adrenal glands from persons aged 20-85 years who died unexpectedly either from road traffic accident or committed suicide and died immediately, were obtained from mortuary of Medical college and Hospital, Kolkata. All samples were collected within 48 hours of death and without any gross sign of putrefaction 24. We tried our best to exclude the cases of known adrenal abnormalities, chronic debilitating illness, or recent use of substances that might alter the hypothalamic-pituitary-adrenal axis function such as corticosteroids, antidepressants, and alcohol. After considering the inclusion and exclusion criteria, 100 adrenal glands were selected from victims of suicide who died immediately after hanging (Case) and 100 more adrenal glands were collected from victims of road traffic accident, died immediately on the spot of accident (Control). Among the 50 cases, 35 were males, 15females and among the 50 controls 36 were males and 14 females. The adrenal glands were removed and immediately placed in 10 % formal saline. After overnight fixation, the adrenal glands were carefully cleaned of adherent fat, blotted dry, weighed on electronic weighing machine having the accuracy of ± 0.1gram. Fixed weight does not differ significantly from fresh weight (2, 17, 23) . After a week fixation, paraffin blocks were prepared. Two to four blocks from each adrenal pair were selected for light microscopic examination and sectioned at 6micron. Sections were stained with haematoxylin and eosin (H and E). Widths of cortical zones were measured in each gland by means of a calibrated eyepiece micrometer. Ten measurements of the width of three cortical zones, the zona glomerulosa, the fasciculata, and the zona reticularis were made from each gland. The criteria by which the zones were defined were that the zona glomerulosa lies under the capsule and consists of patchy nests of cells with deeply staining nuclei, the zona fasciculata consists of parallel columns of cells with pale vacuolated cytoplasm surrounded by narrow sinusoids, and the zona reticularis consists of an irregular pattern of groups of deeply stained cells 16. Precautions observed in the choice of the parts of the sections from which the data were obtained were that they were always at right angles to the surface of the gland, and that infoldings of the gland were avoided because it was observed that the cortex appeared to be distorted and to be thicker in the folds than elsewhere 16. The slides having any adrenal pathology were also excluded from our study after confirmation from pathologists of the Department of Pathology, Kolkata Medical College, Kolkata. The obtained data was subjected to extensive analysis using Microsoft Office and S.P.S.S 16.0 version of software. Comparison of parameters between cases and controls was done by Student –t test.
RESULT
Among the 50 cases, 35 were males, 15 females and among the 50 controls 36 were males and 14 females. The right adrenal gland mean weight for suicide group was 9.57 grams and for control group was 6.64 grams, and left adrenal gland mean weight for suicide group was 10.06 grams and for control group was 7.13 grams. The mean± standard deviation (SD) weight of right and left, both adrenal glands were significantly higher for suicide group than the control group. The width mean of zona fasciculata of right adrenal gland for suicide group was 0.74 mm. and for control group was 0.57 mm. and that of left adrenal gland for suicide group was 0.77 mm. and control group was 0.61 mm. The mean±SD width of zona fasciculata of right and left, both adrenal glands were significantly higher for suicide group than the control group. The total cortical width (mean±SD) of right adrenal gland for suicide group was 0.98±0.070 mm. and for control group was 0.80±0.084 mm. and that of left adrenal gland for suicide group was 1.03±0.132 mm. and control group was 0.86±0.079 mm. The total cortical width (mean±SD) of right and left, both adrenal glands were significantly higher for suicide group than the control group. There was no significant difference in width of zona glomerulosa and zona reticularis between suicide group and the control group (p value >0.05, t test for unequal variance, two-tailed). The enlargement of cortex was mainly restricted to the zona fasciculata. [Table-1]
DISCUSSION
in our study we found that the adrenal weight, width of zona fasciculata, total cortical width were significantly higher for suicide group than the control group. Our findings support the findings of the earlier literatures regarding increased adrenal gland weight and altered adrenal morphology in suicide victims. Dorovini-Zis K, Zis AP (1987) had done a study on increased adrenal weight in victims of violent suicide among Canadian population, and adrenal gland weight was significantly higher in victims of violent suicide than who died suddenly from other cause. The mean±SD combined weight of both adrenal glands was significantly higher for the suicide group (9.77±1.74 g) than for the control group (7.74±0.82g) [p6 g/m2 may be a morphologic sign of a depressive disorder prior to death if no other disease with a known effect on the adrenals is present. A study done at University of Duesseldorf, Germany by Willenberg et al. (1998), on morphological changes in adrenals from victims of suicide. They found a significant enlargement of the adrenal cortex to 158.8% (SD = 29.8%, p < 0.01) that was restricted to the two inner zones only (zona reticularis, 161.6 +/- 35.3%; zona fasciculata, 186.4 +/- 34.4%). Szigethy E et al. (1994) had done a study on ‘Adrenal weight and morphology in victims of completed suicide’ and their results showed a positive correlation between adrenal weight and total cortical thickness in both left and right glands, providing direct evidence that increased adrenal weight in suicide victims is due to cortical hypertrophy. A study done at University of Duesseldorf, Germany by Willenberg et al. (1998), on morphological changes in adrenals from victims of suicide. They found a significant enlargement of the adrenal cortex to 158.8% (SD = 29.8%, p < 0.01) that was restricted to the two inner zones only (zona reticularis, 161.6 +/- 35.3%; zona fasciculata, 186.4 +/- 34.4%). A Computed Tomographic study on adrenal gland enlargement in major depression done by Nemeroff et al.(1994), showed that adrenal volumes in the depressed patients were significantly increased when compared with those of normal controls. Rubin et al. done a study on Adrenal gland volume in major depression: relationship to basal and stimulated pituitary-adrenal cortical axis function. Their study revealed that mean adrenal volume in the depressives was significantly larger, by about 38%, than the adrenal volume of their matched controls 21 . According to us it was very difficult to obtain an intact whole adrenal gland from post-mortem subjects. Many samples were rejected due to putrefactive changes as adrenal gland is one of the organs which undergo putrefaction very early. Weied our best to collect the samples within 48 hours of death and without any gross sign of putrefaction. We also tried to collect the past history of any depression or other mental diseases, any other chronic systemic diseases, history of prolonged intake of steroids or alcohol which might alter the hypothalamic-pituitary-adrenal axis function. But the information in many cases was not complete or reliable enough to warrant a statement regarding the presence and duration of specific psychiatric syndromes before the suicide. Considering that none of our subjects was suffering from a severe, protracted, or debilitating physical ailment at the time of death, we also assume that the observed increase in adrenal weight in our suicide group is largely accounted for by the pre-existing psychiatric disorders.
CONCLUSION
From above discussion we can conclude that depressed patients, who had committed suicide, have increased size of adrenal glands and this increased weight is due to hypertrophy of adrenal cortex which is evident by increased width of zona fasciculata.
ACKNOWLEDGEMENT
The authors of this article acknowledge the inspiration and help received from the scholars whose articles have been cited in the reference section. The authors pay their gratitude to authors/editors/publishers of all those /journals/books from where the reviews and literatures for the discussion have been collected.
Englishhttp://ijcrr.com/abstract.php?article_id=974http://ijcrr.com/article_html.php?did=974REFERENCES
1. Amsterdam, J.D. et al. (1987). Assessment of adrenal gland volume by computed tomography in depressed patients and healthy volunteers: A pilot study. Psychiatry Res., 21: 189-197
2. Beattie, M. K. and Heasman, M. A. (1958): The pituitary and adrenal glands of elderly mental hospital patients with and without hypertension. J. Path. Bact., 75, 83-94.
3. Bransome, Jr, E.D. (1968). Regulation of adrenal growth. Differences in the effects of ACTH in normal and dexamethasonesuppressed guinea pigs. Endocrinology, 83: 956-964.
4. Carroll BJ, Curtis GC, and Mendels J. (1976). Neuroendocrine regulation in depression. II. Discrimination of depressed from nondepressed patients. Arch Gen Psychiatry 33: 1051–1058.
5. Chrousos, G.P. (1998). Stressors, stress, and neuroendocrine integration of the adaptive response. The 1997 Hans Selye Memorial Lecture. Ann. N.Y. Acad. Sci., 851: 311-335.
6. De Kloet, E.R. et al. (1998). Brain corticosteroid receptor balance in health and disease. Endocrine Rev., 19: 269-301.
7. De Kloet, E.R., Joëls, M., and Holsboer, F. (2005). Stress and the brain: From adaptation to disease. Nat. Rev. Neurosci., 6: 463-475.
8. De Rijk, R.H. et al. (2008). Corticosteroid receptor-gene variants: Modulators of the stress-response and implications for mental health. European Journal of Pharmacology, 585: 492-501.
9. Dorovini-Zis K, Zis AP. (1987) Increased adrenal weight in victims of violent suicide. Am J Psychiatry;144:1214-1215.
10. Dorovini-Zis K, Barocka A, Schubert E.(1998). Weight of adrenal glands may be increased in persons who commit suicide. Am J Forensic Med Pathol;19:72-76.
11. Dumser, Thomas; Barocka, Arndt; Schubert, Evelyn (March 1998) - Weight of Adrenal Glands May Be Increased in Persons Who Commit Suicide - American Journal of Forensic Medicine and Pathology: - Volume 19 - Issue 1 - pp 72-76
12. Gibbons JL. (1964) Cortisol secretion rate in depressive illness. Arch Gen Psychiatry 10: 572–575.
13. Jaeckle RS, et al. (1987). Enhanced adrenal sensitivity to exogenous cosyntropin (ACTH alpha 1–24) stimulation in major depression. Relationship to dexamethasone suppression test results. Arch Gen Psychiatry 44: 233– 240.
14. Kalin NH, et al. (1987). Function of the adrenal cortex in patients with major depression. Psychiatry Res 22: 117–125.
15. M. Pompili et al. "The hypothalamicpituitary-adrenal axis and serotonin abnormalities: a selective overview for the implications of suicide prevention."European archives of psychiatry and clinical neuroscience 260.8 (2010): 583-600.
16. Mackinnon, P. C. B., and I. L. Mackinnon. "Morphologic features of the human suprarenal cortex in men aged 20-86 years." Journal of Anatomy 94, no. Pt 2 (1960): 183.
17. Nelson A. Gelfman.(1964). Morphological change of adrenal cortex in disease; Yale journal of biology and medicine, Volume 37, August, 1964
18. Nemeroff CB, et al. (1992). Adrenal gland enlargement in major depression; a computed tomographic study. Arch Gen Psychiatry. 1992;49:384-387.
19. Rubin RT, et al. (1987). Neuroendocrine aspects of primary endogenous depression. I. Cortisol secretory dynamics in patients and matched controls. Arch Gen Psychiatry 44: 328–336.
20. Rubin RT, et al. (1995). Adrenal gland volume in major depression. Increase during the depressive episode and decrease with successful treatment. - Arch Gen Psychiatry. 1995 Mar;52(3):213-8.
21. Rubin RT, et al. (1996). Adrenal gland volume in major depression: relationship to basal and stimulated pituitary-adrenal cortical axis function. - Biol Psychiatry. 1996 Jul 15;40(2):89-97.
22. Sachar EJ, (1973). Disrupted 24-hour patterns of cortisol secretion in psychotic depression. Arch Gen Psychiatry 28: 19–24.
23. Sarason, E. L.(1943): Adrenal cortex in systemic disease. Arch. intern. Med., 1943, 71, 702-712.
24. Siddiqua, Dilruba, Shamim Ara, Abu Sadat Mohammad Nurunnabi, Rukshana Ahmed, and Ara Parven Hosne. "A postmortem study on the weight of the human adrenal glands." Bangladesh Journal of Medical Science 9, no. 4 (2010): 204-207.
25. Stein E,(1993). Adrenal gland weight and suicide. - Can J Psychiatry. 1993 Oct;38(8):563-6.
26. Solberg, L.C., et al. (2006). Genetic analysis of the stress-responsive adrenocortical axis. Physiol. Genomics, 27: 362-369.
27. Szigethy E, et al. (1994). Adrenal weight and morphology in victims of completed suicide. Biol Psychiatry.36:374-380.
28. Ulrich-Lai YM, et al. (2006). Chronic stress induces adrenal hyperplasia and hypertrophy in a subregion-specific manner. American Journal of Physiology - Endocrinology and Metabolis,Published 1 November 2006Vol. 291no. E965-E973
29. Willenberg HS, et al.(1998). Morphological changes in adrenals from victims of suicide in relation to altered apoptosis. Endocr Res 24: 963–967.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524161EnglishN-0001November30HealthcareASSESSMENT OF METAL CONTENT IN LEAFY VEGETABLES SOLD IN MARKETS OF LIBREVILLE, GABON
English2833 Roger Ondo NdongEnglish Armelle Lyvane Ntsame AffaneEnglish Hugues Martial OmandaEnglish Philippe Padoue NzienguiEnglish Richard Menye BiyogoEnglish Jean Aubin OndoEnglishAime-Jhustelin Abogo MebaleEnglishThe rate of urbanization in developing countries imposes to develop standards for efficient food security. This study was conducted in 2013 in Libreville, Gabon to evaluate the metal concentration in three leafy vegetables commonly consumed in West Africa. Amaranthus cruentus (Amaranth), Hibiscus sabdariffa (Roselle) and Manihot esculentus (Cassava) were sampled in seven markets of Libreville (Gabon) and analyzed for their concentration in Al, Ca, Fe, K, Mg and P using ICP-AES. The concentration ranges found were 11-173 mg/kg, 5897-24911 mg/kg, 135-1220 mg/kg, 1531-9728 mg/kg, 1470-7146 mg/kg and 186-1277 mg/kg for Al, Ca, Fe, K, Mg and P, respectively. These results indicated that amongst the leafy vegetables studied, Amaranthus cruentus was the best source of nutrients (Ca, Fe, K, Mg and P). However concerns could be raised for the some high aluminum content found in these leafy vegetables which may be detrimental to human and animal health.
Englishleafy vegetables, nutrients, aluminum, daily intake, target hazard quotient.INTRODUCTION
Population growth forecasts for year 2030 indicate that the world population will increase and reach 9 billion inhabitants. This growth will particularly occur in the urban areas of developing countries, creating a situation of exploding alimentary needs. In response to this considerable challenge, urban agriculture, which was almost insignificant thirty years ago, has developed in cities and has reached a phase of rapid expansion in developing countries. Therefore, it is important to assess the nutritional quality of cultivated vegetables (Ondo et al., 2013). The consumption of vegetable and fruits has increased through urban agriculture, which provides fresh produces throughout the year (Kawashima and Soares, 2003). This has led to improve and balance people’s diets since fresh produces represent important source of proteins, vitamins and minerals for humans (Akbar et al., 2010). Indeed, humans require more than 22 mineral elements, all of which can be supplied by an appropriate diet. Each mineral has a particular function within the body. For example, calcium (Ca) functions as a constituent of bones and teeth, regulation of nerve and muscle function. Calcium absorption requires calcium-binding proteins and is regulated by vitamin D, sunlight, parathyroid hormone and thyrocalcitonin. Growing, pregnant and especially lactating humans and animals require liberal amounts of calcium (Soetan et al., 2010). Phosphorus (P) is located in every cell of the body. It functions as a constituent of bones, teeth, adenosine triphosphate (ATP), phosphorylated metabolic intermediates and nucleic acids. Practically, every form of energy exchange inside living cells involve the forming or breaking of high-energy bonds that link oxides of phosphorus to carbon or to carbon-nitrogen compounds (Soetan et al., 2010; Murray et al., 2000). Potassium (K) is the principal cation in intracellular fluid and functions in acid-base balance, regulation of osmotic pressure, conduction of nerve impulse, muscle contraction particularly the cardiac muscle, cell membrane function and Na+/K+-ATPase. Plant products contain many times as much potassium as sodium. Sources include vegetables, fruits, nuts (Soetan et al., 2010). Magnesium (Mg) is an active component of several enzyme systems in which thymine pyrophosphate is a cofactor. Approximately one-third to one-half of dietary magnesium is absorbed into the body (Murray et al., 2000). Iron (Fe) functions as haemoglobin in the transport of oxygen. In cellular respiration, it functions as essential component of enzymes involved in biological oxidation. Brain is quite sensitive to dietary iron depletion and uses a host of mechanisms to regulate iron flux homostatically (Batra and Seth, 2002). For example, excessive accumulation of iron in human tissues causes haemosiderosis (Akpabio et al., 2012; Murray et al., 2000). Sources of iron include red meat, spleen, heart, liver, kidney, fish, egg yolk, nuts, legumes, molasses, iron cooking ware, dark green leafy vegetables. Aluminum (Al) is the third most abundant element in the earth’s crust. Increased aluminum exposure has the potential to cause a number of health problems such as anemia and other blood disorders, colic, fatigue, dental caries, dementia dialactica, kidney and liver dysfunctions, neuromuscular disorders, osteomalacia and Parkinson’s disease (Lokeshappa et al., 2012). Thus, due to the multiple roles of metals and their importance in human’s diet, the main objective of the present work is to evaluate the metal and nutrient composition of commonly consumed leafy vegetables sold in marketplaces of Libreville.
