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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241519EnglishN2013October19General SciencesSOIL QUALITY AND YIELD DECLINE : PERCEPTION OF FARMERS IN THE SUDAN SAVANNAH REGION OF NIGERIA
English0107S. UsmanEnglish S. S. NomaEnglishAssessment of farmers? perception on soil quality and crop yield decline has been carried out in the Sudan Savannah (SS) of Kebbi State Nigeria with a specific objective to provide a report on soil quality deterioration and yield decline using IPCC climate change impact report on Africa by 2020. The assessment was made using face-to-face-verbal-interview. The interview was divided into four rounds according to four questions. It is reported that the farmers are aware of climate change impact and they have considered this impact as one of the major agricultural problem that would take part in soil quality deterioration and yield decline in the SS by 2020. Generally, the fact that the climate change impact will cause yield reduction for up to 50% in Africa by 2020 remained an open debate issue for most farmers in the SS.
EnglishSoil quality, yield, farmers, climate change, savannahINTRODUCTION
It is well known that farmers are expert because of the daily experiences, which they have been acquiring year after year in farming activities. Their experiences are important for future agricultural management (IPCC, 2001). Farmers are known to have developed intricate systems of gathering, predicting and interpreting agricultural related problems for future management (IPCC, 2007). In the Sudan Savannah (SS) of Kebbi State Nigeria, farmers are much more concern about the soil and crop yield performances (KARDA, 1997). They are very worried about the poor soil fertility and soil quality levels because of low crop yield. Therefore, farmers in the SS are in position to contribute based on their experiences to research development in the identification of soil-crop related problems, namely soil quality deterioration and crop yield decline. Studies in Nigeria (Raji et al., 2000) and Kenya (Defoer et al., 2000) reported that farmers are able to use their experiences on weather condition such as annual rainfall record, hottest season in a year, nature of wind in dry season as well as physical surface soil condition and crop yield performances to make a judgement for present and future agricultural soil and crop related problems. Farmer’s experience was considered as the basis for local-level decision-making in many rural communities because of its value not only for the culture in which it evolves but also for scientists who are working to improve awareness in rural localities (IPCC, 2007). In the present study, the farmers based knowledge in agriculture was used to know and understand the level of soil quality deterioration and crop yield reduction in the SS. The general objective of this study was to provide a report on soil quality deterioration and crop yield reduction based on farmer’s perception on climate change impacts using IPCC climate change impact report on Africa by 2020.
MATERIAL AND METHOD
Study area
The SS of Kebbi State Nigeria is one of the most agriculturally viable environments in northern States of Nigeria. The total landmass of northern Nigeria including the SS is 75.9% of the country (Clara et al., 2003). The region lies between latitude 11o and 13oN and longitudes 4o and 15oE, bordering the Nigerian States of Sokoto to the north, Zamfara to the east and Niger to the south. In sub-Saharan Africa, the SS borders the nations of Niger republic to the west and Benin republic to the southwest (Figure 1). The total land area of Kebbi State including the SS is 36,229 km2 of which 12,600 km2 is under agriculture (KARDA, 1997). The annual rainfall in the SS is variable and declining, being 600 mm to 875 mm and on average 650 mm during the period 1995-2010, against 815 mm over 1962-71; and was only 509 mm in 1993 as reported by Oluwasemire (2004). The annual monthly temperatures are between 25oC-45oC.
http://unowa.unmissions.org/Default.aspx?tabid=793
IPCC (2007) report on climate change impact in Africa
The Third Assessment Report of the IPCC working group on climate change impact in Africa have identified and highlighted a range of impacts and problems associated with climate change and its variability in African continent (IPCC, 2007). These range of climate change impacts as identified by the working group include decreases in grain yields, changes in runoff, increased droughts and floods, as well as significant plant and animal species extinctions and associated human livelihood impacts (IPCC, 2007). However, in line with these climate change impacts, the present study has focussed on two important factors that are physically and socially daily news among the farmers in the SS namely: soil quality deterioration and annual crop yield reduction. Therefore, the third assessment report was used as complete materials to develop and formed the questions, which have been used to collect the necessary information from farmers on climate change impact as related to soil and crop in the SS. The questions are grouped into four. First, ‘Have you notice climate change in your locality?’ Second, ‘Is climate change affecting your agricultural farms? Third, ‘What major agricultural problem has climate change caused so far?’ and Fourth, ‘What do you believe would happen to your farms by 2020 in term of soil-yield quality?’. These four questions were developed based on assumption that farmers in the SS are very aware with the climate change and its impact but not knowing that the local name they have been using (i.e. “chanjin yanayi or damana”) to describe or define the context is the same as ‘climate change’ as strictly understood by global environmental scientists.
Interview format
Face-to-Face-Verbal-Interview was carried out in rural areas of Argungu, Bagaye, Birnin Kebbi, Bui, Fakon-Sarki, Kangiwa and Tungar-Dangwari villages. Farmers were selected randomly. The respondents are all males. The total size of the participants in each village is one hundred (i.e. 100 x 7 = 700 individual farmers). The interview was divided into four rounds according to the first, second, third and fourth questions, consecutively. In the first round, one hundred participants in each village were given chance to answer the first question. In the second round, the numbers of positive respond from the first question were considered for the second round. In the third and fourth rounds, the number of individuals positively responded to question been asked in the second round were considered, accordingly. Each interview was recorded using pen and exercise book, lasted between 55 and 95 minutes for a period of 1 day in each village.
RESULTS
The results of this study are presented in Tables 1, 2, 3 and 4. The total numbers of farmers who respond positively and negatively as well as those who have not responded were presented in Table 1. The percentage analyses of the overall results are given in Tables 2, 3 and 4. In the first round of the interview there were significant responses (Table 1). At Argungu, Bagaye, Birnin Kebbi, Bui, Kangiwa and Tungar-Dangwari more than 50% of the farmers have responded positively but varied in numbers of negative respond and numbers of no respond, accordingly (Table 1). In the second round, where the percentage numbers of positive respond from the first round were considered for the next question, there were also variations in terms of positive and negative responses. In the 3rd round of the assessment, the data show significant farmer’s respond to erosion and yield reductions (Table 3). By comparison, the percentages farmer’s responded to erosion are high in Argungu, Birnin-Kebbi, Bui, Kangiwa and Tungar-Dangwari. Reasonably, there were only high percentages (49% and 58%) of farmer’s respond to yield reduction against soil erosion (34% and 35%) in Fakon-Sarki and Bagaye, accordingly (Table 3). Considerably, all the farmers in Kangiwa responded significantly to both erosion (61%) and yield reduction (39%). Table 4 shows the farmer’s opinion to soil quality and yield decline by 2020 in the SS. Majorities of farmers in Argungu (66%), Bagaye (59%), Birnin Kebbi (45%) and Bui (66%) agreed that by 2020 yield would be decline by 30% due to soil quality deterioration. However, this is contrary to farmers in Fakon-Sarki, Kangiwa and Tungar-Dangwari (Table 4). Generally, only few of these farmers agreed that the agricultural production will reduced to 70% by 2020.
DISCUSSION
The presence study noted that there are some evidences of soil quality and yield decline in the SS as perceived by farmers in the region (Table 1). Also, there would be expectations of yield reduction between 30%, 50% and 70% by the year 2020 in the SS (Table 4). These two areas of observations are worth of consideration. The baseline data on farmer’s perception indicates an important response to questions asked throughout the interview (Tables 2, 3). More importantly, in the third and fourth rounds, it is clear that the farmers are very aware of the problems of soil erosion and yield reduction (Table 3). However, majority of the farmers in all the villages agreed that climate change affects their agricultural lands (Table 2). Farmers in these villages are very aware of climate change because of the seasonal variations in terms of annual rainfall, monthly temperature and wind. Historically, farmers in the SS are aware of climate change and they considered it as ‘chanjin yanayi’ in their native language. Farmers in this part of Africa are very aware of the problems associated with agricultural, soil and environmental conditions (Usman, 2007).
Traditionally farmers in the SS used common term in their native language to differentiate between good and bad season as ‘damana tayi kyau’ or ‘damana batayi kyau ba’, accordingly. One of the potential traditional measures in respect to farmer’s indigenous knowledge on climate change in the SS is available annual data record based on number of monthly rains (e.g. IPCC, 2007). Another potential traditional measure might be related to decrease in annual yield reduction because most of the farmers have complained much about drought and flooding due to shortage of rainfall in the first three or four months of the rainy season but more rainfall than normal in the last two months of the same season (Bai and Dent, 2008). It is well known that rainfall are highly needed during the first few months of plant growth and has less important in the last 1 month, because at this time the farm produces are well matured ready for the harvest.
However, with farmer’s perception as pointed out in this paper, it is clear that the soil erosion impact on land and people reported by KARDA (1997) are in many ways associated with the issues related to climate change and environmental problems such as erosion in the SS. However, the underlying assumption is that the farmers have only used their daily experiences in term of farming and history of annual yield reduction to answer the questions, while some of the future projected data in relation to soil quality deteriorating (Put et al., 2004; Bai and Dent, 2008) and yield reductions (Schmidhuber and Tubiello 2007; IPCC, 2007) were based on scientific models and scientific evidences. Therefore, it is important to note that the results of this assessment is based on the fact that the SS is part of Africa and that the farmer’s perception on soil quality deteriorating and yield reduction by 2020 was assessed based on IPCC report. Thus, the impact of climate change in the SS should be given a special consideration in future soil management decision making (Murwira et al., 2001).
CONCLUSION
The farmer’s perception on soil deteriorating and yield reduction projected by IPCC on Africa by 50% in 2020 was assessed in the SS (Tables 1–4). The assessment was made using face-to-face-verbal-interview. The interview was divided into four rounds according to four questions. In the first round, more than 50% of the farmers in Argungu, Bagaye, Birnin Kebbi, Bui, Kangiwa and Tungar-Dangwari responded positively to the question been asked. In the second round, 60% to 100% responded positively in all the villages, and in the third round, erosion and yield reduction were considered as the two major agricultural problems in all the villages (Tables 1, 2, 3). In fourth round, majority of the farmers in Argungu, Bagaye, Birnin Kebbi, and Bui agreed that by 2020 the agricultural production in Kebbi State would be affected by 30% yield reduction while in Fakon-Sarki, Kangiwa and Tungar-Dangwari 54%, 56% and 54% of the farmers, respectively, agreed that by 2020 the total agricultural yield production will go down by 50% (Table 4). Overall, it can be conclude that the farmers in the SS are very aware of climate change impact but the fact that this impact would be up to 50% in Africa by 2020 remained an open debate issue for most farmers in the SS. Absolutely, it is believe that some farmers have considered climate change impact as one of the major agricultural problems, which could take part in deteriorating soil quality and yield reduction by 30%, 50% and 70% by 2020 (Table 4). Therefore, a similar research investigation in the SS will provide additional information of climate change impact in future.
ACKNOWLEDGEMENT
We thank the rural farmers of the SS who have participated and contributed toward the success of this study. As part of this acknowledgement, we thank the pronounced assistance received from the scholars whose articles cited and included in references of our paper. The results of this study was collected by Suleiman Usman as part of his PhD works, therefore we acknowledge his contribution and effort. We also express the thanks to publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Personally, we are grateful to IJCRR editorial board members and IJCRR team of reviewers who have facilitated to bring quality to this paper.
Englishhttp://ijcrr.com/abstract.php?article_id=1072http://ijcrr.com/article_html.php?did=1072
Bai, Z. G and Dent, D. L. Land Degradation and Improvement in Tunisia 1. Identification by remote sensing: GLADA Report 1f, 1e Version August 2008. World Soil Formation: ISRIC and FAO, 2008.
Clara, E., Suleiman, M., Mairo, M., Ann, W. J., Bilkisu, Y. H. and Saharadeen, Y. Strategic Assessment of Social Sector Actions in northern Nigeria: Draft Report. Assessment team lead by Clara and colleagues. Northern Assessment, Abuja, Nigeria, 2003, Pp 2-5.
Defoer, T., Budelman, A., Toulmin, C. and Carter, S. E. (Eds.) Building common knowledge: participatory learning and action research: Managing Soil Fertility in the Tropics. Series No.1. KTT Publication. IIED, FAO, CTA and KIER. Royal Intitute, Amsterdam, Netherlands, 2000, 165-166pp.
IPCC, IPCC Third Assessment Report – Climate Change 2001: Summary for Policy Makers. Intergovernmental Panel on Climate Change (IPCC), 2001.
IPCC, Summary for policymakers. In: Climate Change 2007: The physical Science Basis. Contribution of working group I to the fourth assessment report of the intergovernmental panel on climate change. Solomon and co-workers (eds.). Cambridge University Press, Cambridge, UK and New York, USA, 2007.
KARDA Diagnostic survey report of agro-forestry and land management practices in Kebbi State. Kebbi Agricultural and Rural Development Authority (KARDA), Kebbi State Nigeria, 1997.
Muriwira, H. K., Mutiro, K., Nhamo, N., and Nzuma, J. K. Research Results on improving cattle manure in Tsholotsho and Shurugwi in Zimbabwe. In: Improving soil management options for women farmers in Malawi and Zimbabwe. Proceeding of a collaborator’s workshop on the DFID-supported project 13 – 15 September 2000. ICRISAT-Bulawayo, Zimbabwe, 2001.
Oluwasemire, K. O. (2004) Ecological Impact of changing rainfall pattern, soil processes and environmental pollution in the Nigerian Sudan and Northern Guinea Savannah Agroecological Zones. Nigerian Journal of Soil Research, 2004, 5, 23-31.
Put, M., Verhagen, J., Veldhuizen, E. and Jellema, P. Climate Change in Dryland West Africa?: The empirical evidence of rainfall variability and trends. Environment & Policy, 2004, 39, 27-32. Earth and Environmental Science, SpringerLink, 2004.
Raji, B. A., Malgwi, W. B., Chude, V. O., and Berding, F. Integrated Indigenous Knowledge and Conventional Soil Science Approaches to Detailed Soil Survey in Kaduna State, Northern Nigeria. 18th World Congress of Soil Science, July 9-15, 2006 – Philadelphia, Pennsylvania, USA and FAO, Nigerian office, Abuja, Nigeria, 2006.
Schmidhuber, J. and Tubiello, F. N. Global food security under climate change. William Easterling, Pennsylvania, University Park, P. A, 2007.
