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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241523EnglishN2013December16HealthcareASSOCIATION BETWEEN FUNCTIONAL REACH TEST AND STAR EXCURSION BALANCE TEST IN HEALTHY CHILDREN OF 14-16 YRS
English0105Atiya A. ShaikhEnglish Radhika WalunjkarEnglishObjective: To score and correlate Functional reach test distance and star excursion balance test distance in children between 12-16 years. Material and Method: 200 healthy children were assessed using Functional reach test and star excursion balance test. Results: Pearson’s correlation showed very strong positive to strong positive association between scores of Functional reach test and Star excursion balance test (in all directions). Conclusion: Functional Reach Test and Star Excursion Balance Test can be used interchangeably to assess dynamic balance in children.
Englishdynamic balance strategies, feed Functional mechanism, children, Functional reach test, star excursion balance test.INTRODUCTION
Balance assessment is necessary for many patients in physiotherapy setting in order to establish appropriate treatment goals, reduce fall risk, increase awareness for appropriate device and treatment prescription, designing of fall prevention programs and prognosis assessment1.
An individual has to perform multiple tasks that challenge dynamic postural control system to perform ADL’s effectively. For the balance assessment to be accurate, the test used should attempt to simulate conditions of day to day life in order to stress postural control system to its maximum limit2. Keeping this in mind, the clinicians should use functional tasks performed in day to day life to assess balance in clinical set up. These tasks are also should be chosen according to their familiarity with the subject, lesser time and resource consumption1,2.
A child develops adult like balance by the age of seven years3. Common functional activities performed by them include reaching in various directions with upper limb and lower limb with in and out of base of support, running and jumping. Scales like Berg balance scale, Bruinnik’s Osterestky test of motor proficiency, balance efficacy scale simulate these activities4 but require more time, space and few equipments hence it is unsuitable for busy clinical setting.
The activities mentioned in above scales are mimicked by functional reach test and star excursion balance test6, 7.
Functional reach test assesses the distance a person can reach in front beyond arm’s length while maintaining fixed base of support in standing position6. Ankle strategy of postural control is challenged in this test where as Star Excursion Balance Test involves moving in
prescribed directions while maintaining balance on contra lateral leg7. The person relies on stepping strategy of postural control for maintaining balance effectively in this test.
Functional reach test has been used traditionally to assess dynamic balance in healthy and patient population of all ages 6,8,9 where as star excursion balance test is gaining popularity as dynamic assessment tool for healthy and sports person of young and elderly 7,10,11,12,13. These two tests can be preferred for healthy children due to their familiarity with the functional activities of children.
Validity of functional reach test for children of 14-16 yrs is proved8 but the same for Star excursion balance test for this age group is yet to be established. As both these tests involve use of feed forward postural control strategies, they may be inter related. A positive association between these two tests will ensure the validity of star excursion balance test for this age group. In that case, any one of these tests can be used instead of two to evaluate balance for all related dynamic activities thus reducing evaluation time.
The co-relation between these two tests and their usefulness to assess dynamic balance in 14-16 yrs of children is still unexplored. Thus this study was designed to find the association between FRT and SEBT in children between 14-16 yrs.
MATERIALS AND METHODS
Research Design: Cross sectional
Inclusion Criteria
Healthy children of both genders between age group of 14 yrs to 16 yrs
Exclusion Criteria
Children with Mental retardation, known behavioural, cognitive, sensory, vestibular, musculoskeletal or neuromuscular disorders
Setting of the study
Public schools in Pune
Sample size
200 children
Sample Selection Method
Convenience
Materials Used
Measuring tape, chalk, Score sheets
PROCEDURE
Ethical committee clearance from college authorities and consents from the school authorities and parents were obtained. Children were assessed using Functional reach test and Star excursion balance test using standardized procedures6,7. Findings were noted and analysed using SPSS11.00 version.
OBSERVATION AND RESULTS
Pearson’s correlation coefficient value for FRT and SEBT in anterior, anterolateral, lateral posterolateral, posterior, posteromedial, medial, anteromedial direction was 0.9109, 0.933, 0.8866, 0.7335, 0.6043, 0.4152, 0.3814, 0.7211.
DISCUSSION
An individual has to perform a varied range of activities in order to complete ADL’s effectively and independently. These different tasks challenge postural control system in different ways and directions thus involving use of feedback, feed forward mechanisms and ankle, hip, or stepping strategies. Appropriate mechanism is chosen according to task being preformed14.
Change in task causes movement of different body segments, alters anticipatory postural adjustments and results in inclusion of other uninvolved segments for stabilising body those body thus altering the muscle activation sequence. The postural control mechanism involved may be same for different activities but, the muscle activation sequence while performing those activities will change according to the part moved out of base of support and parts required to stabilise the body while this task is being performed14.
Activities preformed by children like reaching for objects in different directions or playing, involve variation of centre of gravity in different directions
with in and out of base of support thus a varied activation of muscles involved in anticipation to the movement. FRT involves reaching in front as far as possible keeping foot in complete contact with ground. This task causes displacement of centre of gravity in forward direction by rotating around ankle joint with maintained hip extension thus activating ankle or hip strategy. It has been observed that healthy individual use ankle strategy to perform such tasks. Here, the gastro-soleus are the main muscle activated along with other anti gravity muscles required for a closed chain activity15.
The other commonly performed action by children while playing is running and jumping .These are dynamic activities causing stepping response in relation to the continuously changing base of support and centre of gravity. Test like SEBT is reaching as far as possible with one leg in each of eight directions while maintaining balance on contra-lateral limb. Here, the standing leg requires, good range of motion of ankle dorsiflexion, knee flexion, hip flexion, adequate Glutei and other antigravity muscle strength in order to control closed kinematic motion occurring while performing the task. As this task involves use of antero - posterior and medio-lateral feed forward postural strategies, it challenges gluteus maximus, medius, minimus, gastro-soleus and tibialis anterior both. The feed forward postural control mechanism along with different muscle activation and strategies is challenged while reaching in anterior, anteromedial, anterolateral, medial, lateral, postero-medial, postero-lateral and posterior direction to complete the test12.
FRT and SEBT both challenge feed forward postural responses but the sequencing of stabilisation forces and activation of muscles required and strategy being used while performing these tests is different .12,15
This study shows that, there is a very strong positive co-relation between FRT and SEBT scores of anterior, anterolateral, posterolateral lateral, anteromedial direction whereas, strong positive correlation between FRT and SEBT scores of posterior and medial direction and positive correlation between FRT and SEBT posteromedial direction scores in children between 14-16 yrs. This finding proves the hypothesis that, both tests are associated as the underlying mechanism for postural control is same. It also validates SEBT as a tool for dynamic balance assessment. This can help the therapists to choose appropriate test to assess dynamic balance as per the need of assessment and condition of the subject to be assessed. The patients with upper extremity affection can be judged by their SEBT skills and the patients with lower limb impairment can be judged by their FRT skills for their dynamic balance.
We know that, height and weight are found to influence FRT and SEBT distance12,9 but, since this study was performed to compare distances of same children these factors were not considered. It has been proved that gender does not affect the distance reached in both tests hence children of both gender were included as per the availability of them.
The main limitation of the study is sample selection by convenience sampling method ,a larger sample size with random sampling method would have been more appropriate for generalising the observations of this study.
CONCLUSION
FRT has been used as a valid assessment tool for balance evaluation since a long time .The study proved a positive correlation between both the tests, thus it highlights the validity of SEBT in this age group. As SEBT requires no equipment and is a preferred activity in children it should be used widely to assess balance in this age group. They can be used interchangeably to assess dynamic balance in children. Any one of these tests can be used instead of two to evaluate balance for all related dynamic activities thus reducing evaluation time.
ACKNOWLEDGEMENT
We would like to thank students, parents and principals of all schools visited, along with Dr. Sujit Kadrekar, Dr. Aparna Sadhale (PT), Dr Rashmi Joshi (PT), Dr. Abha Dhupkar (PT), for their support and encouragement. We acknowledge the great help received from scholars whose articles cited and included in references of this manuscript. We are grateful to authors, editors and publishers of all those articles, journals and books from where the literature of this article has been reviewed and discussed. We are also grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=1003http://ijcrr.com/article_html.php?did=1003
Browne J, O'Hare N. A Review of the Different Methods for Assessing Standing Balance. Physiotherapy. 2001. 87; 9:9489-495.
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Shumway –Cook A, Woollacott M:translating research into clinical practice; Motor control posture and balance, Development of posture and balance ,ed-4.Lippincott Williams and Willkins,United states,2011;162,221-222
Alexandra K, Inge D, Wim P et al. Construct Validity of the Assessment of Balance in Children Who Are Developing Typically and in Children With Hearing Impairments
Physical therapy 2010; 90: 1783-1794
Kembhavi G, Darrah J, Magill-Evans J, Loomis J. Using the Berg Balance Scale to distinguish balance abilities in children with cerebral palsy. Pediatr Phys Ther. 2002;14:92–99
Donahoe B, Turner D, Worrel T. The use of functional reach as a measure of balance in boys and girls without disabilities of age 5-15 yrs. Pediatric Physical therapy 1994;6:189-193
Gribble P A. The star excursion balance test as a measurement tool. Athl. Ther Today 2003;8(2):46-47
Bartlett D, Birmingham T. Validity and reliability of pediatric reach test .Pediatric Physical therapy 2003;15:84-92
Volkman K, Stregious N ,Stuberg W et al. Methods to improve the reliability of functional reach test in children and adolescents with typical development. Pediatric physical therapy.2007;19:20-27
Robinson RH, Gribble PA,Support for reduction in number of trials needed for SEBT Archives of physical medicine and rehab. 2008.89(2); 364-370
Kinzey S, Armstrong C. The reliability of the Star-Excursion Tests in assessing dynamic balance. J Orthop Sports Phys Ther. 1998; 27:356-360.
Lauren C, Olmsted, Christopher R, et al. Efficacy of SEBT in detecting reach deficits in subjects with chronic ankle instability. J Athl.Train.2002;37(4):501-506
Gribble PA, Hertel J, Plisky P. Using the Star Excursion Balance Test to Assess Dynamic Postural-Control Deficits and Outcomes in Lower Extremity Injury: A Literature and Systematic Review, Journal of athletic training 2012; 47(3): 339-357
Winter D.Human balance and posture control during standing and walking .Gait and Posture;1995;Vol.3:193-214
Wernick-Robinson M, Krebs DE, Giorgetti MM. Functional reach: does it really measure dynamic balance? Arch Phys Med Rehabil. 1999;80:262–269
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241523EnglishN2013December16HealthcareVARIATION IN THE ORIGIN OF LEFT VERTEBRAL ARTERY WITH INCREASE IN THE LENGTH OF BRACHIOCEPHALIC TRUNK
English0609Gavishiddappa A. HadimaniEnglish Ishwar B. BagojiEnglish B. M. BannurEnglish R. S. BulagoudaEnglish B. G. PatilEnglish Sahana B. N.EnglishAn understanding of the variability of vertebral artery remains most important in angiography and surgical procedures where an incompatible knowledge of anatomy can lead to complications. Vertebral artery is important artery to supply posterior part of cerebral circulation. During routine dissection of cadaver for undergraduate dissection we encountered variations in relation to origin of left vertebral artery. Variant left vertebral artery was arising from arch of aorta directly. In the right side of the same cadaver length of vertebral artery was reduced due to increase in the length of brachiocephalic trunk.
EnglishArch of aorta, Brachiocephalic trunk, Cervical vertebra, Vertebral arteryINTRODUCTION
The vertebral artery is important artery to supply posterior part of cerebral circulation. According to the standard textbooks of anatomy, vertebral artery is the largest and constant stem of subclavian artery, both in origin and distribution. It arises from the superior surface of the first part of the subclavian artery medial to the scalenus anterior muscle. The vessel takes a vertical posterior course to enter into the transverse process of the sixth cervical vertebra. It continues through the transverse foramina of the cervical vertebrae and after passing through the transverse foramen of the atlas, turns posteromedially on its posterior arch, pierces the atlantooccipital membrane and the dura mater, respectively and then enters the foramen magnum [1]. Both Vertebral arteries unite at the caudal border of the pons to form unpaired basilar artery. This vessel courses along the ventral aspect of the brainstem [2, 3]. The segment of the vertebral artery from its origin at the subclavian artery to its entry into the respective transverse foramina is called the pretransverse or prevertebral segment [4].
An understanding of the variability of vertebral artery remains most important in angiography and surgical procedures where an incompatible knowledge of anatomy can lead to complications [5].
CASE REPORT
During routine cadaveric dissection for undergraduate students in the department of anatomy Shri B M Patil Medical College, Hospital and Research centre, BLDE University, Bijapur we found variation in the origin of left vertebral artery and length of brachiocephalic trunk on right side was increased, the details are explained below. Variations were dissected, examined and photographed. Variations include,
Variation in the origin of left vertebral artery: left vertebral artery originated directly from arch of aorta between the origin of left common carotid artery and left subclavian artery. The distance between the origin of left vertebral artery and
neighboring arteries were 3 mm and 4 mm respectively. Diameter of the left vertebral artery at its origin was 6 mm. The variant left vertebral artery coursed upward to the transverse foramen of the 6th cervical vertebra. The length of the prevertebral segment of the variant left vertebral artery was 93 mm. (fig -1)
Increase in the length of brachiocephalic trunk: The length of the brachiocephalic trunk was increased to 74 mm, undue increase in the length of the brachiocephalic trunk is noticeable. After its prolonged course upwards brachiocephalic trunk divided in to right subclavian and right common carotid artery. The right vertebral artery originated from the right subclavian artery like normal right vertebral artery. The right vertebral artery entered the transverse foramen of the 6th cervical vertebra. The length of the prevertebral segment of the right vertebral artery was 23 mm (fig -1).
DISCUSSION
The vertebral artery is subject to mechanical stress, dynamic obstructions, thrombosis that propagates to brain infarction and traumatic dissecting aneurysms in addition to constriction, embolism, and occlusive disease. Pathology of the vertebral artery is characterized by catastrophic strokes in the young and by disability without stroke.
Anatomical variations in the major vessels of have been reported earlier. The review of literature shows many variations. It is very common to find the variation in the origin of left vertebral artery especially from arch of aorta, but it is not common to find the increased length of brachiocephalic
trunk. However, increased length of brachiocephalic trunk has not been reported to the best of our knowledge.
The left vertebral artery may arise directly from left common carotid artery, left subclavian artery or from arch of aorta. The frequency of left vertebral artery arising from arch of aorta in Japanese study was 5.8%. There was no difference between male and female [6]. In the Indian study 1.6% had left vertebral artery as branch of arch of aorta. Five out of six cadavers with the anomalous aortic arch branching were females. One male cadaver presented an anomalous origin of left vertebral directly from arch [7].
A study by poonam et al left vertebral artery originated from the external carotid artery in common with occipital artery at the level of intervertebral disc between C2 and C3 vertebrae and took the course without entering any foramen transversarium [8].
Lippert Pab’s classified the left vertebral artery according to the origin from the aortic arch as Type A, B, C, D, E, F, G and H, left vertebral artery between the left common carotid artery and left subclavian artery as Type A(3%), between a common trunk formed by brachiocephalic trunk and left common carotid artery and left subclavian artery as Type B(Englishhttp://ijcrr.com/abstract.php?article_id=1004http://ijcrr.com/article_html.php?did=1004
Moore KL. The Developing Human. Clinically Oriented Embryology. 3rd Ed. WB Saunders, Philadelphia. 1982; 291–318.
Clemente CD. Anatomy–A Regional Atlas of Human Structure. 4th Ed., Baltimore- Philadelphia-London-Paris-Bangkok-Buenos Aires-Hing Kong-Munich-Sydney-Tokyo-Wroclaw, Williams and Wilkins. 1997; 458–459.
Drake RL, Vogl AW, Mitchell AWM. Gray’s Anatomy for Students. 2nd Ed., Edinburg-London-Melbourne-New York, Churchill Livingstone. 2005; 976.
Matula C, Trattnig S, Tschabitscher M, Day JD, Koos WT. The course of the prevertebral segment of the vertebral artery: anatomy and clinical significance. Surg Neurol. 1997; 48: 125–131.
Wasserman BA, Milkulis DJ, Mananzione JV. Origin of the right vertebral artery from the left side of the aortic arch proximal to the origin of the left subclavian artery. AJNR Am J Neuroradiol. 1992; 13: 355–358.
Koh-ichi. Yenke et. Al anatomical study of vertebral Japanese adults. Anatomical science International; 2006: 81, 100-6
Nayak SR, Pai MM, Prabhu LV, D’Costa S, Shetty P. Anatomical organization of aortic arch variations in India: embryological basis and review. J Vasc Bras 2006; 5:95-100.