MATERIALS AND METHODS
Collection of samples, sample preparation and treatment:
This study was conducted in Libreville, capital of Gabon (9°25’ east longitude and 0°27’ north latitude). The climate is equatorial type. The annual rainfall varies from 1,600 to 1,800 mm. Average temperatures oscillate between 25 and 28°C with minima (18°C) in July and maxima (35°C) in April. Three types of leafy vegetables were randomly purchased in seven markets of Libreville, which were the markets of Okala, Nkembo, Owendo, PK8, Akébé, NzengAyong and Mont-Bouet. The leafy vegetables bought were amaranth (Amaranthus cruentus), roselle (Hibiscus sabdariffa) and cassava (Manihot esculenta). The vegetables were brought to the laboratory where they were washed with distilled water to remove dust particles. Then, after separating the leaves from the other parts of plants with a knife. these latter were air-dried, then oven-dried at 70?C. Dried leaves samples were ground into a fine powder using a mill of IKA A10 type, thereafter stored in polyethylene bags kept at room temperature. 500 mg of plant samples were digested at 150°C for 1 hour in a microwave mineralizer, using a mixture of nitric acid, hydrogen peroxide and ultra-pure water with a volume proportion ratio of 2:1:1 (Nardi et al., 2009). Each mineralization product was filtered through a 0.45-μM filter (PTFE, from Millipore, Massachusetts, USA) and the metal concentrations determined by the ICPAES method (Activa M model, JobinYvon, France). Daily intake of metals (DIM): The estimated daily intake (DIM) of Al, Ca, Mg, Fe, K and P through vegetable consumption was calculated as: DIM=[M]×K×I where [M] is the heavy metal concentration in the plant (mg/kg), K is the conversion factor used to convert fresh part consumed plant weight to dry weight, estimated as 0.085, and I is the daily intake of consumed plant, estimated as 0.255 kg/day per adult. Target hazard quotient (THQ): The health risks to local inhabitants from consumption of vegetables were assessed based on the THQ, which is the ratio of a determined dose of a pollutant to a reference dose level. As a rule, the greater the value of the THQ is above unity, the greater the level of concern is high. The method of estimating risk using the THQ is based on the equation THQ = [(EFr × ED × FI × MC) / (RfD × BW × AT)] × 0.001 where EFr is exposure frequency (365 days/year), ED is exposure duration (60 years for adults), FI is food ingestion, MC is the metal concentration in the food (mg/kg fresh weight), RfD is the oral reference dose (mg/kg/day), BW is the average body weight for an adult (60 kg) and AT is the average exposure time for non carcinogenic effects (365 days/year ×number of exposure years, assuming 60 years in this study). The RfD is an estimation of the daily exposure for people that is unlikely to pose an appreciable risk of adverse health effects during a lifetime and was based on value of 0.14 mg/kg/day for Al. Statistical analysis: The significance of differences between the means of metals in leaves, the edible part of plants, was evaluated by Tukey’s test (P roselle > cassava. The lowest Ca concentration was in cassava of Mt-Bouet (5897 mg/kg) and the highest Ca concentration was in amaranth of Nzeng Ayong (24911 mg/kg). The lowest concentration was observed in cassava of Okala (135 mg/kg) and the highest concentration in amaranth of Owendo (1220 mg/kg). The mean daily intake of Ca of the leafy vegetables studied varied between 13% and 56% of the recommended dietary allowances (RDA), which confirms that consumption of leafy vegetables is of utmost of importance since horticultural crops may be secondary source of calcium in comparison to dairy products but, taken as a whole, fruits and vegetables account for almost 10% of the calcium in the food supply. The dark green leafy vegetables are potential calcium sources because of their absorbable calcium content (Titchenal and Dobbs, 2007). There was no significant difference in Fe uptake in leafy vegetables. Its concentration varied between 135 mg/kg (cassava of Mt-Bouet) and 1220 mg/kg (amaranth of Owendo market). The estimated daily intake of Fe from consumption of the leafy vegetables studied ranged between 4 to 36 mg/day. The recommended dietary allowance (RDA) of Fe is 10-18 mg/day for an adult (Dimirezen and Uruc, 2006). This value was lower than those found for the roselle bought in Okala market (146%) and amaranth of Owendo market (199%). The uptake of K, Mg and P was significantly higher in amaranth than in the other vegetables. Thus, the highest concentrations were found in amaranth of Nkembo (9728 mg/kg), amaranth of NzengAyong (7146 mg/kg) and amaranth of Nkembo (1277 mg/kg) for K, Mg and P, respectively. The lowest concentrations were found in roselle of Mt-Bouet (1531 mg/kg), roselle of Owendo (1470 mg/kg) and cassava of Mt-Bouet (186 mg/kg) for K, Mg and P, respectively. The daily intake of P and K from leafy vegetables studied is the lowest. It is always less than 6% of the RDA. Vicente et al. (2009) indicated that fruit and vegetable contribution to the total phosphorus in the US food supply was an average of 9.5%. But Potassium is the most abundant individual mineral element in vegetables. It normally varies between 600 and 6000 mg/kg of fresh tissue. Leafy green vegetables are known such as potassium-rich vegetables. The daily intake of Mg varied between 43 mg/kg and 210 mg/kg, 10% and 50% of RDA. People who eat of good quantities of green leafy vegetables, nuts, and whole grain breads and cereals ensures a sufficient intake of magnesium and are found to have higher magnesium densities than high-fat users, who consume significantly more servings of meat and higher levels of discretionary fat (Sigman-Grant et al., 2003). Generally, magnesium levels are significantly higher in vegetables than in fruits, but nuts are good sources of this nutrient.
Englishhttp://ijcrr.com/abstract.php?article_id=975http://ijcrr.com/article_html.php?did=975REFERENCES
1. Akbar JF, Ishaq M, Khan S, Ihsanullah I, Ahmad I, Shakirullah M. A comparative study of human health risks via consumption of food crops grown on wastewater irrigated soil (Peshawar) and relatively clean water irrigated soil (lower Dir). Journal of Hazardous Materials 2010; 179: 612-621.
2. Akpabio UD, Akpakpan AE, Enin GN. Evaluation of Proximate Compositions and Mineral Elements in the Star Apple Peel, Pulp and Seed. Journal of basic and applied scientific research 2012; 2: 4839-4843.
3. Batra J, Seth PK. Effect of iron deficiency on developing rat brain. Indian Journal of Clinical Biochemistry 2002; 17: 108-114.
4. Dimirezen D, Uruc K. Comparative Study of trace elements in certain fish, meat and meat products. Meat Science 2006; 74: 255–260.
5. Horbowicz M, Kowalczyk W, Grzesiuk A, Mitrus J. Uptake of aluminum and basic elements, and accumulation of anthocyanins in seedlings of common buckwheat (Fagopyrum esculentum Moench) as a result increased level of aluminum in nutrient solution. Ecological Chemistry and Engineering 2011; 18: 479- 488.
6. Jakobsen ST. Interaction between Plant Nutrients. IV. Interaction between Calcium and Phosphate. Acta Agriculturae Scandinavica Section B 1993; 43: 6–10.
7. Kawashima LM, Soares LMV. Mineral profile of raw and cooked leafy vegetables edible in Southern Brazil. Journal of Food Composition and Analysis 2003; 16: 605-611.
8. Lokeshappa B, Shivpuri K, Tripathi V, Dikshit AK. Assessment of Toxic Metals in Agricultural Produce. Food and Public Health 2012; 2: 24-29.
9. Morard P, Pujos A, Bernadac A, Bertoni G. Effect of temporary calcium deficiency on tomato growth and mineral nutrition. Journal of Plant Nutrition 1996; 19 : 115–127.
10. Murray RK, Granner DK , Mayes PA, Rodwell VW. Harper’s Biochemistry, 25th Ed. McGraw-Hill, Health Profession Division, USA; 2000.
11. Nardi EP, Evangelist ES, Tormen L, Saint´Pierre TD, Curtius AJ, de Souza SS, Barbosa Jr F. The use of inductively coupled plasma mass spectrometry (ICP-MS) for the determination of toxic and essential elements in different types of food samples. Food Chemistry 2009; 112: 727-732.
12. Ondo JA, Prudent P, Massiani C, MenyeBiyogo R, Domeizel M, Rabier J et al. Impact of urban gardening in an equatorial zone on the soil and metal transfer to vegetables. Journal of the Serbian Chemical Society 2013; 78: 1045–1053.
13. Ondo JA, Prudent P, MenyeBiyogo R, Rabier J, Eba F, Domeizel M. Translocation of metals in two leafy vegetables grown in urban gardens of Ntoum, Gabon. African Journal of Agricultural Research 2012; 7: 5621-5627.
14. Sigman-Grant M, Warland R, Hsieh G. Selected lower-fat foods positively impact nutrient quality in diets of free-living Americans. Journal of the American Dietetic Association 2003; 103: 570–576.
15. Soetan KO, Olaiya CO, Oyewole OE. The importance of mineral elements for humans, domestic animals and plants: A review. African Journal of Food Science 2010; 4: 200- 222.
16. Titchenal CA, Dobbs J. A system to assess the quality of food sources of calcium. Journal of Food Composition and Analysis 2007; 20: 717–724.
17. Vicente AR, Manganaris GA, Sozzi GO, Crisosto CH. Nutritional Quality of Fruits and Vegetables. In, Postharvest Handling: A Systems Approach, Second Edition, Elsevier, Oxford; 2009.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524161EnglishN-0001November30HealthcareMUCORMYCOSIS- AN UNUSUAL PRESENTATION
English3438Tevethia H.English Aashish A.English Manigandan G.English Sunny DANEnglish Anjay B.EnglishMucormycosis is a rare life threatening invasive fungal infection caused by fungi of order mucorales commonly rhizopus. It usually occurs in immune compromised individuals like diabetic ketoacidosis, leukemia, lymphoma, severe malnutrition, high dose corticosteroids and organ transplantation. It occurs in many forms but the most common being rhinocerebral mucormycosis. A black necrotic eschar is the hallmark of mucormycosis. Patients present with varying manifestations like multiple cranial nerve palsies, unilateral periorbital facial pain, orbital inflammation, eyelid edema, blepharoptosis, proptosis, ophthalmoplegia, headache, and acute loss of vision. Here we describe an unusual presentation of a case of rhinocerebralmucormycosis in an adult female with diabetes mellitus. The reason to present this case is because of the unusual clinical presentation, course and how we arrived at the final diagnosis of mucormycosis.
EnglishMucormycosis, eschar, diabetes mellitus, rhizopusINTRODUCTION
Mucormycosis is a rare life threatening oppurtunistic infection caused by fungi of the order mucorales. It was called as zygomycosis but recent reclassification has placed the order mucorales in the subphylum mucormycitoma and has abolished zygomycetes, hence the term mucormycosis1. Conditions that predispose to this disease include immune compromised states like diabetic ketoacidosis, neutropenia, severe malnutrition, high dose corticosteroids and organ transplantation, trauma. There are six different forms of mucormycosis, the commonest being rhinocerebral mucormycosis.2
CASE REPORT
38 year old adult female who is a known diabetic and hypertensive on irregular treatment presented to the emergency department with decreased levels of consciousness and fever for 4 days. On examination she was disoriented, febrile, blood pressure of 230/120 mm hg, tachycardia, s1 s2 normally heard, bilateral basal rales, abdominal examination was soft, no organomegaly, CNS examination showed equal but sluggishly reacting pupils bilaterally, bilateral plantar mute. Initial investigations showed leukocytosis, urine ketones positive, metabolic acidosis and CT brain was normal. Provisional diagnosis of hypertensive encephalopathy with diabetic ketoacidosis was made and patient was admitted in intensive care unit and started on intravenous fluids, intravenous insulin correction, broad spectrum antibiotics and other supportive medications.
Next morning patient condition deteriorated, her saturation dropped and she was electively intubated. On examination she had right sided plantar extensor with hypotonia was present. Urgent repeat CT scan was done which showed extensive left sided middle cerebral artery infarct(Figure 5). Diagnosis was revised to cerebrovascular accident with diabetic ketoacidosis. 48 hours after admission patient showed no improvement and she developed swelling of her left eyelid(Figure 1) and oral cavity examination showed black eschar on the hard palate(Figure 2) with bloody left sided nasal discharge. MRI brain revealed pansinusitis and excess fat accumulation around the left eyeball(Figure 4).
With high suspicion of mucormycosis nasal endoscopy was done and biopsy was taken. Histopathology of the biopsy revealed rhizopus fungi. Patient underwent urgent debridement and started on intravenous amphotericin b as per guidelines. In the following days patient GCS improved, total counts came down, blood sugar levels was under control, but patient had weakness of her right upper and lower limb with UMN facial palsy on left side due to left sided infarct.
DISCUSSION
Mucormycosis is a life threatening invasive fungal infection caused by organism of order mucorales most commonest being rhizopus1. Based on clinical presentation and the involvement of a particular anatomic site, mucormycosis can be divided into at least six clinical categories: rhinocerebral, pulmonary, cutaneous, gastrointestinal, disseminated, and miscellaneous. Rhinocerebralmucormycosis continues to be the most common form of the disease, accounting for between one-third and one-half of all cases of mucormycosis. About 70% of rhinocerebral cases are found in diabetic patients in ketoacidosis.2It develops due to inhalation of fungal sporangiospores into the paranasal sinuses. The invading fungus may spread inferiorly to invade the palate, posteriorly to invade the sphenoid sinus, laterally into the cavernous sinus to involve the orbits, or cranially to invade the brain. The fungus invades the cranium either through the orbital apex or the cribriform plate of the ethmoid bone. Sometimes vascular invasion leads to hematogenous dissemination and may or may not produce aneurysms.[3,4]
A black necrotic eschar of nasal mucosa or hard palate is the hallmark of mucormycosis.6 However, the absence of this finding should not exclude the possibility of mucormycosis. Fever, marked leukocytosis in the presence of functioning bone marrow. Signs and symptoms that suggest mucormycosis in susceptible individuals include multiple cranial nerve palsies, unilateral periorbital facial pain, orbital inflammation, eyelid edema, blepharoptosis, proptosis, ophthalmoplegia, headache, and acute vision loss. CT brain and MRI usually reveal features of sinusitis and fat accumulation in the extraocular muscles and thrombosis if there is vascular invasion.5
In our patient there was fever, leukocytosis, raised blood sugar, urine ketones positive with metabolic acidosis but patient was drowsy and disoriented, hence the usual symptoms and signs which are classical for mucormycosis couldn’t be recognized which lead the initial treatment towards hypertensive encephalopathy and diabetic ketoacidosis. Furthermore the second CT brain showed large infarct in the left middle cerebral artery territory (Figure 5), which again lead the diagnosis towards cerebrovascular accident. MRI brain revealed pansinusitis with fat accumulation in the extraocular muscles signifying infection in our case. No evidence of thrombosis or aneurysms.