Usman S. Sustainable soil management of the dryland soils of northern Nigeria. GRIN Publishing GmbH, Germany ISBN (Book): 978-3-640-92136-2, 2007.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241519EnglishN2013October19General SciencesA SURVEY OF PHYTOPLANKTON DIVERSITY IN BAISHAR BEEL OF NADIA DISTRICT OF WEST BENGAL
English0813Jai Prakash KeshriEnglish Subhabrata GhoshEnglish Sutanu BhattacharyyaEnglishAn attempt has been made to study the phytoplankton diversity of a freshwater, seasonal oxbow lake, Baishar Beel of Nadia district of West Bengal. This particular beel is located within Chakdaha block of Nadia district and shows a connection between rural and urban areas. A total of 30 phytoplankton species were recorded from the wetland during the study period of March-November, 2012. Phytoplankton composition of the Baishar Beel was fluctuated by seasonal changes and four algal classes namely Chlorophyceae, Cyanophyceae, Bacillariophyceae and Euglenophyceae form the phytoplankton spectrum within the study period. Among this, Chlorophyceae dominates in monsoon and post-monsoon and Cyanophyceae dominates in pre-monsoon season. Various diversity indices (Shannon Wiener diversity index, Margalef species richness index, Pielou evenness index, and Simpson dominance index) were calculated to illustrate the seasonal changes of phytoplankton. The Shannon Wiener diversity index values (2.52, 2.33 and 2.66 for pre-monsoon, monsoon and post-monsoon season respectively) were recorded. Which pinpoint a moderate pollution status of this beel?
EnglishPhytoplankton diversity, Baishar beel, Nadia, West Bengal.INTRODUCTION
Wetlands represent a transitional zone between terrestrial uplands and aquatic bodies and characterized by a large number of ecological niches which establishes huge biological diversity. The wetlands of West Bengal have been worked out by several authors during the last century (Mukherjee and Palit, 2001; Mandal et al., 2003; Chakraborty et al., 2004; Palit et al., 2006; Palit and Mukherjee, 2007; Bala and Mukherjee, 2007; Mandal and Mukherjee, 2007; Bala and Mukherjee, 2011). Floodplain wetlands are locally known as ‘Beel’. Phytoplankton acts as primary producer and biological filter of water ecosystem. The purpose of this study was to evaluate the phytoplankton diversity of this beel and its seasonal fluctuation. This type of study in continuation can pin point the successional changes of phytoplankton and the effects of anthropogenic load also.
MATERIAL AND METHODS
Study area and wetland characteristics
Baishar beel is a natural non-perennial oxbow lake, located between 22?58'48' ‘N latitude and 88?27'53''E longitude of the Chakdaha block division of the Nadia district, West Bengal, India (Figure. 1).It covers a total area of 333.33 acreas of land surface. Although this wetland is a rain fed one but a small part occasionally gets connected with Bhagirathi River. This establishes its open type flood plain wetland nature. The mean depth of this water body is 7 ft.
Sample collection and analysis
Phytoplankton samples were collected between 9 to 10 am. in 500 ml amber color bottle and fixed with Lugol’s iodine solution in 100 : 1 ratios. The supernatant part was pipetted out and the sample being concentrated to5 ml. for analysis. Drop count method (Trivedy and goel, 1984) was followed for numerical representation of phytoplankton and the phytoplankton densities are expressed as organisms per litre.
Physico-chemical parameters such as water-temperature, pH, conductivity, dissolved oxygen, nitrate, phosphates, potassium were analysed by standard method (APHA, 1998). The community structure was analysed by Shannon-Wiener index of diversity (H/), Simpson’s dominance index (λ), Margalef’s richness index (R) and Pielou’s evenness index (E) with the help of Bio-Diversity pro Ver. 2.0 program (McAleece et al. 1997) software. The pollution status of the water body was described by using the relationship proposed by Wilhm and Dorris (1968). For identification we used handbooks (Cox 1996; Desikachary 1959; Hustedt 1930; Komarek and Anagnostidis 1998, 2005; Prescott 1962; Smith 1950; Turner 1982; Wehr and Sheath 2003).
RESULTS AND DISCUSSION
The environmental characteristics (Table. 2) of the Baishar beel differed from one season to another and these influence the phytoplankton diversity and their biological spectrum. A total of 30 species (Table. 1) of phytoplankton of 4 distinct classes, Chlorophyceae (14), Cyanophyceae (9), Bacillariophyceae (5) and Euglenophyceae (2) were recorded from the beel. The post-monsoon season was represented by the maximum number (20) of phytoplankton taxa and the monsoon one with least representation (15). Phytoplankton density was highest in post-monsoon (12633/L) followed by monsoon (10500/L) and pre -monsoon (7266/L). Maximum values of Shannon-Wiener diversity index (H/) value 2.66 ,Simpson’s dominance index (λ) value 0.911 and Margalef’s richness index (R) value 3.36 observed in post-monsoon season and Pielou’s evenness index (E) value reached its maximum 0.693 in pre-monsoon season (Figure.3). The percentage composition of the phytoplankton class (Figure. 2) showed that member of Chlorophyceae dominate in monsoon and post -monsoon and Cyanophyceae dominate in pre-monsoon season. The lowest percentage composition was represented by the member of Euglenophyceae for the pre-monsoon and post-monsoon season and Bacillariophyceae for the monsoon season.
It has been said that Cyanophycean members by their heat stress tolerating capacities they can withstand the environmental temperature and other conditions of the pre-monsoon season and flourish their maximum limit and other members cannot establish that much in such condition. On the other hand member of Chlorophyceae dominate for the monsoon and post-monsoon season using another specific ecological consideration. The phytoplankton density was also fluctuated due to environmental criteria and in hot and dry situation of pre-monsoon it was lowest and somewhat increased in monsoon. But due to dilution effect of water not so pronounced. The monsoon seasonal condition helps to collect more nutrients from other sources by rain water and these increases the fertility condition of the concerned wetland, which results into maximum density and diversity in post-monsoon. Other factors like competition between and within species are also directly or indirectly influenced under environmental guidance. Wilham and Dorris (1966) have proposed a relationship between species diversity and pollution condition of a water body as, species diversity value > 3 = clean; 1-3 = moderately polluted and < 1 = heavily polluted and this beel shows a moderate level of pollution load. So by this study we can highlight the detail changes of phytoplankton composition in a seasonal frame and also we can correlate these studies in depicting the pollution status of a water body.
CONCLUSION
The present investigation on phytoplankton diversity of the said water body reveals its phytoplankton spectrum within the specific time period. This study not only pinpoints the diversity status but also it depicts the pollution load of the water body using these minute organisms as bio-monitoring tool. As the phytoplankton constitute the basis of the food chain, their study and characterization helps us to understand the details of the nature and type of the members of the subsequent trophic levels. In this study it has been found that the water body exhibits moderate pollution load. Since these water bodies are utilized by local people for various purposes, this is significant because proper conservation methods and use may protect them from further deterioration. It is also necessary for sustainable use of our ecosystem. It is to be noted that such water-bodies are the controlling factor for the neighbouring population of every segment of the ecosystem. So, protective measures are to be taken seriously and not reluctantly.
ACKNOWLEDGEMENTS
The authors are indebted to the Head of the Department of Botany for providing laboratory facilities and UGC, New Delhi for financial assistance for providing fellowship to Subhabrata Ghosh under RFSMS scheme.
Englishhttp://ijcrr.com/abstract.php?article_id=1073http://ijcrr.com/article_html.php?did=1073
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241519EnglishN2013October19HealthcareROLE OF FREE RADICALS AND ANTIOXIDANTS IN HUMAN HEALTH AND DISEASE
English1422NeerajEnglish John PramodEnglish Sheena SinghEnglish Joydeep SinghEnglishOverproduction of free radicals, inconsistent with inactivating capacity of the naturally occurring antioxidants, leads to altered physiology and morbidity. The role of free radicals in normal physiological states like ageing and common health problems like burns, infertility and cancer or systemic diseases of the cardiovascular system e.g. atherosclerosis, hypertension, reperfusion injury as also disease of other systems (CNS, Immunity, endocrine anomalies) have been discussed. This review of available studies explores the role of antioxidants in minimizing the oxidative stress in various disease conditions like diabetes, cataract, inflammatory conditions, AIDS and mutagenic effects of reactive oxygen species.
Englishcellular damage, free radicals, antioxidantsINTRODUCTION
Oxygen is essential element for life. Oxidative properties of oxygen play a vital role in diverse biological phenomena. Oxygen has double-edged properties, being essential for life; it can also aggravate the damage within the cell by oxidative events1.
Free radicals and its adverse effects were discovered in the last decade. These dangerous substances are produced during the normal metabolic processes in the body along with toxins and wastes. Free radicals are generated during oxidation of carbohydrates, fats and proteins through both aerobic and anaerobic process. Overproduction of the free radicals can be responsible for tissue injury. Unsaturated lipid molecules of cell membranes are particularly susceptible to free radicals. In addition, other biological molecules including RNA, DNA and protein enzymes are also susceptible to oxidative damage. Free radicals are responsible for causing a wide number of health problems which include cancer, aging, heart diseases and gastric problems etc.
Anti-oxidants are substances capable of scavenging free radicals and prevent them from causing cell damage. Antioxidants provide protection by neutralizing free radicals, which are toxic byproducts of natural cell metabolism. The human body naturally produces antioxidants but the process is not 100 percent effective in case of overwhelming production of free radicals and that effectiveness also declines with age. Increased intake of antioxidants can prevent diseases and lower the health problems. Foods may possibly enhance antioxidant levels because they contain a lot of antioxidant substances. Fruits and vegetables are rich in key antioxidants such as vitamin A, C, E, beta-carotene and important minerals, including selenium and zinc. Natural products, mainly obtained from dietary sources provide a large number of antioxidants2.
FREE RADICALS
Free radicals, which are independently and freely occurring molecules or fragments of molecules, have long been thought as agents that cause systematic cell damage in various states of health and disease. The rate of production is directly related to the extent of cellular injury. Several types of free radicals have been identified in human beings and other mammals which include superoxide molecules, hydroxyl groups, nitric oxide and hydrogen peroxide. Superoxide, the best known free radical of all the oxygen derived species is an integral part of the process of phagocytosis by leucocytes3. Hydroxyl (OH-) is the most toxic of the oxygen-based radicals and it wreaks havoc within cells, particularly with macromolecules4. Hydroxyl radical is short lived but most damaging radical in the body. Hydrogen peroxide is not a free radical but falls in the category of reactive oxygen species. It is an oxidising agent and is involved in the production of HOCl by neutrophils. Nitric oxide (NO) is another physiological free radical which is made by vascular endothelium as a relaxing factor, and also by phagocytes and in the brain. It has many important physiological functions but excess can be toxic5. It is known to be involved in various age related diseases like atherosclerosis, hypertension etc. and in many other biological effects such as blood vessel dilatation, signaling, neurotransmission, regulation of hair follicle activity and immune response. Increased NO may contribute to the development of oxidative stress during aging6.
SOURCES OF FREE RADICALS
Free radicals and other reactive oxygen species (ROS) are derived either from normal essential metabolic processes in the human body or from external sources such as exposure to x-rays, ozone, cigarette smoking, air pollutants and industrial chemicals7,8. The sources include endogenous production from mitochondria9, microsomes10, enzymes or enzymatic reactions11,12 phagocytes13 and metal ions14,15. Exogenous sources of free radicals include cigarette smoke10,16, alcoholism 17 toxins and drugs18,19 and ionizing radiation10 .
ANTIOXIDANTS
Inactivated free radicals have the potential to cause extensive damage to cellular macromolecules including proteins, lipids, carbohydrates , and nucleic acids8. Fortunately, antioxidants can come to the rescue and minimize the damage. Antioxidants work to protect lipids from peroxidation by free radicals20 and can be defined as a molecule stable enough to donate an electron to a free radical and neutralize it , thus reducing its capacity to damage8 .
A crucial balance between free radical production and antioxidant defense helps in disease prevention7 .Under physiological conditions ROS concentrations are kept low by endogenous oxidant enzymes such as superoxide dismutase (SOD), catalase, glutathione peroxidase21,22 and also by non enzymatic components such as vitamin C, vitamin E, glutathione (GSH) and uric acid22. When the production of free radicals is beyond the protective capability of the antioxidant defenses, condition known as oxidative stress (OS) occurs. So oxidative stress has been defined as the loss of balance between free radical or ROS production and antioxidant systems, with negative effects on carbohydrate, lipid and proteins, thus playing a role in cardiovascular diseases, cancer, diabetes and neurodegenerative disorders etc23. A certain amount of oxidative damage takes place even under normal conditions, however the rate of this damage increases during the ageing process, as the efficiency of antioxidative and repair mechanisms decrease6. One of the important markers of OS is malondialdehyde (MDA) which is an end product of lipid peroxidation24.
ROLE IN HEALTH AND DISEASE
The role of free radicals and their inhibition or suppression in various physiological and pathological conditions is mentioned below. Although many abnormal physiological conditions and overt pathology are linked to endogenous or exogenous production of the free radical, their corresponding antioxidants and their mechanism of inhibition of cellular damage by the free radicals have also been a subject of scientific interest till date. We would be limiting our focus on only those conditions in which the specific role of antioxidants and their relationship have been very well documented.
Burns : Free radical mediated cell injury has been supported by postburn increases in systemic and tissue levels of lipid peroxidation products such as conjugated dienes, thiobarbituric acid reaction products, or malondialdehyde (MDA) levels. Antioxidant therapy in burn (glutathione, N-acetyl-L-cysteine, or vitamins A, E, and C alone or in combination) have been shown to reduce burn and burn/sepsis mediated mortality, to protect microvascular circulation, reduce tissue lipid peroxidation, improve cardiac output, and to reduce the volume of required fluid resuscitation25. Antioxidant vitamin therapy in burn trauma provides cardioprotection, at least in part, by inhibiting translocation of the transcription factor NF-kappaB and interrupting cardiac inflammatory cytokine secretion26.
Ageing: By far, one of the most popular theories of aging is the "Free Radical Theory of Aging." This theory was first proposed by Dr. Denham Harman27, and postulates that aging results from an accumulation of changes caused by reactions in the body initiated by highly reactive molecules known as "free radicals." The changes induced by free radicals are believed to be a major cause of aging, disease development or death.