Poonam , Singla R K , Sharma T . Incidence of anomalous origins of vertebral Artery - anatomical study and clinical significance. J of Cli and Diagnostic Research: 2010; 4:2626-31
Lippert H, Pabst R. Arterial Variations in Man. Classification and Frequency. JF Bergmann Verlag, Munchen. 1985; 30–38.
Arey LB. Development of arteries. The vascular system In Developmental Anatomy. A Textbook and Laboratory Manual of Embryology. 6th Ed., Philadelphia and London, WB Saunders Company. 1957; 367–373.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241523EnglishN2013December16HealthcareA RARE CASE OF EPIDERMOID CYST OF CLITORIS
English1012Latha EkanathEnglish Anandraj RajasekaranEnglishEpidermoid cysts are slow growing tumours of the epidermal cells, commonly seen in neck, scalp, face or trunk. Generally, epidermoid cysts of the clitoris are seen after genital mutilation and trauma. We hereby report a case of epidermoid cyst of clitoris in a 16 year old girl who presented with complaints of genital swelling without any history of previous mutilation / trauma. Simple resection of the cyst was done with complete cosmetic recovery.
EnglishEpidermoid cyst, clitoral cyst, clitoromegalyINTRODUCTION
Cysts of the clitoris are rare and have to be differentiated from clitoromegaly which is a disorder of sexual differentiation. Epidermoid cysts of the clitoris are usually inclusion cysts due to prior genital trauma and / or female circumcision practiced in some communities.
CASE REPORT
A 16 year old adolescent girl presented to the gynaec outpatient department with complaints of swelling in the external genitalia for 2 months duration. There was no history of pain or discharge per vaginum. There was no history of genital trauma. She attained menarche at the age of 13 years and there were no menstrual complaints.
On general examination, secondary sexual characteristics were found to be normal. There were no features of hyperandrogenism. On local examination, there was 4 X 4 cm cystic swelling in the region of clitoris (Figure 1). Cyst was palpable separately on top of the clitoris; thereby ruling out clitoromegaly (Figure 2). Hymen was intact. She was planned for cyst excision. Lab investigations were within normal limits.
After obtaining proper consent, cyst excision was done under anaesthesia (Figure 3). Specimen was sent for histopathological examination (Figure 4). There was no difficulty in separation of the cyst. Post operative recovery was uneventful. On a followup period of 2 weeks, complete cosmetic recovery was evident. Histopathological examination revealed epidermoid cyst of clitoris.
DISCUSSION
Vulvar and vaginal cysts are generally rare. Differential diagnoses for cystic lesions of vulva include Bartholin duct cyst, Skene duct cyst, cyst of the canal of Nuck and epithelial inclusion cyst. Cysts of the vulva can be differentiated by their relative position. Of these, Bartholin’s duct cysts are common. Hymenal and clitoridal cysts are thought to arise from remnants of lower part of wolffian (gartner’s) duct and are usually lined by cuboidal epithelium. They usually cause trouble by becoming infected and leading to recurrent abscesses or persistent sinuses. Cysts of the clitoris should be differentiated from clitoromegaly.
Clitoromegaly in paediatric and adolescent age group is usually indicative of a disorder of sexual differentiation. The differential diagnoses for clitoromegaly are true hermaphroditism; adrenal hyperplasia; clitoral, ovarian and adrenal neoplasms; stromal hyperthecosis; PCOS and exogenous androgen exposure.1
Usually other causes of clitoromegaly can be differentiated from cysts of clitoris by simple clinical examination.2 Among the cysts, epidermoid cysts of the clitoris are commonly seen after type I female genital mutilation done in some ethnic communities in Africa and West Asia.
Clitoral cysts without genital tract mutilation are rare and only very few cases are reported in literature. (3, 4)
CONCLUSION
Clitoral cysts are rare; they have to be differentiated from clitoromegaly which require extensive investigations. Our case is a rare presentation of epidermoid cyst of clitoris without prior genital trauma. Epidermoid cysts of the clitoris are usually asymptomatic and do not require excision. Our patient is an adolescent girl who had only genital swelling with no other complaints; cyst excision was done only for cosmetic reasons. Complete cosmetic recovery was achieved with good patient satisfaction.
ACKNOWLEDGEMENT
The authors are very thankful to the patient who has kindly consented to use photographs for academic purposes and case reporting. The authors acknowledge the great help received from the scholars whose articles are cited and included in the references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. We the authors, are grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=1005http://ijcrr.com/article_html.php?did=1005
Aggarwal SK, Manchanda V, Pant N. Epidermoid cyst of clitoris mimicking clitoromegaly. J Indian Assoc Pediatr Surg. 2010 Jan – Mar; 15(1): 23 – 24.
Abudaia J, Habib Z, Ahmed S. Dermoid cyst: A rare cause of clitoromegaly. Pediatr Surg Int. 1999; 15: 521 – 522.
Lambert B. Epidermoid cyst of the clitoris: a case report. J Low Genit Tract Dis. 2011 Apr; 15(2): 161 – 162.
Anderson – Mueller BE, Laundenschlager MD, Hansen KA. Epidermoid cyst of the clitoris: an unusual case of clitoromegaly in a patient without history of previous female circumcision. J Pediatr Adolesc Gynecol. 2009 Oct; 22(5): 130 – 132.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241523EnglishN2013December16HealthcarePREVALENCE OF RETINAL MICROVASCULAR ABNORMALITIES IN PATIENTS WITH CHRONIC KIDNEY DISEASE AMONG DIABETIC POPULATION
English1320Narendra P. DattiEnglish K. KanthamaniEnglish B.N. Raghavendra PrasadEnglish Krishnamurthy DonthiEnglish Manasa KorthiwadaEnglishPurpose: To study prevalence of retinal microvascular abnormalities in patients with Chronic Kidney Disease(CKD) among diabetic population Methods: All known cases of Type II diabetes mellitus patients attending R.L.J. Hospital, Kolar between january and december 2011 were subjected to complete renal and ophthalmic evaluation. The diagnosis of CKD was done based on the presence of contracted kidney on abdominal ultrasonography and microalbuminuria. Ocular fundus examination was performed by an ophthalmologist. Results: A total of 2094 Type II diabetic patients were examined. Among them 920(44%) patients had CKD. Of these, 650(70.7%) patients had diabetic retinopathy. Among them, 575(88.5%) had Non Proliferative Diabetic retinopathy(NPDR), 75(11.5%) had Proliferative Diabetic retinopathy(PDR) , 167(25.7%) had Diabetic maculopathy, 74(11.4%) had Hypertensive retinopathy and 37(5.7%) had Age related macular degeneration. Among patients without CKD (1174), 152 had diabetic retinopathy (13%). Among them 130(85.5%) had NPDR, 22(14.5%) had PDR and 20(13%) had Diabetic maculopathy. Compared to patients without CKD, patients with CKD had higher prevalence of retinopathy(pEnglishDiabetes, microalbuminuria, CKD, diabetic retinopathy.INTRODUCTION
Diabetes is one of the most common metabolic diseases in which insulin is lacking or the body’s cells are insensitive to its effects[1]. Diabetes mellitus (DM) due to its effect on small and large blood vessels is known to cause various microvascular and macrovascular complications. The incidence of microvascular complications namely nephropathy, retinopathy and neuropathy increase with duration of diabetes[2].
Diabetic Retinopathy (DR) is the most common microvascular complication of diabetes and leading cause of acquired blindness. The burden of DR is increasing with the rising prevalence of type2 DM[3].
Microalbuminuria (MA) seems to reflect a state of pathophysiological vascular dysfunction that makes an individual susceptible to organ damage. Persistence of MA in diabetes patients is a risk marker not only for kidney and cardiac disorders but also for severe ocular morbidity[3].
The two most common causes of chronic kidney disease (CKD) and end stage renal disease are diabetes mellitus and hypertensive nephrosclerosis[4]. Several studies have shown correlation between retinopathy and nephropathy changes in diabetes, in systemic hypertension and in individuals without these two conditions[5].
The main aim of our study is to detect prevalence of retinal microvascular abnormalities in patients with Chronic Kidney Disease (CKD) among diabetic population visiting a tertiary care hospital.
MATERIALS AND METHODS
Study Design
This retrospective randomized study was conducted on 2094 type2 diabetic patients attending R. L. Jalappa Hospital, Kolar, Karnataka from January-December2011.
Patient Selection
The study was approved by Institutional ethics committee of SDUMC and the selected patients fulfilling the inclusion criteria were enrolled in the study. Inclusion criteria being all diabetic patients and exclusion criteria being patients with acute and chronic infections, collagen vascular disorders and malignancies and any other pre existing ocular diseases.
All patients were subjected to complete renal and ophthalmic evaluation which included serum creatinine, abdominal ultrasonography, 24 hr urine albumin levels and direct and indirect ophthalmoscopy .
Type2 Diabetes mellitus was defined as Fasting blood glucose of>126mg/dl or Random blood sugar of>200mg/dl with symptoms of diabetes. Microalbuminuria is defined by the presence of 30-300mg of albumin in a 24hr urine sample.The diagnosis of CKD was done based on the presence of contracted kidney on abdominal ultrasonography and microalbuminuria and Retinopathy changes were diagnosed by the presence of microaneurysms, cotton wool spots, dot and blot haemorrhages, hard exudates, intra retinal microvascular abnormalities and neovascularisation of retina.
Retinopathy changes are graded based on ETDRS classification.
STATISTICAL ANALYSIS
Statistical analysis was done using chi-square test for qualitative analysis. For statistical calculation SPSS for windows statistical packages with general significance of a p valueEnglishhttp://ijcrr.com/abstract.php?article_id=1006http://ijcrr.com/article_html.php?did=1006
Manaviat MR, Afkhami M, Shoja MR. Retinopathy and microalbuminuria in type II diabetic patients. BMC Ophthalmology 2004;4:1471-2415.
Chandy A, Pawar B, John M, Isaac R. Association between Diabetic Nephropathy and Other Diabetic Microvascular and Macrovascular Complications. Saudi J Kidney Dis Transplant 2008;19:924-928.
3)Chen H, Zheng Z, Huang Y, Guo K, Lu J, Zhang L, et al. A Microalbuminuria Threshold to Predict the Risk for the Development of Diabetic Retinopathy in Type 2 Diabetes Mellitus Patients. PLoS ONE 2012; 7:e36718.
Edwards MS, Wilson DB, Craven TE, Stafford J, Fried LF, Wong TY, et al. Associations Between Retinal Microvascular Abnormalities and Declining Renal Function in the Elderly Population: The Cardiovascular Health Study. American Journal of Kidney Diseases2005;46:214-224.
Grunwald JE, Alexander J, Maguire M, Whittock R, Parker C, McWilliams K, et al. Prevalence of Ocular Fundus Pathology in Patients with Chronic Kidney Disease. Clin J Am Soc Nephrol. 2010;5:867-873.
Prakash J, Lodha M, Singh SK, Vohra R, Raja R, Usha. Diabetic Retinopathy is A Poor Predictor of Type of Nephropathy in Proteinuric Type 2 Diabetic Patients. JAPI 2007;55:412-416.
Gao B, Zhu L, Pan Y, Yang S, Zhang L, Wang H. Ocular fundus pathology and chronic kidney disease in a Chinese population. BMC Nephrology 2011;12:62.
Wong TY, Coresh J, Klein R, Muntner P, Couper DJ, Sharrett AR, et al. Retinal Microvascular Abnormalities and Renal Dysfunction: The Atherosclerosis Risk in Communities Study. J Am Soc Nephrol;15:2469-2476.
Lu B, Song X, Dong X, Yang Y, Zhang Z, Wen J, et al. High prevalence of chronic kidney disease in population-based patients diagnosed with type 2 diabetes in downtown Shanghai. Journal of Diabetes and Its Complications 2008;22:96-103.
Sabanayagam C, Shankar A, Koh D, Chia KS, Saw SM, Lim SC, et al. Retinal Microvascular Caliber and Chronic Kidney Disease in an Asian Population. Am J Epidemiol 2009; 169: 625-32.
Wong TY, McIntosh R. Systemic associations of retinal microvascular signs: a review of recent population-based studies. Ophthalmic Physiol Opt. 2005;25:195-204.
Cavanaugh KL. CLINICAL DIABETES 2007; 25:90-7.
Coresh J, Byrd-Holt D, Astor BC, Briggs JP, Eggers PW, Lacher DA, et al. Chronic kidney disease awareness, prevalence, and trends among U.S. adults. J Am Soc Nephrol 2005;16:180–8.
Foley RN, Murray AM, Li S, Herzog CA, McBean AM, Eggers PW, et al. Chronic kidney disease and the risk for cardiovascular disease, renal replacement, and death in the United States Medicare population. J Am Soc Nephrol 2005;16:489–95.
Valmadrid CT, Klein R, Moss SE, Klein BE.The risk of cardiovascular disease mortality associated with microalbuminuria and gross proteinuria in persons with older-onset diabetes mellitus. ArchIntern Med 2000;160:1093–1100.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241523EnglishN2013December16HealthcareANTHROPOMETRIC FACTORS AND BREAST CANCER RISK AMONG WOMEN IN SOUTHERN RAJASTHAN, INDIA
English2124Mukul DixitEnglish Hemlata MittalEnglishBackground: Breast cancer one of the most common cancer affecting women health worldwide cancer and cause of death from cancer. Obesity has been related with breast cancer risk. Materials and Methods: For the present study patients of breast tumours who attended surgical outdoor or breast clinic or patients admitted to the surgical wards of Maharana Bhopal Hospital, Udaipur from Jan’97 to Jun’97 were included. A complete clinical examination and of the patients was done to see the symptoms, clinical manifestations, involvement of tissues etc. Anthropometric measurements of weight and height were measured by the standard equipments and methodology. Results: It was observed 9.57 percent patients were obese and 90.42 percent patients were not obese among benign group, whereas 5.31 percent were obese and 94.11 percent patients were not obese among malignant group. Conclusions: The results of the present study had shown a negative association of overweight and obesity with breast cancer in the southern Rajasthan, India population.
EnglishBreast cancer, Obesity, BMI, Height.
INTRODUCTION
A variety of cancers can affect women but breast has highest incidence and a common cause of death in women from cancer. (1) Breast cancer has a complex pathology and we cannot say true that there is any one single etiological or risk factor that is blame for causing it. Anthropometric factors such as weight, height, and body mass index (BMI) have been predicted as risk for breast cancer.(2) Obese females have high level of free estrogen , particularly in those with abdominal obesity.(3) High estrogen is explained as body fat provide a place for production and storage.(4) Also, It increases bioavailability of estrogen which further may prop up the growth of tumor and has been implicated as a risk factor for breast cancer. Overweight and obesity have now become foremost community health problem in both developed and developing countries. (6,7) The causative relation between obesity and Breast Cancer have been observed in previous studies , Most of these conducted on the Western population, and there have been only a few studies in the Asian population, who might have a changed diet pattern, lifestyle, genetic background, and disease prevalence. (8). However, most previous studies on this issue have been conducted mainly on the Western population, and there have been only a few studies in the Asian population, who might have a different lifestyle, genetic background, and disease prevalence.
Although a large number of women are affected with breast cancer and obesity in India. To our knowledge, assessing the correlation between obesity and Breast cancer in Indian population is lacking in literature. We aimed to evaluate this association in addition to other biological features of breast cancer in Indian women.
MATERIAL AND METHODS
For the present study patients of breast tumours who attended surgical outdoor or breast clinic or patients admitted to the surgical wards of Maharana Bhopal Hospital, Udaipur from Jan’97 to Jun’97 were included. A complete clinical examination of the patients was done to see the symptoms, clinical manifestations, involvement of tissues etc.
The diagnostic criteria were based upon the histopathological examination. Histopathological and Fine needle aspiration cytology (FNAC) reports were collected from the Department of Pathology, RNT Medical College, Udaipur. Anthropometric measurements of weight and height were measured by the standard equipments and methodology.
RESULTS
Most of patients of benign group young age group while in patients with malignant tumours most of them were from higher age group suggesting an increased risk of benign breast tumour at a considerably younger age. Most of patients (75.53%) were in 26-45 age groups suggesting an increased risk of benign breast tumour at a considerably younger age.
Occupational status of cases in the present study indicates that majority (63.82%) were housewives, whereas small numbers of women were engaged in service (12.76%), agriculture (15.95%) and labourers (7.44%) in cases with benign tumours. Similarly in malignant group, 74.11 percent were housewives, 14.11 percent and 11.76 women were in service and in agriculture respectively.