Eventhough cerebrovascular accident could occur in mucormycosis by means of infarct or hemorrhage due to vascular invasion, in this patient there was no evidence of vascular invasion in the form of mycotic aneurysms or cavernous sinus thrombosis in MRI. Only because of the presence of left eyelid swelling (Figure 1), bloody nasal discharge and classical black eschar in the hard palate (Figure 2) with underlying diabetic ketoacidosis mucormycosis was suspected which was later confirmed with histopathological diagnosis.
CONCLUSION
This case highlights the devastating complications that occur in diabetes mellitus. Any immune compromised patient especially those with diabetes mellitus even with subtle symptoms or signs mucormycosis especially rhinocerebral mucormysis should be ruled out, because of its rapid invasive nature it could be life threatening and fatal . Hence due to its varied presentations early recognition and prompt treatment is necessary for better outcome and survival of the patients.
Englishhttp://ijcrr.com/abstract.php?article_id=976http://ijcrr.com/article_html.php?did=976
Hibbett DS, Binder M, Bischoff JF, et al. A higher-level phylogenetic classification of the fungi. Mycol Res 2007; 111:509 - 47.
Spellberg B, Edwards J Jr, Ibrahim A. Novel perspectives on mucormycosis: pathophysiology, presentation, and management. ClinMicrobiol Rev 2005; 18:556 - 69.
Hosseini SM, Borghei P. Rhinocerebralmucormycosis: pathways of spread. Eur Arch Otorhinolaryngol 2005; 262:932 - 8.
Terk MR, Underwood DJ, Zee CS, Colletti PM. MRI imaging in rhinocerebral and intracranial mucormycosis with CT and pathologic correlation. Magn Reson Imaging 1992; 10:81 - 7.
Petrikkos G, Skiada A, Lortholary O, Roilides.E et al. Epidemiology and Clinical Manifestations of Mucormycosis Clinical Infectious Diseases 2012;54(S1): S23 - 34
Mallis.A, Mastronikolis S.N, Naxakis S.S, Papadas A.Trhinocerebral mucormycosis: an update European Review for Medical and Pharmacological Sciences 2010; 14: 987- 992
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524161EnglishN-0001November30HealthcareFINE NEEDLE ASPIRATION (FNAC) AS A DIAGNOSTIC TOOL IN PAEDIATRIC LYMPHADENOPATHY.
English3943Heming AgrawalEnglish R.N. GonsaiEnglish Shilpa SingalEnglish H.M. GoswamiEnglishAim - This Study has been undertaken to evaluate the diagnostic role of Fine Needle Aspiration Cytology (FNAC) in paediatric lymphadenopathy. Materials and Method - 102 paediatric patients (upto 14 years of age) with Lymphadenopathy were subjected to FNAC over a period of 6 months (January 2013 to June 2013). FNAC was done as a routine procedure using 22 gauge needle with standard precautions. Smears obtained were stained with May-Grunwald-Giemsa (MGG), Papanicolaou (PAP) and Hematoxylinand Eosin (Hand E). Special stain used was Ziehl-Neelsen (ZN) for Acid Fast Bacilli (AFB). Result - In this study, out of 102 cases 56(54.9%) patients were males and 46(45.0%) patients were females. The male and female ratio was 1.22:1. Inflammatory lymphadenopathy comprised 97.05% of the total lesions of the lymph nodes. It included 66.66% cases of chronic non specific lymphedenitis, 27.45% cases of granulomatous lymphadenitis, 1.96% cases of acute suppurative lymphadenitis and 0.96% cases of Kikuchi's diseases. Malignant lesions were seen in 3(2.94%) patients. Conclusion - FNAC is a very simple and expeditious procedure which can be carried out with ease in children. The diagnostic accuracy of the cytosmears was 98.89% and the overall sensitivity and specificity were 91.3% and 99.1%, respectively so, FNAC is fairly accurate in the diagnosis of lymphadenopathy.
EnglishFine needle aspiration cytology, FNAC, paediatric, children, lymphadenopathy.NTRODUCTION
Lymphadenopathy is one of the commonest clinical presentations in paediatric patients. It is necessary to arrive at a definitive diagnosis in order to administer proper treatment in a easy, fast way. It has several aetiologies ranging from an inflammatory process to a malignant condition, thus posing diagnostic dilemma to a paediatrician. Therefore, it is necessary to arrive at a definitive diagnosis in order to administer proper treatment. The objective of this study was to evaluate the diagnostic role of fine needle aspiration cytology in lymphadenopathy in the paediatric age group. It has been shown in several studies like ours, that FNA is fairly accurate in the diagnosis of lymphadenopathy.1,2 In the last few years, FNAC has emerged as a reliable diagnostic procedure in the paediatric age group, thus obviating the need for excision biopsy3,4 .
MATERIALS AND METHODS
The study was carried out in OPD and ward patients up to 14years of age, who had palpable lymph node. The duration of study was 6 months. Lymphadenopathy was considered to be significant if the cervical group was >1.0cm and the inguinal group was >1.5cm. Detailed clinical history and general, local and systemic examination, along with routine and special investigations was taken. 102 patients weresubjected to FNAC; Histopathological examination was performed in 40 patients. Both dry and wet fixed smears were prepared in all cases and were stained by Hand E, MGG and Papanicolaou stains. Ziehl-Neelsen’s stain was used wherever indicated.
RESULT
In this study, out of 102 cases, 56(54.9%) patients were males and 46(45.0%) patients were females. The male and female ratio was 1.22:1 Generalised lymphadenopathy was defined as the enlargement of more than two non-contiguous node regions.5 In the present study, localised lymphadenopathy was seen in 99 cases (90%) and the generalised category was seen in 11 cases (10 %.). The maximum number of cases had cervical lymphadenopathy (82%), followed by involvement of the axillary (11%) and the inguinal (7%) nodes. Out of the cervical group of nodes, the upper anterior and the upper posterior deep cervical nodes were involved in a majority of cases (60.0%). The size of the nodes was measured in all the cases. The largest node which was seen had a maximum diameter of 3.5 cm. The diagnosis of 102 cases of lymphadenopathy based on cytological examination alone is shown in [Table 1]. However, Cytohistological correlation could be done in 40 cases only, as shown in [Table 2]. The cytological criteria which were adopted for classification were as follows: Inflammatory lesions
Ninety nine nodes were diagnosed as inflammatory by FNAC. They were further grouped into sub-categories.
Chronic non specific lymphedenitis and reactive hyperplasia:
The cytosmears of these cases showed a mixed population of lymphoid cells. The cytological pattern of distribution of the cells depended on whether the follicular or intrafollicular tissue was aspirated. The active germinal centre had many centrocytes and centroblasts, and sparse mature lymphocytes, plasma cells and immunoblasts. (Figure1). Interfollicular tissues have predominantly mature lymphocytes, plasma cells and immunoblasts. They were probably from cases of lymphadenopathy following viral infection
Tubercular lymphedenitis
Out of the 102 cases, 28 cases were diagnosed as Tubercular lymphadenitis (Figure 2). Some cases presented with secondary infection and in them, a course of antibiotics was advised and repeat FNAC was done. In those cases in which only caseous material was seen, repeat FNAC was advised to search for a granuloma. Acid Fast Bacilli (AFB) and only 7% cases proved to be positive. Though granulomatous response is seen in a wide variety of infectious agents and non infectious processes (both benign and malignant), as tuberculosis is so common in our country, every clinically relevant case of granulomatous lymphadenitis should be considered as tuberculous lymphadenitis, unless proved otherwise6 . Out of 10 cases which were diagnosed by cytology, 09 were confirmed by histopathology. One case where the diagnosis of tuberculosis was made on the basis of epithelioid cells, turned out to be reactive hyperplasia by histology. We had correlated all our cases of granulomatous lymphadenitis with the clinical presentation, if done Montoux test, AFB and Culture.
Acute suppurative lymphadenitis
The cytosmears showed degenerated and viable inflammatory cells, predominantly polymorphs (Figure 3). Repeat aspiration was advised after a course of antibiotic therapy.
Malignant lesions Non-Hodgkin’s Lymphoma
Monotonous population in the smear, was the most important basis for the diagnosis of non Hodgkin’s lymphoma in cytological smears. (Figure 4). In this study, one case was diagnosed correctly by FNAC. One case diagnosed by us as reactive hyperplasia turned out to be non-Hodgkin’s lymphoma. Conversely, one case which we diagnosed as non-Hodgkin’s lymphoma was reactive hyperplasia
Hodgkins lymphoma
The presence of Reed Sternberg cells was essential to diagnose Hodgkin’s lymphoma. Numerous atypical large mononuclear cells with prominent nucleoli were also seen. Besides these cells, variable numbers of plasma cells, lymphocytes, eosinophils and reactive cells were seen in the background (Figure 5). In the present study, one case was diagnosed as Hodgkin’s lymphoma by FNAC and was confirmed by histology.
DISCUSSION
This study was carried out primarily to evaluate the role of FNAC as a diagnostic tool, with it’s advantages and limitations, in paediatric lymphadenopathy. In the present study, cytological examination was done on 102 patients, but histopathological examination of the lymph nodes could be done only in 40 patients. Overall, inflammatory lymphadenopathy comprised 97.05% of the total lesions of the lymph nodes; it included 66.66% cases of reactive hyperplasia, 27.45% cases of tubercular lymphadenitis and 1.96% cases of acute suppurative lymphadenitis. Malignant lesions were seen in 2.94% of the patients. These findings are in agreement of those reported by Locham et al, who diagnosed reactive hyperplasia in 68% cases, tubercular lymphadenopathy in 29% cases and malignancy in 3% cases7 . Tripathi et al found reactive hyperplasia in 64% cases and tuberculosis and neoplasia in 4% of the patients.8 Sankaran et al also observed lymphoid hyperplasia as the most common condition in benign lesions, followed by tuberculosis.9 Jain et al reported 1.8% malignant cases in their study. 10 The overall sensitivity and specificity reported by Prasad et al were 89.2% and 100%, respectively, which matched with our findings.11
CONCLUSIONS
FNAC is a very simple and expeditious procedure which can be carried out with ease in children. The diagnostic accuracy of the cytosmears was 98.89%and the overall sensitivity and specificity were 91.3% and 99.1%, respectively so, FNAC is fairly accurate in the diagnosis of lymphadenopathy. It reduces the neccessity to perform excision biopsy in many cases, thus saving children from surgical complications. It is difficult to understand why such an effective, simple and safe diagnostic modality is so underutilised in the diagnostic workup of paediatric TB, it can be a good diagnostic tool for it in paediatric patients.
Englishhttp://ijcrr.com/abstract.php?article_id=977http://ijcrr.com/article_html.php?did=977
REFERENCES
1. Byun JC, Choe BK, Hwang JB, Kim HS, Lee SS. Diagnostic effectiveness of fine needle aspiration cytology on pediatric cervical lymphadenopathy. Korean J Pediatr 2006;49:162-6.
2. Chu EW, Hoye RC. The clinician and the cytopathologist evaluate fine needle aspiration cytology. Acta cytological.,1973; 21:413-17.
3. Handa U, Mohan. H, Bal .A. Role of fine needle aspiration cytology in evaluation of paediatric lymphadenopathy. Cytopathology. 2003:14; 66 – 69.
4. Ajmal F, Imran A. Comparison of FNAC vs excision biopsy for suspected tuberculous cervical lymphadenopathy. Annals King Edward med coll 2003; 9:216-8.
5. Bedros AA, Mann JP. Lymphadenopathy in children. Adv Pediatr 1981;28:341– 76.
6. Bari A, Wadood A, Qasim K, Fine needle aspiration cytology; evaluation in thediagnosis of lymphadenopathy in children, Professional Med J 2007; 14: 237-240.
7. Locham KK al. Lymphadenopathy in children role of FNAC. Journal of Cytology. 2002; 19:183-86.
8. Tripathi S et al. Orissa Journal of Pathology and Microbiology. 2003; 7: 34-36.
9. Sankaran V, Prasad RR, Narasimhan R, Veliath AJ. Fine needle aspiration cytology in the diagnosis of superficial lymphadenopathy. An analysis of 2,418 cases. Diagn cytopathol. 1996; 15 : 382-16.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524161EnglishN-0001November30HealthcarePREVALENCE OF DEPRESSION IN PATIENTS WITH TYPE 2 DIABETES MELLITUS IN GUJARAT REGION
English4452Maharshi TrivediEnglishBackground: Patients with diabetes are more likely to experience depression than the population in general. Any level of depression is associated with worse diabetes outcomes, poorer quality of life, increased functional impairment, increase in death rate and increased rate of complications like blindness and heart disease. Any patient who is having poor diabetes control should be screened for depression. Objective: To find out the score of Patient Health Questionnaire to assess the depressive symptoms in the type 2 diabetes mellitus patient and the association between fasting blood sugar and depressive symptoms and between age and depressive symptoms. Materials and Methodology: 200 patients having diagnosed type 2 diabetes mellitus filled the PHQ form. The PHQ score was assessed for the prevalence of depression in the patients. Result: Result showed that 54% patients have minimal depressive symptoms. 27% patients have minor depression and 12% have moderately major depression. 2% of the patients have severe major depression. Conclusion: There was significant prevalence of depression in type 2 diabetes mellitus patients. The depressive symptoms are associated with age and fasting blood sugar of the patients.
Englishdepression, diabetes mellitusINTRODUCTION
The term diabetes mellitus describes a metabolic disorder of multiple etiologies characterized by chronic hyperglycemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action or both. Diabetes mellitus may present with characteristic symptoms such as thirst, polyuria, blurring of vision, and weight loss(1)International Diabetes Federation (IDF) reported that the total number of diabetic subjects in India is 41 million in 2006 and that this would rise to 70 million by the year 2025. (3) (4) Risk factors for type 2 diabetes mellitus are following; (6)(7)(8) Age >45 years Gestational Diabetes Body mass index ≥ 25 kg/m2(48) Family history of diabetes HDL cholesterol 250 mg/dL Blood pressure >140/90 mmHg Impaired glucose tolerance Impaired fasting glucose: FPG from 110 to Englishhttp://ijcrr.com/abstract.php?article_id=978http://ijcrr.com/article_html.php?did=978REFERENCES
1. Definition, diagnosis and classification of diabetes mellitus and its complications (report of WHO consulation)1999
2. Emanuel Rubin, Howard M. Reisner, Essentials of Rubin's pathology, page 491
3. Scheen AJ, Pathophysiology of type 2 diabetes, Acta Clin Belg. 2003 Nov-Dec; 58(6):335-41.
4. American Diabetes Association, Standards of Medical Care in Diabetes—2010, Diabetes Care January 2010 vol. 33 no. Supplement 1 S11-S61
5. Richard J. Mahler, Michael L. Adle, Type 2 Diabetes Mellitus: Update on Diagnosis, Pathophysiology, and Treatment, JCE and M,1999, vol 84,no.4
6. Diagnosis and Classification of Diabetes Mellitus: New Criteria, Jennifer Mayfield, Indianapolis Bowen Research Centre, Indiana University, Indiana.