Cancer: Mutations caused by ROS can result in malignant transformation and the development of cancer28. Since oxidative stress is generally perceived as one of the major causes for the accumulation of mutations in the genome, antioxidants are believed to provide protection against cancer7. Fortunately, certain antioxidant supplements like vitamins C and E can prevent much oxidative damage to DNA and thus reduce the ability of the oxidants to induce cancer8. Supplementing cancer patients with adjuvant therapy of resveratrol (a flavonoid) may have some benefit for a more successful radiotherapy29 . Dietary deficiencies in zinc can contribute to single- and double-strand DNA breaks and oxidative modifications to DNA that increase risk for cancer development30.
Cardiovascular Diseases (CVD): Oxidative damage and the production of free radicals in the endothelium are two of the main factors involved in the pathogenesis of the atherosclerotic process that causes CVD. Research concerning nutritional regimens has shown that persons who consume large amounts of fruit and vegetables have lower incidences of cardiovascular diseases, stroke, and tumors, although the precise mechanisms for this protective effect are elusive. Possible explanations include (a) increased consumption of dietary fiber, (b) reduced consumption of dietary cholesterol and other lipids, and (c) increased intake of the antioxidant vitamins (A, C, and E)31,32. Risk factors such as hypertension, smoking and diabetes mellitus are all associated with increased oxidative stresses due to excess free radical activity in the vascular wall. This may facilitate the development of vascular disease because of (i) increased oxidation of low-density lipoprotein (LDL) particles which increases their propensity to deposition in the vascular wall, (ii) inactivation of endothelium-derived nitric oxide, and (iii) direct cytotoxicity to endothelial cells. Protective antioxidant molecules include vitamin C and vitamin E of which the latter is the primary antioxidant defense in circulating LDL particles33. Many studies showed that vitamin E intake over an extended period was associated with decreased risk of cardiovascular events34. Tea and wine, rich in flavonoids, seem to have beneficial effects on multiple mechanisms involved in atherosclerosis35.
Reperfusion injury: Reperfusion injury is defined as the damage to cells which occurs following restoration of the blood and oxygen supply to the tissue after a period of ischemia. Antioxidants are able to prevent or reduce the severity of this type of tissue damage36. Bhakuni P et al in their study found that oxidative stress parameters in the post reperfusion patients were restored back to normal or near normal levels by supplementation with vitamin C37.
Hypertension: Increased oxidative stress in hypertensive patients reduces activity of SOD38. Vitamin E supplementation provides protection against oxidative stress by restoring the enzyme activity and preventing further damage caused by lipid peroxidation38. Inclusion of vitamin E in antihypertensive therapy in post reperfusion hypertensive patients results in better management of blood pressure39. So the consumption of diet rich in vitamin E should be increased in hypertension38.
Atherosclerosis: High levels of ROS (e.g the highly reactive hydroxyl radical) exert antiangiogenic effects and promote arteriosclerosis and endothelial cell death28.
The oxidative modification hypothesis of atherosclerosis centres on the well-known association between low-density lipoprotein (LDL) cholesterol and atherosclerosis and, in particular, on the uptake of oxidised LDL by macrophages within the arterial wall to form foam cells, the earliest stage in atherogenesis38.
Increased plasma levels of MDA and nitrite in patients of myocardial infarction indicate that oxygen free radicals cause endothelial damage, and elevated superoxide dismutase levels in these patients may imply that the body attempts to combat this oxidative stress by raising its level of anti-oxidants40. Antioxidant compounds found in fruit and vegetables, such as vitamin C, carotenoids, and flavonoids, may influence the risk of CVD by preventing the oxidation of cholesterol in arteries42.
Diabetes: oxidative stress plays a major role in the pathogenesis of diabetes mellitus and its underlying complications43. Under conditions of hyperglycemia, excessive amounts of superoxide radicals are produced inside vascular cells and this can interfere with NO production leading to the possible complications44. It is found that dietary GSH suppresses oxidative stress in vivo in prevention of diabetic complications such as diabetic nephropathy and neuropathy45 .
Cataract: Oxidative stress resulting from extensive oxidation of lens protein and lipid is an initiating factor for the development of maturity onset cataract. H2O2 is the major oxidant involved in cataract formation46.The young lens has substantial reserves of antioxidants to prevent lens damage and proteolytic enzymes, proteases that selectively remove damaged proteins. Compromises of function of the lens with aging are associated and may be causally related to depleted antioxidant reserves, diminished antioxidant enzyme capabilities and decreased proteases47.
Chronic high dose intake of lutein has improved visual acuity in small numbers of subjects with age-related cataract48. Pro-drug antioxidant N-acetylcarnosine, which is acetyl derivative of the natural dipeptide antioxidant l-carnosine found in meat has shown promising results in the prevention of cataract49.
Inflammatory diseases: In inflammation neutrophils and macrophages by virtue of antibacterial killing mechanisms generate superoxide, H2O2, and hypochlorite resulting in activation of proteases and tissue damage. ROS are produced in abnormally high levels in inflammatory bowel diseases. Their destructive effects may contribute to the initiation and/or propagation of the disease50. Antioxidant therapy such as green tea polyphenols and gene therapy with superoxide dismutase has a markedly attenuated disease51. Oxidative stress is an important factor in the pathogenesis of acute pancreatitis52 and of chronic pancreatitis (CP)53. Antioxidant supplementation is effective in relieving pain and reducing levels of oxidative stress in patients with CP53. Giving antox (specially formulated nutritional supplement) which contains the antioxidants selenium, betacarotene, L-methionine, and vitamins C and E improves the quality of life and reduces pain in patients suffering from chronic pancreatitis54.
Rheumatoid Arthiritis (RA): ROS as well as reactive nitrogen species (RNS) can directly or indirectly damage basic articular constituents and lead to the clinical expression of the inflammatory arthritis.There is an inverse association between serum antioxidant levels and inflammation in RA patients55. There is enhanced production of superoxide ion and peroxynitrite by bloodstream neutrophils and of superoxide ion by monocytes from RA patients56.
It is known that ROS can function as a second messenger to activate nuclear factor kappa-B, which orchestrates the expression of a spectrum of genes involved in the inflammatory response. Therefore, an understanding of the complex interactions between these pathways might be useful for the development of novel therapeutic strategies for rheumatoid arthritis57. .Role of oxidative stress in RA patients is confirmed now and indicates that antioxidant supplementation play an important role in controlling oxidative stress and decreasing disease activity in these patients58. There is necessity for therapeutic co-administration of antioxidants along with conventional drugs to such patients59.
AIDS: oxidative stress may contribute to several aspects of HIV disease. For this reason, the exogenous supply of antioxidants, as natural compounds (vitamin A, C, E, Se and Zinc) and new-generation antioxidants (cyclodecan-9-yl-xanthogenate (D609), GPI 1046 , Memantine ) that scavenge free radicals might represent an important additional strategy for the treatment of HIV infection in the era after HAART therapy has been applied60.
Diseases of the Central Nervous System: Recent interest has focused on antioxidants such as carotenoids and in particular lycopene, flavonoids and vitamins as potentially useful agents in the management of human neurological disorders like Parkinson's disease, Huntington's disease, Alzheimer's disease (AD) and Schizophrenia61. Overactivity of excitatory amino acid receptors is an important pathogenetic factor that leads to seizure genesis and increased oxidative stress has been implicated in the mechanism of excitotoxicity induced neurodegeration62.
Therefore use of antioxidants could be a potential approach in arresting or inhibiting the seizure genesis caused by excitotoxic agents63.
The study done by Yogendera K. Gupta et al demonstrates the potential antiepileptic effect of antioxidant curcumin64.
An increasing number of studies demonstrated the efficacy of primary antioxidants, such as polyphenols, or secondary antioxidants, such as acetylcarnitine, to reduce or to block neuronal death occurring in the pathophysiology of AD65.
Several studies have indicated that oxidative stress is a major risk factor for the initiation and progression of sporadic PD and AD. Even a-synuclein and b-amyloid fragments that are associated with the PD and AD, respectively, mediate part of their action via oxidative stress. Therefore, reducing oxidative stress appears to be a rational choice for the prevention and reduction in the rate of progression of these neurological disorders66.
Infertility: Recent research in the field of male infertility is focused on ROS, which is suspected to be one of the major causes of infertility at molecular level67. Seminal ROS levels increase with increase in age68. Increased lipid peroxidation of the plasma membrane of sperms caused by ROS is damaging to the sperms24. There is a negative correlation between sperm concentration, motility and normal morphology and seminal MDA level24. Recently the role of L-carnitine and L-acetyl carnitine in scavenging the free radicals and protecting the cell membrane has gained much importance in treatment of male infertility71.
Also drug intake, smoking, pollution, radiation etc are reported to increase seminal oxidative stress which causes spermatozoa dysfunction leading to male infertility67. Recent studies have shown raised ROS levels and sperm DNA (nuclear and mitochondrial) damage in idiopathic infertile men67. Vitamin E, a major chain breaking antioxidant in the sperm membrane appears to have dose dependent effect70. Administration of 100mg of vitamin E thrice daily for six months in a group of asthenozoospermic patients with normal female partner has been found to cause a significant decrease in lipid peroxidation and increase in motility70.
ROS have a statistically significant effect on fertilization rate after IVF, and that the measurement of ROS level in semen specimens before IVF may be useful in predicting IVF outcome71. Assisted reproductive techniques may show significant improvement in in vitro supplementation of antioxidants and metal chelators to achieve a better success72.
CONCLUSION
Although a lot has been documented about role of antioxidants, the field is vast and open for more research in development of inhibitors of molecules or fragments that cause cellular damage and increase morbidity in human beings. The prevention of such damage which is likely to cause enhanced apoptosis, temporary or permanent change and even mutations in the existing DNA is the call of the day. Further sources of free radical production and newer methods of production of antioxidants to supplement the naturally occurring defense mechanisms need to be explored.
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Cocuzza M, Athayde KS, Agarwal A, Sharma R, Pagani R ,Llucon AM, et al. Age related increase of reactive oxygen species in neat semen in healthy fertile men. Urology 2008; 71: 490-4.
Lenzi A, Sgro P, Salacone P, Paoli D , Gilio B, Lombardo F, et al. A placebo – controlled double blind randomized trial of the use of combined 1- carnitine and 1- acetyl – carnitine tratment in men with asthenoazoospermia. Fertil Steril 2004; 81(6): 1578-84.
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Agarwal, Allamaneni SSR, Nallella, KP, George AT, Masha E. Correlation of reactive oxygen species (ros) levels with fertilization rate following in vitro fertilization (IVF): A meta - analysis .Fertil Steril 2005; 84(1): 228-31.
Sikka SC. Role of oxidative stress and antioxidants in andrology and assisted reproductive technology. J Androl 2004; 25(1): 5-18.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241519EnglishN2013October19HealthcareOSTIUM SECONDUM ATRIAL SEPTAL DEFECT: A CASE REPORT
English2325M.S. RajeshwariEnglish Fasila P.EnglishAtrial septal defect is one of the commonest congenital cardiac anomaly present in adulthood. An outsized ostium secondum that persists in adulthood is a cause for ASD. It is commonly regarded as a ‘hole’ in the septum in the region of foramen ovale and ostium secondum. It is the common form of atrial septal defect, present in 8 out of 10 congenital heart disease. It occurs as a result of defects in septum primum and septum secondum viz. inadequate formation of septum secondum or excessive resorption of septum primum thereby leaving ostium secondum incompletely covered.
EnglishInteratrial septum, Septum secondum, Ostium secondum, Congenital heart disease.INTRODUCTION
Congenital defects of the interatrial septum are the most common congenital heart diseases and accounts for about 8 per 1000 live births. 90% of atrial septal defects comprises of Ostium secondum defect. Atrial septal defect occurs with a female preponderance of approximately [F:M=2:1]1. Ostium secondum atrial septal defect occurs in the centre between left atrium and right atrium due to incomplete formation of septum secondum or incomplete active closure of ostium secondum.
Atrial septal defects are classified by its size and location.
a) Secondum defect: The defect is in the middle of septum. It is the most common form of ASD which closes on its own, unless it is large. This type is seen in 8 out of 10 CHD. b) Primum defect: The defect is seen in the lower part of the septum. It also involves an incomplete or partial ASD and the valves that separate the atrial and ventricular chambers are not normal, 2 out of 10 babies who are born with ASD have this type of defect which does not close on its own.
c) Sinus Venosus: This defect is seen in the upper part of septum near the opening of superior venacava, which is very rare and is seen in 1 out of 10 ASDs. The babies present with associated partial pulmonary venous return2.
OBSERVATION
During routine dissection for I M.B.B.S in the department of Anatomy at Bangalore Medical College and Research Institute, a significantly large opening in the interatrial septum was noted which is called as the Ostium secondum atrial septal defect. The opening was present in the centre of interatrial septum, the shape of the opening was almost circular measuring 2cms vertically and 1.8 cms anteroposteriorly, the margins of the opening was smooth and well defined(fig 1&2). The interior of the heart was observed in detail, the atria and the ventricles appeared to be normal, with normal pattern of blood vasculature, there was no cardiac hypertrophy or dilatation. No other systemic abnormalities encountered.
DEVELOPMENT OF INTERATRIAL SEPTUM
The interatrial septum is a structure that divides the primary atrium into right and left chambers. At the beginning of 5th week of gestation the septum primum, a thin crescent shaped membrane develops, growing towards the endocardial cushions from the roof of the primordial atrium. As it grows, the space between the endocardial cushions and the septum primum gets diminished progressively and a small opening is formed known as the ostium primum, which serves as a shunt enabling the oxygenated blood to pass from the right to the left atrium. Before the septum primum fuses with the endocardial cushions small perforations appear and coalesce in the cephalic portion of septum primum to form another opening, the foramen secondum. Simultaneously the free edge of septum primum fuses with the fused endocardial cushions thus obliterating the foramen primum. The foramen secondum now ensures a continuous flow of oxygenated blood from the right to the left atrium. To the right of septum primum, another crescentric muscular membrane septum secondum grows from the ventrocranial wall of the atrium overlapping the foramen secondum in the septum primum. The septum secondum forms an incomplete partition between the atria and an oval opening is formed –the foramen ovale. The part of septum primum forms the flaplike valve of foramen ovale. After birth the foramen ovale fuses with the cranial end of septum primum and thus forming a complete partition between the two atria3.