Most of the patients (96.80 percent in benign and 94.11 percent in malignant group) gave history of regular menstrual cycles. The association between regularity of menstrual cycles of the patients and breast tumours was seen, which came out to be non significant. In case of patients with benign tumours, 5.31 percent and 3.19 percent patients complained of dysmenorrhoea and menorrhagia respectively. In malignant group, 3.52 percent and 2.35 percent patients suffered from dysmenorrhoea and menorrhagia respectively.
Regarding dietary status, most of the patients were vegetarian 78.72 percent patients in case of benign group and In case of malignant group, 78.82 percent patients. No association between diet and breast tumours could be established.
Only 9.57 percent patients among benign group and 5.31 percent patients in malignant group were obese, but the association between obesity and breast tumours was insignificant.
Regarding the haemoglobin status, 74.76 and 25.53 percent patients of benign and 76.46 percent and 23.52 percent patients of malignant group were of 5-10, and more than 10 gm percent haemoglobin respectively. The association between the patients having haemoglobin (5-10 and >10) and breast tumours was found to be non-significant.
DISCUSSION
Continuous Change in lifestyle and diet pattern over the past few decades have been come in results in an increment of the proportion of obese people in both developed and developing countries. De Waard F et al initially observed a positive relation between obesity and increased risk of breast cancer. (10) Subsequent studies related with obesity and breast cancer have shown some diversity between premenopausal and postmenopausal women. (11) Premenopausal women do not show a high risk for breast cancer even they have a high BMI or gain weight during their adult life. (11)
Postmenopausal women have a high breast-cancer risk of about 40% for women whose BMI values are in the high. In prospective cohort studies, however, this increase in risk is more modest at around 20%. This association becomes stronger with increasing age and years after menopause, but is not affected by adjustment for reproductive and
lifestyle factors, including physical activity, which are known to affect risk estimates. (12) These findings are consistent with the protective effect of obesity against breast cancer in premenopausal years; the decreased risk associated with youthful obesity must be offset before a later.
Cole P et al observed that incidence rates of benign breast lesions are strongly and inversely associated with obesity. The trend is seen throughout the range of obesity and thus seems unlikely to be due to a greater difficulty of detecting lesions in markedly obese women. This inverse relationship of obesity to risk of benign breast disease is the reverse of the direct relationship usually seen in breast cancer.(13)
Other studies did not consider obesity, except the study by Fasal and Paffenbarger in which women with benign breast lesions were also lighter than controls.(14)
In our study, 9.57 percent patients were obese and 90.42 percent patients were not obese among benign group, whereas 5.31 percent were obese and 94.11 percent patients were not obese among malignant group. Obesity is not well correlated with breast cancer in our study because women in our region doing all house work which is comparable with moderate exercise and they were taking less diet and less fat. The low prevalence of obesity can be explained by a lifestyle characterised by less-consumption of energy combined with high to moderate physical activity. Most of the women in our study were vegetarians. Timothy J Key et al did not find any significant differences between vegetarians and non vegetarians in mortality from breast cancer. (15)The prevalence of vegetarian is high in study population that may a explanations of high number of vegetarian in breast cancer group.
Genetic risk factor may also be a causative risk factor for our study population. A study from north India showed that BRCA1 and BRCA2 mutations appear to account to some extent for breast cancer patients (6/204, 2.9%) (16) Some environmental factor may be related with breast cancer patients of this study. Some studies showed that some types of chemicals in the home that may be linked to a higher risk of breast cancer. It is important to find out the variety of chemicals easily available in the home environment. (17)
CONCLUSION
The results of the present study revealed a negative association of overweight and obesity with breast cancer in the Indian population. Hence, there might be some other factors may promote growth in breast which should be explored for Indian population they might be genetic and environmental.
Englishhttp://ijcrr.com/abstract.php?article_id=1007http://ijcrr.com/article_html.php?did=1007
Parkin DM. Cancers of the breast, endometrium and ovary: geographic correlations. Eur J Cancer Clin Oncol 1989;25:1917-25
Li CI, Malone KE, White E, Daling JR. Age when maximum height is reached as a risk factor for breast cancer among young U.S. women. Epidemiology 1997; 8:559-65.
Stoll BA. Diet and exercise regimens to improve breast carcinoma prognosis. Cancer 1996;78:2465-70
Graham S, Hellmann R, Marshall J, Freudenheim J, Vena J, Swanson M, et al. Nutritional epidemiology of postmenopausal breast cancer in western New York. Am J Epidemiol 1991;134:552-66.
Persson I. Estrogens in the causation of breast, endometrial and ovarian cancers- evidence and hypothesis from epidemiological findings. J Steroid Biochem Mol Biol 2000;74:357-64.
K. M. Flegal, M. D. Carroll, C. L. Ogden, and L. R.Curtin, “Prevalence and trends in obesity among US adults,1999–2008,” Journal of the American Medical Association, vol.303, no. 3, pp. 235–241, 2010.
C. L. Ogden, S. Z. Yanovski, M. D. Carroll, and K. M. Flegal,“The Epidemiology of Obesity,” Gastroenterology, vol. 132, no.6, pp. 2087–2102, 2007.
Kuriyama S, Tsubono Y, Hozawa A, et al:Obesity and risk of cancer in Japan. Int J Cancer 113:148-157, 2005.
Physical status: The use and Interpretation of Anthropometry. Report of a WHO Expert Committee. World Health Organisation Technical Report Series 854. Geneva: WHO; 1995. p. 427-30.
de Waard F, Baanders-van Halewijn EA. A prospective study in general practice on breast-cancer risk in postmenopausal women. Int J Cancer 1974; 14: 153–60.
Blitzer PH, Blitzer EC, Rimm AA. Association between teen-age obesity and cancer in 56 111 women: all cancers and endometrial carcinoma. Prev Med 1976; 5: 20–31.
Ballard-Barbash R, Swanson CA. Body weight: estimation of risk for breast and endometrial cancers. Am J Clin Nutr 1996; 63:437S–41S
Cole P, Elwood JM, Kaplan SD. Incidence rates and risk factors of benign breast neoplasms. Am J Epidemiol 1978;108:1 12-20
Fasal E, Paffenbarger RS. Oral contraceptives as related to cancer and benign lesions of the breast. J Nati Cancer Inst 1975;55:767-773
Timothy J Key,Gary E Fraser,Margaret Thorogood,Paul N Appleby,Valerie Beral, Gillian Reeves et al Mortality in vegetarians and nonvegetarians: detailed findings from a collaborative analysis of 5 prospective studies. Am J Clin Nutr September 1999 vol. 70 no. 3 516s-524s.
Sunita Saxena, Anurupa Chakraborty, Mishi Kaushal, Sanjeev Kotwal, Dinesh Bhatanager et al . Contribution of germline BRCA1 and BRCA2 sequence alterations to breast cancer in Northern India BMC Medical Genetics 2006, 7:75
Ruthann A. Rudel , Julia G. Brody , John D. Spengler , Jose Vallarino , Paul W. Geno , Gang Sun and Alice Yau. Identification of Selected Hormonally Active Agents and Animal Mammary Carcinogens in Commercial and Residential Air and Dust Samples, Journal of the Air and Waste Management Association, 2001 ;51:4, 499-513, DOI: 10.1080/10473289.2001.10464292
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241523EnglishN2013December16HealthcareREVIEW OF VARIATIONS OF RADIAL ARTERY
English2530Nitin R. MudirajEnglish Manisha R. DhobaleEnglish Uttama U. JoshiEnglishRadial artery is one of the smaller terminal branches of brachial artery which originates at the level of neck of radius. During routine dissection, a lot of variations in the arterial pattern of the upper limb were encountered which ignited our curiosity to review literature regarding the normal anatomy and variations of radial artery. There is marked difference in the arrangement of these arteries in different individuals as well as on the two sides of the body of same individual. Any of these may interfere in the clinical diagnosis and surgical management of a given case.
Englishradial artery, volar arch, anastomosis, variations, bifurcationINTRODUCTION
The aim of clinical medicine is to identify the problematic foci in normal anatomy and physiology, i.e. the pathology, and rectify the same and restore them to as normal as possible. These foci can be identified only with a sound knowledge of normal anatomy and all its variations.
Any physician or surgeon having anything to do with the radial artery “ought” to know the normal anatomy and variations of the radial artery to enable their “eye to see” all that their “minds know and want to do!”
It will help the anatomists in a greater understanding of the subject and to accordingly teach the relevant anatomy with more accuracy. As the radial artery is used in bypass surgery it is of immense help to know the exact location of the radial artery to harvest it for the Coronary Artery Bypass Graft (CABG). It helps the urosurgeons to make the arterio-venous fistula for the purpose of haemodialysis. Radial artery is also the preferred route for renal artery stenting.2 It helps the radiologists in the diagnostic and therapeutic interventional procedures. Plastic surgeons reconstruct severely damaged tissues with the help of fascio-cutaneous flaps based on radial artery forearm flap.
Accurate knowledge of the relationship and course of these arterial conduits and particularly of their patterns of variation is of considerable practical importance in the context of reparative surgery in the arm, forearm and hand. 3
HISTORY
McCormack et al have traced the following history of the record of arterial patterns in the upper limb.3 In 1600, Laurentius described the variation in the arterial pattern. Eventually in 1831, Tiedeman first systematically described the variations in the arterial pattern of the upper extremities. In 1844, Quain was the first to provide sufficient data for useful statistical evaluation. In 1868, Henle provided an analysis of a large European series. Drizenko et al have mentioned that since 19th century, variations of the arterial network of the upper limb in man have aroused the interest of anatomists.4 They also have quoted the classification first elaborated by Dubreuil-Chambardel in 1926 and by Adachi in 1928.4
Rodriguez-Baeza et al have described the variations in the arterial pattern of the upper limb quoting the following authors.5 Frequently either in routine dissection or in clinical practice variations in the arterial pattern have been observed by Lippert and Pabst. Anatomy textbooks do make a reference to 'vas aberrans' in the main brachio-antebrachial pattern as described by Shafer and Thane, Testut and Latarjet, and Williams and Warwick.5 Tountas and Bergman in 1993 have described these arterial variations in more detail and explanation for arterial variations in the human upper limb is generally based on the classical lines of arterial development according to Singer and Carlson as quoted by Rodriguez-Baeza.5
DISCUSSION
According to Karlsson and Niechajev, who have quoted Muller and Quain, prevalance of anatomic variations in the arteries of upper limb based on autopsy reports, is quite variable from 14% to 19.5%. 6
McCormack had studied the arterial patterns in 750 upper extremities and had observed that instances of origin of radial artery proximal to intercondylar line formed by far the largest group of variations. In his study, he found the above pattern in 14.27% of all specimens and 77 % of all the variations. He categorised variations of radial artery in two groups. In 2.13% of specimens radial artery arose from the axillary artery and in 12.4 % of specimens it arose from the brachial artery. He described variations of radial artery and categorised them on the basis of anastomotic connection, without considering any reference point for measurement. Group I
Those radial arteries, which made no significant gross anastomosis with other major vessels in the course through the arm and forearm.
Group II
Those radial arteries in which an anastomosis was established with the deep or regular brachial artery in the ante cubital region, the communicating vessels in these cases passing anterior to the biceps tendon.
Group III
Those radial arteries in which long slender anastomosis with the brachial artery that passes posterior to the biceps tendon.
Group IV
Those radial arteries in which there was anastomosis with the median artery.3
Drizenko described three cases of variant origin of radial artery.4 In one case, he had observed bilateral instances of high origin of radial artery. Here, the brachial artery was situated at the lateral border of the median nerve and divided in the middle of the arm below the tendon of pectoralis major into two branches. The slender lateral branch skirted the medial border of biceps brachii muscle and then straddled the distal part of muscle to travel towards the elbow region. Beyond this, it had normal course in the forearm and hand. The stout medial branch remained in company with the posterior aspect of the median nerve up to the elbow. Beyond this it gave off interosseous trunk and ulnar arteries. In another case, the brachial artery had precocious bifurcation in the middle part of the arm into two branches i.e. medial and lateral. They then continued as radial and ulnar arteries .
Literature abounds with variations in the site of origin of radial artery. According to Keen, superficial brachial artery arose from the upper part of the brachial artery.7 Actually it was bifurcation, because two trunks of equal diameter (3 mm) continued downwards, one superficial and other deep to the median nerve. The superficial brachial artery descended in the superficial fascia, and in front of bicipital aponeurosis and then bifurcated into radial and ulnar arteries. The more deeply placed trunk supplied interosseous, recurrent and muscular arteries.
Keen classified the superficial brachial artery into three types.7
Superficial brachial artery that continued in the cubital fossa and then bifurcated as usual.
Superficial brachial artery continued as radial artery known as high origin of radial artery.
Superficial brachial artery continued as ulnar artery known as high origin of ulnar artery.
According to Jurjus immediately after the origin of the profunda brachii, the brachial artery bifurcated into the two brachial arteries of equal size.8 These arteries were running parallel in the expected path of the brachial artery. Brachial artery I was possibly a high origin and persisting embryonic radial artery in the arm and in the forearm brachial artery I divided into two equal sized radial and ulnar arteries. In contrast the brachial artery II was the prospective common interosseous. The course of brachial artery II resembled the course of the brachial axis artery.8
Bergman studied arterial patterns in 610 upper extremities.9 He had observed the usual textbook description of the axillary artery continuing as brachial artery in 80% specimens. However he had found a major variation i.e. a high proximal division of brachial artery into radial and ulnar arteries. This variation could occur at any point in the normal course, but was most common in the upper third of arm and least common in the middle third of arm. The radial artery arose from the brachial artery more proximally than usual, from the axillary artery, or from the brachial artery lower than the bend of elbow, but this low division of the brachial artery was rare.9
The double branching pattern of the brachial artery has been reported by McCormack and Rodriguez-Baeza et al, i.e. superficial and deep brachial artery.3,5 Superficial brachial artery divided into the radial and ulnar arteries or sometimes as superficial ulnar artery and deep brachial artery continued as common interosseous artery.
Gonzalez-Compta described bilateral high origin of the radial artery, where the axillary artery divided into anterior and posterior branches, the anterior branch being the high origin of radial artery and posterior branch, the proper brachial artery.10 The course and distribution of the radial artery was normal in the forearm.
Gonzalez-Compta had mentioned two types of variations.
High origin of radial artery because of precocious bifurcation.
Superficial brachial artery arising from brachial artery and providing radial and ulnar arteries and brachial artery proper continuing as common interosseous artery.
Rodriguez-Baeza et al studied the arterial patterns in 23 upper extremities and categorised the high origin of radial artery into two groups depending on whether a median artery was present or not. In three cases there was high origin of radial artery with the presence of median artery but the origin of radial artery was different in each case. In this pattern radial artery arose from upper third, middle third, lower third of the brachial artery. In four cases there was high origin of radial artery without median artery, in two cases it arose from axillary artery, whereas in others it arose from upper third of brachial artery.5
According to Nakatani superficial brachial artery continued as the common interosseous artery and the deep brachial artery continued as radial and ulnar arteries.11 Proximal to the loop of lateral and medial pectoral nerve, the axillary artery branched and gave rise to the posterior circumflex humeral and subscapular arteries and then continued distally as the brachial artery. The profunda brachii artery arose 1 cm proximal to the lower border of pectoralis major. Brachial artery was 5 mm in diameter and divided 1 cm distal to the lower border of pectoralis major into superficial and deep brachial arteries. The superficial brachial artery 1mm in diameter crossed over the confluence of the medial and the lateral roots of the median nerve, descended ventral and lateral to the median nerve. Then it continued as the common interosseous artery. In the cubital fossa the common interosseous artery branched into the recurrent ulnar, median, posterior interosseous and muscular branches and then continued as anterior interosseous artery. Deep brachial artery passed dorsal and medial to the median nerve,
progressively spiralling ventral to it at the distal third of the upper arm. It split into radial and superficial ulnar artery. The radial artery gave off the recurrent radial artery and muscular branches and had a normal course in the forearm.11
Rodriguez – Baeza et al also described the superficial brachial artery usually continued beyond the elbow to give off the radial and ulnar arteries and brachial artery proper provided the common interosseous artery.5
Sahin described bilateral high origin of the superficial radial artery but with two different sites of origin in the same individual. On the right side, the superficial radial artery was a branch of the axillary artery and the axillary artery continued as the brachial artery becoming the ulnar artery in the cubital fossa. On the left side it came from the lateral side of the brachial artery midway down the arm and its later course and ramification was similar to the right superficial radial artery. It continued as the ulnar artery in the cubital fossa.12
Keen had described entirely different pattern of variation where an “arterial island” may form as mentioned by Adachi as “inselbildung” [German- island].7 A small branch 2 mm in diameter which arose from the upper part of the brachial artery (5 mm) passed superficial to the median nerve and then rejoined the main trunk a short distance above the bifurcation in the cubital fossa.