7. Risk factors for type 2 diabetes, Pubmed health, April 19, 2009
8. Rajbharan Yadav, Pramil Tiwari et al, Risk factors and complications of type 2 diabetes in Asians, CRIPS Vol. 9 No. 2 April-June 2008
9. Amir A Moheet, MD1 and Elizabeth R Seaquist, MD, Diabetes and the Brain, An Overview of Existing Knowledge and future implication, US Endocrinology, 2010;6:28– 32
10. Dr. S. Sandeep, Mr. A .Ganeshan et al, Developement and upgradation of the diabetes atlas of India
11. V Mohan, S. Sandeep et al, Epidemiology of type 2 diabetes- Indian scenario, India j med res 125, march 2007 pp217-230
12. Buffie Clodfelder-Miller, Patrizia De Sarno et al, Physiological and Pathological Changes in Glucose Regulate Brain Akt and Glycogen Synthase Kinase, The American Society for Biochemistry and Molecular Biology, August 10, 2005
13. Amit Raval, Ethiraj Dhanaraj et al, Prevalence and determinants of depression in type 2 diabetes patients in a tertiary care centre, Indian J Med Res 132, August 2010, pp 195-200
14. Ryan J Anderson, Kenneth E. Freedland et al, The Prevalence of Co morbid Depression in Adults With Diabetes, the met analysis, diabetes care, vol 24, no 6, June 2001
15. Jennifer Warner, WebMD Health News, Negative Life Events, Obesity, Poor Disease Control May Raise Depression Risk in People With Diabetes, march,2011
16. Prasuna Reddy, Benjamin Philpot, Grad Dip, Dale Ford and James A Dunbar, Identification of depression in diabetes: the efficacy of PHQ-9 and HADS-D, Br J Gen Pract. 2010 June 1; 60(575): e239–e245.
17. Pirunee Suppaso, The Prevalence of Depression among Type 2 Diabetic Patients in PhangKhon Hospital, PhangKhon, Sakonnakhon, Thailand, Srinagarind Med J 2010; 25(4) 279
18. Pouwer F, Geelhoed-Duijvestijn PH, Tack CJ, Bazelmans E, Beekman AJ, Heine RJ, Snoek F J. Diabet Med. Prevalence of co morbid depression is high in out-patients with Type 1 or Type 2 diabetes mellitus. Results from three out-patient clinics in the Netherlands.2010 Feb; 27(2):217-24.
19. Pibernik-Okanovic M, Peros K, Szabo S, et al. Depression in Croatian Type 2 Diabetic Patients: Prevalence and Risk Factors. A Croatian Survey from the European Depression in Diabetes (EDID) Research Consortium. Diabet Med 2005; 22: 942-5.
20. Lustman, P. J., Anderson, R. J., Freedland, K. E., De Groot, M., Carney, R. M., and Clouse, R. E. (2000). Depression and poor glycaemic control. Diabetes Care, 23,934- 942.
21. Ikeda, K., Aoki, H., Saito, K., Muramatsu, Y., and Suzuki, T. (2003). Associations of blood glucose control with self-efficacy and rated anxiety/depression in type II diabetes mellitus patients. Psychological Reports, 92, 540-544.
22. Katon WJ, Rutter C, Simon G, Lin EH, et al: The association of comorbid depression with mortality in patients with type 2 diabetes. Diabetes Care 28:2668– 2670, 2005
23. de Groot M, Anderson R, Freedland KE, Clouse RE, Lustman PJ: Association of depression and diabetes complications: a meta-analysis. Psychosom Med 63:619– 630, 2001
24. Gonzalez JS, Safren SA, Cagliero E, et al: Depression, Self-Care, and Medication Adherence in Type 2 Diabetes: relationships across the full range of symptom severity. Diabetes Care 30:2222–2227, 2007
25. Lustman PJ, Skor DA, Carney RM, Santiago JV, Cryer PE: Stress and diabetic control. Lancet 1:588, 1983
26. Black SA, Markides KS, Ray LA. Depression Predicts Increased Incidence of Adverse Health Outcomes in Older Mexican Americans with Type 2 Diabetes. Diabetes Care 2003; 26: 2822-28.
27. Lin EH, Katon W, Von Korff M, Rutter C et al, Relationship of depression and diabetes self-care, medication adherence, and preventative care. Diabetes Care 27:2154– 2160, 2004
28. Katon, W., Simon, G., Von Korff, M., Ludman, E., Ciechanowski, P., Walker, E.,
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524161EnglishN-0001November30HealthcareDISTALLY BASED SURALIS FASCIOCUTANEOUS FLAP IN THE ARMAMENTARIUM OF THE ORTHOPAEDIC TRAUMA SURGEON
English5362Mohammed Lafi Al-OtaibiEnglishIntroduction: To present the experience of an Orthopaedic Surgeon, certified consultant with no microsurgery or plastic surgery qualification working at a level one trauma center in managing soft tissue coverage of lower one third of tibia, ankle and the heel. Patients and Methods: Four patients, three males and one female, with soft tissue defect of lower one third tibia, ankle and the Heel requiring soft tissue cover were treated from August 2008 to August 2010. The Distally based suralis fasciocutaneous flap was harvested from the posterior aspect of the calf. The pedicle pivot is at least 5 cm proximal to the lateral mallelous to allow anastomosis with the peroneal artery via the constant peroneal perforators. Skin incision was started along the mid line of the calf posteriorly stoping 5 cm at least proximal to lateral malleolus which the fascial pedicle would be taken. The subdermal layer dissected to expose the sural nerve, accompanying superficial sural vessels and short saphenous vein.1 The subcutaneous facial pedicle elevated, with a width of 3cm to include the nerve and these vessels will pivot. At the proximal margin of the flap, the nerve and the vessels were ligated and severed.2 The skin island was elevated with the deep fascia. The donor site defect was covered with a split thickness skin graft from epsilateral thigh. Results: Well tolerated procedure by all patients, no plastic surgery or reoperation was need for any of the four cases, Survival of all flaps, maintenance of orthopaedic fixation, one flap showed some venous engorgement which subsided gradually in a few days. Complete take of all split skin graft over donor site bed. Conclusion: Distally based Sural artery flap is a good choice for reconstruction of soft tissue defects of lower 1/3 tibia, ankle and foot. The procedure is easy and should be done by an Orthopaedic surgeon when needed.
EnglishINTRODUCTION
Defects in Soft tissue accompanying fractures of lower 1/3 tibia, ankle and foot are a challenging problem facing orthopaedic surgeon's world wide. Hospitals with no plastic surgery departments where these patients usually being treated put there orthopaedic surgeons at the challenge.3 Distal third of tibia is subcutaneous and not forgiving in terms of soft tissue problems usually arise in situations such as open fractures or pilon fracture. Wound problems of the hind foot complicating Calcaneus fracture or after its open reduction and internal fixation is another challenging site for soft tissue coverage. Different forms of soft tissue cover are available e.g., Random cutaneous, arterial cutaneous (axial), musculocutaneous, muscle, fasciocutaneousand free flaps with their own indications, advantages and disadvantages. The distally based Sural artery flap, first described as a distally based neuro cutaneous flap by Masquelet et al.,4 is skin island flap supplied by the vascular axis of sural nerve. He reported, using colored latex injection studies in 1992, the blood supply to the skin from the arteries accompanying the nerves and described the concept of neuro cutaneous island flap. The objective of this paper was to present our experience of soft tissue cover of lower 1/3 of tibia, ankle and foot treated by an Orthopedic surgeon without any special training, and also the reliability of this flap.
PATIENTS AND METHODS
Approved by the Ethical Committee in our center four patients, three males and one female, with soft tissue defect of lower 1/3 tibia ankle and foot requiring soft tissue cover were treated from May 2008 to may 2010. The patient’s age ranged from 14 to 36 Years (mean 25 Years). Two of the wounds were over the distal third of the tibia, one on the lateral malleolus and one on the lateral aspect of hind foot. All four cases underwent same surgical technique as shown Figures 1 to 12. Donor flaps sutured in place or stabled over a haemovac drain and with no tension at the edges. The limb is warped in enough cotton and immobilized in Ankle foot orthosis to prevent pressure on the flap Fig -12. The procedure is done without tourniquet and all patients were given prophylactic dose of antibiotics, wounds inspected second post operative day as the drain removed. Oxygenation via face mask to keep saturation above 95% and assuring enough oxygen tention at the wounds as they heel. All patients kept in hospital until wounds heal and sutures removed.
RESULTS
The mechanism of injury was road traffic accident in three patients with open fracture tibia Fig-13 in two patients one is skeletally immature with growth plate injury Fig-14 and open ankle fracturein the third patient, the fourth case after operative treatment of fracture of the calcaneum complicated by wound necrosis Fig-15. Reveres flow suralis flap used in all cases (Table 1). All flaps survived.one flap showed slight venous congestion which subsided within a few days. Complete take of split skin graft over the donor site. No loss of sensation persisted at two years post op.
DISCUSSION
Previously, mostly lower limb flaps were based on the concept of random skin flap design, thus were limited by a certain length-to-width ratio (usually 1:1 in the lower extremity). Ponten flaps had length-to-width ratios as great as 3:1. These flaps have been referred to as Ponten super flaps. The concept of a neuroskin island flap has been first developed and applied by Masquelet4 as he reported its use in six clinical cases for coverage of some specific areas of the lower limb and gained attention since 1992. Cormack and Lamberty classified fasciocutaneous flaps according to their vascular anatomy.5 Mathes and Nahai also discussed the classification of fasciocutaneous flaps.6 Tolhurst, Haeseker, and Zeeman demonstrated a 15% greater survival length in flaps that included fascia.7 Cormack and Lamberty classified fasciocutaneous flaps based on vascular anatomy.Circulation to a fasciocutaneous flap is based on the prefascial and subfascial plexuses. There are also arterial plexuses at the subdermal and subcutaneous levels. These plexuses are supplied by regional arteries that may enter the deep fascia through an underlying muscle (musculocutaneous), through the septum between underlying muscles (septocutaneous), or through a direct cutaneous branch. Often, more than one source of blood supply to a particular area of skin or a particular muscle is present. If one of these arteries is ligated, the skin and fascia continue to receive blood supply from an alternative source. The arteries generally are accompanied by paired venae comitantes and are reasonably consistent in their location. In the extremities, many perforators pierce the septa between long slender muscles, while musculocutaneous perforators tend to supply the skin over the broad flat muscles of the trunk. Because of the directionality of the fascial plexus, particularly in the extremities, the orientation of the flap is important. Chan and colleagues8 in their study proved that early vascularized soft-tissue closure has long been recognized to be essential in achieving eventual infection-free union. The question of whether muscle or fasciocutaneous tissue is superior in terms of promoting fracture healing remains unresolved. In this article, the authors review the experimental and clinical evidence for the different tissue types and advocate that the biological role of flaps should be included as a key consideration during flap selection. Ebrahimi et al.9 concluded that reverse sural flap is a useful and versatile reconstructive method in patients with gunshot wounds of the lower leg and foot. Mukherjee et al.10 studied prospectively 20 cases and fined that Perforator flaps are a reliable option for closure of soft tissue defects of lower limb irrespective of size, location and depth. There is minimal donor site morbidity. It has the advantage of rapid dissection, flap elevation and reliable skin territory. As no special equipment is required it can be replicated in smaller centers also. Zayakova11 as other researchers proved the pedicle fascio cutaneous and muscle flaps are used in reconstructive surgery to treat large and deep defects of the lower leg. Full tissue coverage, functional recovery and good aesthetic results are achieved with minimum damage to the donor site. In addition, the surgical procedure is relatively short and easy to perform, and it doesn’t require microsurgical skills and instruments. Esezobor et al.12 mentioned in their study, though the loss of sensation on the area innervated by the sural nerve may resolve within some months after the use of reverse sural artery flap, preserving sensation on the foot is an advantage especially in patient with sensoneural problem. In some selected patients that require flap cover for the upper part of the distal 3rd and the mid 3rd on the ipsilateral leg, the sural nerve preserving sural artery flap is an option. Its area of coverage on the contralateral leg may extend to the whole of distal 3 rd. This is possible as long as the pivot of the flap is not more than 5cm distal to the level of the point where the sural nerve pierces the deep fascia and the arc of rotation is not more than 100°. Elsaftawy et al.13 reported 16 cases and find the reverse sural flap, technically easy, offers a viable, low-risk alternative to free and perforator-based flaps. Proving carrying the lowest risk of complication and failure. Chen Wang et al.14 concluded in a study involving 16 consecutive cases that The distally based flap pedicled with the lateral sural nerve and lesser saphenous vein was a reliable source for repairing soft tissue defects in the lower leg and foot due to its advantages of infection control, high survival rate, and sufficient blood supply without the need to sacrifice a major blood vessel Chang et al.15 stated that the reconstruction of the distal third leg and weight-bearing heel, especially when complicated with infection and / or dead space, remains a challenge in reconstructive surgery. The distally based sural neurofasciomyocutaneous flap has been proved a valuable tool in repair of the soft tissue defects of those areas. a modified distally based sural neurofasciomyocutaneous flap including the distal gastrocnemius muscle component was designed and used for repairs of the soft tissue defects in the distal lower limb and plantar heel pad in six patients. The blood supplies of flaps comprised either the peroneal perforator and adipofascial pedicle or the peroneal perforator only.
CONCLUSION
Distally based Sural artery flap is a good choice for reconstruction of soft tissue defects of lower 1/3 tibia, ankle and foot (Fig 17). The procedure is easy and should be done by an Orthopaedic surgeon when needed.
Englishhttp://ijcrr.com/abstract.php?article_id=979http://ijcrr.com/article_html.php?did=979REFERENCES
1. Motamed S, Yavari M, Mofrad HRH, Reza R, Shahraki FN. Distally based sural artery flap without sural nerve. Acta Medica Iranica 2010; 48(2): 127-9.
2. Ali MA, Chowdhury P, Ali M, Ifteker Ibne Zuha, Dev J. Distally-based sural island flap for soft tissue coverage of ankle and heel defects. J Coll Physicians Surg Pak. 2010; 20(7): 475-7.
3. Ponten B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg. Br J Plast Surg. 1981; 34(2):215-20.
4. Masquelet AC, Romana MC, Wolf G. Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg. Plast Reconstr Surg. 1992; 89(6):1115-21.
5. Cormack GC, Lamberty BG. A classification of fascio-cutaneous flaps according to their patterns of vascularisation. Br J Plast Surg. 1984; 37(1):80-7.
6. Mathes SJ, Nahai F. Reconstructive Surgery: Principles, Anatomy, and Technique. New York: Churchill Livingstone; 1997.
7. Tolhurst DE, Haeseker B, Zeeman RJ. The development of the fasciocutaneous flap and its clinical applications. Plast Reconstr Surg. 1983; 71(5):597-606.
8. Chan JK, Harry L, Williams G, Nanchahal J. Soft-tissue reconstruction of open fractures of the lower limb: muscle versus fasciocutaneous flaps Plast Reconstr Surg. 2012; 130 (2): 284e-295e.
9. Ebrahimi A, Nejadsarvari N, Koushki ES. Experience With Reverse Sural Flap to Cover Defects of the Lower Leg and Foot. Trauma 2012; 16(4): 178-81.
10. Mukherjee MK, Parwaz MA, Chakravarty B, Langer B. Perforator flap: A novel method for providing skin cover to lower limb defects. Medical Journal Armed Forces India 2012; 68: 328-34.
11. Zayakova YK. Application of pedicle flaps for wound coverage of lower leg. J IMAB 2013, 19(1):382-386; DOI: 10.5272/jimab.2013191.382.
12. Esezobor EE, Nwokike OC, Aranmolate S, Onuminya JE, Abikoye FO. Sural nerve preservation in reverse sural artery fasciocutaneous flap-a case report. Ann Surg Innov Res. 2012; 6(1):10. doi: 10.1186/1750- 1164-6-10.