DISCUSSION
ASDs are the commonest forms of congenital heart disease. Atrial septal defect is characterized by a defect in the interatrial septum allowing pulmonary venous return from the left atrium to pass directly to the right atrium.The formation of foramen secondum and septum primum was discovered in 19354. Ostium secondum defects are relatively larger than PFO defects. Ostium secondum ASDs represent 80-90% of ASDs. Excessive apoptosis of the cephalic portion of the setum primum or incomplete growth of septum secondum results in ostium secondum defect. CT images can differentiate an ostium secondum from a patent foramen ovale. Ostium secondum ASDs are a direct continuation between the two atria, whereas a PFO defect is a tunnel of variable width and length between two atria5. Ostium secondum ASDs in adults remain clinically silent for decades, produce left to right shunts. Long standing left to right shunting from ASDs leads to dilatation of the right sided chamber and enlargement of pulmonary arteries. Depending on the size of the defect and size of the shunt this can result in a spectrum of disease from no significant sequel to right sided volume overload, pulmonary hypertension, and atrial arrythmias6. Although heart failure in children is rare due to ASD, this can often occur in adults. Chronic right atrial dilation causing atrial arrythmias in adults may not be reversible in individuals if the defect is not closed. Contrary to this, data also indicate that closure in adults may not spare these individuals from atrial arrhythmias7. ASD is an autosomal dominant inheritance attributed to a gene defect in TBX5.It is shown that TBX5 and GATA4 have a role to play in chamber specification as well as inhibition of cardiomyocyte proliferation resulting in regional morphological features of heart.8,9. ECG may be an important clue to diagnosis which shows sinus rhythm, first degree heart block and right axis deviation in ostium secondum defect9.
CONCLUSION
Ostium Secondum ASD is a congenital abnormality and therefore, is present at birth. An ostium secondum ASD occurs as a result of excessive apoptosis of the cephalic portion of the septum primum or incomplete growth of septum secondum which fails to cover ostium secondum. It may be diagnosed at any age, usually the findings go undiagnosed in infancy until the patient presents with symptoms in his/her adulthood. The presence of this defect has been identified as a potential risk factor for stroke due to embolization into the systemic arterial circulation. There is no single, known cause of ASD, interaction of heredity and environmental factors or difference in one or more genes may play a role in ASD. Although an ASD would go undetected, there is always a chance that it can have a negative impact on patient’s life, therefore a precise knowledge of its occurrence and existence in adults can improve the patient’s standard of living and life expectancy.
ABBREVIATION
ASD-Atrialseptal defect
CHD-Congenital heart disease
PFO-Patent foramen ovale.
Englishhttp://ijcrr.com/abstract.php?article_id=1075http://ijcrr.com/article_html.php?did=1075
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241519EnglishN2013October19HealthcarePROSPECTIVE EVALUATION AND MORTALITY OUTCOME OF NOSOCOMIAL INFECTIONS IN MEDICAL INTENSIVE CARE UNIT AT TERTIARY CARE TEACHING CENTRE IN MUMBAI
English2640Bhadade Rakesh R.English deSouza Rosemarie AEnglish Harde Minal J. English Prarthana PatilEnglishBackground: Hospital acquired infections are a worldwide phenomenon and infection rates in ICU's have been documented to be ranging from 12% to 45%. Methods and Material: To study epidemiology of nosocomial infections and its clinical outcome. Study Design and Setting: It is a prospective observational study; carried out in the Medical intensive care unit (MICU) of a tertiary care teaching hospital. Results and Conclusion: 205 patients developed nosocomial infection. The commonest nosocomial infections developing in MICU were ventilator associated pneumonia (VAP); hospital acquired pneumonia followed by urinary tract infection. 94.1% isolates were gram-negative and gram-positive contributing to 2.5%, of which most common organisms isolated were Klebsiella, Acinetobacter and E. coli. 93.4% of blood stream infections were associated with intravenous lines, 68.1% of pneumonia with intubation, 91.7 % of UTIs were associated with urinary catheter. As number of risk factors increase, like duration of mechanical ventilation, prolonged ICU stay (60.0%), increasing age, and number of organs failed, mortality increased significantly. Sensitivity of E.coli isolates to carbapenams, polymyxin was 100%. Klebsiella and Acinetobacter showed a maximum sensitivity to carbepenem, polymyxin followed by piperacillin-tazobactum. 75.1% of patients with nosocomial infections improved and mortality in current study was 30.3%.v
EnglishCritical illness, Nosocomial infection, Antibiotics.INTRODUCTION
A nosocomial infection also called “Hospital acquired infection” can be defined as: “An infection occurring in a patient, in a hospital or other health care facility in whom the infection was not present or incubating at the time of admission. This includes infections acquired in the hospital but appearing after discharge and also occupational infections among staff of the facility”. [1]
The term “Healthcare associated infection” is now widely used instead of the traditional “nosocomial infection” and is defined by the centre for disease control and prevention (CDC) “as a localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s). There must be no evidence that the infection was present or incubating at the time of admission to the acute care setting”. [2]
The most frequent nosocomial infections are blood stream infections, urinary tract infections, lower respiratory tract infections and infections of surgical wounds. The WHO studies, and others, have shown that the highest prevalence of nosocomial infections occurs in intensive care units and in acute surgical and orthopaedic wards. Infection rates are higher among patients with increased susceptibility because of old age, underlying disease, or chemotherapy. In the USA the most frequent type of infection, hospital wide is urinary tract infection (36%), followed by surgical site infection (20%), bloodstream infection (BSI), and pneumonia (both 11%).[3] In France , the most common infection sites are urinary tract infections (30.3 %), pneumonia (14.7 %), infections of surgery sites (14.2 %). infections of the skin and mucous membrane (10.2 %), other respiratory infections (6.8%) and bacterial infections / blood stream infections (6.4 %).[4]
A prevalence survey conducted under the auspices of WHO in 55 hospitals of 14 countries representing 4 WHO Regions (Europe, Eastern Mediterranean, South-East Asia and Western Pacific) showed an average of 8.7% of hospital pts had nosocomial infections. At any time, over 1.4 million people worldwide suffer from infectious complications acquired in hospital. [5].The highest frequencies of nosocomial infections were reported from hospitals in the Eastern Mediterranean and South-East Asia Regions (11.8 and 10.0% respectively), with a prevalence of 7.7 and 9.0% respectively in the European and Western Pacific Regions. [6]International comparisons of nosocomial infection rates in various countries are as follows United States (10%), France (21.6%), Italy (6.7%), United Kingdom (10%), Finland (8.5%), and India (19.7%) [3] [7-11]
A 6-year surveillance study from 2002-2007 involving intensive care units (ICUs) in Latin America, Asia, Africa, and Europe, using CDC's NNIS definitions (National nosocomial infection surveillance), revealed higher rates of central-line associated blood stream infections (BSI), ventilator associated pneumonias (VAP), and catheter-associated urinary tract infections than those of comparable United States ICUs.[12] In 2005, the National Healthcare Safety Network (NHSN) was established by CDC with the purpose of integrating and succeeding previous surveillance systems at the Centres for Disease Control and Prevention. [13] Percentage of most frequently isolated nosocomial organisms as per CDC, National nosocomial infection surveillance (NNIS) system (January1990-March1996) and the top 3 pathogens in various nosocomial infections are shown in [Table 1,2] [13-17]
MATERIAL AND METHODS
It is a prospective observational study done in the Medical Intensive Care Unit (MICU) of a tertiary care teaching public hospital and, we aimed, to study rates of nosocomial infections (as per CDC definitions of nosocomial infections in adults) [18-21] , sites of infections and risk factors involved, empirical antibiotics used in treatment and its effectiveness by studying culture sensitivity of various body fluids/ secretions, time of initiation of antibiotics, effects of antibiogram on clinical outcome. We included all adult patients (pts), who have been admitted in critical care unit for more than 48 hours. Patients, who already have an infection and were on antibiotics within less than 48 hours, were followed for superadded infections. We excluded surgical, immunocompromised pts, and those below 12 years of age. Institute’s Ethics committee approval was taken. After valid written informed consent, all patients were assessed, investigated, and treated as per the existing practices without disturbing their routine care appropriate for the disease condition till either the patient was discharged from MICU or expired. All hospital infection control practices were strictly adhered too. All the routine investigations done in MICU patients were taken into consideration. We noted all the haemodynamic parameters Type and class of antimicrobial drugs used, route of administration, dosage and its frequency, duration of antimicrobial drug used, reason for selection of drug, reason for change of drug were noted. Resistance and sensitivity of various organisms isolated in present study to the drugs used to treat patients in current study were those that were supplied under government schedule.
Study Design and Setting: It is a prospective observational study; and was carried out in the MICU of a tertiary care, teaching, public hospital in India over a period of 2 years.
Statistical analysis: Outcome of each nosocomial infection was classified as either survived (improved) or expired. Data thus obtained was statistically analysed, using Pearson Chi-square test and logistic regression analysis using SPSS software.
RESULTS
Out of 2935 patients admitted to MICU during the study period, 205 patients developed nosocomial infections, with an incidence rate of 14.31% during study period. Results are noted in [Tables 3, 4, 5.]
DISCUSSION
Nosocomial infection rates in ICU’s have been documented to be highest of all hospital acquired infections, ranges from 12% to 45%. The data from various studies shows variable results of nosocomial infection in MICU statistics, Ak O et al reported 25.6% mortality, Ustan C et al reported 45.4%, Madani N et al reported 14.5%, Sax H et al reported 29.7%, Habibi S et al reported 34.1%, Rizwi MF et al reported 39.7%, and Present study had 14.31% mortality rate. [22-27]
In present study, majority of patients (85 pts) developing nosocomial infections were between age group of 21 – 40 years (41.5%) and 29.8% (61 pts) patients were between age group of 41-60 years which may be explained by the higher incidence of patients in age group of 21-40 years getting admitted with complications. The mean age of patients was 44.29 years in present study. Dahmash MS et al, included patients with age ranging from 14 to 100 years with median age being 54 years. [28] In another study done by Gagneja D et al, it was found that 21.61% of patients were in age group of less than 17 years, 42.15% in 18-64 years and 36.38% were of more than 65 years of age. [29] The present study showed higher mortality rate in age group of > 80 years (50%) followed by second peak in the age group between 41-60 years (36.1%) which was not statistically significant.
In current study, 63.4 % (130 pts) of MICU patients developing nosocomial infections were males while females (75 pts) contributed to 36.6% of total cases. In study done by Dahmash MS et al, 51.4% were males while 48.6% were females. [28] Most frequently identified nosocomial infections in current study were pneumonia (65.9%) (VAP responsible for 44.9% of cases), urinary tract infections (UTI) (17.6%) followed by wound infections (9.3%). Habibi S et al showed that 77% had pneumonia, 24% had urinary tract infection, and 9% had blood stream infection which is comparable to our study. [26] Ak O et al and Moreno CA et al showed that blood stream infection was most common infection followed by VAP and UTI. [22] [31] While, Lyytikainen O et al showed Surgical Site Infection (SSI) (29%) being most common followed by UTI (19%). [10]
In current study, most frequently isolated organisms were Klebsiella pneumoniae (35.1%), Acinetobacter baumannii (24.9%) and E. coli (16.5%). Kallel H et al showed multidrug-resistant P. aeruginosa (44.7%) and A. baumannii (21.3%) being most frequently isolated organisms. [30] Ak O et al reported that 68.8% of the isolates were gram-negative, 27.6% were gram-positive. [22] While present study showed 94.6% isolates being gram-negative with gram-positive organisms contributing to only 1.5% isolates. Ak O et al reported that 3.6% of the isolates were fungi, which is comparable with our study which showed 3.9% of the isolates being fungi. [22]
In current study, 66.7% isolates of Acinetobacter baumannii, 73.6% isolates of Klebsiella pneumoniae and 64.7% isolates of E.coli were ESBL (Extended spectrum beta lactamases). Most common infection caused by ESBL organisms was pneumonia (71.6%) with VAP contributing to 52.3% of cases followed by UTI (15.6%). Isolate from pts with VAP caused by ESBL organisms was Acinetobacter baumannii (49.1%) followed by Klebsiella pneumoniae (40.4%). While most common isolate patients with UTI caused by ESBL organisms was Klebsiella pneumoniae (70.6%).In present study, no significant difference in mortality was found among the patients with nosocomial infections caused by non-ESBL organisms (42.1%) and those caused by ESBL organisms (43.1%).The mortality was higher in cases with non-ESBL strains of Acinetobacter baumannii (70.6%) as compared to ESBL strains (55.9%).While in case of Klebsiella pneumoniae ESBL strains (39.6%) were associated with higher mortality as compared to non-ESBL strains (10.5%). In case of E.coli, mortality was almost equal in both ESBL (31.8%) and non-ESBL (33.3%) strains. Fagon JY et al showed that pneumonias occurring in ventilated patients were especially those due to Pseudomonas or Acinetobacter species and were associated with considerable mortality(71.3%) in excess of that resulting from the underlying disease alone, and significantly prolong the length of stay in the MICU. [32]
In present study, organism’s isolated from patients with UTI were E. coli (55.5%), Klebsiella pneumoniae (25.0%) and Pseudomonas aeruginosa (16.7%). Bagshaw S et al reported their findings as E .coli, Pseudomonas, Enterococcus and Candida. [33] In similar study done by Laupland K B et al, the most common UTI aetiologies were found to be Enterococcus species (24%), Candida albicans (21%), and Escherichia coli (15%). [34] There were no Candida species isolated from patients with nosocomial UTI in our study which is in contrast to other studies mentioned above. [33-34]
In the current study, organism’s isolated from patients with nosocomial pneumonia were Klebsiella pneumoniae (37.8%), Acinetobacter baumannii (32.6%) and Pseudomonas aeruginosa (12.6%). A 5 years (2004-2009) study done by Gagneja D et al reported Pseudomonas aeruginosa (30-50%) as most common organism followed by Klebsiella species, they also reported that the rate of isolation of Acinetobacter species increased from 11.78% (2004-2005) to 25% (2008-2009) becoming the second most common isolate. [29] Trivedi TH et al showed enteric gram-negative organisms were commonest isolates (61.9%), followed by Staph aureus (29.8%). [35] While in present study, 94.8% of isolates causing nosocomial pneumonia were gram-negative organisms.