Keen also described a large superficial brachial artery (6 mm in diameter) which arose from the upper part of the brachial artery and a small parallel artery (2 mm) running downwards deep to the median nerve at the level of the radio-humeral joint. These two vessels united again to form a single trunk. This artery bifurcated in the cubital fossa at the normal level below the radio-humeral joint.7
McCormack described accessory brachial artery arising from the brachial artery.3 Throughout its course it was medial to the main brachial artery, however, midway in the arm it passed deep to the median nerve and 4 cm proximal to its termination it crossed back over the median nerve and rejoined the brachial artery.3
McCormack while recording the presence of anomalous arteries in the upper limb has also measured the distance between the site of origin of radial artery and intercondylar line of humerus. He had found the variation of high origin of radial artery in 107 out of 750 cases and in 33 of them the distance of this origin, from intercondylar line ranged 15-19.5 cm.3
Mullan studied the variation in the bifurcation of brachial artery in 30 Caucasian cadavers. He recorded the bifurcation of brachial artery with reference to interepicondylar line. He had found high bifurcation in 15% (9/60).13
Bergman quoting of Quain noted that when the radial artery itself arises higher up, the radial recurrent artery usually comes from the residual brachial trunk or sometimes from the ulnar artery or more rarely from interosseous artery. A variation in origin of the radial recurrent artery was noted in relation to the anastomotic vessels. In this the radial recurrent artery arose from the anastomotic vessel within 1 cm of its junction with the radial artery.15
In his study, McCormack had noted that the course of radial artery remained normal even in cases of high origin. In our study also no variation was found in the course of radial artery in the forearm even in all cases of high origin of radial artery. It also maintained the normal relation with the superficial branch of radial nerve i.e. the nerve was lateral to the artery.3
Coleman and Anson in their exhaustive study arterial pattern in 650 specimens found that in 97% of cases the deep palmar (volar) arch was complete and it was less variable than superficial palmar (volar) arch.16
Absence of the radial artery is a relatively uncommon variation. Poteat has quoted Charles and Kandanoff and Balkansky having reported such cases. It may be the most primitive pattern and has potential embryologic and surgical significance.17
CLINICAL SIGNIFICANCE
The knowledge of the arterial variation of the superior extremity is useful as one can get confused with veins, which can lead to accidental injection of anaesthetic agent in the artery leading to distal necrosis of limb.4 Similar catastrophic sequelae were presented by Cohn and quoted by McCormack, e.g. accidental intra-arterial injection of Pentothal sodium leading to gangrene of forearm, hand and fingers.3 It is essential for a surgeon to keep in mind the major arterial variations while performing certain surgical procedures. When a surgeon fails to recognize and ligate aberrantly originating radial arteries running in the depth of wounds, it can lead to serious haemorrhage.3 In the radiological diagnostic studies for peripheral vascular diseases injection of contrast medium in the brachial artery sometimes may lead to opacification of palmar arches without the opacification of radial artery. This may lead to erroneous diagnosis of occlusion of radial artery without considering the possibility of high origin of radial artery. Similarly during the ascending catheterization, the interventional radiologists need to take into account the variation in the origin of radial artery before concluding their study. 4
CONCLUSION
The radial artery is an important arterial conduit from the clinical point of view and the radial artery is indispensable to anatomists, general surgeons, radiologists, plastic surgeons, and even cardiovascular thoracic surgeons.
Englishhttp://ijcrr.com/abstract.php?article_id=1008http://ijcrr.com/article_html.php?did=1008
G J romanes. General introduction. In: Cunningham’s Manual of Practical Anatomy Vol. I. 15th ed. Oxford University Press, Oxford; 1986. p.16.
Kessal DO, Robertson L, Taylor EJ, Patel JV. Renal Stenting From the Radial Artery: A Novel Approach. Cardiovasc Interventiont Radiol 2003; 26:146-149.
Mc Cormack LJ, Cauldwell EW, Anson BJ. Brachial and antebrachial arterial patterns; a study of 750 extremities. Surg Gynecol Obstet. 1953; 96: 43–54.
Drizenko A, Maynou C, Mestdagh H, Bailleul JP. Variations of the radial artery in man. Surg Radiol Anat. 2000; 22 (5-6): 299-303.
Rodriguez-Baeza A, Nebot J, Ferreira B, Reina F, Perez J, Sanudo JR, Roig M. An anatomical study and ontogenetic explanation of 23 cases with variations in the main pattern of the human brachio-antebrachial arteries. J Anat.1995; 187(2):473–479.
Karlsson S, Niechajev IA. Arterial anatomy of the upper extremity. Acta Radiol Diagn 1982; 23: 115-121.
Keen JA. A Study of the arterial variations of the limbs. Am J Anat.1961; 108: 245-261.
Jurjus A, Sfeir R, Bezirdjian R. Unusual variation of the arterial pattern of the human upper limb. Anat Rec. 1986; 215:82-83.
Bergman RA, Thompson SA, Afifi A.K., and Saade FA. (1988): Compendium Of Human Anatomic Variation. Text, Atlas and World Literature. Urban and Schwarzenberg, Baltimore P-71.
Gonzalez-Compta. Origin of radial artery and associated hand vascular anomalies. J Hand Surg Am. 1991; 16(2): 293-296.
Nakatani T, Tanaka S, Mizukami S. Superficial brachial artery continuing as the Common interosseous artery. J Anat. 1997; 191: 155-157.
Sahin B. (2000) Arterial, Neural and Muscular Variations in the upper limb of a single cadaver. Surg Radiol Anat. 2000; 22 (5-6): 305-308.
Mullan, Geoffrey, Naeem PJ, H. Ellis. Variation in the bifurcation of brachial artery in 30 Caucasian cadavers. Clin. Anat. 2003; 16(5):461-465.
Patnaik, VVG, Kalsey G, Singla, R K.(2001) Bifurcation of Axillary artery In Its 3rd Part -A case report. J. Anat. Soc. India. 2001; 50(2): 166-169.
Bergman R.A., Afifi A. K., Ryosuke Miyauchi, Virtual Hospital-Illustrated Encyclopedia Of Human Anatomic Variation: Opus II : Cardiovascular system : Arteries : Upper Limb(2004) (http://www.vh.Org/adult/provider/anatomy/ Anatomicvariants/cardiovascular/Text/Arteries/Radial.html) accessed on 19/07/2013.
Coleman SC, Anson BJ. Arterial Pattern of the hand- Based upon a study of 650 specimens. Surg. Gynecol Obstet. 1961; 113: 409-424.
Poteat WL. Report of a rare human variation: absence of radial artery. Anat. record 1986. 214; 89-95.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241523EnglishN2013December16HealthcareCEREBROVASCULAR ATTACK: NEW THERAPEUTIC AREAS OF INTEREST
English3136Partha S. SahaEnglishCerebrovascular attack (CVA) or stroke is one of the leading causes of adult disability in world. The current treatments of the stroke are preventive treatment, acute-phase stroke treatment and post-stroke rehabilitation. But the need of more sophisticated therapies and the drawbacks of the existing therapies in their usages call for the new therapies to replace them or develop them. This essay summarizes some of the major new therapeutic approaches, such as the use of statin agents, ACE-I, vitamins, minocycline, edaravone, other neuroprotective agents, stem cell therapy and hyperbaric oxygen therapy. It also describes new methods of implanting of Penumbra system for prevention of the stroke.
EnglishStroke, penumbra system, minocycline in stroke, edaravone in stroke, ReN001 stem cell therapy, hyperbaric oxygen therapy.INTRODUCTION
Stroke, also known as a cerebrovascular attack (CVA), is the rapid loss of brain function(s) due to disturbance in blood supply to brain. This can be due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial embolism), or a hemorrhage (leakage of blood) [1]. As a result, the affected areas of brain cannot function, which might result in an inability to move one or more limbs on one side of the body, to understand or formulate speech, or to see one side of a visual field [2].
A stroke is a medical emergency that can cause permanent neurological damage, complications, and even death. It is the leading cause of adult disability in the United States and Europe and the second leading cause of death worldwide [3]. Risk factors for stroke include old age, hypertension (high blood pressure), previous stroke or transient ischemic attack (TIA), diabetes, high cholesterol, cigarette smoking and atrial fibrillation. High blood pressure is the most important risk factor of stroke [2].
OBJECTIVE
Stroke is a major public health problem throughout the world. Stroke is usually considered as a disease of the elderly, but strokes can occur at any age and their consequences in terms of lost productivity are even greater in younger patients than that of older ones. Stroke is regarded as the third leading cause of death after heart disease and cancer, and it is a leading cause of disability as well. In addition, stroke is the single largest cause of adult disability in developed world. Over 150,000 people suffer a stroke each year in the UK, and over 700,000 people in the US. The annual health and social costs of caring for disabled stroke patients is estimated to be in excess of £5 billion in the UK, with stroke patients occupying 25 per cent of long term hospital beds [3].
Current Therapies
Strokes can be classified into two major categories: ischemic and hemorrhagic, and the treatment of the stroke can be classified into three
major categories - preventive treatment, acute-phase stroke treatment and the post-stroke rehabilitation.
The preventive treatment is aimed in reduction of associated risks of stroke earlier than its occurrence. There are several ways by which preventive treatment can be done. Some of the treatment includes the use of the drugs, such as anticoagulants or antiplatelets, surgical procedures like Carotid Endarterectomy, Hemicraniectomy, Angioplasty, etc. Among these techniques, the most prevalent treatment therapy is through use of anticoagulants and antiplatelets. Several antiplatelet agents and anticoagulants interfere with the blood's clotting ability and thereby play a significant role in preventing stroke.
The acute-phase stroke treatment aims at arresting a stroke when it takes place. This therapy is done by using thrombolytics or clot-busting drugs, such as tissue plasminogen activator (tPA). Therefore, it is also known as thrombolytic therapy. This is the most promising treatment for the ischemic stroke till today.
Lastly, post-stroke rehabilitation therapies are effective for improving both functional and cognitive recoveries in a patient some weeks or months after the event of stroke. Transcranial infrared laser therapy, for example, reduces the infarct area and improves the intra-cerebral microcirculation.
Drawbacks of the current therapies
Among the preventive therapies, use of antiplatelet drugs or anticoagulant drugs involves increasing the incidence of the drug interaction in patients. On the other hand, the surgical preventive treatments are very costly and life-threatening.
The acute-phase treatment with thrombolytic drugs is more complex as it needs to be done in hospitals with professional intervention. In addition to that, to ensure best therapeutic effect of the dose, the thrombolytic drugs should be administered within a three-hour interval from the onset of symptoms. But in this short interval of time, only 3 to 5% of the patient can reach hospitals. Therefore, the disadvantage of this therapy can alone keep out patients to harvest maximum benefits out of this so-called ‘most promising’ treatment of ischemic stroke.
Like acute-phase therapy, the post-stroke rehabilitation therapies also need the professional intervention of physicians, rehabilitation nurses, vocational therapists, and mental health professionals. Moreover, they are involved with the use of sophisticated instrument which is never a cost-effective way. Moreover, patients do not get cured fully.
Therefore, the existing therapies have several drawbacks of their usage which call for the new therapies to replace them or develop them.
New Therapeutic Approaches
Use of Statin agents, ACE-I, vitamins for prevention of the stroke
Atherosclerosis, a major risk factor for stroke, was first realized as an inflammatory disease. This insight helped to make suggestion regarding its therapeutic agents, such as statins, vitamins and angiotensin-converting enzyme inhibitors (ACE-I) as they have certain anti-inflammatory activities. These agents reduce inflammation by stabilising atherosclerotic plaque or by other protective mechanism. Here, the statins like atorvastatin lower the risk factor of stroke. ACE-I, on the other hand, lowers the risk of vascular outcomes and related complications in high-risk patients, especially those with diabetic and non-diabetic renal diseases. In addition to that, vitamin C, beta carotene and vitamin E are the sources of the antioxidant nutrients. These antioxidants reduce the atheroma formation by inhibiting oxidation of LDL, which is an important step for atherosclerotic process [4].
The Penumbra System
To prevent the damage caused in the penumbral region, timely revascularization and the establishment of the reperfusion are mostly essential. The Penumbra System is an embolectomy device which is designed for removing thrombus in acute ischemic stroke. The
device functions through 2 mechanisms - aspiration and extraction. The device is composed of three parts: a reperfusion separator, catheter, and thrombus removal ring. For aspiration, the reperfusion catheter is used along with the separator and an aspiration source to separate the thrombus and aspirate it from the occluded vessel. If residual thrombus still remains after revascularization with aspiration, the thrombus removal ring is used to directly removal of the thrombus. Overall, it is an effective device to reduce the neurologic deficit, stroke-related mortality and morbidity, and also to improve clinical outcomes [5]. It was approved by FDA in 2007 [6].
On July, 2013, Penumbra Inc. has launched a next-generation clot-extraction device, namely 5MAX™ ACE. This device uses aspiration technology as a primary tool to revascularize the clots more effectively than any other devices which use aspiration approach [7]. A Direct Aspiration First-Pass Technique (ADAPT) - a simple and effective technique using a large bore aspiration catheter to recanalize the vessel in AIS- when optimized with 5MAX™ ACE showed superior clinical outcomes as a first-line approach. In this way, it is now possible to remove complete thrombus without causing distal embolism- which is regarded as the highest state-of–art in reperfusion technology [7, 8].
Use of Minocycline for the treatment of the stroke
Minocycline is a protease inhibitor which was found to be useful in treatment of stroke in preclinical state of a preclinical stroke model. Being a promising anti-inflammatory, it has shown its effectiveness as a potential vascular-protective agent. Moreover, it has also shown a significant success in dropping bleeding effects during tissue plasminogen activator (tPA) trial. Overall, this drug has already shown a great success to be used as an adjunctive therapy to tPA in stroke. It is to be noted here that since it shows no adverse effect in the fibrinolytic activity of tPA, the impact of reperfusion homorrhage is highly reduced; however, it was observed in some other experimental models [9].
Significance of Neuroprotection in Ischemic Stroke treatment
Neuroprotection is regarded as “any strategy, or combination of strategies, that antagonizes, interrupts, or slows the sequence of injurious biochemical and molecular events that, if left unchecked, would eventuate in irreversible ischemic injury” [10].
It is considered that some of the important mechanisms, such as activity of the excitotoxic neurotransmitters, production of the free radicals in neurons and apoptotic signalling of them can give a complete picture to draw conclusion about the mechanisms of the neuronal cell death in the brain even in the stroke condition [11]. In the preclinical condition, the neuroprotective agents have their own merits and demerits. Some of these types of the neuroprotective agents are the glutamate antagonists, GABA agonists, nitric oxide signal regulators, glutamate antagonists, etc. Use of the neuroprotective agents for the use of inhibiting neuronal cell death is a matter of recent concern and some of these protective therapies, which are considered to be used shortly, are the therapeutic hypothermia, hyperacute magnesium therapy, high-dose human albumin therapy, etc. The effectiveness of these therapies, even in their combinations, is also being studied [12].
Use of Edaravone for Acute of the stroke
Since 2001, in Japan, the edaravone has been marketed by Mitsubishi Pharma. This was being used an antioxidant. But later on, it was found to have effectiveness in treating acute brain ischemia and cerebral infraction, along with different mechanism of the neurological recovery. The mechanism that is involved with the activity of the edaravone in causing the neurological recovery is the ability to take away the hydroxyl radicals and thus inhibiting the hydroxyl dependent and independent lipid peroxidation. This is the reason that it can act as a potent antioxidant in protecting
against oxidative stresses and neuronal cell deaths [12].
The edaravone is effective for both acute ischemic stroke (AIS) and acute haemorrhage stoke (AHS). According to an investigator, “a clinical trial has shown that the administration of edaravone alone within 72h of the onset of AIS significantly reduced the infarct volume and produced sustained benefits during a 3-month follow-up period”. He observed the effects of edaravone on AHS and found that “in an AHS model, rats treated with edaravone immediately after a hemorrhage showed a stronger reduction in brain water content and quicker functional recovery compared with rats treated with edaravone at 2h or 6h after hemorrhage” [13]. Most recently, Kono et al. has concluded through a clinical research on ischemic stroke patients older than 80 years of age that edaravone may be used as a partner for combination therapy with tPA; this may enhance recanalization and reduce hemorrhagic transformation [14]. On the other hand, safety and efficacy of multi-doses Edaravone injection is being trailed at phase II level [15].