13. Elsaftawy A, Jab?ecki J, Domanasiewicz A, Paruzel M, Kaczmarzyk J, Kaczmarzyk L. Treatment possibilities of reverse-flow sural flap in covering the defects of lower extremities. Pol Przegl Chir. 2013; 85(4):192- 7. doi: 10.2478/pjs-2013-0029.
14. Wang C, Xiong Z, Xu J, Huang H, Li G. The distally based lateral sural neuro-lesser saphenous veno-fasciocutaneous flap: anatomical basis and clinical applications J Orthopaed Traumatol. DOI 10.1007/s10195- 012-0202-2.
15. Chang SM, Zhang K, Li HF, Huang YG, Zhou JQ, Yuan F, Yu GR. Distally based sural fasciomyocutaneous flap: anatomic study and modified technique for complicated wounds of the lower third leg and weight bearing heel. Microsurgery. 2009; 29(3): 205-13. doi: 10.1002/micr.20595.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524161EnglishN-0001November30HealthcareSTUDY OF KNOWLEDGE, ATTITUDE AND PRACTICE OF GENERAL POPULATION OF WAGHODIA TOWARDS DIABETES MELLITUS
English6368Gunvanti B. RathodEnglish Sangita RathodEnglish Pragnesh ParmarEnglish Ashish ParikhEnglishObjectives: The prevalence of diabetes in India has grown over the past decade. There are virtually less number of epidemiological studies assessing the level of awareness of diabetes mellitus among the general population. This study aims to assess the baseline levels of knowledge, attitude and practices of general population of Waghodia. The baseline results were used to develop a counselling program and to assess whether this intervention could produce any improvement in diabetes awareness and practices. Material and methods: A suitably designed and validated KAP questionnaire was administered and responses were coded and analysed. Results: Altogether, 56.14 % of respondents scored 100% in the questions related with knowledge. However 17.58% scored 100% in the attitude questions and15.78% scored 100% in practice questions. Conclusion: We can conclude that the responders had good knowledge but poor attitude and practice towards diabetes. Repeated reinforcement and motivation along with health education will definitely bring about a positive change in practices.
EnglishDiabetes, KAP, General populationINTRODUCTION
Demographic transition combined with urbanisation and industrialisation has resulted in drastic changes in lifestyles globally. Consequently, lifestyle related diseases like diabetes mellitus, have emerged as a major public health problem. Diabetes mellitus, a common metabolic disorder, which accounts for a high incidence of morbidity leads to various events including micro and macro vascular complications. [1] Diabetes is characterised by a state of chronic hyperglycemia resulting from a diversity of aetiologies, environmental and genetic, acting jointly. [2] Diabetes affects 10-16 % of urban population and 5.33-6.36 % of rural population and this is projected to double by 2030. [3] It is now a global epidemic with devastating humanitarian, social and economical consequences. It is an epidemic of 21st century. [4] Total number of people with diabetes is projected to double between 2000 and 2030. [5] In India, the older members of the population who have had diabetes for a relatively long time are protected from risk of diabetic complications because of their physical activity patterns and dietary habits (making healthier food choices), while the current younger generation face high risk of diabetic complications due to a sedentary and stressful lifestyle. Over the past few years, the working patterns have changed, with fewer people involved in manual labour (e.g., as in the agriculture sector) and more and more people opting for physically less demanding office jobs. Another factor for the increase in risk for diabetes mellitus is the 'fast food culture' that has overwhelmed our cities and towns. The 'fast foods' that are rich in fats and calories are readily available in numerous food shops. As the majority of the young working population depend on these unhealthy 'junk foods,' this may partly explain the rise in diabetes incidence in the younger age-groups. The serious spread of disease can cripple the nation’s fiscal and human resources; therefore, it is the time to act now and do as much as possible to cover almost all aspects of the disease. The overwhelming burden of the disease threatens to stunt economic growth and undermine the benefits of improved standards of living and education. Proper education and awareness programmes developed according to the need of the society can improve the knowledge of general population and change their attitude. [6] Obtaining information about the level of awareness is the first step in formulating a preventive programme for the disease. There is need to investigate KAP among general population to aid in future development of programmes and techniques for effective health education. KAP surveys are effective in providing baseline for evaluating intervention programmes. [7] This study aims to assess the baseline levels of knowledge, attitude and practices of general population of Waghodia towards diabetes.
MATERIAL AND METHODS
A suitably designed and validated KAP questionnaire was administered at baseline. [8] The questionnaire was pretested and verified for errors. [9] The questionnaire covered three areas: knowledge, attitude and practice. There were a total of 25 questions, with 14 questions related to knowledge about diabetes, 5 questions to assess the attitude of the patient towards the disease, and 6 questions regarding practices. This questionnaire was filled in at a face-to-face interview with the investigator. In scoring method, twenty five was the maximum possible score in which each correct answer was carry one point and incorrect or unsure answer was carry no point. The interviewer did not in any way try to improve the knowledge of respondents. Gujarati or English version of questionnaire was provided as per requirement of individual.
RESULTS
Most of the respondents (42.1 %) were aged 31- 40 years, followed by those aged 20-30 years. Most of them (71.9 %) were educated up to graduate level as per Table – 1. The major source of knowledge for the general population was television (32 %) and newspaper (30 %) followed by family physician (28 %). However 10 % received information from friends and relatives. Majority were aware about the causes, symptoms and complications of the disease as per Table – 2. We observed poor score in attitude part of the questionnaire and only 35 % had positive attitude towards exercise as per Table – 3. Only 43.85 % of responders had their blood sugar checked. Only 17 % of responders were able to answer 50 % of practice questions correctly as per Table – 4.
DISCUSSION
Diabetes mellitus is believed to be the commonest and most devastating chronic disease in human history. It has afflicted mankind for thousands of years and continues to do so at anexponential rate. [10] Diabetes mellitus (DM) is a group of metabolic disorders characterized by hyperglycemia. It is associated with abnormalities in carbohydrate, fat and protein metabolism, and results in chronic complications, including micro vascular, macro vascular and neuropathic disorders. [11] The prevalence of Diabetes mellitus has risen dramatically over the past two decades. It is estimated that the prevalence of diabetes in adults worldwide will rise to 5.5 % in 2025 (as compared to 4 % in year 1995), with India contributing the major part. [12] Many causes have been postulated for the rise in the number of cases, including urbanization, sedentary lifestyles, poor nutrition and obesity. People with Diabetes mellitus who wish to live normal lives need to know a lot about their illness. [13] Thus, awareness on Diabetes mellitus and its complication has become an integral and essential part of Diabetes mellitus care for the people in the society. Almost 90 % of responders answered 50 % of the knowledge questions correctly. Still a large proportion of population that is almost 40.3 % were not able to score above 10. This is comparable to the results of a study done in Malaysia by Ambigapathy R., et al. [14] who reported 87 % respondents able to answer 50 % knowledge questions correctly. The lack of proper knowledge of each responder should be given individual attention for good practice and fill the gap of this 10 % to 100 % as studies report that there is a positive correlation between knowledge and good attitude. [14] Regarding Attitude 17.5 % scored above 50 % in this study, however, reports from Malaysia revealed good attitude with 98 % scoring above 50 %. [14] Attitude towards Here we can observe that 35 % had habit of exercise. Many studies have confirmed the beneficial role of physical activity in improving glycemic control. Due to inadequate glycemic control there are high chances of developing complications. Great efforts would be needed by health teams to enhance education and improve the knowledge of the diabetics in our society. There is increasing amount of evidence that patient education is the most effective way to lessen the complications of diabetes. [15] Over all 49 % answered the 50 % of practice questions and only 15.74 % scored 100 % which was showing poor score for practice whereas Malaysian study revealed 99 % answering 50 % questions correctly. [14] Monitoring of blood glucose is a simple and practical procedure acceptable for those who can afford it and facilitates the attainment of good glycemic control but unfortunately in our local population the practice was not good as 56 % responded that their blood sugar level has not been checked in past as per Table – 4. Education and counselling about all the aspects of diabetes is needed. Knowledge regarding diabetes forms the basis for informed decisions about diet, exercise, weight control, blood glucose monitoring, and use of medications, foot and eye care, and control of macro vascular risk factors. [16] Group education as well as individualized education programmes should be planned which can lead to better preventive and management techniques in diabetes. The educational programmes for the health professionals and paramedical staff are also important because several studies have reported the positive impact of counselling by clinical pharmacists on glycemic control and quality of life outcomes in the diabetic population. [17] Thus there is need for arranging large scale awareness programs for the general population and also to identify and use media to spread the message which could change the attitude of our population in the future.
CONCLUSION
Though good number of the respondents had positive knowledge levels regarding diabetes, the same can’t be said about the levels of attitudes and practice. Diabetes and its complications can largely be prevented if appropriate and timely measures are taken. Health education plays a verycrucial role in prevention and control of diabetes and its complications. We found reasonable gap between knowledge, attitudes and practices, so to overcome that it is very important to formulate and implement certain strategies by which positive attitudes can be converted into beneficial practices. Attitude and practices of general population can be definitely improved by structured programmes. Knowledge of medical and para-medical personnel regarding diabetes can be improved by frequent continued medical education programs, seminar and short discussion on diabetes. All of the above can be achieved by increasing quality of health education and improving applicability of scope of health education at all level.
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=980http://ijcrr.com/article_html.php?did=980REFERENCES
1. Srinivasan AR, Niranjan G, Kuzhandai Velu V, Parmar P, Anish A. Status of serum magnesium in type
2 diabetes mellitus with particular reference to serum triacylglycerol levels. Diabetes Metab Syndr., 2012; 6: 187- 189. 2. Epidemiology of chronic non-communicable diseases and conditions. In: Park’s Textbook of Preventive and Social Medicine, 20th edition, M/s Banarsidas Bhanot Publishers, Jabalpur, 2009, p. 314-358.
3. Pradeepa R, Mohan V, The changing scenario of the diabetes epidemic: Implications for India, Indian J Med Res, 2002; 116: 121-32.
4. Tabish SA, Is diabetes becoming biggest Epidemic of the twenty first century?, International Journal of health sciences, 2007; 1: 5-8.
5. Upadhyay DK, Palaian S, Shankar PR, Mishra P., Knowledge, attitude and practice about diabetes among diabetes patients in western Nepal, Rawal Med J., 2008; 33(1): 8- 11.
6. Shera AS, Jawad F, Basit A, Diabetes related knowledge, attitude and practices of family physicians in Pakistan, J Pak Med Assoc, Oct 2002; 52(10): 465-70.
7. Ruzita T, Osman A, Fatimah A. et al., The effectiveness of group dietary counselling among non- insulin dependent diabetes mellitus (NIDDM) patients in resettlement scheme areas in Malaysia, Asia Pacific J Clin. Nutr, 1997; 2: 84-87.
8. Rathod GB, Parmar P. Comparison regarding knowledge, attitude and practice of blood donation between health professionals and general population. Int J Cur Res Rev, Nov 2012, 04 (21): 114-120.
9. Parmar P, Rathod GB. Study of knowledge, attitude and perception regarding medicolegal autopsy in general population. Int J Med Pharm Sci, Feb 2013; 03 (06): 1-6.
10. Aldasouqi SA, Alzahrani AS, Terminology in diabetes; an example of resistance to change, Saudi Med J, Sep 2004; 25(9): 1289-91.
11. Stephan ND, Daryl KG, Insulin, oral hypoglycaemic agents, and the pharmacology of the endocrine pancreas. In: Hardman JG, Limbird LE editors. Goodman and Gilman's The Pharmacological basis of Therapeutics, 10th edition, New York: Mc Graw Hill; 2001, p. 1686-7.
12. King H, Aubert RE, Herman WH, Global burden of diabetes, 1995-2025: Prevalence, numerical estimates, and projections, Diabetes Care, 1998; 21: 1414.
13. Stam DM, Graham JP, Important aspects of self management education in patients with diabetes, Pharm Pract Manag Q, 1997; 17: 12-25.
14. Ambigapathy R, Ambigapathy S, Ling HM, A knowledge, attitude and practice (KAP) study of diabetes mellitus among patients attending Klinik Kesihatan Seri Manjung, NCD Malaysia, 2003; 2: 6-16.
15. Mazzuca SA, Moorman NH, Wheeler Ml, The diabetes education study: A controlled trial of the effects of diabetes education, Diabetes Care, 1986; 9: 1-10.
16. Murata GH, Shaha JH, Adam KD, Wendel CS, Bokhari SU, Solvas PA, et al., Factors affecting diabetes knowledge in Type 2 diabetic veterans, Diabetologia, 2003; 46: 1170-8.
17. Adepu R, Raheed A, Nagavi BG, Effect of patient counselling on quality of life in Type- 2 diabetes mellitus patients in two selected south Indian community pharmacies: A study, Indian J Pharm Sci, 2007; 69: 519-24.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524161EnglishN-0001November30HealthcareDIAGNOSTIC SIGNIFICANCE OF ADA (ADENOSINE DEAMINASE) IN TUBERCULOUS PLEURAL EFFUSION
English6971Kalpana K. DaveEnglish Nikunj V. MehtaEnglish R.N. GonsaiEnglish Dimple J. DangiaEnglishIntroduction: Adenosine deaminase (ADA) is a useful biochemical parameter for tuberculous pleural effusion. Studies have confirmed diagnostic role of Adenosine deaminase for early diagnosis of pleural tuberculosis in high prevalence countries like India. Objective: To assess the diagnostic level of ADA in tubercular pleural effusion and to determine its Sensitivity, Specificity, Positive and Negative predictive value. Material and Methods: The Retrospective study was carried out on 51 patients suffering from pleural effusion in B.J.M.C. Ahmedabad during May to Aug-2012. Detailed clinical history, physical examination and routine investigation of all patients including ADA estimation by Galanti And Giusti method was done. Results : ADA level in tuberculous pleural effusion ranged from 25-160 U/L with a mean level of 72 U/L and at >60 U/L the Sensitivity-69.2%, Specificity-92%, Positive Predictive Value-90% and Negative Predictive Value -74%. So this was best cut off point for ADA level to confirm diagnosis. Conclusion: ADA was found positive with a mean value of 72 U/L in tuberculous pleural effusion with 69.2% sensitivity and 92% specificity at cut off value of 60 U/L.
EnglishAdenosine deaminase, Tuberculousis, Pleural effusion.INTRODUCTION
Tuberculosis is one of the commonest infectious diseases which causes morbidity and mortality in countries like India(1) . Tuberculosis usually affects lungs but extra pulmonary tuberculosis is also common, of which tuberculous pleural effusion is one. Diagnosis of pulmonary tuberculosis is confirmed by sputum examination of AFB (Acid Fast Bacilli), while the diagnosis of tuberculous pleural effusion requires investigation of pleural fluid biochemistry, cytology and pleural biopsy. Pleural biopsy is usually the main diagnostic support but it is invasive and difficult procedure. So many biologic parameters have been introduced. One such parameter is ADA (Adenosine deaminase) which is excellent parameter for the diagnosis of tuberculous pleural effusion
OBJECTIVE
For Assessment of diagnostic level of ADA in tubercular pleural effusion and to determine its Sensitivity, Specificity, Positive Predictive value and Negative predictive value.
MATERIALS AND METHODS
This Retrospective study was carried out on 51 patients in B.J.M.C, Ahmedabad during May-Aug 2012 of both sexes admitted as cases of exudative lymphocytic pleural effusion. Detailed clinical history, Physical examination and investigation e.g. AFB, cytology, Biochemical Examination Xray chest, pleural biopsy for exclusion of cases of tuberculosis enteric fever, leprosy, Viral Hepatitis and malignancy. ADA Estimation in pleural fluid was done by GALANTI and GIUSTI method.