In present study, 42.4% of isolates causing VAP were Acinetobacter baumannii followed by Klebsiella pneumoniae (29.3%), Pseudomonas aeruginosa (10.9%). Chatre J et al showed that Staphylococcus aureus, Pseudomonas and Enterobacteriaceae were most common among isolates causing VAP. [36] Richard MJ et al reported their findings as Pseudomonas and Acinetobacter being most common organisms causing VAP. [37] In another study done by Japoni A et al, most commonly isolated organisms were Acinetobacter, MRSA (methacillin resistant staphylococcus aurous), Pseudomonas and MSSA (methacillin sensitive staphylococcus aurous). [38] While Esperatti M et al showed that non-fermenter, enteric gram negative bacilli and MSSA were most commonly isolated from patients with VAP. [39]
In current study, most common bloodstream infection isolates were Klebsiella pneumoniae (40.0%), Acinetobacter baumannii (33.3%) and Coagulase Negative Staphylococci (CONS) (20.0%). Edmond MB et al found that gram-positive organisms accounted for 64% of cases, gram-negative organisms accounted for 27%, and 8% were caused by fungi with most common organisms being CONS (32%), Staphylococcus aureus (16%), and Enterococci (11%).[40] Laupland KB et al showed Staphylococcus aureus (18%),CONS (11%), and Enterococcus faecalis (8%) being most common bloodstream infection isolates. [41] Thus Edmond MB et al differs from our study where gram-negative organisms were most common bloodstream infection isolates (80.0%) demonstrating the changing trends of the isolates. [40]
In present study, most common isolates from wound infection were Klebsiella pneumoniae (31.6%) followed by Pseudomonas aeruginosa (21.0%). Peromet M et al showed that most common organisms isolated from pressure ulcers were Proteus mirabilis, group D streptococci, Escherichia coli, Staphylococcus species, Pseudomonas species, and Corynebacterium organisms. [42]
In present study, 93.4% of blood stream infections were associated with central lines, 68.1% of pneumonia with intubation, 91.7 % of UTI,s were associated with urinary catheter. Rosenthal VD reported that VAP posed the greatest risk (41% of all device-associated infections or 24.1 cases [range, 10.0 to 52.7 cases] per 1000 ventilator days), followed by central venous catheter (CVC)-related bloodstream infections (30% of all device-associated infections (DAI) or 12.5 cases [range, 7.8 to 18.5 cases] per 1000 catheter days) and catheter-associated urinary tract infections (29% of all device-associated infections or 8.9 cases [range, 1.7 to 12.8 cases] per 1000 catheter days).[43]
In current study, patients with 1-2 risk factors (100%) had better survival than those with 3 or more risk factors (60.1%). Majority of patients in present study (85.5%) stayed for more than 7 days in MICU, mortality rate was high in patients with prolonged ICU stay (60.0%) followed by second peak in patients with ICU stay of less than 7 days (47.2%), most of these patients were referred from other hospitals in moribund condition. Wong DT et al showed that the mortality for long-stay patients approached 50% which is comparable with our finding. [44] Similar finding was observed in the study done by Laupland KB et al. [45] While Williams T A et al showed that an increase in length of stay was not independently associated with an increased risk of hospital mortality with most of hospital deaths occurring within the first 10 days in ICU. [46]
The patients on mechanical ventilation (56.0%) had higher mortality as compared to non-ventilated patients (11.2%), and as duration of mechanical ventilation increases, mortality also increased significantly. The risk factors such as Diabetes mellitus, hypertension, COAD and duration of mechanical ventilation were found to be associated with development of VAP, but association was not statistically significant. [Table 6] This is in contrast to the study done by Craven DE et al which showed that host factors, oropharyngeal and gastric colonization, cross-infection, and complications from the use of antibiotics and nasogastric and endotracheal tubes increased the risk of bacterial VAP. [47]
In current study, increasing age was associated with higher risk, whereas Diabetes Mellitus, female sex, foley’s catheter were not statistically associated with risk of developing ICU-acquired UTI in logistic regression analysis.[Table 7] In a study done by Bagshaw S M et al it was found that indwelling urinary catheters, increased duration of urinary catheterization, female sex, length of stay in a ICU, and preceding systemic antimicrobial therapy were associated with risk of developing ICU-acquired UTI.[33] No differences in vital signs on admission, routine blood tests, APACHE II and TISS scores (therapeutic intervention scoring system), or overall hospital mortality rate were observed among patients who developed an ICU-acquired UTI as compared with those who did not.
In present study, it was found that 88.21% isolates of Enterobacteriaceae, 93.75% isolates of Acinetobacter baumannii, 89.4% isolates of Klebsiella pneumoniae, and 81.5% cases of E. coli were resistant to ceftriaxone. But this finding is in contrast to studies done by Moreno CA et al, Rosenthal VD et al, Cuellar LE et al in western world which showed resistance of Enterobacteriaceae to ceftriaxone was between 40-50%.[31][43][48] In current study, 48.9% isolates of Acinetobacter baumannii, 25.4% isolates of Klebsiella pneumoniae, and 4.3% cases of E. coli were resistant to piperacillin-tazobactum and it was found that about 37.5% isolates of Pseudomonas aeruginosa were resistant to ciprofloxacin, whereas studies done by Rosenthal VD et al, Cuellar LE et al found resistance between 40%-70% [43][48] Further, 84.2% isolates were sensitive to meropenem, while 93.8% isolates were sensitive to imipenem. Resistance of Pseudomonas aeruginosa to imipenem was found to be low (6.2%) which is in contrast to other studies done by Moreno CA et al, Cuellar LE et al which reported resistance in the range of 13-38%.[31] [48] In present study, sensitivity of Staphylococcus aureus and CONS to methicillin was not tested. In studies done by Rosenthal VD et al ,Cuellar LE et al it was found that methicillin resistant Staphylococcus aureus were in range of 75-95%.[43][48] Emerging drug resistance may be explained by the indiscriminate use of antibiotics in developing countries like India.
In present study, sensitivity of E.coli isolates to Carbapenems and Polymixin was 100%. While Klebsiella pneumoniae and Acinetobacter baumannii showed a maximum sensitivity to carbepenem, polymyxin followed by piperacillin-tazobactum. Pseudomonas aeruginosa showed a maximum sensitivity to piperacillin-tazobactum followed by Imipenem. In current study 100% isolates of ESBL organisms were resistant to amoxicillin-clavunate and ceftriaxone. 60.0% isolates of ESBL Acinetobacter baumannii, 74.5% isolates of ESBL Klebsiella pneumoniae and 94.1% isolates of ESBL E.coli were sensitive to piperacillin-tazobactum. While 75.0% isolates of ESBL Acinetobacter baumannii, 88.6% isolates of ESBL Klebsiella pneumoniae and 100.0% isolates of ESBL E.coli were sensitive to meropenem. 100% isolates of ESBL organisms were sensitive to Carbapenems. While79.2 % isolates of ESBL Acinetobacter baumannii, 95.6% isolates of ESBL Klebsiella pneumoniae and 100.0% isolates of ESBL E.coli were sensitive to Imipenem. Gunserena F et al showed that amikacin, ciprofloxacin and imipenem were effective against, respectively, 41.3%, 48.2% and 92.0% of the ESBL producers, however, only 12.5% of these were susceptible to piperacillin-tazobactum and Cefepime was found to be active against 35.5% of these problem pathogens. [49] Thus our observations found that there is changing trend of organisms causing nosocomial infection and also change in the sensitivity patterns of these organisms to various antibiotics.
Resistance of gram-negative organisms isolated from patients with lower respiratory tract infections to various antibiotics in current study is ceftriaxone 86.0%, ceftazidime 85.7%, piperacillin-tazobactum 18.4%, gentamicin 73.3%, amikacin 57.8%, netlimycin 53.6%, ciprofloxacin 71.4%, meropenam 31.9% and imipenam 34.8%. Gagneja D et al showed increasing trend of resistance of gram negative organisms to third generation cephalosporins, amoxicillin/clavulanic acid and piperacillin-tazobactum and declining trend of resistance to aminoglycosides, they also showed increasing trend of resistance to carbapenems. [29] Thus, judicious use of older/newer antimicrobial agents is essential to prevent the emergence of multidrug-resistant bacteria in the ICU.
In our study, 3 out of 10 patients with swine flu were females while 7 were males and most common nosocomial infection was lower respiratory tract infection (70%) with HAP contributing to 50% of cases. The most common organism isolated was Klebsiella pneumoniae (80%) with ESBL strains contributing to 50% cases followed by Acinetobacter baumannii (20%). Out of 10 patients, 4 required mechanical ventilation. 3 patients had 1-2 risk factors while remaining 6 had 3 or > 3 risk factors. Piperacillin-tazobactum was used in 70% cases; mostly in combination with levofloxacin (50%). The mortality in patients on mechanical ventilation was 50% and those without ventilation, was 16.7% .70% patients of swine flu with nosocomial infection survived while 30% died.
In current study, antibiotics were started empirically in 19% cases, while in 79.5% patients antibiotics were started empirically and modified according to culture sensitivity report. Antibiotics started after culture sensitivity report in only 1.5% cases. In present study, ceftriaxone, Piperacillin-tazobactum, Meropenem was started empirically in 51.3%, 35.9%, 5.1% cases and after culture sensitivity reports in 38%, 67.5%, 17.8% cases respectively. The mortality was significantly higher (56.4%) in patients in whom antibiotics started empirically as culture sensitivity report were not made available before the patient had died, as compared to those in whom antibiotics were started empirically and modified according to culture sensitivity report or antibiotics started after culture sensitivity report (32.6%). No significant difference in mortality was found between, in those with antibiotics started empirically and modified according to culture sensitivity report and antibiotics started only after culture sensitivity report.
In our study, we found the statistically significant association between types of nosocomial infections and final outcome. In study done by Esperatti M et al, it was found that the type of isolates and outcomes are similar regardless of whether pneumonia is acquired or not during ventilation, indicating they may depend on patients' underlying severity rather than previous intubation. [39] It was seen that patients with Glasgow coma score < 10 at the time of admission had significantly high mortality as compared to patients with > 10. Knaus WA et al showed that the mortality was 40.0% in patients with single organ failure as against 98% in three or more organ failure which was consistent with our findings.[50] The commonest procedure performed was insertion of central venous lines in almost 96.58% of patients. It was done especially in cases of circulatory shock, acute renal failure and pulmonary edema for fluid management purpose. Intubations were performed 106 patients (51.7%) mostly for ventilatory support but also for prophylactic purposes to secure the airway. Tracheostomies were performed in 11.2% of the total patients who required prolonged ventilatory support. Amongst the 21 patients who received dialysis, 12 survived, while 9 died. Described by Knaus WA et al, the mean APACHE II score at time of admission in our study was 16.85; we found that as APACHE II score increases, mortality also increased significantly. [50]
In present study, need of mechanical ventilation and elevated APACHE II score at the time of admission were associated with higher mortality while length of MICU stay between 16-30 days were associated with less mortality in a logistic regression analysis. No statistical significance between factors such as number of risk factors, age, gender and final outcome was found in our study by logistic regression analysis. [Table 8] Yologlu S et al showed that extrinsic risk factors such as urinary catheter, mechanical ventilation, total parenteral nutrition, intubations, antimicrobial treatment prior to nosocomial infections, nasogastric catheter and central catheter were associated with nosocomial infections. [51]
CONCLUSION
From the experience of the present study, we put forth the following:
Thus in current study of 205 critically ill patients who developed nosocomial infection in MICU, 130 (63.4%) patients improved, and mortality in our study was 36.6% (75 patients). The commonest nosocomial infections developing in MICU were VAP; HAP followed by urinary tract infection. 94.1% isolates were gram-negative with gram-positive organisms contributing to only 2.5% of isolates, of which most common organisms isolated were Klebsiella pneumoniae, Acinetobacter and E.coli. Most common isolates from cases of UTI were E.coli followed by Klebsiella pneumoniae, from nosocomial pneumonia were Klebsiella pneumonia followed by Acinetobacter baumannii, from wound infection were Klebsiella, and from bloodstream infection, isolates were Klebsiella pneumoniae, Acinetobacter baumannii and CONS, thus demonstrating the changing trends in the isolates. Nosocomial infection seen in patients with swine flu was lower respiratory tract infection; organism isolated was Klebsiella pneumoniae (80%) with ESBL strains contributing to 50% cases. The mortality was significantly higher in patients, in whom antibiotics were started empirically, as compared to those in whom antibiotics were started empirically and modified according to culture sensitivity report or antibiotics started after culture sensitivity report, emphasizing the importance of culture sensitivity report in treatment of infections. Thus our observations found that there is changing trend of organisms causing nosocomial infection as compared to the western world, and also change in the sensitivity patterns of these organisms to various antibiotics.
High APACHE II score on admission was associated with significantly high mortality and thus can be used as effective tool to determine outcome and accordingly modify treatment strategy in these patients. Association between types of nosocomial infection and its outcome as well as between types of nosocomial infections and final outcome was statistically significant. Thus, early recognition of all the discussed co-morbid factors in patients with nosocomial infections going downhill before one or multiple systems start failing is important as is the importance of good intensive care once this does occur.
B- Coefficient for the constant in the null model (also called the "intercept")
S.E. - Standard error around the coefficient for the constant.
Wald - Wald chi-square test
df - Degree of freedom
Sig- Significance
Exp (B) -Exponentiation of the B coefficient
VAP- Ventilator associated Pneumonia
Dependent Variable Encoding- For VAP yes, it’s 1
B- Coefficient for the constant in the null model (also called the "intercept")
S.E. - Standard error around the coefficient for the constant.
Wald - Wald chi-square test
df - Degree of freedom
Sig- Significance
Exp (B) -Exponentiation of the B coefficient
UTI-Urinary tract Infection
Dependent Variable Encoding- For UTI yes, it’s 1
B- Coefficient for the constant in the null model (also called the "intercept")
S.E. - Standard error around the coefficient for the constant.