ReN001 Stem cell therapy
Recently, stem cell therapy has proven effective to address the rehabilitation of post-stroke patients. ReN001 is a standardised, clinical and commercial-grade cell therapy product which is capable of treating all eligible patients. In short, it involves a neural cell line (CTX), cell selection technologies, cell-expansion procedures for selected cells and quality testing procedure. An extensive pre-clinical testing has shown to improve functional deficits associated with stroke disability, and it also indicated that the therapy is safe, with no adverse effects. A ground-breaking first-in-man clinical trial with ReN001 is proceeding in the UK under the name of PISCES (Pilot Investigation of Stem Cells in Stroke) study, which is being coordinated by ReNeuron Group. This is the world's first fully regulated clinical trial with neural stem cell. Based on the results already shown by the on-going study, the authority has already submitted an application for commencing a multi-site Phase II clinical trial to inspect the efficacy of ReN001 stem cell therapy on patients disabled by an ischaemic stroke [16]. Undoubtedly, the report of PISCES study indicates so far that ReN001 stem cell therapy is an effective treatment, but it is only useful for the patients who are in third treatment stage, not for any other two classifications [16].
Hyperbaric oxygen therapy (HBO2T)
Hyperbaric oxygen (HBO) has proved itself effective in treating acute and sub-acute focal cerebral ischemia in several animal models [reviewed in 17]. Observing its apparent promise in treating different diseases, the scientists have been practising hyperbaric oxygen therapy or HBO2T to cure or treat several diseases. This therapy involves placing one or more patients in an enclosed chamber and supplying with 100% oxygen in a pressure-regulated manner for respiration for a stipulated period of time, once or twice daily. In 2010, a clinical trial was organized by Bennett et al. to assess the effectiveness and safety of HBO2T. Due to adoption of less number of randomized controlled trials, the study could not show consistent evidence of its efficacy [18]. However, in this year, FDA has already warned on the potential health risks that are associated with the HBO2T.
Yet, certain groups of medical practitioners are still hopeful over the value. In tune with this, again in this year itself, Lim et al. observed the neuroprotective effect of HBO in attenuating microgliosis and pro-inflammatory cytokinine TNF-α expression [19]. This suggests again the need of performing a well set-up clinical trial to find its true effectiveness in treating stroke, at least as a rear-liner in stoke treatment.
CONCLUSION
Many substances or agents are still in pipeline for the treatment of the stroke. With the advancement of molecular biology and bio-therapeutics, newer agents are emerging day to day with strong promises to treat stroke. The days are not far when the patients from each phase of stroke will be able to get full range of effective treatments to come round all in all.
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Feigin VL. Stroke epidemiology in the developing world. Lancet. 2005; 365(9478): 2160–1.
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Kono S, Deguchi K, Morimoto N, Kurata T, Yamashita T, Ikeda Y, Narai H, Manabe Y, Takao Y, Kawada S, Kashihara K, Takehisa Y, Inoue S, Kiriyama H, Abe K. Intravenous Thrombolysis with Neuroprotective Therapy by Edaravone for Ischemic Stroke Patients Older than 80 Years of Age. J Stroke Cerebrovasc Dis. 2013 Oct; 22(7):1175-83.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241523EnglishN2013December16HealthcareTHE INCIDENCE OF COMMON CANCERS IN SOUTH INDIAN REGION - A HOSPITAL BASED CROSS SECTIONAL STUDY - RESEARCH ARTICLE
English3743Raja Sekhar KatikireddiEnglish Siva Nageswara Rao Sundara SettyEnglishObjectives: To study the commonest cancers encountered in both male and female sexes in the regional population of Andhra Pradesh in south Indian region. Methods: The study was conducted on total number of 450 patients, who were admitted in Mehdi Nawaz Jung (MNJ) government central cancer hospital, Hyderabad, Andhra Pradesh after histologically confirmed various cancers. Results: the study revealed that Breast cancer (57 cases, 12.6%), Lung cancer (47 cases, 10.4%), Cervical cancer (41 cases, 9.1%), Oral cancer (41 cases, 9.1%), (264 cases, 58.8%) constitute remaining cancers. Males constitute 48. 8% (220 cases) out of 450 cases and Females constitute 51.2% (230 cases) out of of (450 cases). Age and sex distribution revealed maximum number of cancer patients were present between 40 to 50 years (23.3%). Males, majority of cases are present in 40-50 years age group (11.1%) and females majority of cases are seen in 30-40 year age group (12.8%). Distribution of study sample revealed 55.7% cancer cases (251 patients) residing in urban areas and 44.2% cases (199 patients) were found in rural areas and following data discussed in results. Conclusion: Cancer is projected to become a leading cause of death worldwide in low and middle income countries. This will have the impact of high cancer incidence and death rates more sharply than developed countries.
EnglishCancer, Brest cancer, Lung cancer, Oral cancerINTRODUCTION
Cancer is a disease, in which abnormal cells proliferate rapidly without control and are able to occupy other tissues. The abnormal Cancer cells can spread to other parts of the body through various routes. According to the world cancer report, global cancer rates could increase by 50% by the year 2020, this increase can be attributed to increased life expectancy in highly populated countries like China and India.
According to the new edition of the World Cancer Report (WCR 2008), given by the International Agency for Research on Cancers (IARC), the burden of cancer doubled globally between 1975 and 2000. It is estimated that it will double again by 2020 and nearly triple by 2030.The report estimates that there were 12 million new cancers diagnosed worldwide in 2009 and more than seven million people will die of this disease. The projected numbers for the year 2030 are 20-30 million new diagnoses and 13-17 million deaths.
MATERIALS AND METHODS
The present study is hospital based cross sectional study, which conducted on 450 cancer patients, histologically proved as various cancers, who were admitted in a government central cancer hospital. Out of these 220 were male and 230 were female.
H/o Treatment: Previous Hormone Therapy, Previous Radiation Therapy, Drug Overdose
Menstrual History: Age at Menarche, Menstruation Cycle, Duration, Flow, Pain
Obstetric History: Marriage age, No. of children, Mode of delivery,
H/o Abortion/SBS/Premature Labour, Completed Family: Yes/No
General physical examination: Weight, Height, Built, Nourishment, Anaemia, Cyanosis, Clubbing,, Lymphadenopathy, Pedal Oedema, Jaundice, Alopecia
Systemic Examination, Provisional Diagnosis, Investigations, Final Diagnosis, Grade/Stage
RESULTS
Out of 450 cancer patients studied, the most common cancer, over all in the study is Breast cancer(57 cases,12.6%).It is followed by Lung cancer(47 cases,10.4%). It is followed by cervical cancer (41 cases, 9.1%), Oral cancer (41 cases, 9.1%), the remaining (264 cases, 58.8%) constitute other cancers (TABLE: 01). Males constitute 48.8% (220 cases) of total cancer study population (450 cases). Females constitute 51.2% (230 cases) of total cancer study population. (450 cases) (TABLE: 02).
The age / sex distribution revealed maximum number of cancer patients is present between 40 to 50 years (23.3%). Very few patients are present between 0-10 years age group (0.2% 1 case only). In males, majority of cases are present in 40-50 years age group (11.1%), followed by 50-60 year age group (10.4%), 30-40 year age group (8%). While there was no female case in the age group 0-10 years, there was one male in this group.
Females majority of cases are seen in 30-40 year age group (12.8%) followed by 40-50 year age group (12.2%), 50-60 year age group (11.7%). 13.3% (60 patients) of total study group are above 60 years age group (TABLE: 03).
Distribution of study sample revealed 55.7% cancer cases (251 patients) residing in urban areas and 44.2% cases (199 patients) were found in rural areas. Majority of females patients (141 patients, 31.3%) are in urban areas. Males are equally distributed in urban and rural areas (24.4% of total population in each area) (TABLE: 04). Out of a total of 450 cases studied, respiratory cancers (10%, 45 cases) are more common in urban areas. followed by GIT(Gastro Intestinal Tract ) cancer (38 cases,8.4%), breast cancer (38 cases,8.4%), cervix cancer (25 cases,5.5%), oral cancer (25 cases,5.5%) in the urban areas. In the rural areas, GIT cancers (10.6%, 48 cases) are more common followed by breast cancer (19 cases, 4.2%), blood cancer (17 cases, 3.7%). The least number of cancer cases seen in both urban areas and rural areas is with testicular cancer. 1.3% or 6cases in urban and 0.8% or 4 cases in rural areas) (TABLE: 05).
The colorectal cancer has highest incidence of positive family history (23.5%, 8 cases) in the study population. It is followed by ovarian cancer (16.6%, 4 cases), carcinoma breast (6.5%, 4 cases), carcinoma cervix (2.3%, 1 case) in the total study population. Out of total 450 cancer patients studied, 17 cases (3.7%) were found to have positive family history. Remaining 433 patients (96.2%) of the total study population were found to be family history negative (TABLE: 06).
Total of 450 cases, the majority of cancers are present in organs related to reproductive system (94 cases, 20.8%).It included female reproductive system (16.8%, 76 cases) and male reproductive system (4%, 18 cases). It is followed by cancers of gastro intestinal system (86 cases, 19%), connective tissue cancers (81 cases, 18%), respiratory system cancers (61 cases, 13.5%). The least number of cases are seen in endocrine system cancers (1.5%, 7 cases) in males, majority of cases belong to gastro intestinal system followed by, respiratory system. In females majority of cases belong to female reproductive system followed by, gastro intestinal system. In males least number of cases was seen in endocrine system cancers. (2 cases, 0.4%) In females least number of cases are seen in central nervous system cancers (4 cases, 0.8%) .
Out of a total of 230 female cases studied, it was found that breast cancer is the most common cancer in the females (24.7%, 57 cases). It is followed by cervical cancer (17.8%, 41 cases). It is followed by ovarian cancer(24 cases,10.4%), blood cancer(22 cases,9.5%), colorectal cancer(12 cases,5.1%), endometrial cancer(10 cases,4.3%), oral cancer(9 cases,3.9%). Least number of cases are seen in Edwings sarcoma (0.4%, 1 case) and invasive Hydatiform mole (1 case, 0.4%). Highest percentage of female cancer patients is present in labourers (44.7%, 103 cases) It is followed by house wives (70 cases, 30.4%), employees (40 cases, 17.3%). The least percentage of cancer is present in students (7.3 %, 17 cases) the term labourer included agricultural, constructional and domestic workers. Out of a total of 220 male patients, highest percentage of cancer cases are present in Manual labourers (33.1%, 73 cases), followed by semiskilled workers (23.1%,51 cases) . The least percentage of cancer is present in students (8.6%, 19 cases).
Out of a total of 450 cases studied, there were 98 cases of carcinoma cervix/breast obtained. History of menarche was taken in all. It was seen that 52women (53%) had attained menarche between 10-12 years and 33 women (33.6%) had attained menarche between 12-14 years. A total of 85 women (86.6%) had attained menarche between 10-14 years.
Out of a total of 450 cases studied, there were 57 cases of carcinoma breast. History of lactation was taken. It was found that 82.4% (47 cases) of women with breast cancer have breast fed their children. A percentage of17.6% of carcinoma
breast patients did not have a positive lactational history.
Out of a total of 220 male cases studied, it was found that Lung cancer is the most common cancer in males in our study (17.7%, 39 cases). It is followed by oral cancer(32 cases,14.5%), colorectal cancer (22 cases,10%), lymphoma(20 cases,9%), stomach cancer (16cases,7.2%), esophagus cancer (13cases,5.9%), blood cancer (13cases,5.9%), testicular cancer (10 cases ,4.5%). The least number of cases are seen in duodenal cancer (0.4%, 1 case), (54 cases 24.9%) constitute the remaining cancers. Tobacco smoking is present in 63.9 %( 39 patients) of male respiratory cancer patients (48 patients) and in 4.9% (3 patients) of female respiratory cancer patients. Males constitute 78.6% (48 patients) of total respiratory cancers. Females constitute 21.3% (13 patients) of total respiratory cancers.
Out of a total of 450 cases studied, there were 61cases (13.5%) of respiratory cancers,(48 male and13 female).of these Tobacco smoking is present in 68.8% (42cases) of total respiratory cancers and 31.2% (19 cases)of respiratory cancer patients are non smokers.
X2=16.14, PEnglishhttp://ijcrr.com/abstract.php?article_id=1010http://ijcrr.com/article_html.php?did=1010
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Giedre Smailyte and Juozas Kurtinaitis. Cancer mortality differences among urban and rural residents in Lithuania.BMC public health 2008; 8:56.
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Christopher I. Timing of menarche and first full term birth in relation of breast cancer risk. American Journal of epidemiology 2008; 167 (2):230-239.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241523EnglishN2013December16HealthcareCORRELATION BETWEEN PHYSICAL FITNESS AND BODY MASS INDEX
English4448Sameer SrivastavaEnglish Usha DharEnglish Varun MalhotraEnglishBackground: Physical inactivity is a major cause of morbidity and mortality. The aim of the present study was therefore, to co-relate the incidence and relationship between the measures of efficiency physical fitness and the body mass index. Method: A cross-sectional study was done to determine the correlation between the measures of efficiency fitness Index and body mass index. Subjects’ physical fitness & body mass index was assessed using standardized protocols. Result: Twenty-two young subjects (age group 18-25 years) participated in the study. The study revealed high prevalence of low fitness among obese subjects and significant correlation between the selected indices of physical fitness (efficiency fitness index) and body mass index. Conclusion: The results showed that the efficiency fitness index of the subjects differed significantly from one another in the various BMI categories, with the subjects of normal weight possessing a higher fitness than the overweight or obese subjects. Fitness capacity therefore decreased progressively as the BMI increased.
EnglishPhysical Fitness, Body Mass IndexINTRODUCTION
There has been a great deal of concern in recent years about the levels of physical fitness of many young people. Young adult obesity rates have almost quadrupled in the last 25 years. The number of obese children has tripled in 20 years. 10% of six year olds are obese, rising to 17% of 15 year olds. There are various causes of obesity such as environmental pollution, stress, and lack of exercise, overeating combined with lack of exercise is considered to be the main cause according to most scientists (Na et al. 2001). Simple obesity caused by overeating and lack of exercise makes up 95% of the people suffering from obesity, without cause from hereditary illness, endocrine disorders, or neurotic disabilities (Kim 1990). Science of disease prevention and health improvement are crucial matters in our society and obesity is becoming a big issue for example, heart related diseases recently came up as a major cause of death. Research has shown that obesity can lead to health problems, including arthritis, heart disease and diabetes. One way to help to ensure that these problems do not arise is to improve people's physical fitness levels by taking regular exercise and awareness of physical fitness in the general population.
A key concept in testing physical fitness is that of a person's pulse rate and, in particular, how quickly this returns to normal after excessive exercise. It is important that the pulse rate returns to normal after strenuous exercise, otherwise the heart is put under continuous stress. The purpose of this study was to examine the relationship between body mass index (BMI) and physical fitness. The negative impact of obesity on physical
fitness has been documented; however, this issue has not been explored in youth.
AIM AND OBJECTIVE
This study was to examine the relationship between body mass index (BMI) and physical fitness. Correlation between efficiency fitness Index and body mass index assessed.
REVIEW OF LITERATURE
The literature carried out in this area showed that there was a negative significant correlation between BMI and aerobic fitness (r=-0.55) (Chen et al., 2002). There was a negative significant correlation between BMI and results of physical fitness (Chen et al., 2002). A negative significant correlation was observed between percent of body fat and aerobic fitness (Nikbakht, 1991; Hoseini, 1998). The correlation between percent of body fat and abdominal muscle endurance was negative and significant (Afarinesh, 1991). There was a negative significant correlation between percent of body fat and flexibility (Karimi, 1999). The relationship between waist circumference and physical fitness was negative (Delaux et al., 1999). There was a negative significant correlation between weight and aerobic fitness (Nikbakht, 1991; Hosseini, 1998). There was a correlation between weight and sit and reach (Afarinesh, 1991). Increased prevalence of obesity was associated with decrease of PA level (Lioret S.. 2007 ; Riddoch CJ, et al, 2004).
MATERIALS AND METHODS
This cross-sectional study was carried out on twenty-two students, age group 18-25 years. The subjects were divided into 3 groups based on BMI (Group I?BMI < 25, Group II? BMI ≥25 to < 30, Group III?BMI ≥ 30) and the correlation between BMI and physical fitness was assessed.
Inclusion criteria: Only apparently healthy subjects, who volunteered to participate in the study, were included.
Exclusion criteria: Subjects with medical and surgical conditions such as diabetics, hypertension and other cardiac, renal, respiratory disease and chronic disease were excluded from the study.