RESULT
During the study period, 51 patients with exudative lymphocytic pleural effusion were investigated, out of which tuberculous pleural effusion was diagnosed in 26 patients. Other causes of exudative lymphocytic pleural effusion were malignancy (44.7%), chronic nonspecific inflammation (10%) and systemic lupus erythematosus (0.7%). ADA level in tuberculous pleural effusion ranged from 25-160 U/L with mean level of 72 U/L. At 60 U/L cut off point, sensitivity and specificity of the test for patient with tuberculous pleural effusion was 69.2% and 92% respectively while Positive Predictive Value and Negative Predictive Value was 90% and 74% respectively.
DISCUSSION
In our study we investigated 51 cases of exudative lymphocytic pleural effusion, out of which 32 were males and 19 were females ( Figure I ). Our findings seem to confirm the ADA activity is a useful parameter is Tuberculous pleural effusion. The mean level of ADA in tuberculous pleural effusion were higher than in any other disease (2) . Many studies have reported the utility of ADA in diagnosis of tuberculous pleural effusion with a wide Range of cut off value (40-85U/L). In our study ADA Level of 60 U/L was most suitable cut off value yielding sensitivity 69.2%, Specificity 92%, Positive predictive value 90% and Negative predictive value 74%. ( Table I and II). ADA, a product of T lymphocytes, is a very good parameter for diagnosis of tuberculous pleural effusion. Almost all research workers are using different cut off levels for measuring sensitivity and specificity of ADA level in pleural fluid. Burgess L.J.(2) showed ADA activity in tuberculous effusion was higher than in any other diagnostic group. At a level of 50U/L the DISCUSSION In our study we investigated 51 cases of exudative lymphocytic pleural effusion, out of which 32 were males and 19 were females ( Figure I ). Our findings seem to confirm the ADA activity is a useful parameter is Tuberculous pleural effusion. The mean level of ADA in tuberculous pleural effusion were higher than in any other disease (2) . Many studies have reported the utility of ADA in diagnosis of tuberculous pleural effusion with a wide Range of cut off value (40-85U/L). In our study ADA Level of 60 U/L was most suitable cut off value yielding sensitivity 69.2%, Specificity 92%, Positive predictive value 90% and Negative predictive value 74%. ( Table I and II). ADA, a product of T lymphocytes, is a very good parameter for diagnosis of tuberculous pleural effusion. Almost all research workers are using different cut off levels for measuring sensitivity and specificity of ADA level in pleural fluid. Burgess L.J.(2) showed ADA activity in tuberculous effusion was higher than in any other diagnostic group. At a level of 50U/L the
CONCLUSION
Estimation of ADA level is a simple, cheaper, inexpensive, highly sensitive and specific test employed routinely to differentiate between tubercular and non tubercular etiology in patients of pleura
ACKNOWLEDGEMENT We would like to express our gratitude to Department of Pathology, B.J. Medical College, Ahmedabad. We also acknowledge the great help received from the scholars whose articles cited and included in references of this manuscript. We are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. We 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=981http://ijcrr.com/article_html.php?did=9811. Light R W. Pleural diseases. 3rd edition. Baltimore, Williams and Wilkins, 1995.
2. Burgess L.J. Use of adenosine deaminase as a diagnostic tool for tuberculous pleurisy. Thorax 1995 June; 50 (6): 672- 674.
3. Mathur P C, Tiwari K K, Trikha S, Tiwari D. Diagnostic value of adenosine
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524161EnglishN-0001November30HealthcareISCHEMIC STROKE: RELEVANCE OF MAGNETIC RESONANCE ANGIOGRAPHY (MRA) FINDINGS AND CORRELATING THE CHANGES WITH VARIOUS CONVENTIONAL AND NONCONVENTIONAL RISK FACTORS
English7278Ravinder KumarEnglish JyotiEnglishObjective: This study aims to correlate the magnetic resonance angiography (MRA) changes in ischemic stroke (IS) patients to identify various conventional and nonconventional risk factors. Material and Methods: Total 100 cases with Ischemic stroke ( IS) were clinically evaluated including body mass index, dietary habits, and family history of stroke. MR imaging, MRA, and testing for blood sugar and lipid profile were carried out. Results: The MRA abnormality positively correlated with low density lipids (LDL), Cholesterol and diabetes, and negatively with alcohol consumption and high density lipids (HDL). Out of total 100 patients, 50% were normal, 35% had significant stenosis and 15% had total occlusion. Males have equal incidence of Intracranial stenoses (ICS) and Extracranial stenoses (ECS) but Females are more likely to have ICS. The patients having age 60yrs are more likely to have extracranial stenosis. Middle cerebral artery (MCA) was the most common arterial territory involved in all stages of infarct. Posterior cerebral artery (PCA) was the next common arterial territory to be involved. Single stenoses are more common in intracranial atherosclerosis (ICAs) and multiple stenoses are more common in extracranial atherosclerosis (ECAs). Conclusion: MRA is a robust imaging technique for determining the severity of stenosis, vascular occlusion, and collateral flow and in the determination of stroke etiologies.
EnglishExtracranial, Ischemic stroke, Lipid profile, Magnetic resonance angiography, Stenosis.INTRODUCTION
The term “stroke” according to WHO is defined as rapidly developing clinical symptoms and or signs of focal and at times global cerebral functions with symptoms lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin. A focal neurologic deficit less than 24 hours is defined as a transient ischemic attack (TIA) and when it exceeds 24 hours and resolves within one week, termed reversible ischemic neurologic deficit (RIND). Approximately 75% of all strokes are ischemic in origin. Out of these, four fifth by atherosclerosis and about one fifth cases by thromboembolism from heart. Very few cases of ischemic stroke can also result from fibro muscular dysplasia, intracranial dissection, Moya-Moya disease, or vasculitis (Takayasu disease, giant cell arteritis, collagen vascular diseases, systemic necrotizing vasculitis, granulomatous angiitis of the nervous system). A reduction in blood flow that lasts for several seconds or minutes causes Cerebral ischemia and if the cessation of blood flow lasts for more than 5 minutes „infarction of brain? tissue results. Risk factors for carotid disease are : age, cigarette smoking, alcohol consumption, hyperlipidemia, hypercholesteremia, hypertension, diabetes mellitus, obesity, type A personality, insufficient physical exercise, newer risk factor like homocystiene and lipoprotein (a) etc., contributes to development of plaque formation and subsequent narrowing of the lumen of the vessels. Angiography, especially the three-dimensional time-of-flight technique, is very helpful noninvasive diagnostic tool for early identification of suspected steno-occlusive disease either extracranial or intracranial. In the studies of Masaryk2 et al and Heiserman1 et al, the findings of MRA and conventional angiography were well correlated as about 80% to 98% in diagnosis of ECCA diseases. Overall sensitivities of 85% and 88% and specificities of 96% and 97% for ICCA and middle cerebral artery, respectively, have been reported.1,2 However the studies regarding the Indians are incomplete. Our purpose is to evaluate the location and distribution of severe atherosclerotic stenosis in Indian patients by using MR angiography and to correlate the changes with various risk factors.
MATERIALS AND METHODS
A total of 100 patients belonging to all age and sex groups with H/O focal neurological deficit with suspected stroke underwent MR angiography study by using 3-D time of flight technique on a 1.5T machine with a standard head coil. According to clinical history all the extracranial angiography findings were grouped into symptomatic side and contralateral side. Results that were 50% were recorded as significant stenosis
Pre Procedural Work up of patients: A detailed history has been taken from all patients and they underwent a thorough neurological examination and designated as having (l)TIA (2) RIND (3) Stroke in evolution (4) Completed Stroke Patients are designated as having ischemic stroke by following criteria: 1. Patients have stroke as indicated by clinical examination, and CT scan / MR document the presence of infarction. 2. Patients have stroke as indicated by clinical examination, with a normal CT scan / MRI study (hemorrhage ruled out). Scanning parameters taken are shown in Table I. H / O alcohol consumption recorded. Other Investigations Along with baseline investigations, blood sugar and lipid profile was done to estimate LDL, HDL and Cholestrol levels. RESULTS In all the patients, Vessels are classified as (1) Normal or clinically non significant stenosis (ie, 50% stenosis), (3) Total occlusion on the symptomatic side and the contralateral side respectively. Table II shows that patients having age 60 yrs are more likely to have extracranial stenosis. Also Males have equal incidence of ICS and ECS but Females are more likely to have ICS. MCA was the most common arterial territory involved in all stages of infarct. (Figure I andIII). PCA was the most common arterial territory to be involved next to MCA. ACA and MCA both were involved in 6% of cases. (Figure II andIV). The commonest presenting symptom in patients with cerebral infarction was hemiparesis (52.6%), right being slightly more common (30.7%) than left (21.9%)
Headache was seen in 17.5% cases. Cerebellar symptoms were noted in 13.2% of cases. Monoparesis was found in 9% of cases. Single stenoses are more common in ICAs and multiple stenoses are more common in ECAs. However ICAs are more likely to have stenoses. Table III shows that increased LDL, Cholesterol and blood sugar level and decreased HDL level are associated with increased frequency of stenoses.
DISCUSSION
The present study was undertaken to evaluate the location and distribution of vascular lesions in cerebrovascular steno-occlusive diseases in Indian patients with the use of Magnetic Resonance Angiography. A total of 100 patients were included in the study. Out of total, 50% are either normal or having clinically non-significant stenosis (50% stenosis), 15% are having total occlusion of the vessel. In this study, 45 patients are having age 60yrs. Out of these, 20(20%) have ECS and 15(15%) have ICS. So, the patients having age 60yrs are more likely to have extracranial stenosis. These findings correlate well with G. Neil Thomas et al19 . The study group comprised of 65 males and 35 females. Out of these, 50 males and 15 females have stenotic lesions. Males have equal incidence of ICS (25%) and ECS (25%) but Females are more likely to have ICS(10% ICS and 5% ECS). Similar findings were observed in study done by Tatjana Rundek18 . The commonest presenting symptom was hemiparesis in 60(52.6%) patients, right sided being slightly more common (30.7%) than the left (21.9%). Truwit et al and Winer et al also reported a similar incidence of hemiparesis in their studies. Monoparesis was seen in 10 (9%) patients, headache in 20(17.5%) patients and cerebellar symptoms were noted in 15(13.2%) patients. MCA was the most common arterial territory to be involved in all stages of infarcts 34(34%). PCA was the next most common 10(10%) to be involved.These findings correlate well with study done by Hossein Zarei et al15 . The present study shows single stenoses are more common in ICAs (25%) and multiple stenoses are more common in ECAs (15%). Findings were similar to the study done by Dae Chul Suh et a116 . The study shows increased LDL (>l30mg/dl), Cholesterol level (>200mg/dl), blood sugar (> 120 mg/dl) and decreased HDL (Englishhttp://ijcrr.com/abstract.php?article_id=982http://ijcrr.com/article_html.php?did=982REFERENCES
1. Heiserman JE, Drayer BP, Fram EK, Keller PJ, Bird R, Hodak JA, Flom RA. Carotid artery stenosis: clinical efficacy of 2D TOF MR Angiography. Radiology, 1992:182:761- 768
2. Masaryk AM, Ross JS, DiCello MC, Modic MT, Paranandi L, Masaryk TJ. 3D TOE MR Angiography of carotid bifurcation: potential and limitation as screening examination. Radiology, 1991; 1 79:797-804.
3. S Warach, W Li, M Ronthal and RR Edelman Acute cerebral ischemia: evaluation with dynamic contrast-enhanced MR imaging and MR angiography Radiology, Vol 182, 41-47.
4. Yang Janice J. ; Hill Michael D. ; Moorish William F. Hudon Mark E. ; Barber Philip A.; Demchuk Andrew M. Sevick Robert J. ; Frayne Richard. Comparison of Pre- and postcontrast 3D time-of-flight MR angiography for the evaluation of distal intracranial branch occlusions in acute ischemic stroke. Amer journal of neuroradiology 2002, vol. 23, no.4, pp. 557- 567.
5. Nicoletta Anzalone, MD, Francesco Scomazzoni, MD, Renata Castellano, MD, Laura Strada, MD, Claudio Righi, MD, Letterio S. Politi, MD, Miles A. Kirchin, PhD, Roberto Chiesa, MD and Giuseppe Scotti, MD Carotid Artery Stenosis: Intraindividual Correlations of 3D Time-of-Flight MR Angiography, Contrast-enhanced MR Angiography, Conventional DSA, and Rotational Angiography for Detection and Grading Radiology 2005;236:204-213.
6. Michel Nonent, MD, Jean-Michel Serfaty, MD, PhD, Norbert Nighoghossian, MD, Francois Rouhart, MD, Laurent Derex, MD.Concordance Rate Differences of 3 Noninvasive Imaging Techniques to Measure Carotid Stenosis in Clinical Routine Practice Stroke. 2004; 35:682.
7. Luca Remondaa, Pascal Sennb, Alain Barthb, Marcel Arnoldc, Karl Olof Lovblada and Gerhard Schroth Contrast-Enhanced 3D MR Angiography of the Carotid Artery: Comparison with Conventional Digital Subtraction Angiography .American Journal of Neuroradiology 23:213-219, February 2002.
8. Mirco Cosottini, MD; Alessandro Pingitore, MD, PhD; Michele Puglioli, MD; Maria Chiara Michelassi, MD; Giancarto Lupi, M DContrast-Enhanced Three-Dimensional Magnetic Resonance Angiography of Atherosclerotic Internal Carotid Stenosis as the Noninvasive Imaging Modality in Revascularization Decision Making. Stroke. 2003;34:660
9. Nederkoorn PJ, Mali WP, Eikelboom BC, Elgersma OE, Buskens E, Hunink MG, Kappelle U, Buijs PC, Preoperative diagnosis of carotid artery stenosis: accuracy of noninvasive testingStroke. 2002 Aug;33(8):2003-8.
10. Tomanek Al, Coutts SB, Demehuk AM, Nudon ME, Morrish WE, Sevick RJ, MR angiography compared to conventional selective angiography in acute stroke Can J Neurol Sd. 2006 Feb;33(1 ):58-62
11. Sarah M. Debrey, BA; Hua Yu, MD; John K. Lynch, DO, MPH; Karl-Olof LOvblad, MD; Violet L. Wright, RN; Sok-Ja D. Janket, MD, MPH Alison E. Baird, FRACP, PhD Diagnostic Accuracy of Magnetic Resonance Angiography for Internal Carotid Artery Disease 2008.
12. TS Riles, EM Eidelman, AW Lift, RS Pinto, F Oldford and GW Schwartzenberg Comparison of magnetic resonance angiography, conventional angiography, and duplex scanning 1992.
13. C.G. Choia, D.H. Leea, J.H. Leea, H.W. Pyuna, D.W. Kangb, S.U. Kwonb, J.K. Kimc, S.J. Kima and D.C. Suh Detection of Intracranial Atherosclerotic Steno-Occlusive Disease with 3D Time of-Flight Magnetic Resonance Angiography with Sensitivity Encoding at 3T 2007.
14. L Remonda, 0 Heid and G Schroth Carotid artery stenosis, occlusion, and pseudo- occlusion: first-pass, gadoliniumenhanced,three-dimensional MR angiography- -preliminary study 1998 Vol 209, 95-102.
15. Hossein Zarei(1), Hosseinali Ebrahimi(2), Kaveh Shafiee(3), Mehrdad Yazdani(4), Kazem Aghili intracranial stenosis in patients with acute cerebrovascular accidents.
16. Dae Chul Suh, Soo-Hyun Lee, Kyung Rae Kim, Sung Tae Park, Soo Mee Urn, Sang Joon Kim, Choong Gon Choi and Ho Kyu Lee Pattern of Atherosclerotic Carotid Stenosis in Korean Patients with Stroke: Different Involvement of Intracranial versus Extracranial Vessels 2003.
17. Ellisiv B. Mathiesen, Oddmund Joakimsen, Kaare H. Bønaa Prevalence of and Risk Factors Associated with Carotid Artery Stenosis: The Tromsø Study 2001.