Wald - Wald chi-square test
df - Degree of freedom
Sig- Significance
Exp (B) -Exponentiation of the B coefficient
* - Multiplication
Dependent Variable Encoding- For Expired yes, it’s 1
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241519EnglishN2013October19HealthcareCOMPUTED TOMOGRAPHIC SCAN STUDY OF MORPHOMETRY OF FORAMEN MAGNUM
English4148Surwase Ramdas GopalraoEnglish Prity SolankeEnglish Mahesh UgaleEnglish Smita BalsurkarEnglishAims and objectives: The objectives were to study the morphometry of the foramen magnum on C.T. Scan and to evaluate its anteroposterior diameter, transverse diameter of the foramen magnum. Also to compare the diameter of foramen magnum in males and females. Material and Methods: We examined 100 C.T.Scans of normal persons. The anteroposterior and transverse diameters of foramen magnum were measured with help of computer software and analysis done statistically. We observed for any variations in the shape of foramen magnum. Results: Out of 100 C.T. scans studied, 61 cases were of males in whom the anteroposterior and transverse diameter were observed to be 33.90+2.61 mm & 28.05+2.22 mm respectively. In 39 females, anteroposterior diameter and transverse diameter of foramen magnum were 32.35+3.16 mm, 26.88+2.96 mm respectively. Conclusion: Unpaired t-test shows diameters of foramen magnum were greater in males than in females as p-value less than 0.05 hence it is statistically significant. The data obtained may be of useful to the neurosurgeons in analyzing the morphological anatomy of craniovertebral junction. The findings are also enlightening for the anthropologists, morphologists and clinical anatomists.
EnglishForamen magnum, Morphometry, anteroposterior diameter, transverse diameter.INTRODUCTION
The articles related to the base of skull were searched and it is found that very few studies have been done in this regard in Indian population.
Computed tomographic scan is noninvasive modality for the imaging the skull base. Since this procedure is widely done, this modality was preferred.
The cranial base is such a complex structure that it is only studied morphometrically. The sites where a number of vital structures have their entrance or exits are very important for clinical application. Therefore the assessment of these morphometrics is helpful for lateral surgical approaches for reaching lesions in the middle and posterior part of cranial base 1.
The dimensions of the foramen have clinical importance because the vital structures that pass through it may suffer compression such as in cases of foramen magnum achondroplasia and brain herniation. In a transcondylar surgical approach to the foramen magnum, such as resection of tumors of the foramen magnum region, the anatomic features of the foramen magnum and variations of this region have been considered in several studies. Waneboet. al. stated that longer anteroposterior dimensions of foramen magnum permitted greater contralateral surgical exposure for condylar resection. The anatomic and radiologic values have been the objectives of several studies 2.
Knowledge of normal and variant positions of canals and foramina of skull base is important for radiologists, neurosurgeons and anatomists 4.
The soft tissues are better visualized by MRI, while the bony structures of the skull are better visualized by CT 5.
When planning treatment, clinicians relay on both modalities, as MR and CT provide different information, all of which may be useful for proper management. As a result, physicians who treat skull base tumors must integrate information provided by CT & MR images 6.
Recent advances in microsurgical technique and more widespread use of the operating microscope have now enabled surgeons to approach previously inoperable deep seated lesions of the skull base. It is therefore necessary that the clinicians should have a thorough knowledge of anatomy of this region for evaluation of various disease processes affecting this region 7.
Radu et al (1987), then in 1988 Koster tried to study the base of skull on C.T. Scan
Muthukumar et al studied the morphometric analysis of foramen magnum on dry skulls 8.
Kazikanat and colleagues studied the morphometry of foramen magnum and stated that morphometric analysis of all these components will help in planning of surgical intervention involving the skull base 9.
Kosif Rengin studied the midsagittal magnetic resonance images & measured the diameter of foramen magnum 10.
Murshed K.A. evaluated morphometrically the foramen magnum and also studied variations in its shape on C.T. scan 11.
AIMS AND OBJECTIVES
Aims and objective of present study were
To study morphometry of foramen magnum by computed tomography.
To note variations associated with them, if present.
To measure anteroposterior & Transverse diameters of the foramen magnum by computed tomography.
To compare and do statistical analysis of foramen magnum between males and females.
MATERIALS AND METHODS
Computed tomography is optimal for demonstrating osseous structures, so this modality was selected for the present study.
This study was conducted in collaboration with the Department of Radiology, K.E.M. Hospital Mumbai with prior permission from the Head of the Department.
C.T. scan images of base of skull were taken on C.D. and preserved.
This was the cross sectional study in the Department of Radiology.
Study Sample
Because tumors, space occupying lesions, fractures, congenital disorders involving skull base may distort the normal Anatomy of skull base, such positive cases were excluded from present study. 100 normal (61 male is 39 female) persons C.T. scan pictures were selected and studied. Those patients referred from various departments for any other purpose and having normal skull base, were taken for the study. Both males and females were selected. All age groups were selected. Identity of the patient is not revealed.
Ethics Committee Approval
The study was carried out after the approval of institutional ethics committee.
Computerized Tomography Scan Procedure
The C.T. scan of skull base were obtained using Simens Somatom (third generation C.T. machine having pixel size of 512 X 512 ) continuous 1mm sections were taken in axial plane and to the radiographic baseline (Reid’s baseline or anthropological baseline), parallel to a line drawn from the orbitomeatal line 12.
Continuous axial sections of 1mm thickness in bone window were obtained and foramen magnum was identified. (Fig: 1)
Anteroposterior and transverse diameters of foramen magnum were measured by using computer software and analyzed statistically.
Modern high resolution CT with 1mm sections provides precise measurements which differ little from the actual distance in anatomical specimen. It is to be assumed, however, that the canals and foramina lie perpendicular to the scan line.
OBSERVATIONS AND RESULTS
It is found that mean A.P. diameter of foramen magnum in 61 males is 33.90 mm and in 39 females it is 32.35 mm with S.D. of 2.61 and 3.16 in males and females respectively (Table I).
Unpaired t–test shows that mean difference is 1.56 and 95% confidence interval having upper limit 0.40 and lower limit 2.71 and p-value is 0.009 which is less than 0.005 hence it is significant. So unpaired t-test proves that mean A.P. diameter of Foramen magnum is more in males than in female (Table II and Graph I).
Highest and lowest value of A.P. diameter of foramen magnum found to be 39.5 mm and 21.4 mm and range was 18.1 mm. Highest and lowest value of transverse diameter of foramen magnum found to be 17.9 mm and 32.5 mm and range was14.6 mm.
It is found that mean transverse diameter of foramen magnum in 61 male is 28.05 mm and in 39 female it is 26.88 mm with S.D. of 2.22 and 2.96 in male and female respectively (Table I).
Unpaired t–test shows that mean difference is 1.16 and 95% confidence interval having upper limit 0.13 and lower limit 2.19 and p-value is 0.028 which is less than 0.005 hence it is significant. So unpaired t-test proves that mean transverse diameter of Foramen magnum is more in males than in female (Table II & Graph II).
DISCUSSION
According to Radu et al (1987), C.T. examination of small structures is made impossible by partial volume effect. Then in 1988 Koster stated that the increased spatial resolution of C.T. has overcome this difficulty. However, because of this uncertainty, only a few publications listing C.T. measurements of these foramina and canals have so far appeared.
Muthukumar et al studied the morphometric analysis of foramen magnum for the purpose of transcondylar approach on 50 dry skulls. They had given the anteroposterior length of foramen magnum 33.3 mm and width as 27.9 mm. Also they stated that shape of foramen magnum was ovoid 8.
Kazikanat and colleagues studied the morphometry of foramen magnum on 59 dry skulls and given anteroposterior and transverse diameter of foramen magnum as 34.8+2.2 mm and 29.6+2.4 mm and stated that morphometric analysis of all these components will help in planning of surgical intervention involving the skull base 9.
Kosif Rengin studied the midsagittal magnetic resonance images of 194 adults (101females and 93 males) to reveal the relationship between occipitocervical region and cervical height. They measured the diameter of foramen magnum as 38.19+3.85 mm in males and 36.09+2.79 mm in females 10.
Murshed K.A. evaluated morphometrically the foramen magnum and also studied variations in its shape on C.T. scan of 110 normal subjects with 57 males and 53 females. They had given sagittal diameter as 37.3+3.43 mm and transverse diameter 31.6+2.99 mm in males and sagittal diameter 34.6+3.16 mm and transverse diameter 29.3+2.19 mm in females 11.
Lastly they stated that there was significant sex difference in quantified parameters indicating that the foramen magnum is larger in males.
The 100 C.T. scans were studied including all age groups and of both sexes. In 61 males, anteroposterior and transverse diameters of foramen magnum were 33.90+2.61 mm & 28.05+2.22 mm respectively. In 39 females anteroposterior and transverse diameters of foramen magnum were 32.35+3.16 mm & 26.88+2.96 mm respectively.
Unpaired t-test shows diameters of foramen magnum were greater in males than in females as p-value is less than 0.05, hence it is statistically significant.
SUMMARY
This was a cross sectional study in which all age groups. Out of 100 cases, 61 were males and 39 were females. During this procedure foramen magnum was identified and anteroposterior and transverse diameters of foramen magnum were measured.
Normal range of all these diameters were determined in males and females.
Then data was analyzed statistically by using S.P.S.S.
While analysis unpaired t-test applied to compare diameters of these foramina in males and females.
It was found that foramina magnum were greater in males as compared to females.
CONCLUSIONS
To conclude, the present study regarding morphometry of foramen magnum was in agreement with earlier studies done so far.
To approach the base of skull surgically, it is very important to know the normal anatomy of base of skull by imaging modalities.
The study of base of skull is very important because significant structures pass through it. Recognition of normal variants of skull base include foramina, vascular channels, foramen like defects, clefts, fissures, notochordal remnants and segmental anomalies may prove necessary in evaluation of patients with skeletal dysplasia and disorders of skull base development. This knowledge may be useful so that these variants are not misinterpreted as fractures, destructive lesions or clinically important chondrocranial malformations 13.
The radiologists must have knowledge of normal anatomy and pathological spectrum of skull base to determine the extent of abnormality and to help plan the surgical approach 14.
Platybasia or flat skull base or martin’s anomaly is the flattening of angle between the clivus and body of sphenoid. When the angle exceeds 148° the base of skull is abnormally flat 15, 16.
In basilar impression or basilar invagination the margins of foramen magnum are inverted 16, 17.
In occipitalization of atlas the first cervical vertebra is fused to the skull base & the odontoid is abnormally high 16.
In Arnold chiari malformation the brain changes are characterized by downward displacement or elongation of the brainstem and cerebellar tonsils through the foramen magnum 18, 19, and 20.
In the fractures of posterior cranial fossa there may be possibility of formation of arteriovenous fistula within cavernous sinus 21, 22.
ACKNOWLEDGEMENT
Authors are thankful to Dr. Lopa Mehta & Dr. Manu Kothari for their valuable guidance. Also very thankful to Dr. Ravi Ramakantan (Prof & HOD Dept. of Radiology K.E.M. Hospital) for giving permission to work in the Dept. of Radiology K.E.M. Hospital, Mumbai
ABBREVIATIONS
C.T. scan--computed tomography scan, M.R.I.--magnetic resonance imaging, A.P. diameter –anteroposterior diameter, S.D.--Standard deviation,S.E.M.—standard error of mean, 95% C.I.—95% confidence interval, d.f.—degree of freedom, S.P.S.S.—statistical package of social sciences, TR Diameter –Transverse Diameter
Englishhttp://ijcrr.com/abstract.php?article_id=1077http://ijcrr.com/article_html.php?did=1077
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Laine FJ, Nade L, Braun FI. CT and MR imaging of the central skull base Part1 Technique, embryology development and anatomy. Radiographics 1990; 4: 591.
Madeline LA, Elster DA. Post natal development of central skull base: normal variants. Journal of Radiology 1995; 196: 757-763.
Laine FJ, Nade L, Braun FI. CT and MR imaging of the central skull base Part1 Technique, embryology development and anatomy. Radiographics 1990; 4: 591.
Spillane JD, Pallis C, Jones AM. Developmental anomalies in the region of foramen magnum. Orain1957; 80: PP 11.
Grainger RG, Allison DJ. Diagnostic Radiology –A textbook of medical imaging Volume III. Third edition. New York: Churchill Livingstone publication, 1992. PP 2132.
Mcrae DL. Bone abnormalities in the region of foramen magnum: correlation of anatomic and neurologic finding. Acta radiology 1953; l40: 335.
Elster AD, Chen MYM. Chiari I malformation: Clinical and radiological reappraisal. Radiology1992; 183: 347.
Susman J, Jones C Wheatley D. Arnold Chiari malformation: A diagnostic challenge. Am Fam Physician1989; 39: 207.
Susman J, Jones C, Weatley D. Arnold Chiari malformation: A diagnostic challenge. Am Fam Physician1987; 39: 207.
Snell RS. Clinical Anatomy the Head and Neck. 7th edition. Philadelphia: Lippincott Williams and Wilkins publication, 2003. PP 799-802.
Moore K, Dally FA. Clinically Oriented Anatomy. Fifth edition. Philadelphia: Lippincott William and Wilkins, 2006. PP 899.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241519EnglishN2013October19HealthcareEFFECT OF SUDARSHAN KRIYA YOGA ON LIPID PROFILE
English4955Mungal Shreechakradhar U.English Bondade AnilEnglishAims and Objectives: This study is undertaken to see whether practice of Sudarshan Kriya Yoga can help in reducing hyperlipidemia which is an independent risk factor of Coronary Heart Disease and also to see whether this simple Yogic technique can be used as preventive measure on large scale. Material and Method: The present study was conducted at ‘Art of Living centre’ at Ambajogai and Parli Vaijanath, Maharashtra, India. 60 persons practicing Sudarshan Kriya Yoga and 60 controls were taken from three age groups. The Lipid profile was estimated of study as well as control group on a semi auto analyzer. Results: Statistically significant decrease in serum total cholesterol, triglycerides, Low Density Lipoprotein-Cholesterol, Very Low Density Lipoprotein-Cholesterol, was observed and a significant increase in High Density Lipoprotein-Cholesterol was observed. These changes in lipid profile are probably due to reduced stress, decreased lipid peroxidation and decreased sympathetic activity due to Yoga. Conclusion: In conclusion the hypocholestrimic action of Sudarshan Kriya Yoga practice can be useful in prevention of derangement of lipid profile and hypertension which are major risk factors for Coronary Heart Disease.