The following anthropometric and physiological measurements were measured: Height, body weight, measure of overall obesity (body mass index [BMI]). Statistical analyses included descriptive statistics (mean, standard deviation. The study protocol was approved by ethical committee. Written consent from the subjects was taken before they were considered for inclusion in the study.
1) Measuring height and weight
Wearing light clothing, the subject stands comfortably barefooted with eyes leveled on a Height and Weight Measuring Instrument.
2) Measuring efficiency fitness index (EI) by Gallagher and Brouha Test
They were asked to exercise for 5 minutes on bicycle ergo meter in the department of Physiology of Santosh Medical College. The pulse rate will be recorded before the start of exercise, during exercise, 1 minute after the exercise (a), 2 minute after the exercise (b), and 4 minute after the exercise (c).
The efficiency fitness index will be calculated as,
EI = (Duration of Exercise in seconds) X 100
2(a + b + c)
The fitness of the subject will be graded on basis of Heart rate recovery as,
>90% - Superb
80 - 90 - Excellent
70 - 80 - Good
55 - 70 - Average
Below 55 – Poor Physical condition
RESULTS
Table 1: Represents the mean values of efficiency fitness index of the subjects in the various BMI groups and various BMI parameters along with correlation between BMI and Efficiency fitness index (EI)
N
Wt (kg)
Ht (m)
BMI
EI
r*
p Value
Overall
22
86.14
1.77
27.36 (±4.53)
55.28(±4.16)
-0.91629
HS
Group I
7
68.57
1.73
22.81(±2.26)
58.9(±1.76)
-0.91258
HS
GroupII
9
85.33
1.78
26.8(±1.25)
55.99(±3.19)
-0.65916
HS
GroupIII
6
107.83
1.79
33.56(±1.44)
50(±0.53)
-0.44449
HS
* Correlation
** p Value < .005
Table 1, which represents the mean values of efficiency fitness index of the subjects in the various BMI groups, confirmed a decrease in the mean values of efficiency fitness index as the BMI of the subjects increases and shows negative correlations in the efficiency fitness index with BMI. These negative correlations in the efficiency fitness index with BMI in all groups were significant.
DISCUSSION
The results from table no.1 showed that the efficiency fitness index of the subjects differed significantly from one another in the various BMI categories, with the subjects of normal weight possessing a higher fitness than the overweight or obese subjects. Fitness capacity therefore decreased progressively as the BMI increased. These results correlate with other studies that researched the same variables (Graf C, et al. 2004, Chen LJ, et al. 2006, Tokmakidis SP, et al. 2006). The overweight and obesity are associated with lowered muscle strength (Wearing et al and Tokmakidis et al). Study of anthropometric measures focusing on health indices and female students' physical fitness, concluded that there was a negative significant between most of health-related anthropometric measures and physical fitness factors (Leila Jaafari, 2012).
CONCLUSION
Physical fitness is negatively affected to a great degree in Young adults who are overweight and obese. Although the negative health effects of poor health-related physical fitness are not necessarily present at this age as a sickness or a disease, it is apparent that obesity is the precursor of various chronic diseases, which includes hypertension, type II diabetes mellitus, coronary heart disease and hyperlipidaemia. Statistics worldwide also indicate that the obesity rates seen among these young adult will most probably not improve in the future. The information obtained from this study can therefore be used in the compilation of health related fitness programmes and awareness of use of yoga and physical training. The study, however, had a shortcoming that must be taken into account when interpreting the results. The subject size was relatively small, which made generalization of the results difficult.
Englishhttp://ijcrr.com/abstract.php?article_id=1011http://ijcrr.com/article_html.php?did=1011
Afarinesh. Examination physical capabilities of physical education colleges' entrance candidates. M. A. Thesis. Tarbiat Moallem University, 1991. (Persian).
A. H. Karimi. Relationship between Well's Test, Corrected Well's Test with some anthropometric measures of male of National Karate Teams of Iran. M. A. thesis. Tehran University. 1999. (Persian)
Brouha, Lucien (1943), “The Step Test: A Simple Method for Measuring Physical Fitness for Muscular Work in Young Men”, Res.Quart. 14, pp. 31-36.
Chen LJ, Fox KR, Haase A, Wang JM. Obesity, fitness and health in Taiwanese children and adolescents. Eur J Clin Nutr 2006;60:1367–75.
Graf C, Koch B, Kretshmann-Kandel E, et al. Correlation between BMI, leisure habits and motor abilities in childhood (CHILT-Project). Int J Obesity 2004;28:22–6.
K. Delaux, R. Lysens, R. Philippaerts, M. Thomis, B. Wanreusel, A. L. Claessens, B. Vonden Eynde, G. Beunen, J. Lefevre. Association between physical activity, nutritional practices and health-related anthropometry in Flemish males: a 5-year follow-up study. International Journal of Obesity. 1999, 23: 1233- 1241.
Kim YS(1990)?Symposium?Recent Progress in Obesity Research?Classification and Evaluation of Obesity. Korean J Nutr 23 (3)?337-340
Lioret S. Child overweight in France and its relationship with physical activity, sedentary behaviour and socioeconomic status. Eur J Clin Nutr. 2007;61:509–16.
Leila Jaafari. Health-related anthropometric measures in connection with physical fitness factors; IPEDR vol.31 (2012) © (2012) IACSIT Press, Singapore
M. Hoseini. Correlation between body composition and some selective body measures with VO2Max on non- sportive female students of 17-18 years old in Tehran. M. A. Thesis. Tarbiat Moallem University. 1998. (Persian).
M. Nikbakht. Correlation between body Type with physical and motor fitness factors in one selective group of Tehran University students. M. A. Thesis. Tehran University. 1991. (Persian).
Na JC, Seo HG(2001)?Effect of 12 weeks Combined Punning and Muscular Resistance Exercise on Physical Fitness in Obese Female. Korean J Edu 40?440-447
Riddoch CJ, et al. Physical activity levels and patterns of 9- and 15-yr-old European children. Med Sci Sports Exerc. 2004;36:86–92.
Tokmakidis SP, Kasambalis A, Christodoulos AD. Fitness levels of Greek primary schoolchildren in relationship to overweight and obesity. Eur J Pediatr 2006;165:867–74.
Wearing SC, Hennig EM, Byrne NM, Steele JR, Hills AP. The impact ofchildhood obesity on musculoskeletal form. Obes Rev 2006;7:209–18
W. Chen, C.C. Lin, C.T. Peng, C. I. Li, H.C. Wu, J. Chiang, J.Y. Wu, and P.C. Huang. Approaching healthy body mass index norms for children and adolescents from health related physical fitness. Journal of Obesity Reviews. 2002, 3: 225-232.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241523EnglishN2013December16HealthcareVULVAR CANCER WITH BONE METASTASES: A RARE CASE REPORT
English4952Saptarshi Ghosh1English Sivasankar KotneEnglish Samir Ranjan NayakEnglish SPV TurlapatiEnglishPurpose - Vulvar carcinoma with bone metastases is an extremely rare entity with only twelve cases reported in literature till date. We report a case of squamous cell carcinoma vulva with multiple bone metastases. Case - A 32 year old female presented with a Stage IIIB (FIGO Classification) vulvar malignancy, in which radical vulvectomy with bilateral Ilio-inguinal lymphadenectomy was done. Four weeks later the patient presented with pain in the left shoulder region which was proved to be metastases later. She was started on palliative radiation therapy and palliative chemotherapy. Conclusion – History of bone pains in patients with gynaecological malignancies should always be investigated properly so as not to miss such uniquely aggressive presentation, especially in higher stage diseases. Here, a patient with well differentiated squamous cell carcinoma vulva developed multiple osseous metastases within a month following surgery.
EnglishSquamous cell carcinoma vulva; Multiple bone metastases; Radical vulvectomy; Bilateral Ilio-inguinal lymphadenectomy.INTRODUCTION
Vulvar cancer accounts for about 4% of all gynaecological malignancies. Like other gynaecological malignancies, vulvar cancer spread mainly through the lymphatic rather than the hematogenous route. [1] Vulvar cancer with hematogenous bone metastases is an extremely rare presentation with only twelve cases reported in literature till date, of which all women were of age greater than 50 years. Bone metastases in gynaecological malignancies are often under-diagnosed. [2] The presence of bone metastases in vulvar carcinoma alters the management protocol of the treating oncologist, thereby warranting the need for palliative radiotherapy and palliative chemotherapy. It also marks a very poor prognostic signature for the patient. So it is gravely important to take a plain radiograph of the affected site when a patient with gynaecological cancer complaints of bone pain and rule out the rare possibility of bone metastases in such cancers.
CASE REPORT
We report a 32 year old female who presented with complaints of burning sensation and itching in the clitoris of six months duration. Clinical examination revealed a 2.5cm x 2.0cm ulcerative lesion at the clitoris and bilateral inguinal lymphadenopathy. Histopathological examination
revealed a well differentiated squamous cell carcinoma of the vulva.
The patient underwent radical vulvectomy and bilateral Ilio-inguinal lymphadenectomy. Postoperative histopathology confirmed metastatic squamous cell carcinomatous deposits in bilateral inguinal lymph nodes - pT1b, pN2a, M0; G1(FIGO Stage III B) vulvar carcinoma. She was advised for adjuvant radiation six weeks post-surgery, following wound healing. But the patient presented earlier, only four weeks following surgery with complaints of pain in the left shoulder region. Plain chest radiograph demonstrated a well defined lytic lesion involving the head of the left humerus. Fine needle aspiration cytology of the left humeral head lesion rendered a diagnosis favouring squamous cell carcinomatous deposit. A further bone scan demonstrated increased radiotracer uptake in the left proximal humerus, trochanteric region of left femur and left fibula.
She was started on palliative radiation to the left humeral head and left fibula in view of pain relief. Palliative radiation was given till a dose of 30Gy in 10 fractions in 12 days with 3Gy per fraction. She was also started on palliative chemotherapy with three weekly Cisplatin and 5-Fluorouracil in view of systemic metastases and tumor cytoreduction. At last follow-up of six months following surgery, the patient was responding well to chemotherapy and was free of any bone pain.
DISCUSSION
Distant metastases outside the pelvis and abdomen may be seen rarely in vulvar malignancy. Vulvar carcinoma with bone metastases is an even rarer presentation.[3] Autopsies performed on 305 patients with gynaecological malignancies revealed four cases of asymptomatic bone metastases in patients with vulvar malignancies.[2] Bone scan is useful in detecting multiple bone metastases from vulvar cancer which can be confirmed immunohistochemically by the over expression of pan-cytokeratin MNF-116.[4] Palliative radiation therapy has been used in some cases for pain relief and tumor burden reduction.[3]
CONCLUSION
Bone metastases should be borne in mind in cases of unclear bone pains in women with gynaecological malignancies [4] and should be investigated properly. A plain radiograph is the most useful preliminary and cost-effective investigation in such cases and should be followed with a cytological or histopathological confirmation of the metastases. A bone scan will further supplement in delineating precisely the different sites of osseous metastases and to plan the treatment accordingly.
Englishhttp://ijcrr.com/abstract.php?article_id=1012http://ijcrr.com/article_html.php?did=1012
Brufman G, Krasnokuki D, Biran S. Metastatic bone involvement in gynaecological malignancies. Radiologica Clin. 1978;47:456-63.
Abdul-Karim FW, Kida M, Wentz WB, Carter JR, Sorensen K, Macfee M et al. Bone Metastasis from Gynecologic Carcinomas: A clinicopathologic Study. Gynecol Oncol. 1990;39,108-14.
Tolia M, Tsoukalas N, Platoni K, Dilvoi M, Pantelakos P, Kelekis N et al. Metastatic bone involvement in vulvar cancer: Report of a rare case and review of the literature. Eur J Gynaecol Oncol. 2012;33(4):411-13.
Fischer F, Kuhl M, Feek U, Rominger M, Schipper ML, Hadji P et al. Bone metastases in vulvar cancer: a rare metastatic pattern. Int J Gynecol Cancer 2005;15:1173-76.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241523EnglishN2013December16HealthcareCADAVERIC FLOATING GALLBLADDER AND ITS CLINICAL SIGNIFICANCE - A CASE REPORT
English5354Siva nageswara Rao Sundara SettyEnglish Raja Sekhar KatikireddiEnglishAcute cholecystitis may be due to strangulation of a floating gall bladder. We report a case of floating gallbladder in an adult cadaver which was freely floating from the inferior surface of liver by a peritoneal fold. This case report may be a rare anomaly which is important for radiologists and laparoscopic surgeons.
EnglishCholecystitis, Gall bladder, LiverINTRODUCTION
The gallbladder is 10 cm long in adults, which is located in the gall bladder fossa on the inferior surface of the right lobe of the liver. Gall bladder is a pyriform sac that consists of body neck and fundus. It develops in the beginning of the 4th week from the hepatic diverticulum of the foregut. The caudal part of the diverticulum gives rise to the gall bladder and the cystic duct [1].
CASE REORT
In the present case we are reporting a rare anatomical variation of floating gallbladder (FIGURE: 01), which is located on the inferior surface of the liver. The gallbladder is suspended by a peritoneal fold measuring 3 cm length and 2.5 cm width. This present case found in the 50 years old male cadaver, department of anatomy, Bhaskar Medical college, Yenkapally, Moinabad, Ranga Reddy District, Andra Pradesh.
DISCUSSION
A cadaveric floating gallbladder is a rare anatomic variation, which only few cases have been reported. Morales AM et al [2008] reported a case of wandering gallbladder [2]. Wen Chieh Wu et al [2013] reported a floating gall bladder in a 40 year old woman [3]. Lyons KP et al [2000] reported a case of floating gallbladder in a 55-year-old woman [4]. Kabaroudis A et al [2003] found a case of hypoplasia of the right hepatic lobe associated with floating gall bladder in a 65-year old female [5]. Ueo T et al [2007] reported a case of acute cholecystitis due to strangulation of a floating gall bladder by a lesser omentum by an abdominal sonography in a 35 year old japanese woman [6].
CONCLUSION
Strangulation of floating gall bladder is the one of the reason for acute cholecystitis, so awareness of this anomaly may provide the right diagnosis for surgeons dealing with liver and gallbladder surgeries. This present rare anatomic variation may be significant for radiologists and gastro hepatic surgeons.
Englishhttp://ijcrr.com/abstract.php?article_id=1013http://ijcrr.com/article_html.php?did=1013
Vakili K, Pomfret E. Biliary Anatomy an Embryology. Surg Clin N Am. 2008; 88:1159-74.
Morales A M, Tyroch AH. Wandering gallbladder. American Journal of Surgery2008; 196:240–1.
Wen Chieh Wu, Gar-Yang Chaubc, Chien-Wei Sua,e, Jaw-Ching Wu. Wandering abdominal pain due to a floating gallbladder. Digestive and Liver Disease 45 (2013) e13.
Lyons KP , Challa S, Abrahm D, Kennelly BM. Floating gallbladder: a questionable prelude to torsion: a case report. Clin Nucl Med. 2000; 25(3):182-3.
A. Kabaroudis, B. Papaziogas, K. Atmatzidis, E. Argiriadou, A. Paraskevas, I. Galanis, T. Papaziogas. Hypoplasia of the Right Hepatic Lobe Combined with a Floating Gallbladder. Acta chir belg, 2003; 103. 425-427.
T Ueo, S Yazumi, S Okuyama, Y Okada, T Oono, M Watanabe, Y Umehara, H Honjo, Y Mitumoto, T Mori, H Tomioka, T Mogitani, S Mizuno, T Chiba, S Shimizu. .Acute cholecystitis due to strangulation of a floating gall bladder by a lesser omentum. Abdom imazing. 2007; 32: 348-350.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241523EnglishN2013December16HealthcareFORMATION OF MEDIAN NERVE BY THREE ROOTS AND ORIGIN OF MUSCULOCUTANEOUS NERVE FROM LATERAL ROOT OF MEDIAN NERVE
English5558Sumi GhoraiEnglishThe present case report describes the unusual formation of median nerve by the fusion of three roots, two from the lateral and one from the medial cord of the brachial plexus in left upper extremity. One root after arising from lateral cord joined with medial root of median nerve after crossing in front of axillary artery high up in the axilla and another root joined the medial root at normal site. Normally musculocutaneous nerve originates from lateral cord of brachial plexus but in this case it took its origin from the lateral root of median nerve. I illustrate this as a unique case of “Formation of Median Nerve by three Roots and Origin of Musculocutaneous Nerve From Lateral Root of Median Nerve.”