18. Tatjana Rundek, MD, PhD Do Women Have Worse Outcome After Stroke Caused by Intracranial Arterial Stenosis 2007.
19. G. Neil Thomas et al Increasing Severity of Cardiovascular Risk Factors With Increasing Middle Cerebral Artery Stenotic Involvement inType 2 Diabetic Chinese Patients With Asymptomatic Cerebrovascular Disease 2004.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524161EnglishN-0001November30HealthcareEFFICACY OF BARK OF ACACIA ARABICA IN MANAGEMENT OF BACTERIAL VAGINOSIS : A RANDOMIZED CONTROLLED TRIAL
English7988Rumaiza JahuferEnglish Wajeeha BegumEnglishBack ground and Objective: Bacterial vaginosis (BV) is a polymicrobial syndrome having alteration of vaginal flora involving a decrease in Lactobacilli and predominance of anaerobic bacteria. Objective was to evaluate the efficacy of the Bark of Acacia arabica (chal babool) as an alternate therapy in the management of Bacterial Vaginosis. Methodology: This was a prospective, single blind, standard controlled randomized clinical trial on 45 patients (30 patients in test group and 15 in control group) who attended in and outpatient Department of OBG, National Institute of Unani Medicine hospital, Bangalore, India with complaint of abnormal vaginal discharge or vulvovaginal pruritus. Married patients aged 18- 45 years with regular cycles and diagnosed as having BV were included in this study. Patients were excluded if there was a blood stained discharge, any organic pelvic pathology, systemic illness, malignancy, AIDS, syphilis, gonorrhoea, pregnant and lactating women. Decoction of Chal babool was given orally (30gms twice daily) for one month and standard drug Tab. Metronidazole (400mg twice daily) for 7 days was given in test and control group respectively. For diagnosis and cure rate of bacterial vaginosis, Amsel’s criteria were used. Results: There was a significant improvement in the subjective and objective parameters; test drug was found to have similar effective as in control drug in the management of Bacterial Vaginosis (P =1.000) statistically. Conclusion: Patients in both groups have shown improvement by treatment. This study confirms the efficacy of chal Babool as potent astringent and antimicrobial. Phase -3 clinical study shall be recommended with large sample size and prolonged duration.
EnglishBacterial vaginosis, Chal babool, Clue cells, Whiff test, Randomized controlled trialINTRODUCTION
Bacterial vaginosis (BV) is a polymicrobial syndrome having alteration in vaginal flora involving a decrease in Lactobacilli and predominance of anaerobic bacteria including Gardnerella vaginalis, Mobiluncus species, Prevotella species, Mycoplasma hominis and Atopobium vaginae, is among the most common cause. Vaginal discharge is the most common complaint of women of childbearing age. At least 50% of patients have no symptoms [1,2,3]. The Centers for Disease Control and Prevention (CDC) has recently included bacterial vaginosis on their list of emerging infectious diseases [2]. The BV diagnosis was based on Amsel’s criteria [3,4]. The pH of normal vaginal fluid is usually in the range of 3.8 to 4.5. Low pH inhibits bacterial growth and decreases bacterial attachment. In BV the pH is usually above 4.7[5]. Overall there is a significant increase in the vaginal secretion to 109 –1011/gm instead of 105 –106 /gm, with increase of 100 fold to 1,000 fold bacteria[6].BV is more common in women with sexual transmitted infections (STIs), who have recently changed their sex partner, multiple sexual partner, cigarette smoking, stress, low Socioeconomic Status (SES), use of intra uterine contraceptive device (IUCD), frequent vaginal douches, early age at first intercourse and black ethnicity[1,5,7,8,9].The prevalence was 63% in women with multiple sexual partners, 34% in monogamous sexual relationship and 24-51% in lesbian women [10,11]..Women taking vitamin or nutritional supplements were less likely to have bacterial vaginosis[12], and recurrence is common[5,10,13]. BV has been associated with complications like a six fold increased rate of postpartum endometritis, a threefold of pelvic inflammatory, a three to fourfold of vaginal cuff cellulites, amniotic fluid infection and chorioamnionitis [14] and increases the risk of HIV transmission 2-4 fold [14, 15]. In Unani system of medicine white discharge per vaginum (sailanur rehm) is treated with many single drugs since ancient period. Therefore Bark of Acacia Arabica (Chal babool) was selected as research drug as it possess astringent (habis), styptic (qabiz)[16,17,18,19,20], desiccant (mujaffif), tonic(muqawi)[18], antibacterial, antimicrobial, antiseptic properties [20,21,22,23,24].Keeping the above mentioned properties in view an attempt has been made to evaluate the effect of bark of Acacia Arabica in the management of BV.
METHODOLOGY
Study design: A prospective, single blind, standard controlled randomized, pre and post evaluation clinical trial was conducted on 45 patients (30 patients in test group and 15 in control group) who attended in and outpatient department of OBG at National Institute of Unani Medicine hospital, Bangalore, India with complaint of abnormal vaginal discharge or vulvovaginal pruritus during November 2011 to April 2013.The study was performed in accordance with the Declaration of Helsinki and approved by institutional Ethical Committee, NIUM, Bangalore. Married patients aged 18- 45 years with regular cycles and diagnosed as having BV were included in this study after receiving informed consent. In both symptomatic and asymptomatic groups, the diagnosis of BV was based on the presence of at least 3 of the 4 clinical criteria proposed by Amsel and co-workers: adherent watery vaginal discharge, vaginal pH > 4.5, positive amine test, and presence of clue cells [25].Women were excluded if there was a blood stained discharge, any organic pelvic pathology, systemic illness, malignancy, AIDS, syphilis, gonorrhoea, pregnant and lactating women. A detailed history including demographic profile of patients was noted. Following complete evaluation of history and clinical examination, patients were subjected to baseline investigations of complete blood picture, complete urine analysis, random blood sugar, ESR, HIV, VDRL, pelvic ultrasound and Pap smear to exclude systemic illness and pelvic pathology. Safety of drug was assessed by SGOT, SGPT, alkaline phosphatase, blood urea and serum creatinine before and after the treatment. Diagnosis by Amsel’s criteria ie.Vaginal pH was measured by Ranbaxy pH indicator with a range of 4 to7. The pH strip used was a colour-fixed indicator stick. The amine test was considered positive when secretions emitted a fishy amine odor with the addition of 10% KOH[26]. Vaginal secretions were combined with 2 drops of normal saline on a slide and covered with a cover slip for the wet mount. Examination under high-powered microscopy identified the percentage of clue cells
Interventions
The patients were randomly allocated in to test (n=30) and control (n=15) groups by lottery method. Decoction of chal babool was given orally (30gms twice daily) before meal for one month and standard drug Tab. Metronidazole (400mg twice daily) for 7 days in test and control group respectively. Patients were called after two weeks during trial. At each visit vaginal pH, wet mount and amine test were performed. After the completion of the 4 weeks, pre and post treatment values of symptoms and signs were analyzed to evaluate the response or effect of the treatment. Follow up was scheduled to look for recurrence in two visits at 2 weeks and 4 weeks following completion of therapy in those patients who respond with treatment or who were clinically cured.
Assessment
Cure rate was assessed by Amsel’s criteria. Complete cure was considered when there was absence of signs of Amsel’s criteria and associated symptoms. Relief of disease was considered when significant changes in Amsel’s criteria with absence of associated symptoms. Partially relieved was considered when significant changes in Amsel’s criteria with presence of associated symptoms. No response for treatment was labelled when no change in pre-treatment subjective and objective parameters either during or after the treatment.
Statistical Analysis
The Statistical software SPSS 15.0 was used for the analysis of the data. Descriptive and inferential statistical analysis has been carried out in the present study. Results on continuous measurements were presented on Mean ? SD (Min-Max) and results on categorical measurements were presented in number (%).Significance was assessed at 5 % level of significance. Student’s 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 or more groups.
RESULTS
Patients’ recruitment is mentioned in Fig. 1. A significant improvement of white discharge was observed in test group 23(76.7%) compared to control group 11(73.3%) after intervention Table2. In present study associated symptoms like pruritus vulvae in 28(62.2%), low backache in 32(71.1%), burning micturition in 25(55.5%) and dyspareunia in 9(20%) were reported in test group. The symptoms were reduced with suggestive significance with P value 0.05< P< 0.10 after comparison of both groups after treatment. (Table2) DISCUSSION A detailed analysis revealed that the mean age of patients was 31.90±6.22 in the test group and 29.73±6.16 in the control group. According to SES majority of patients belongs to Upper Lower class (64.4%). Women educated in primary and secondary schools were the most commonly affected groups [13/45(28.9%) and 22/45(48.9%), respectively]. A majority of the patients were housewives (91.1%) as shown in Table 1. Present study showed that the test drug was significantly effective as metronidazole in BV. Table 1 shows majority of the patients were in the age group of 19 - 40 years. The mean ages of participants were 31.90±6.22 and 29.73±6.16 in test and control group respectively. This finding is correlated with the statement of Ayenalem S et al and Xueqiang et al. that disease is more commonly seen in childbearing age group [1, 27].In present study the incidence of bacterial vaginosis was observed more in low SES i.e 40 (88.8%) when compare to upper group, 5 (11.2%) (Table1). This finding is correlated with the statement of many studies conducted. [11, 28,29,30].Yang LR et al. reported that lower genital tract infections are found in low SES [31]. Table 1 shows the number of patients were maximum in the illiterate and secondary level education 40(88.9%) compared to intermediate and higher education 5(11.1%). This finding is in accordance with the statement of previous studies that the disease is more prevalent in illiterate people [28,29,32,33]. Our study showed that incidence of bacterial vaginosis is concerned with occupation of patients (Table 1) i.e., maximum in house wife group 41(91.1%) compare to working class 4(8.9%). Similar finding were reported by Holzman C et al [34]. A significant improvement of white discharge was observed in test group 23 (76.7%) compared to control group 11(73.3%) after intervention. This improvement may be due to antibacterial, antimicrobial, astringent properties of bark of Acacia arabica. [20,21,24]. In present study associated symptoms like low backache and dyspareunia were reported. The symptoms were reduced with suggestive significance. These findings are correlated with previous study conducted by Rajvaidhya et al states that the extract from bark of babool is highly astringent herb may block the body's pain triggers [35]. No adverse effect of test drug was observed during the trial and all the safety profile investigations were within normal limits, hence Acacia arabica was found as safe drug. The limitation of the study was small sample size causing statistical error. Therefore further trial can be carried out to confirm the efficacy and potency of drug on large number of patients.
CONCLUSION
It may be concluded that bark of Acacia Arabica was found to be beneficial in patients of bacterial vaginosis due to its antimicrobial, antibacterial, astringent, styptic, desiccant and tonic effects. It can serve as an alternate remedy for metronidazole, in which relapses are more. This study confirms the efficacy and safety of Acacia arabica as alternate therapy in the management of bacterial vaginosis. Phase three clinical trial can be carried out to confirm the efficacy and potency of research drug. Conflict of interest None
ACKNOWLEDGEMENT
The authors are grateful to the Department of Ayurveda, Yoga, Unani, Siddha and Homeopathy (AYUSH), Ministry of Health, India, Director IIM and commissioner, Colombo for providing all facilities to complete the research.
Englishhttp://ijcrr.com/abstract.php?article_id=983http://ijcrr.com/article_html.php?did=983REFERENCES
1. Ayenalem S, Yusuf L, Ashenafi M. Lactic Acid Bacterial Vaginosis among Outpatients in Addis Ababa. Ethiop J Health Dev. 2010; 24(3):198-204.
2. Misic M, Randelovic G, Kocic B, Antic S, Stojanovic M, Mladenovic V. Complications associated with Bacterial Vaginosis. A Review Article ACTA FAC MED NAISS 2005; 22 (4): 161-165.
3. Martinez RCR, Franceschini SA, Patta MC, Quintana SM, Gomes BC, Martinis ECPD et al. Improved cure of bacterial vaginosis with single dose of tinidazole (2g), Lactobacillusrhamnosus GR-1, and Lactobacillus reuteri RC- 14: a randomized, double-blind, placebo-controlled trial. Can J Microbiology 2009; 55: 133-138.
4. Larsson PG, Pedersen BS, Ryttig KR, Larsen S. Human lactobacilli as supplementation of clindamycin to patients with bacterial vaginosis reduce the recurrence rate; a 6- month, double-blind, randomized, placebocontrolled study. BMC Women's Health 2008; 8(3):1-8.
5. Eschenbach DA. Screening, Diagnosis and Management of Bacterial Vaginosis. Issues in Management of STDs in Family Planning Settings: 71-75. [cited on 06/03/12] Available at www.popline.org. 6. Robinson DT, Boustouller YL. Damage to oviduct organ cultures by Gardnerella vaginalis.Int J Exp Path 2011; 92: 260–265.
7. Turovskiy Y, Noll KS, Chikindas ML. The aetiology of bacterial vaginosis. Journal of Applied Microbiology 2011 May; 110(5):1105-28.
8. Hay P. Bacterial Vaginosis. Journal of Paediatrics, Obstetrics and Gynaecology 2002 ;Sep/Oct; 36-40
. 9. Gillet E, Meys JF, Verstraelen H, Bosire C, Sutter PD, Temmerman M et al. Bacterial vaginosis is associated with uterine cervical human papillomavirus infection: a metaanalysis. BMC Infectious Diseases 2011; 11(10): 1-9.
10. Verstraelen H, Verhelst R, Vaneechoutte M, Temmerman M. The epidemiology of bacterial vaginosis in relation to sexual behavior. BMC Infectious Diseases 2010; 10(81):1-11.
11. Anonymous Bacterial Vaginosis.Inverness Medical International (IMIL), Priory Business Park 2009 July; 3-16 [cited on 23/04/12] Available at www.balanceactiv.com.
12. Holzman C, Leventhal JM, Jones NM, Wang J. Factors Linked to Bacterial Vaginosis in Non pregnant Women. American Journal of Public Health 2001 Oct; 91(10):1664-1670.
13. Berek JS, Adashi EY, Hillared PA. Novak’s Gynaecology. 12th ed. London: Williams and Wilkins; 1996;430-431.
14. Zahra A, Fateme G, Reza AM. Comparison of the effectiveness of vitamin C vaginal tabletwith metronidazole vaginal gel in the treatment of bacterial vaginosis African Journalof Pharmacy and Pharmacology 2010 July; 4(7): 484-489.
15. Pirotta M, Fethers KA, Bradshaw CS. Bacterial vaginosis. Australian Family Physician 2009 Jun; 38 (6): 394-397.
16. Ghani N. Khazainul Advia. New Delhi: Idarae Kitabul Shifa; YNM: 339-340.
17. Ibn Sina. Al-Qanoon Fit-Tib (Urdu trans. by Kantoori GH). New Dehli: Idarae Kitabus Shifa; 2007:341.
18. Kabeeruddin M. MakhzanulMufradat. New Delhi: Ejaz Publication House; YNM; 118- 119.
19. Hakeem MAH. Bustan ul Mufradat. New Delhi: Idarae Kitabul Shifa; 2002: 120.
20. Zahoor N, Usmanghani K, Akram M, Asif HM , Saleem QE, Sami A et al. Pharmacological activities of Acacia arabica. Crown Journal of Medicine 2011 Nov; 1(2): 09-11.
21. Shazia M, Saadia MA, Jasmine F, Arif JM, Huma M. Anti-Microbial screening of some medicinal plants extracts. International Journal of Research in Ayurveda and Pharmacy 2011; 2 (4):1258-1264.
22. Malviya S, Rawat S, Kharia A, Verma M. Medicinal attributes of Acacia nilotica LinnA comprehensive review on ethno pharmacological claims. Int J of Pharm and Life Sci 2011 June; 2(6): 830- 837.