EnglishSudarshan Kriya Yoga – Sudarshan Kriya Yoga, Lipid profile, serum cholesterol, triglycerides Low Density Lipoprotein-Cholesterol, Very Low Density Lipoprotein-Cholesterol, HDL –C.INTRODUCTION
The ultimate aim of medical science is attainment of optimum physical and mental health for the individual. The ultimate aim of yogic practices is also the same, viz physical and mental well being. The difference, however, lies in the methodologies and modalities to achieve those ends1. Many scientific studies in India and abroad have focused on beneficial effects of Yoga on central nervous system, hormonal balance, cardiovascular system and respiratory system 2.
During recent years, a new Yoga practice has been introduced by His Holiness Shri. Shri Ravishankarji, named Sudarshan Kriya Yoga. The word Sudarshan Kriya is translated from its original Sanskrit - Su = right, Darshan = vision and Kriya means purifying action3.
Modern man has become a victim of various kinds of stresses and stress related disorders like essential hypertension, angina and Coronary Heart Disease. Prevalence of these diseases is increasing in developing countries like India. A few scientists claimed that regular practice of Sudarshan Kriya Yoga lead to fall in serum cholesterol and LDL-Cholesterol and better antioxidant levels4, 5.
As scientific research work in Sudarshan Kriya Yoga in this regard is less, this study is undertaken to see whether practice of Sudarshan Kriya Yoga can help in reducing hyperlipidemia which is an independent risk factor of Coronary Heart Disease and also to see whether this simple Yogic technique can be used as preventive measure on large scale.
In present study lipid profile of normal adult was compared with that of regular practitioners of Sudarshan Kriya Yoga and analyzed for effect of Sudarshan Kriya Yoga on lipid profile.
MATERIAL AND METHODS
Selection of Subjects: The present study was conducted between regular practitioners of Sudarshan Kriya Yoga and non practitioners of Sudarshan Kriya Yoga. Estimation of lipid profile was carried out in 120 healthy male individuals. Out of them 60 were regular practitioners of Sudarshan Kriya Yoga (study group, n=60) and remaining 60 were non practitioners of Sudarshan Kriya Yoga (control group, n=60) with same age and socioeconomic status.
The Sudarshan Kriya Yoga practitioners and controls were divided according to age in following three groups.
Daily practice of Sudarshan Kriya Yoga for 45 minutes for minimum six months was the selection criterion for inclusion in study group. Control group subjects were faculties and office workers of medical college. Subjects suffering from diabetes, cardiovascular illness or any infection and those who are having addictions of tobacco, smoking or alcohol were excluded from the study.
Study Protocol: The study was conducted at Art of Living Centres located at Ambajogai and Parli Vaijnath and S.R.T.R. Government Medical College, Ambajogai. The study protocol was approved by ethical committee of S.R.T.R. Government Medical College, Ambajogai. Parameters for the present study were serum cholesterol, triglycerides, LDL cholesterol, VLDL cholesterol, HDL cholesterol. For estimation of these serum lipids 2 ml of blood was collected from every individual in study group as well as control group.
Collection of sample: Collection of blood samples of study group as well as control group had done after overnight fasting. Serum cholesterol was estimated with Modified Roeschlau’s method which is dynamic extended stability CHOD-POP method, end point with lipid clearing agent6. Serum triglycerides were estimated with dynamic extended stability with lipid clearing agent GPO – TRINDER method7. HDL Cholesterol was estimated by Phosphotungustic Acid method8.
LDL – Cholesterol and VLDL Cholesterol were calculated as reported by Friedwald, Levy and Frederickson as follows:
VLDL Cholesterol = TG/5
LDL Cholesterol = Total Cholesterol – ( HDL Cholesterol +TG/5 )
Statistical Analysis: The results were presented as mean ± S.D. All the results were statistically analyzed by applying 'unpaired t' test. P value less than 0.001 is considered as statistically significant
Our study showed that serum cholesterol, triglycerides, LDL – Cholesterol, VLDL – Cholesterol was significantly lower in Sudarshan Kriya Yoga practitioners in all age groups as compared to non practitioners of Sudarshan Kriya Yoga (Table 2 to 5). Our study revealed that HDL – Cholesterol was significantly higher in Sudarshan Kriya Yoga practitioners in Group II and Group III as compared to non practitioners of Sudarshan Kriya Yoga but in Group I increase in HDL – cholesterol was not statistically significant (Table-6).
DISCUSSION
Serum Cholesterol
Our study shows highly significant decrease in serum total cholesterol level when compared with age, sex matched controls of all the three groups.
A similar statistical significant decrease was reported by Geeta H. et al (2002) 9 in Sudarshan Kriya Yoga practitioners. However similar decline in serum total cholesterol in different kinds of yoga practices are also reported by Udupa K.N. et al (1972)10 , Santa Jaseph et al (1981) 11, D. Ornish et al (1990) 12, T. Schmidt (1997) 13, S. C. Machanda et al (2000)14, Rashmi Vyas et al (2002) 15, J. Yogendra (2004) 16.
Triglycerides
In the present study, triglyceride showed significant decrease in all three groups. Similar findings were reported by S. C. Manchanda et al (2000) 14 in Coronary Heart Disease patients after yoga life style intervention.
Low Density Lipoprotein-Cholesterol
In our study Low Density Lipoprotein-Cholesterol showed a highly significant decrease in all groups which correlates with the finding of Geeta H. et al (2002) 9 in Sudarshan Kriya Yoga practitioners.
A similar correlating findings are also reported by D. Ornish et al (1990) 12, T. Schmidt (1977) 13, S. C. Machanda et al (2000) 14, Rashmi Vyas et al (2002) 15, J. Yogendra et al (2004) 16.
Very Low Density Lipoprotein -Cholesterol
In the present study Very Low Density Lipoprotein-Cholesterol showed highly significant decrease in all groups, however we could not compare our data because so far no study in this regards is available.
High Density Lipoprotein-Cholesterol
Our study revealed significant increase in Group II and Group III. In Group I increase in High Density Lipoprotein-Cholesterol was not significant statistically.
A similar correlating finding was reported by Geeta H. et al (2002) 9 in Sudarshan Kriya Yoga practitioners.
Similar significant increase in HDL - Cholesterol due to Kriya Yoga practice was also reported by T. Schemidt (1997) 13.
However D. Ornish (1990) 12, S.C. Manchanda et al (2000) 14, Rashmi Vyas et al (2002) 15, reported that there was no significant change in level of serum HDL - Cholesterol.
A careful statistical analysis of observation and results in present study reveals a highly significant decrease in serum level of total cholesterol, triglycerides, LDL - Cholesterol, VLDL - Cholesterol and increase in Serum High Density Lipoprotein-Cholesterol in all age groups when compared with age, sex matched controls.
These changes are due to:-
Reduction in stress
Reduction in sympathetic activity
Reduction in lipid peroxidation
Reduction in stress
Sudarshan Kriya Yoga produces calm and relaxation and decreases stress as proved by increased alpha activity in Sudarshan Kriya Yoga practitioners17. Various kinds of pranayama, meditation and shavasana are also known to reduce stress18, 19,20,21,22. Stress is known to increase the levels of serum total cholesterol, triglycerides, LDL - Cholestrol, VLDL - Cholesterol and decrease HDL-Cholesterol level by increasing levels of lipolytic hormones like cortisol, adrenaline, noradrenaline, growth hormone. These hormones mobilize lipid store of adipose tissue and liver to meet extra caloric requirement during stress23, 24. Thus reduction in stress in Sudarshan Kriya Yoga practitioners, decreases levels of serum total cholesterol, triglycerides, LDL - Cholesterol, VLDL - Choleterol and increase HDL-Cholesterol level.
Reduction in sympathetic activity
Stimulation of sympathetic innervations to fat releases norepinephrine which act via beta adrenergic receptors to increase lipolysis. Due to this there is increase in the levels of serum total cholesterol triglycerides, Low Density Lipoprotein-Cholesterol and Very Low Density Lipoprotein-Cholesterol 25, 26, 27. Yoga lifestyle result in decreased sympathetic activity and increased parasympathetic activity20, 21, 28, 29. Therefore in Yoga lifestyle decreased sympathetic activity may result in decreased lipolysis and thus decreases the levels of serum total cholesterol, triglycerides Low Density Lipoprotein-Cholesterol, Very Low Density Lipoprotein-Cholesterol.
Reduction in lipid peroxidation
It is known that increased lipid peroxidation leads to increased total cholesterol, Low Density Lipoprotein-Cholesterol, Very Low Density Lipoprotein-Cholesterol and decreased High Density Lipoprotein-Cholesterol concentration30. Sudarshan Kriya Yoga decreases lipid peroxidation as evidenced by improved status of antioxidants e.g. SOD (Superoxide dismutase), glutathione and decreased level of MDA(Malondialdehyde) in Sudarshan Kriya Yoga practitioners31.Yogic breathing exercises decreases lipid peroxidation as evidenced by decreased level of MDA in plasma32. Thus decrease in lipid preoxidation in Sudarshan Kriya Yoga supports decrease in serum total cholesterol, triglyceride, Low Density Lipoprotein-Cholesterol, Very Low Density Lipoprotein-Cholesterol and increase in High Density Lipoprotein-Cholesterol.
CONCLUSION
These changes in lipid profile are probably due to reduced stress, decreased lipid peroxidation and decreased sympathetic activity due to Yoga. Sudarshan Kriya Yoga is very feasible to practice at home and it does not require any money expenditure. In developing countries like India it is very useful exercise for prevention of diseases related to stress and sympathetic over activity. In conclusion the hypocholestrimic action of Sudarshan Kriya Yoga practice can be useful in prevention of derangement of lipid profile and hypertension which are major risk factors for Coronary Heart Disease.
ACKNOWLEGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=1078http://ijcrr.com/article_html.php?did=1078
B. K. Anand. Yoga and Medical Sciences. IJPP 1991; 35(2): 84-872.
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Hemlata. Effect of starvation stress on Lipid profile. IJPP 2002; 46(3): 371 - 374.
Sharma H. et al. Sudarshan Kriya Practitionors exhibit better antioxidant status and lower blood lactate levels. Biological Psychology. 2003 Jul; 63(3):281-91.
Sandeep Bhattacharya et al. Improvement in oxidative status with Yogic breathing in young healthy males. IJPP 2002; 46 (3): 349 - 354.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241519EnglishN2013October19HealthcareA RARE CASE OF ADENOCARCINOMA LUNG WITH SECONDARIES TO PROXIMAL ULNA
English5660Supradeeptha ChallaEnglish Vikram Kumar KadiyamEnglish Kota AdityaEnglish Satyaprasad J.EnglishMetastasis of lung carcinoma to proximal ulna is very rare. We report a case of 55 year male patient with adenocarcinoma of lung, with metastasis to proximal ulna.
Englishadenocarcinoma lung, metastasis.INTRODUCTION
Bone is one of the most common locations for metastasis1. While any type of carcinoma is capable of forming metastasis within bone, the microenvironment of the marrow tends to favor particular types of cancer, including prostate, breast, and lung carcinoma2. Particularly in prostate carcinoma, bone metastases tend to be the only site of metastasis3.
Bone metastases most commonly affect the axial skeleton. The axial skeleton contains the red marrow, while appendicular skeleton contains relatively fatty marrow4. The drainage of blood to the skeleton via the vertebral-venous plexus may, at least in part, explain the tendency of breast and prostate, kidney, thyroid, and lung cancers, to produce metastases in the axial skeleton and limb girdles5. The vertebral-venous plexus does not provide the entire explanation of why these cancers metastasize to the skeleton. Molecular and cellular biological characteristics of the tumor cells and the tissues to which they metastasize are of paramount importance and influence the pattern of metastatic spread6-8.
Skeletal metastases account for 70% of all malignant bone tumours9. The incidence of bone metastases from lung carcinoma is 36%10. The frequency of bone metastasis is significantly higher among patients with adenocarcinoma than small cell or squamous carcinoma11, 12. Because of the relatively avascular marrow, metastases below the elbow and knee are relatively rare13. No case report of adenocarcinoma lung with secondaries to proximal ulna is published till date except in felines14.
CASE REPORT
A 55 year old male patient came to department of Orthopaedics with complaints of pain and swelling at right elbow and forearm since 2 months which is insidious in onset and gradually progressing. Pain is of diffuse in elbow region, stabbing in nature, non-radiating, severe with movements of elbow, and rated 7/10 on a visual analogue score. Patient had no history of trauma. Additional symptoms included mild shortness of breath. Patient is a smoker (1 packet beedies/day) and alcoholic (90 ml/day). The patient was afebrile. Vital signs were normal. Respiration is 19 cycles per minute. On auscultation of lungs, there is mild decrease in breath sound on right side of chest. On inspection of the forearm, there is diffuse swelling at right elbow and forearm of size 12x6 cms. Skin over swelling darkened, shiny. No scars, no sinuses, no visible pulsations.
On palpation, local rise of temperature present. Severe tenderness present over olecranon which is irregular in outline. Radial head is not palpable. Swelling is hard to firm in nature, pitting edema present, skin not pinchable over swelling. Distal radial pulse felt. No distal neurological deficits. Mild decrease in flexion of elbow and other movements are normal. Radiographs of right forearm showing osteolytic lesion of proximal ulna extending into diaphysis (Figure 1 and2). Articular surfaces are maintained. Radiograph of chest showing radio dense lesion in right lung (Fig 3).
FNAC Smears (Figure 4) from lytic lesions of right ulna shows abundant cellularity of cuboidal cells arranged in small and large clusters, sheets and papilloid structures and also scattered discretely. At places, these cells show acinar or microfollicular arrangement. The nuclei are large hyperchromatic with well dispersed chromatin and prominent nucleoli cytoplasm is densely eosinophilic. These features suggestive of metastasis of adenocarcinoma of lung to proximal ulna. The FNAC report of right supraclavicular lymphnodes shows same features. Patient was referred to cancer trust hospital for further management.
DISCUSSION
Lung cancer can metastasize to virtually any bone, although the axial skeleton and proximal long bones are most commonly involved15. Metastatic tumor cells colonize the bone matrix and stimulate the activity of osteoclasts and/or osteoblasts, causing osteolysis and possible excessive bone formation around sites of tumor cell deposits in bone. This disruption in bone metabolism leads to significant skeletal morbidity most commonly bone pain16. To our knowledge, this is the first case report of adenocarcinoma lung metastasis to proximal ulna.