EnglishMedian nerve, musculocutaneous nerve, variation.INTRODUCTION
The median nerve, branch of the brachial plexus, commonly shows variation in its formation and distribution.1 The median nerve (C5-T1) is formed by union of medial and lateral roots, anterior or anterolateral to the third part of axillary artery2. Anterior division of lower trunk (C8,T1) continues to form the medial cord which give rise to medial root. The lateral root originates from the lateral cord coming from anterior divisions of upper and middle trunks(C5,C6,C7).3 After giving the first branch (Lateral pectoral nerve), the lateral cord divides into musculocutaneous nerve and lateral root of median nerve (Fig. 1).4 The musculocutaneous nerve shows frequent variations in connection to the median nerve. It may run behind the coracobrachialis muscle or adhere for some distance to the median nerve and pass behind the biceps brachii muscle or some fibers of the median nerve may run in the musculocutaneous nerve and less frequently the median nerve sends a branch to the musculocutaneous nerve.5,6 The present case report deals with a rare variation of origin of musculocutaneous nerve from lateral root of median nerve and formation of median nerve by three roots. This is important to know the anatomical variations of the peripheral nerves in the upper limbs as these abnormal nerves could be injured during surgical procedures and also explain unusual clinical symptoms.
CASE REPORT
The present case was encountered during routine dissection of left upper limb of a male cadaver in the department of Anatomy, I.Q.City Medical College, Durgapur. An unusual branching pattern of brachial plexus in the formation of median nerve was detected and also a rare case of origin of musculocutaneous nerve was observed. Median nerve was formed by three roots; two of them came from lateral cord and one from medial cord. The first root from lateral cord joined the medial root high up in the axilla crossing infront of third part of axillary artery. The second one joined the medial root in the lower part of axilla antero-lateral to the artery and the first root was smaller.
Musculocutaneous nerve took its origin from the second root of lateral cord. Then it pierces the coracobrachialis muscle (Fig. 2).
DISCUSSION
It is interesting as every arm can show different variants in the formation and course of the median nerve. Sontakke BR. et al.7 described a case where median nerve was formed by three roots; two of them came from lateral cord and one from medial cord. The first root that arose from lateral cord joined the medial root in the axilla but the second one joined with the medial root in the arm to form the median nerve, however Pais D. et al.8 reported that median nerve were formed by three roots. Two roots came from lateral cord and one from medial cord. Both the roots coming from lateral cord joined with medial root in the axilla. The first root of lateral cord was a smaller branch arising from its terminal portion. In the present study it has been observed that in left upper limb the third root (additional root) arose from lateral cord of brachial plexus and the musculocuteneous nerve took its origin from this root.
Several variations of median nerve was reported in the literature, include abnormal communications with other nerves such as musculocutaneous and ulnar nerves9. In the study of Choi D et al10, connections of the median and musculocutaneous nerves were observed in 26.4% of 138 arms. The nerves were either fused, or there were one or two communicating branches from the musculocutaneous nerve to the median nerve. Loukas M et al11 found the communicating branch between the median and musculocutaneous nerves in 63.5% of cadavers, most of these connections located proximal to the point of entry of the musculocutaneous nerve into the coracobrachialis muscle. There was no such study regarding origin of musculocutaneous nerve from median nerve, as in this case the musculocutaneous nerve took its origin from the second larger lateral root of median nerve.
CONCLUSION
The connections and distribution patterns of both nerves are important in surgical approaches to the arm and implications of clinical findings. Surgeons and clinicians should know the presence of variations during surgical procedures and clinical investigations of the arm.
ACKNOWLEDGEMENT
The author of this case report gratefully acknowledges the inspiration and help received from the scholars whose articles have been cited in the reference section. The author pays gratitude to authors/editors/publishers of all those articles/journals/books from where the reviews and literatures for the discussion have been collected.
PCM: Pectoralis Minor Muscle, AA: Axillary Artery, AV: Axillary Vein CBM: Coracobrachialis Muscle, TLDM: Tendon Of Latissimus Dorsi Muscle, LRM1: Lateal Root Of Median Nerve 1, LRMN2: Lateral Root Of Median Nerve 2, MRM: Medial Root Of Median Nerve, MN: Median Nerve, MCN: Musculocutaneous nerve ICBN: Intercostobrachial Nerve, MCNA: Medial Cutaneous Nerve Of Arm, MCNF: Medial Cutaneous Nerve Of Forearm, LSCN: Lower Subscapular Nerve.
Englishhttp://ijcrr.com/abstract.php?article_id=1014http://ijcrr.com/article_html.php?did=1014
Saeed M, Rufai AA. Median and Musculocutaneous nerves: Variant formation and distribution. Clinical Anatomy 2003; 16:453-57.
Williams PL, Bannister LH, Berry MM, Collins P, Dyson M, Dussek JE, et al editors. Gray’s anatomy. 38th ed. Philadelphia: WB-Saunders;1995.
April EW. Anatomy. Toronto: Harval Publishing Co; 1985.
Brachial plexus. http://en.wikipedia.org/wiki/Brachial_plexus#Root. [Last accessed on 2013 Aug. 18]
Standring S. Gray’s anatomy. The anatomical basis of clinical practice. 39th ed. London: Elsevier Churchill Livingstone; 2005.
Moore KL, Dalley AF. Clinically oriented anatomy. 4th ed. Philadelphia: Lippincott Williams and Wilkins; 1999.
Sontakke BR, Tarnekar AM, Waghmare JE, Ingole IV. An unusual case of an asymmetrical formation and distribution of median nerve. International Journal of Anatomical Variations, 2011, vol. 4, p. 57-60.
Pais D, Casal D, Santos A, O’neill JG. A variation in the origin of median nerve associated with unusual origin of the deep brachial artery. Journal of morphological sciences 2010; vol. 27, p. 35-38.
Chauhan R, Roy TS. Communication between the median and musculocutaneous nerve- A case report. Journal of anatomical society of India 2002; 51: 72-5.
Choi D, Rodriguez NM, Vazquez T, Parkin I, Sanudo JR. Patterns of connections between the musculocutaneous and median nerves in the axilla and arm. Clin Anat 2002;15:11-7.
Loukas M, Aqueelah H. Musculocutaneous and median nerve connections within, proximal and distal to the coracobrachialis muscle. Folia Morphol 2005; 64: 101-8.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241523EnglishN2013December16HealthcareMULLERIAN AGENESIS WITH AGENESIS OF LEFT KIDNEY- A CASE REPORT
English5962Pradnya Pradeep KulkarniEnglish M.V. RavishankarEnglishObjective: To present a case of mullerian agenesis associated with agenesis of left kidney. Background: Advanced technologies used during the investigation helped a lot in understanding the developmental anomalies in female reproductive system as well as excretory system. With the help of modern technologies we often find the association of unusual presentation. Method: Here 16 year’s old patient came with complains of not showing signs of menarche. She was examined and subjected to radiological investigations like ultrasonography (USG) Result: Abnormal structural presentation was noted. There was agenesis of uterus, cervix and vagina along with agenesis of left kidney. Conclusion: During the development there is a mutual and marginal differentiation exists between reproductive and excretory systems, are witnessed clinically with structural and functional abnormalities.
EnglishMenarche, Thelarche, Ultrasonography.INTRODUCTION
Every individual should have systems and organs which are normal structurally as well as functionally. Every system has its own importance. During the fetal life, development of different systems takes place within genetically programmed cells. Many birth anomalies are not recognized till the patient attains a certain age. In the event of differential growth and development, the agenesis of kidney, uterus, cervix and vagina has been reported in the existing literature. During agenesis of one kidney, if another normally functioning kidney gets infected or diseased, needs immediate clinical attention to face the situation. Depending on complaints patient has to undergo investigations to point out the exact defect and its cause to tackle the case with suitable measures.
CASE REPORT
A 16 years old female came with complaint of history of no signs of menarche. The patient was having signs of primary amenorrhea. The urine and blood was sent for investigations to find the cause of primary amenorrhea and sonography of abdomen and pelvis was done. During sonography it was clearly shown that patient’s left renal fossa was empty. The left kidney was not identified, but right kidney and right ureter was normal. Uterus, cervix and vagina were also not identified.
Right ovary was normal in size and echo texture. Left ovary showed a well-defined, iso to hypo echoic solid mass lesion, measuring 105x73x91mm. The lesion showed whorled architecture and slightly nodular outline. Architecture was uniform and no significant internal necrosis or calcific foci were seen. Mild to moderate intralesional vascularity was noted. There was no evidence of fixity of bowel or omentum to this mass. Uterus, cervix and vagina were not identified.
Embryology
A baby starts to develop its reproductive organs during 4th and 5th weeks of pregnancy. This development continues until the 20th week of pregnancy. The development is a complex process; many different factors can interrupt the process. Severity of baby’s problem depends on which trimester the interruption has occurred. In general, earlier the interruption is directly proportional to more severity of the defect. Uterus develops from mesodermal urogenital ridge. The paramesonephric ducts arise as a longitudinal invagination of the epithelium on the surface of the urogenital ridge. These ducts fuse at caudal end to produce uterus, cervix and vagina in female. The proximal and lateral part remains as fallopian tube1.
Kidney is a major organ in the urinary system, its development proceeds through a series of successive phases, each marked by the formation of pronephros, mesonephros, and metanephros2.
DISCUSSION
Menarche is the first menstrual cycle, or first menstrual bleeding, in female humans. From both social and medical perspectives, it is often considered the central event of female puberty, as it signals the possibility of fertility. The average age of menarche is 133.In 2011, in one study found that each 1 kg/m2 increase in childhood body-mass index (BMI) can be expected to result in a 6.5% higher absolute risk of early menarche (before age 12 years)4.|displayauthors= suggested (help) The decline in onset of menarche is commonly attributed to larger body size and earlier average attainment of sufficient body fat. But other factors such as exposure to chemicals that mimic estrogen or the urbanization and sexualization of western society have also been considered as contributing factors.
When menarche occurs, it confirms that the girl had a gradual estrogen-induced growth of the uterus, especially the endometrium, and that the "outflow tract" from the uterus, through the cervix to the vagina, is open. When menarche has failed to occur for more than 3 years after thelarche (the beginning of female pubertal breast development, normally occurring between 9 and 13 years of age.) or beyond 16 years of age, this delay is referred to as primary amenorrhea5.
Müllerian agenesis is a congenital malformation characterized by a failure of the Müllerian duct to develop, resulting in a missing uterus and variable malformations of the upper portion of the vagina. It is the third most common cause of primary amenorrhea. The condition is also called Mayer-Rokitansky-Kuster-Hauser syndrome or MRKH, named after August Franz Joseph Karl Mayer, Carl Freiherr von Rokitansky, Hermann Kuster, and G. A. Hauser. A review of the literature can be found in the Orphanet Journal of Rare Diseases6.
A uterine malformation is a type of female genital defect resulting from an abnormal development of the Müllerian duct(s) during embryogenesis. Its symptoms range from amenorrhea, infertility, recurrent pregnancy loss, and pain. Patients with uterine abnormalities may have associated renal abnormalities including unilateral renal agenesis7. The prevalence of uterine malformation is estimated to be 6.7% in the general population, slightly higher (7.3%) in the infertile patients and significantly it is higher in a population of women with a history of recurrent miscarriages (16%)8. Problems during the development of a girl's reproductive organs may be caused by broken or missing genes or it could be due to drug impact.
The reproductive tract develops in close differentiation with the urinary system. It also develops at the same time as several other organs. As a result, developmental problems in the female reproductive tract sometimes occur with problems in other areas as well.
An individual with this condition is hormonally normal; that is, they will enter puberty with development of secondary sexual characters including thelarche and adrenarche (pubic hair).
Their chromosome constellation will be 46,XX. If there is no uterus, she cannot be conceived. However, as the right ovary is normal this patient should undergo investigations to see normal ovulation process.It is possible to have offspring by the process of in vitro fertilization (IVF) and surrogacy. But some trials are like uterine transplantation is still in its phase of infancy9.
Early diagnosis is essential to plan further treatment.Routine pregnancy sonographic scans (which are not done in this case) should be performed to detect developmental defects before birth. This includes checking the status of limbs and vital organs. Some abnormalities were detected by ultrasound can be treated medically in utero or by perinatal care.In our patient sonography was not performed during her early age. There was no history of any birth defect in her family. After birth also patient was not having any complaint which requires sonography till she was 16 years old. At this age because of sonography report it was a sudden mental trauma to her as well as to her family members. Somehow they managed to face this problem. But is this a final solution for patient? How medical science is going to help? Can she go for uterine and vaginal implants? How much money is required to undergo this surgery and what is its success rate? Mullerian agenesis along with agenesis of left kidney probably indicates a close relationship (molecular association) during the development of genital and urinary systems.
CONCLUSION
Advanced technology used in clinical practice definitely helps in early diagnosis. Timely and justified use of this technology by experts will help patients. Agenesis of uterus, cervix and vagina with agenesis of kidney shows their developmental and structural intimacy.
CONFLICT OF INTEREST
Here the author declares that they don’t have any conflicts of interest.
Englishhttp://ijcrr.com/abstract.php?article_id=1015http://ijcrr.com/article_html.php?did=1015
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Bruce M. Carlson 2004. Human Embryology and Developmental Biology 3rd edition ed. Saint Louis: Mosby. ISBN 0-323-03649X.
Shawky, S.; Milaat, W. (2000). "Early teenage marriage and subsequent pregnancy outcome". Eastern Mediterranean Health Journal6 (1)
Mumby, HS; Elks, CE; Li, S; Sharp, SJ; Khaw, KT; Luben, RN; Wareham, NJ; Loos, RJ et al. (2011). "Mendelian Randomisation Study of Childhood BMI and Early Menarche". Journal of obesity2011: 180729. doi:10.1155/2011/180729. PMC 3136158. PMID 21773002.
"Amenorrhea, Primary: eMedicine Obstetrics and Gynecology". Archived from the original on 29 January 2010. Retrieved 2010-01-16. ^ Speroff L et al.
Morcel, Karine; Laure Camborieux, Daniel Guerrier (2007). "Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome." Orphanet J Rare Dis2 (13). doi:10.1186/1750-1172-2-13
(Li, S; Qayyum, A; Coakley, FV; Hricak, H (2000)."Association of renal agenesis and mullerian duct anomalies.” Journal of computer assisted tomography24 (6): 829–34. doi: 10.1097/00004728-200011000-00001. PMID 11105695.)
(Sotirios H. Saravelos, Karen A. Cocksedge and Tin-Chiu Li (2008). "Prevalence and diagnosis of congenital uterine anomalies in women with reproductive failure: a critical appraisal.” Human Reproduction Update14 (5): 415–29. doi: 10.1093/humupd/dmn018. PMID 18539641. )
"Woman 'to receive mother's womb'". 13 June 2011. Retrieved date=13 June 2011.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241523EnglishN2013December16HealthcareBIOCHEMICAL ASSESSMENT OF LIVER DAMAGE IN SMOKELESS TOBACCO USERS
English6369Velayutharaj AlwarEnglish Ramesh R.English Niranjan G.English Chandrahas KalaEnglishSmokeless tobacco is as dangerous as cigarette smoking. In fact, smokeless tobacco is equally addictive and carcinogenic. Damage to the antioxidant defence mechanism is noted in smokeless tobacco (ST) users. Even drug doses have to adjust to smokeless tobacco users as it affects the detoxifying capacity of the liver. We need more studies in south Indian population involving liver enzymes and oxidative stress parameters in ST users. Hence, we planned our study to find out whether ST induced liver damage can be detected in the initial stages by estimating the liver enzyme and MDA levels. In this study we included 30 individuals who were smokeless tobacco chewers and healthy controls. It was a prospective case control study performed in adult males between the ages 30 - 50 years. Subjects: Smokers and alcoholics were excluded from this study. Serum ALT, AST, ALP, GGT and MDA levels were estimated and compared using un-paired students t test between the two groups. The liver enzymes namely AST, ALT and ALP and GGT were significantly higher than healthy controls with a `p' value < 0.05. MDA level was significantly higher in ST chewers than healthy controls with a `p' value < 0.05. It is imperative to monitor liver enzymes in order to create an awareness on the hazards of using smokeless tobacco products among the Indian population. Smokeless tobacco is used has an alternative to cigarettes by poor people as it is less costly. Avoidance of tobacco chewing could avert many cancer deaths in India.
Englishsmokeless tobacco (ST) users, MDA, ALT, AST, ALP, GGT levels, Puducherry.INTRODUCTION
Smokeless tobacco is being made available in many forms and cheaper. It is easily available and used by literates and illiterates alike in India, as an alternative to smoker's tobacco (1). Smokeless tobacco consumption is a significant source of morbidity and mortality in India (2). As per survey (Global Adult Tobacco Survey), across 16 countries, 3 billion peoples are using tobacco products in different forms (3). According to the survey, in India smokeless tobacco use is more compared to other countries in the world. In India, Smokeless tobacco products have been in existence for thousands of years among different populations. Over time, these products have gained popularity throughout the world. The term chewing tobacco is often associated with dipping tobacco (split tobacco, moist snuff) where users place a dip of tobacco between the lower or upper lip and gum by resting the dip on the inside lining of the mouth.