23. Yasir M, Shrivastava R, Jain P, Das D. Hypoglycaemic and Antihyperglycemic Effects of Different Extracts and Combinations of Withania coagulans Dual and Acacia arabica Lamkin Normal and Alloxan Induced Diabetic Rats. Pharmacognosy Communications 2012 AprJun; 2(2): 61-66.
24. Banso A. Phytochemical and antibacterial investigation of bark extracts of Acacia nilotica J Med Plant Res 2009 Feb; 3(2): 082- 085.
25. Amsel R, Totten PA, Spiegel CA, Chen KS, Eschenbach DA, Holmes KK. NSV Diagnosticcriteria and microbial and epidemiological association.Am J Med 1983; 74:14-22.
26. Egan ME, Lipsky MS. Diagnosis of vaginitis. Am Fam Physician. 2000; 62:1095-1104.
27. Xueqiang F, Yingzhi Z, Yanfang Y, Yutao D, Huiqing L. Prevalence and risk factors of Trichomoniasis, Bacterial vaginosis and candidiasis for married women of child bearing age in rural Shandong. Jpn J Infect Dis 2007; 60:257- 261.
28. Pawanarkar J and Chopra K. prevalence of lower reproductive tract infection in infertile women. Health and population 2004; 27(2):67-75.
29. Jones FR, Miller G, Gadea N, Meza R, Leon S, Perez J et al. Prevalence of bacterial vaginosis among young women in low-income populations of coastal Peru. International Journal of STD and AIDS 2007; 18: 188–192.
30. Valiani M, Zolfaghari M,Nazemi M, Pirhadi M, Ebrahimian S. The relationship between family planning methods, individual hygiene, and fertility with vaginal infections among the women referring to selected health centers in Isfahan city. Iran J Nurs Midwifery Res. 2011 winter; 16(1):83–92.
31. Yang LR, Zhao H, Wang HP, Li Y, Niu JP, Su KJ et al. Improving ability of married women to prevent reproductive tract infections in rural western China. Environmental health and preventive medicine 2006 Sep; 11: 233-240.
32. Ashraf-Ganjoei T. Risk factor for bacterial vaginosis in women attending a hospital in Kerman, Islamic Republic of Iran. East Mediterr Health J 2005 May; 11(3):410-5.
33. Bhalla P, Chawala R, Garg S, Singh MM, Raina U, Bhalla R et al. Prevalence of bacterial vaginosis among women in Delhi, India. Indian J Med Res 2007 Feb; 125: 167- 172.
34. Holzman C, Leventhal JM, Jones NM, Wang J. Factors Linked to Bacterial Vaginosis in Nonpregnant Women. American Journal of Public Health 2001 Oct; 91(10):1664-1670.
35. Rajvaidhya S, Nagori BP, Singh GK, Dubey BK, Desai Pand, Jain S. A Review on Acacia Arabica- An Indian medicinal plant. IJPSR, 2012; 3 (7):1995-2005.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524161EnglishN-0001November30HealthcareSTUDYING ANTI RETRO VIRAL THERAPY A CAUSATIVE FACTOR FOR OSTEONECROSIS IN HIV INFECTED PATIENTS
English8994Vetrivel Chezian SengodanEnglishBackground and Objectives: Avascular necrosis of femoral head is a common entity. Avascular necrosis of femoral head due to anti-retroviral therapy is an emerging health problem in the world. In India, avascular necrosis of femoral head due to anti-retroviral therapy is not yet reported. We report a case of bilateral avascular necrosis of femoral head as a complication of anti-retroviral therapy. Material and methods: A 41 year old female, a known case of pulmonary tuberculosis had anti tuberculous treatment. While she was on anti tuberculous treatment, she was diagnosed for human immune deficiency infection and put on stavudine, lamivudine and efavirenz [transcriptase inhibitors] and continued for one year. Results: In the follow up period of our patient, she was found to have low back pain and pain in right hip and limp and she was diagnosed of having bilateral avascular necrosis of the femoral head. The diagnosis was confirmed by biopsy of both the femoral heads which revealed avascular necrosis. Interpretation and conclusion: Till date avascular necrosis of the bone due to anti-retroviral therapy is not yet reported from India. We report this case for its rarity and to stress the role of MRI in early detection of avascular necrosis of hip in patients with anti-retro viral therapy.
EnglishAnti-retroviral therapy, avascular necrosis, Nucleoside and Non-Nucleoside reverse transcriptase inhibitors.INTRODUCTION
Avascular necrosis is termed as “osteonecrosis” indicates ischemic death of the bone as a result of insufficient arterial blood supply.[1] Risk factors associated with avascular necrosis have included corticosteroid use, alcoholism, intravenous drug use, smoking, antiphospholipid antibodies, hyperlipidemia, sickle cell anemia, radiation exposure and systemic lupus erythematosus. Metabolic factors such as hyperlipidaemia have also been strongly associated with use of protease inhibitors, nucleoside and non nucleoside reverse transcriptase inhibitors. Regardless of the aetiology avascular necrosis has become an emerging manifestation within the Human immuno deficiency virus population. [1, 2]
MATERIAL AND METHODS
A forty one year old female, presented with history of pain over the lower back for three months and pain in the right hip for one month. She had pulmonary tuberculosis three years back, and was treated with antituberculous treatment under category one of Revised National Tuberculous Control Programme. While she was on anti tuberculous treatment, patient was diagnosed to have Human immuno deficiency virus Infection and was started on antiretroviral drugs stavudine, lamivudine and efavirenz. At one year follow up after anti retroviral therapy she presented with pain in the lower back and right hip. There was no history of steroid intake, cardiac disease and radiation exposure. On clinical examination patient was found to have tenderness over the lower lumbar spine. There was no obvious deformity or swelling. There was no distal neurological deficit. On examination of both the lower limbs, tenderness was present over the scarpa’s triangle on right side with no fixed deformity. Extremes of movements were painful and restricted on the right hip joint. There was no limb length discrepancy. The left hip was clinically normal. Antalgic gait was noted. Laboratory parameters showed that there is no raise in acute phase reactants. CRP and ESR were normal. Complete blood count was within normal limits. CD4 count was 590 cells/mm3 . Lipid profile showed high triglyceride level (420mg/dl) and high cholesterol level (364mg/dl). Peripheral smear was also normal.
RESULTS
Radiograph of the pelvis showed increased density on the right hip joint, slight flattening of the weight bearing zone of the femoral head more on right side. MRI of the lumbar spine and screening of the pelvis showed minimal disc bulge at L4 L5 level with bilateral lateral recess stenosis[figure 1] and avascular necrosis involving both femoral heads[figure 2] which was confirmed by biopsy [figure 3 and 4]. As per Ficat and Arlet classification, it was stage 3 on right and stage 2 on left side [figure 5].
DISCUSSION
Anti retroviral therapy is the only treatment option available for human immuno deficiency infected individuals. Normally combinations of anti retroviral drugs are used. In our country, nucleoside and non nucleoside reverse transcriptase inhibitors are used as a first line of drugs for the diseased individuals. Whereas in western countries protease inhibitors is used as a part of regimen. Both protease inhibitors and nucleoside and non nucleoside reverse transcriptase inhibitors causes’ hyperlipidaemia. The Incidence rate of avascular necrosis have been reported to be 0.135% in the general population, although incidence rates ranging 0.3-0.45% have been observed in human immuno deficiency virusinfected patients. [3].The femoral head is the main location of avascular necrosis and is bilateral in approximately 80% of the cases. Other sites of avascular necrosis involved are knee, ankle, shoulder and wrist. [4, 5] Previously, avascular necrosis has been infrequently described in human immuno deficiency virus -infected patients; but in recent reports, its incidence in these patients has grown between 45–58 times over the rate expected in the general population. [6, 7] A retrospective chart review conducted from 19 human immuno deficiency virus clinics in Spain reported 23 cases of avascular necrosis over a 10- year period with a notable increase in frequency of avascular necrosis from 1.6 per 1,000 AIDS patients during 1993-1996 to 14 per 1,000 patients during 1997-2000. [1] Elevation of cholesterol has been observed with the use of efavirenz and nucleoside reverse transcriptase inhibitors such as stavudine. [8, 9] More recently, higher triglycerides levels were reported in subjects taking stavudine, compared with tenofovir-based regimen. [10] A prospective, randomized, double blind study assessed 602 antiretroviral-naive patients who received tenofovir or stavudine, in combination with lamivudine and efavirenz, and who were observed for 144 weeks. [10] A significant increase in the triglyceride level was observed among stavudine-treated patients. [10] Osteonecrosis was seen in patients with different levels of immune status. In most patients, CD4 counts at diagnosis of osteonecrosis were above 200 cells/mm3 . In some of the reported cases, although the average CD4 count was 501 cells/mm3 and the human immune viral RNA was suppressed (Englishhttp://ijcrr.com/abstract.php?article_id=984http://ijcrr.com/article_html.php?did=984REFERENCES
1. Ramani Reddy MD, Monika ND, Robert D, Arjun Dutta, Jacquay Oliver, and Winston Frederick. Avascular Necrosis and Protease Inhibitors. Journal of the National Medical Association. November 2005; 97: no.11.1543- 1546.
2. Paul Monier, Kevin McKown, Michael S. Bronze. Osteonecrosis Complicating Highly Active Antiretroviral Therapy in Patients Infected with Human Immunodeficiency Virus.CID 2000; 31 (December).1488-1492
3. Fe´lix Gutie´rrez, eT al. Osteonecrosis in Patients Infected with HIV: Clinical Epidemiology and Natural History in a Large Case Series from Spain .J Acquir Immune Defic Syndr .July 2006; Vol 4:No3.
4. Aurélie C Molia, Christophe Strady, Christine Rouger, Isabelle M Beguinot, Jean-Luc Berger, and Thierry C Trenque. Osteonecrosis in Six HIV-Infected Patients Receiving Highly Active Antiretroviral Therapy. The Annals of Pharmacotherapy. 2004 December; Volume 38:2050-2054.
5. Gerster JC, Camus JP, Chave JP, et al. Multiple site avascular necrosis In HIV infected patients. J Rheumatol 1991; 18:300– 2.
6. Wolfe Cj, Taylor-Butler Kl. avascular necrosis. A case history and literature review. Arch FAM Med. 2000; 9:291–294.
7. Mankin HJ. Nontraumatic necrosis of bone (osteonecrosis) N Engl J Med. 1992; 326:1473–1479.
8. Calza L, Manfredi R, Mastroianni A, Osteonecrosis and highly active antiretroviral therapy during HIV infection: report of a series and literature review. AIDS Patient Care STDS. 2001 Jul; 15(7):385-9.
9. Hamilton D, Rivaldo VC and Anamaria MM Paniago. Dyslipidaemia Associated with the Highly Active Antiretroviral Therapy in AIDS Patient: Reversion after Switching (Stavudine to Tenofovir and Lopinavir/Ritonavir to Atazanavir/Ritonavir). The Brazilian Journal of Infectious Diseases 2007; 11(2):290-292.
10. Gallant JE, Staszewski S, Pozniak AL, et al. Efficacy and safety of tenofovir DF vs. Stavudine in combination therapy in antiretroviral-naïve Patients: a 3-year randomized trial. JAMA 2004; 292:266–8.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524161EnglishN-0001November30HealthcarePRIMARY HYPERPARATHYROIDISM DUE TO BILATERAL PARATHYROID ADENOMA - A CLINICAL CASE REPORT
English95100Mousumi MukhopadhyayEnglish Sharmistha ChattopadhayEnglish Sanghamitra ChakrabortyEnglish Swati BhattacharyyaEnglish Soumika BiswasEnglishPrimary hyperparathyroidism is known by inappropriate secretion of parathyroid hormone that results in hypercalcaemia. The most common cause of primary hyperparathyroidism is solitary adenoma of the parathyroid followed by multiple adenoma, parathyroid hyperplasia and carcinoma, in that order. This paper describes the case of a fifty two year old man who presented with pain and swelling over multiple joints on trivial trauma( right elbow, right knee and left shoulder) against a backdrop of diverse symptoms like anorexia, nausea, weight loss, etc. of insidious onset over the past ten months. Detailed laboratory workup revealed hypercalcaemia (measured on more than one occasion) with concomitant hypophosphatemia, hypercalciuria, raised serum intact parathyroid hormone and elevated skeletal isoenzyme of serum alkaline phospatase. The causes of non parathyroid hypercalcaemia in the differential diagnosis were excluded by the serum 25 hydroxy vitamin D estimation which was found to be in the upper normal range. Finally, the diagnosis was clinched by the serum iPTH assay which is the most sensitive and specific test for parathyroid function. The histological picture was consistent with parathyroid adenoma. Subsequently, surgical resection of the parathyroid achieved normocalcaemia and the patient was discharged with bisphosphonates and calcium supplements.
EnglishPrimary Hyperparathyroidism, Adenoma, HypercalcaemiaINTRODUCTION
Primary Hyperparathyroidism is known by inappropriate secretion parathyroid hormone that result in hypercalcemia. 1 The incidence of the disease is 0.1% in general population, females being affected more than males by a ratio 3:2. 2 The disease occurs most often due to solitary adenoma of parathyroid gland ( 80-85% of cases) and less commonly due to multiple adenoma and parathyroid hyperplasia (15%) parathyroid cancer being the rarest (Englishhttp://ijcrr.com/abstract.php?article_id=985http://ijcrr.com/article_html.php?did=985REFERENCES
1. Bringhurst FR, Demay MB, Krokenberg HM : Hormones and Disorders of Mineral Metabolism : William Textbook of Endocrinology, Melmeds, Polonosky KS, Larsen PR, Krokenberg HM (eds) , 2012, 12ed, 1260 Philadelphia
2. Deshmukh, R. G.; Alsagoff, S. A. L.; Krishnan, S.; Dhillon, K. S.; Khir, A. S. M. (1998). "Primary hyperparathyroidism presenting with pathological fracture". Journal of the Royal College of Surgeons of Edinburgh 43 (6): 424–427.
3. Bilezikian, John P.; Silverberg, Shonni J. (2002). "Primary hyperparathyroidism: Epidemiology and clinical consequences". Clinical Reviews in Bone and Mineral Metabolism 1 (1): 25–34.
4. Bolland, M. J.; Grey, A. B.; Gamble, G. D.; Reid, I. R. (2004). "Association between Primary Hyperparathyroidism and Increased Body Weight: A Meta-Analysis". Journal of Clinical Endocrinology and Metabolism 90 (3): 1525.
5. "Endocrine Pathology". Retrieved 2009-05- 08.
6. Bile Zikian JP. Calcium and bone metabolism. In : Becker KL, Ed. Principles and Practice of Endocrinology and metabolism. Philadelphia: JD Lipincott, 1990: 398-569.
7. Jorde R, Bonaa HK, Sundsfjord J Primary hyperparathyroidism detected in a health screening: The Tromso Study. Journal of Clinical Epidemiology 2000; 53: 1164-9.
8. Health Hodgson SF, Kennedy MA. Primary Hyperparathyroidism: incidence, morbidity and potential impact in a community. NewEnglJMed 1980; 302:189_93.
9. WassifW, Kaddam I, Prentice M, Iqbal ST, Richardson A. Vitamin D deficiency and primary hyperparathyroidism presenting with repeated fractures.J Bone Joint Surg 1991:73- B:343-4.
10. Wengreen HJ, Munger RG, West NA et al Dietary protein intake and risk of osteoporotic hip fracture in elderly residents of Utab. J Bone Miner Res 2004: 19: 537-545
11. Gauger PG, Doherty GM. Parathyroid Gland. In: Townsend CM, Evers BM, Beauchamp RD, Mattox KL, editors. Sabiston Textbook of surgery. 17th ed. Philadelphia: Saunders/Elsevier;2004.p.1063-78.