Once considered a harmless pleasure of gaining euphoria smokeless tobacco is now considered as dangerous as cigarettes and even more addictive (4) .Damage to the antioxidant defence mechanism is noted in smokeless tobacco users (5) . We need
more studies in south Indian population involving liver enzymes and oxidative stress parameters in ST users and its effect on liver functions have to explore.
Hence, we planned our study to find out whether ST induced liver damage can be detected in the initial stages by estimating the liver enzymes and MDA levels
Review of literature
Every year, the use of tobacco products causes a heavy toll of deaths and severe human disease worldwide. Smokeless tobacco products (STP) are used without combustion and this eliminates the danger of direct exposure of toxic combustion compounds to the lung and other tissues of the user and of the people around. But the use of STP may result in other health hazards, local or systemic according to the manner of administration and to the content of various toxic products, including nicotine and tobacco-specific nitrosamines (7). Smokeless tobacco comes in two main forms: snuff and chewing tobacco. In India, the use of domestic types of chewing tobacco is a major cause of oral cancer and is also harmful during pregnancy. Different ways in which ST is used are Gutkha, Pan Masala, Zarda, etc. and other forms. The majority of commercial tobacco products use N. Tabacum species
Nicotine is psychoactive ingredient, is metabolically inactivated by CYP2A6 to cotinine (8). Nicotine is metabolized by the liver and detoxified (9). Tobacco contains more than 2,500 documented chemical constituents, including chemicals applied to tobacco during cultivation, harvesting, processing (10). Chewing tobacco contains more than two dozen cancer causing ingredients; chewing tobacco contains three to four times more nicotine than that delivered by a cigarette and it stays for a longer time in the bloodstream.
The major tobacco alkaloid nicotine and its principal metabolite cotinine are metabolized to pyridine-N-glucuronides, Nicotine-N-Gluc and cotinine-N Gluc in the liver(11). Nicotine also inhibits antigen mediated signalling in T-cells and this block the proliferation and differentiation of lymphocyte and suppression of antibody forming cells. There is an increased production of pro-inflammatory cytokines (IL-1,IL-6 and TNF-à)which are involved in liver cell injury (12). Studies have shown that there is a decrease in antioxidant enzymes [hepatic glutathione (GSH), glutathione peroxidase (GPx), Super oxide dismutase (SOD) and catalase (CAT)] and increased lipid peroxidation (Lpx)(13). These factors lead inflammation of liver (14). This depends on the concentration and duration of STs use. There are reports revealing hepatic lipid peroxidation induced damage to the DNA causing mutation which later may lead to hepatocellular carcinoma in patients using STs.
Hence, it is imperative that liver function test and oxidative stress level is monitored in these smokeless tobacco users and to advise regarding hazards of smokeless tobacco.
Aims
To assess the degree of liver damage and antioxidant status in smokeless tobacco users
Objectives
To estimate liver enzymes such as AST (Aspartate transaminase), ALT (Alanine transaminase), ALP (Alkaline phosphatase) and Gamma Glutamyl Transferase GGT) in smokeless tobacco users and to compare with normal healthy controls.
To estimate the levels of MDA (Malondialdehyde) in smokeless tobacco users and compared with normal healthy subjects.
MATERIALS AND METHODS
We collected a total of 60 samples which were divided into two (1) Smokeless tobacco chewers and (2) Controls. Cases [n=30] :This was a Prospective case control study performed in adult males between the ages 30 - 50 years who had visited a tertiary care hospital in Puducherry, during the months of May and June 2012. All these cases
were collected from smokeless tobacco users. Controls [n=30] Age and gender matched healthy controls were included in our study. Healthy controls having the same dietary habits were selected from those who had no previous history of using smokeless tobacco in any form.
Exclusion criteria: [For both control and cases groups]
Criteria Reasons : Males 50 years of age The age where addiction is less Female subjects Hormonal disturbance due to the menstrual cycle that may alter the values. Patients with liver pathology (e.g.: Viral Hepatitis, post hepatic jaundice) , chronic clinical conditions, metabolic and kidney disorder , and smokers as they cause liver damage and the values may be altered . Males who consume alcohol >2 drinks per day* Alcohol consumption causes liver damage and alters values especially GGT.
(* One drink - one 12-ounce bottle of beer or wine cooler, 1.5 ounces).
Estimation of biochemical parameters
Five ml of venous blood was collected from the subjects after obtaining proper written informed consent. The following biochemical parameters were estimated based on established spectrophotometric and automated procedures, approved by the International Federation of Clinical Chemistry and Laboratory medicine (IFCC)
ALT and AST were estimated using kinetic methods based on liquid stable reagents
GGT was estimated by carboxysubstrate method using a liquid stable GGT kit
Malondialdehyde (MDA) was estimated spectrophotometrically using the TBARS assay kit.
The Ethical Clearance - Protocol was duly submitted to the Institutional Human ethics committee and approval was taken before starting the study. All the procedure was informed to the patient in his native language and informed written consent was taken from them.
Statistical analysis: All the data were expressed as mean+/- SD; unpaired Students t- test was used to compare the data between the two groups of smokeless tobacco chewers and healthy control. A p value Englishhttp://ijcrr.com/abstract.php?article_id=1016http://ijcrr.com/article_html.php?did=1016
R, Suresh K, Sasikala K, Kumar BL, Venkatesan R, Ganesh GK, et al. Genotoxicity assessment in smokeless tobacco users: a case-control study. Toxicol IND Health. 2013 Mar;29(2):216-23.
Zhou J, Michaud DS, Langevin SM, McClean MD, Eliot M, Kelsey KT. Smokeless tobacco and risk of head and neck cancer: Evidence from a case-control study in New England. Int J Cancer. 2013 Apr 15;132(8):1911-7.
Giovino GA, Mirza SA, Samet JM, Gupta PC, Jarvis MJ, Bhala N, et al. Tobacco use in 3 billion individuals from 16 countries: a nationally representative cross-sectional household surveys. The Lancet, Volume 380, Issue 9842, Pages 668 - 679, 18 August 2012
Phillips CV, Guenzel B, Bergen P. Deconstructing anti-harm-reduction metaphors; mortality risk from falls and other traumatic injuries compared to smokeless tobacco use. Harm Reduction Journal 2006, 3:15
Philips CV, Wang C, Guenzel B. You might as well smoke; the misleading and harmful public message about smokeless tobacco. BMC Public Health.2005; 5:31.
Patel BP, Rawal UM, Dave TK, Rawal RM, Shukla SN, Shah PM, et al. Lipid peroxidation, total antioxidant status, and total thiol levels predict overall survival in patients with oral squamous cell carcinoma. Integr Cancer Ther. 2007 Dec;6(4):365-72.
Jensen K, Nizamutdinov D, Guerrier M, Afroze S, Dostal D, Glaser S. General mechanisms of nicotine-induced fibrogenesis. FASEB J. 2012 Dec;26(12):4778-87
Zhu AZX, Bennington MJ, Renner CC, Lanier AP, Hatsukami DK, Stepanov I, et al.Alaska Native smokers and smokeless tobacco users with slower CYP2A activity have lower tobacco specific nitrosamine bioactivation .Carcinogenesis.2013Jan;34(1):93-101.
Raunio H, Rahnasto-Rilla M. CYP2A6: genetics, structure, regulation, and function. Drug Metabol Drug Interact. 2012 May 5;27(2):73-88.
Borgerding MF, Bodnar JA, Curtin GM, Swauger JE. The chemical composition of smokeless tobacco: A survey of products sold in the United States in 2006 and 2007. Regul Toxicol Pharmacol. 2012 Dec;64(3):367-87
Marclay F, Saugy M. Determination of nicotine and nicotine metabolites in urine by hydrophilic interaction chromatography-tandem mass spectrometry potential use of smokeless tobacco products by ice hockey players.J Chromatogr A.2010 Nov.26;1217(48):7528-38.
Yanagita M, Kobayashi R, Kojima Y, Mori K, Murakami S. Nicotine modulates the immunological function of dendritic cells through peroxisome proliferator-activated receptor-? upregulation. Cell Immunol. 2012;274(1-2):26-33
Bagchi M, bagchi D, Hassoun EA, Stohs SJ. Smokeless tobacco induced increases in hepatic lipid peroxidation, DNA damage and excretion of urinary lipid metabolites. Int J Exp Pathol.1994 June; 75(3):197-202.
Mitchell C, Joyce AR, Piper JT, McKallip RJ, Fariss MW. The role of oxidative stress and MAPK signaling in reference moist smokeless tobacco-induced HOK B cell death. Toxicol Lett. 2010 May 19;195(1):23-30.
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Samal IR, Maneesh M, Chakrabarti A. Evidence for systemic oxidative stress in tobacco chewers. Scand J Clin Lab Invest. 2006;66(6):517-22.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241523EnglishN2013December16TechnologyUNSTRUCTURED PEER - TO - PEER NETWORKS USING OPTIMIZING OVERLAY TOPOLOGIES
English7073M. ArulrajaEnglish K. UmasankarEnglish S. ManikandanEnglishIn its simplest form, a peer-to-peer (P2P) network is created when two or more PCs are connected and share resources without going through a separate server computer. A P2P network can be an ad hoc connection-a couple of computers connected via a Universal Serial Bus to transfer files. A P2P network also can be a permanent infrastructure that links a half-dozen computers in a small office over copper wires. Or a P2P network can be a network on a much grander scale in which special protocols and applications set up direct relationships among users over the Internet.
EnglishSerial bus, protocols, copper wiresINTRODUCTION
The initial use of P2P networks in business followed the deployment in the early 1980s of free-standing PCs. In contrast to the mini mainframes of the day, such as the VS system from Wang Laboratories Inc., which served up word processing and other applications to dumb terminals from a central computer and stored files on a central hard drive, the then-new PCs had self-contained hard drives and built-in CPUs. The smart boxes also had onboard applications, which meant they could be deployed to desktops and be useful without an umbilical cord linking them to a mainframe.
Many workers felt liberated by having dedicated PCs on their desktops. But soon they needed a way to share files and printers. The obvious solution was to save files to a floppy disk and carry the disk to the intended recipient or send it by interoffice mail
MATERIALS AND METHODS
That practice resulted in the term "sneaker net." The most frequent endpoint of a typical sneaker net was the worker who had a printer connected to his machine. While sneaker nets seemed an odd mix of the newest technology and the oldest form of transportation, the model is really the basis for today's small P2P work groups. Whereas earlier centralized computing models and today's client/server systems are generally considered controlled environments in which individuals use their PCs in ways determined by a higher authority, a classic P2P workgroup network is all about openly sharing files and devices. In general, office and home P2P networks operate over Ethernet (10M bit/sec.) or Fast Ethernet (100M bit/sec.) and employ a hub-and-spoke topology. Category 5 (twisted-pair) copper wire runs among the PCs and an Ethernet hub or switch, enabling users of those networked PCs access to one another's hard drives, printers or perhaps a shared Internet connection.
BOTH CLIENT AND SERVER
In effect, every connected PC is at once a server and a client. There's no special network operating system residing on a robust machine that supports special server-side applications like directory services (specialized databases that control who has access to what). In a P2P environment, access rights are governed by setting sharing permissions on individual machines.
For example, if User A's PC is connected to a printer that User B wants to access, User A must set his machine to allow (share) access to the printer. Similarly, if User B wants to have access to a folder or file, or even a complete hard drive, on User A's PC, User A must enable file sharing on his PC. Access to folders and printers on an office P2P network can be further controlled by assigning passwords to those resources.
TRENDS AND IMPACT
The first appearance of open source systems such as Napster in 1999 radically changed file-sharing mechanisms. The traditional client-server file sharing and distribution approach using protocols like FTP (File Transfer Protocol) was supplemented with a new alternative — P2P networks. At the time, Napster was used extensively for the sharing of music files. Napster was shut down in mid-20012 due to legal action by the major record labels.
The shutting of Napster did not stop the growth of P2P applications. A number of publicly available P2P systems have appeared in the past few years, including Gnutella, KaZaA, WinMX and BitTorrent, to name but a few. From analysis of P2P traffic in 2007, BitTorrent is still the most popular file sharing protocol, accounting for 50-75% of all P2P traffic and roughly 40% of all Internet traffic3.
P2P technology is not just used for media file sharing. For example, in the bioinformatics research community, a P2P service called Chinook4 has been developed to facilitate exchange of analysis techniques. The technology is also used in other areas including IP-based telephone networks, such as Skype5, and television networks, such as PPLive6. Skype allows people to chat, make phone calls or make video calls. When launched, each Skype client acts as a peer, building and refreshing a table of reachable nodes 7 in order to communicate for chat, making phone calls or video calls. PPLive shares live television content. Each peer downloads and redistributes live television content from and to other peers8.
GOVERNANCE AND REGULATIONS
In the U.S., a number of politicians have raised concerns about possible threats to national security due to P2P network technology. The possibility of accidental leaks of classified information by government officers to foreign governments, terrorists or organized crime via P2P file sharing programs has prompted a view that “new laws and rules should be enacted to protect personal information held by federal agencies and other organizations”. The proposal does not restrict P2P networks as a whole, but attempts to strike “a balance that protects sensitive government, personal and corporate information and copyright laws”9.
A P2P network itself is only a form of technology, and is not related to disputes over content and intellectual property rights. However, there have been court cases in Hong Kong against illegal P2P activities. In 2005, a Hong Kong resident was convicted of Peer-to-peer Network Page 7 of 14 breaching the Copyright Ordinance by uploading illegal copies of copyrighted works to the Internet using the BitTorrent peer-to-peer file sharing program, and making files available for download by other Internet users10.
SECURITY THREATS
A P2P network treats every user as a peer. In file sharing protocols such as BT, each peer contributes to service performance by uploading files to other peers while downloading. This opens a channel for files stored in the user machine to be uploaded to other foreign peers. The potential security risks include:
1. TCP ports issues
Usually, P2P applications need the firewall to open a number of ports in order to function
properly. BitTorrent, for example, will use TCP ports 6881-6889 (prior to version 3.2). The range of TCP ports has been extended to 6881-6999 as of 3.2 and later16. Each open port in the firewall is a potential avenue that attackers might use to exploit the network. It is not a good idea to open a large number of ports in order to allow for P2P networks.
2. Propagation of malicious code such as viruses
As P2P networks facilitate file transfer and sharing, malicious code can exploit this channel to propagate to other peers. For example, a worm called VBS. Gnutella was detected in 2000 which propagated across the Gnutella file Peer-to-peer Network Page 10 of 14
sharing network by making and sharing a copy of itself in the Gnutella program directory17.
Algorithm 1: Building Hierarchical Summaries
1. for each peer
2. for each document
3. Generate its vector vd by VSM
4. Generate peer weighted term dictionary vp
5. for each document vector vd
6. transform it into D(vp) dimensionality
7. generate high-dimensional point for vd by SVD
8. Pass vp to its super peer
9. for each super peer
10. Generate group weighted term dictionary vs
11. for each vp
12. transform it into D(vs) dimensionality
13. generate high-dimensional point for vp by SVD
14. Pass vs to other super peers
15. Generate global weighted term dictionary vn
16. for each vs
17. Transform it into D(vn) dimensionality
18. Generate high-dimensional point for vs
RESULT AND DISCUSSION
While P2P networks open a new channel for efficient downloading and sharing of files and data, users need to be fully aware of the security threats associated with this technology. Security measures and adequate prevention should be implemented to avoid any potential leakage of sensitive and/or personal information, and other security breaches. Before deciding to open firewall ports to allow for peer-to-peer traffic, system administrators should ensure that each request complies with the corporate security policy and should only open a minimal set of firewall ports needed to fulfil P2P needs. For end-users, including home users, care must be taken to avoid any possible spread of viruses over the peer-to-peer network.
CONCLUSION
The P2P paradigm is becoming increasingly popular for developing internet-scale applications. P2P content sharing systems, as popularized by the initial endeavors of Napster, Gnutella, etc., are receiving increasing attention from academics and industry as an important class of internet data management applications.
In this paper we have presented the problem of managing content and resources in P2P sharing systems so to ensure the efficiency of operation. Efficiency is viewed both from the point of view of the system, in the sense of ensuring globally fair load distribution among all Peers, and from the point of view of the users, in the sense of facilitating low user-request response times.
Englishhttp://ijcrr.com/abstract.php?article_id=1017http://ijcrr.com/article_html.php?did=1017
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