CONCLUSION
Metastasis of adenocarcinoma to ulna is very rare.
Englishhttp://ijcrr.com/abstract.php?article_id=1079http://ijcrr.com/article_html.php?did=1079
Coleman RE. Clinical features of metastatic bone disease and risk of skeletal morbidity. Clin. Cancer Res. 2006; 12: 6243–49.
Guise T. Examining the metastatic niche: targeting the microenvironment. Semin. Oncol. 2010; 37: 2–14.
Jimenez-Andrade JM, Mantyh WG, Bloom AP, Ferng AS, Geffre CP, Mantyh PW. "Bone cancer pain". Ann. N. Y. Acad. Sci. 2010; 1198: 173–81.
Boland PJ, Lane JM, Sundaresan N. Metastatic disease of the spine. Clin Orthop. 1982; 169: 95–102.
Batson O. The role of vertebral veins in metastatic processes. Ann Intern Med 1942; 16: 38–45.
Bundred N, Walker RA, Ratcliffe WA, et al. Parathyroid hormone related protein, and skeletal morbidity in breast cancer. Eur J Cancer 1992; 28: 690–2.
Coleman R, Rubens R. The clinical course of bone metastases in breast cancer. Br J Cancer 1987; 77: 336–40.
Koenders P, Beex LV, Langens R, et al. Steroid hormone receptor activity of primary human breast cancer and pattern of first metastasis. Breast Cancer Res Treat 1991; 18: 27–32.
Greenspan A, Jundt G, Remagen W. Differential diagnosis in orthopaedic oncology. Philadelphia: Lippincott Williams and Wilkins, c2007. (2006) ISBN:0781779308
Galasko C. The anatomy and pathways of skeletal metastases. In: Weiss L, Gilbert A, editors. Bone metastases. Boston: GK Hall; 1981. p. 49–63.
Ryo H, Sakai H, Yoneda S, Noguchi Y. Bone metastasis of primary lung cancer. Nihon Kokyuki Gakkai Zasshi. 1998; 36(4): 317-22.
A.S. Shinto, L. Pachen, S. T K, C.D. Joseph. Skeletal Metastases In Apparently Operable Lung Cancer Evaluated With Whole Body Bone Scan – A Pilot Study In South India. The Internet Journal of Thoracic and Cardiovascular Surgery. 2010; 14: Number 2.
Samuel Kenan, Jeffrey I. Mechanick. Skeletal matastases. Holland-Frei Cancer Medicine. 6th edition. Hamilton (ON): BC Decker; 2003.
Raquel Salgüero, Sorrel Langley-Hobbs, James Warland, Malcolm Brearley. Metastatic carcinoma in the ulna of a cat secondary to a suspected pulmonary tumour. Journal of Feline Medicine and Surgery. 2012; 4: 1-4.
Beckles MA, Spiro SG, Colice GL, R udd RM. Initial evaluation of the patient with lung cancere- symptoms, signs, laboratory tests, and paraneoplastic syndromes. Chest. 2003; 123: 97s-104s.
Mercadante S. Malignant bone pain: pathophysiology and treatment. Pain. 1997; 69: 1–18.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241519EnglishN2013October19HealthcareEFFECT OF CHRONIC ADMINISTRATION OF ATORVASTATIN, SIMVASTATIN AND LOVASTATIN ON ANIMAL MODELS OF EPILEPSY
English6165Nayak V.English Adiga S.English Poornima B.M.English Sharma R.English Garg A.English Shetty M.English Kamath S.English Hegde M.English Koshy S.S.EnglishIntroduction: Statins, the widely used hypolipidemics drugs have a number of pleotropic effects. Objective: To study the effect of chronic administration of atorvastatin, simvastatin and lovastatin on maximal electroshock and pentylenetetrazole induced seizures in Wistar rats. Material and Methods: After obtaining institutional animal ethics committee clearance the study was conducted in male wistar rats. The animals were dosed with the various statins for 30 days. The effect of statins on maximal electroshock and pentylenetetrazole induced seizures was then studied. The animals were then sacrificed and the brain tissue was used for antioxidant estimation. Results: Statins showed a protective effect against seizures in both the models. The levels of glutathione were increased and malonadialdehyde decreased in the brain tissue in statin treated groups. The present study confirms the anticonvulsant action of statins, their antioxidant action being the possible mechanism.
Englishstatins, seizures , antioxidant actionINTRODUCTION
Statins, the most widely used and efficacious hypolipidemic which act by inhibiting HMG-CoA reductase enzyme are now known to have many pleotropic effects1 .The pleiotropic effects of statins include improving endothelial function, enhancing stability of plaques, decreasing oxidative stress, inflammation and inhibiting thrombosis1,2.
It has been hypothesized that statins reduce the risk of developing epilepsy in the elderly. 3 High dose atorvastatin has been shown to reduce the frequency of tonic-clonic seizures induced by quinolinic or kainic acid. 4 A cohort study also showed that statins reduced the hospitalization due to seizures3. Based on these studies, the authors had studied the effect of statins in animal models of epilepsy after a single dosing, wherein simvastatin had reduced the duration of seizures in maximum electroshock (MES) model without abolishing hindlimb extension. In pentylenetetrazole (PTZ) model simvastatin and lovastatin decreased the duration of seizures and also increased the latency for the onset of seizures in comparison to the control group. Atorvastatin at a dose of 3.6mg/kg increased the latency but had no effect on duration of seizures in PTZ model. 5 The results of the study indicated that statins do have an antiepileptic action but needed further confirmation. Hence the authors planned to study the effect of chronic administration of various statins on MES and PTZ induced seizures and also their impact on oxidative changes which occur during seizures.
MATERIALS AND METHODS
Animals
Albino rats weighing 150-200g were used for the study. They were maintained under standard conditions in Central animal house, Manipal University, Manipal approved by the CPCSEA.
The rats were kept in polypropylene cages (U.N. Shah Manufacturers, Mumbai) and maintained on standard pellet diet (Amrut Lab Animal Feed, Pranav Agro industries Ltd, Sangli, Maharashtra) and water ad libitum. The rats were maintained at a room temperature 26 ±20C, relative humidity 45?55% and light/ dark cycle of 12 h.
Reagents : Special chemicals such as 5 5’-dithio-bis (2-nitrobenzoic acid) (DTNB), 1-cholro 2, 4-dinitrobenzene (CDNB) ,reduced glutathione (GSH), thiobarbituric acid (TBA), trichloroacetic acid (TCA) were obtained from Sigma Chemicals Co. (St Louis, MO). All the reagents used were of analytical grade
Drugs: Atorvastatin (Zydus Cadila Healthcare Ltd), simvastatin (Micro Labs Ltd), lovastatin (Dr.Reddy’s Laboratories Ltd), carbamazepine (Novartis India Ltd, Mumbai), sodium valproate (Sun Pharmaceutical Industries Ltd, Mumbai) and pentylenetetrazole (Sigma – Aldrich,
Mumbai) were used for the study. The doses selected were in accordance to that of the previous study done by the authors. 5
Methodology: The study was undertaken after obtaining permission from the Institutional Animal Ethics committee, Manipal. A total of sixty animals were used for the study. They were divided into two sets for testing in two experimental models, the maximal electroshock and pentylenetetrazole seizures.
I: Maximal electroshock model
Rats were divided into 5 groups (n=6). The groups I to V received gum acacia (1ml), carbamazepine (108mg/kg), atorvastatin (7.2 mg/kg), simvastatin (1.80mg/kg) and lovastatin (3.60mg/kg ) respectively orally once daily for 30 days. Maximal electroshock seizures was induced as described by Toman et al6 with a current of 150 mA delivered through the ear clip electrode for 0.2 sec with the help of convulsiometer after a month of drug administration. Absence of hind limb extension (HLE) was taken as protection against seizures. Only the animals which show hind limb extension during the screening procedure on the earlier day were included in the study.
II: PTZ induced seizures7
Rats were divided into 5 groups (n=6).The groups I to V received gum acacia (1ml),sodium valproate (180mg/kg), atorvastatin (7.2mg/kg), simvastatin (1.80mg/kg) and lovastatin (3.60mg/kg) respectively orally once daily for 30 days. Pentylenetetrazole (60mg/kg i.p) was then given to induce seizures after a month of drug administration. Each animal was then placed in an individual cage for observation lasting 30min. The duration of the seizures in each group was recorded.
BIOCHEMICAL ESTIMATIONS
Collection of tissue samples: The animals were sacrificed by cervical dislocation and brain tissues were carefully removed and chilled in ice-cold phosphate buffer. After washing in ice-cold buffer, the hippocampus was dissected out and homogenized in phosphate buffer (pH 7.4, 10% w/v) using Teflon homogenizer. The tissue homogenate was then utilized for
malondialdehyde (MDA) assay and glutathione-S- transferase (GST) assay.
Malondialdehyde assay Level of MDA was analyzed in the rat brain by the method of Okhawa et al with slight modifications8.100µL of homogenate, 1000µL of TBA and 500 µL of TCA were mixed and incubated at 100° for 20 minutes , then centrifuged at 12000 rpm for 5minutes . Absorbance was read spectrophotometrically at 532 nm.
Glutathione-S-transferase assay GST assay was analyzed in the rat brain by the method of Habig.9 Phosphate buffer (850µL), CDNB (50 µL) and GSH (50 µL) were mixed and incubated at 37°C for ten minutes, then 50 µLof homogenate was added and absorbance was read spectrophotometrically at 340 nm.
Statistics: The results were analysed by one way ANOVA followed by Dunnett’s test. Statistical analysis was done using the SPSS 16.0 version.
RESULTS
In the present study, there was a significant (p≤ 0.05) reduction in the duration of PTZ induced seizures in atorvastatin, lovastatin, simvastatin and sodium valproate treated groups in comparison to the control group (62.93±3.43). In maximal electroshock induced seizure model carbamazepine, atorvastatin, simvastatin and lovastatin significantly (< 0.01) reduced the duration of seizures in comparison to control group (Table1). The tissue glutathione levels were significantly (pEnglishhttp://ijcrr.com/abstract.php?article_id=1080http://ijcrr.com/article_html.php?did=1080
Bersot TP. Drug therapy for hypercholesterolemia and dyslipidemia. In: Brunton LL, Chabner BA, Knollmann BC, editors. Goodman and Gilman‘s The pharmacological basis of therapeutics .12thed. New York: Mc Graw Hill ; 2006.p. 877-908.
Zhou Q, Liao JK. Pleiotropic effects of statins. Circulation journal. 2010; 74: 818-826
Das RR, Herman ST. Statins in epilepsy. Neurology 2010; 75: 1490-1491
Lee JK Won JS, Singh AK, Singh I. Statin inhibits kainic acid-induced seizure and associated inflammation and hippocampal cell death. Neurosci Lett 2008; 440(3):260-4.
Nayak V, Adiga S, Poornima BM, Sharma R, Garg A. Effect of atorvastatin, simvastatin,lovastatin on animal models of epilepsy : a comparative study. International journal of current research and review 2012; 4(11):30-33.
Toman JEP, Swinyard EA, Goodman LS. Properties of maximal seizures and their alteration by anticonvulsant drugs and other agents. J Neurophysiol 1946; 9:231-39.
Visweswari G, Prasad KS, Chetan PS, Lokanatha V, Rajendra W. Evaluation of the anticonvulsant effect of Centella asiatica (gotu kola) in pentylenetetrazol-induced seizures with respect to cholinergic neurotransmission. Epilepsy and Behavior 2010; 17(3):332-335.
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Pandey MK, Mittra P, Maheshwari PK. The lipid peroxidation product as a marker of oxidative stress in epilepsy. JCDR 2012; 6(4): 590-92.
Mueller SG, Trabesinger AH, Boesiger P, Wieser HG. Brain glutathione levels in patients with epilepsy measured by in vivo(1)H-MRS. Neurology 2001; 57(8): 1422-47.
Moazzami K, Emamzadeh-Fard S, Shabani M. Anticonvulsive effect of atorvastatin on pentylenetetrazole induced seizures in mice: the role of nitric oxide pathway. Fundamental and clinical pharmacology 2013; 27:387-92.
Mirhadi K. Anticonvulsant effect of pitavastatin in mice induced by pentylenetetrazole. American journal of animal and veterinary sciences 2011; 6(4):166-70.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241519EnglishN2013October19HealthcareDISASTROUS REACTION TO METHYLENE BLUE DYE - A CASE REPORT
English6668K. NatarajanEnglish N. MurugesanEnglishMethylene blue is used as a diagnostic and therapeutic agent in humans. Adverse reaction to the dye is very rare. But when adverse reaction occurs it can be very severe and dangerous. The reaction may be local or generalized and sometimes life threatening and can be even fatal. This should be kept in mind to avoid or minimize the severe reactions to the dye. We hereby present a female patient who developed severe chemical peritonitis with small bowel perforations to the methylene blue dye in the course of investigation for primary infertility.
EnglishMethylene blue, Chemical peritonitis, Ileal perforationINTRODUCTION
Methylene blue is a versatile dye which is used in a variety of situations from diagnosis to therapy, across all branches of medicine. It is used in the investigations of sinuses, fistula, sentinel node localization in malignancy, normal and abnormal tissue identification (tattooing of colonic mucosa during colonoscopy) and patency of Fallopian tubes. Gynecologists routinely use methylene blue dye solution to test the patency of Fallopian tubes in the course of investigations for infertility. Reactions to the dye are very rare. But when it occurs it can be very serious and can lead to major complications like chemical peritonitis1,2,3, general skin reactions, tissue necrosis4,5, methemogobinemia6,7, anaphylaxis8, pulmonary edema09,10 etc.
CASE REPORT
A 30 year old patient underwent diagnostic laparoscopy and tube patency test using 0.5% sterile methylene blue dye solution. The whole procedure was uneventful. She recovered from the anaesthesia completely and started taking oral fluids after 6 hours. She developed lower abdominal pain after 24 hours which was constant and not associated with any vomiting. On examination she had mild diffuse tenderness in the lower abdomen with no rebound tenderness. Bowel sounds were present. She was started on IV fluids and antibiotics and kept nil oral. She continued to have abdominal pain and on the fourth day developed severe abdominal pain with signs of peritonitis. Immediately she underwent emergency laparotomy. At laparotomy the peritoneal cavity was found to have turbid fluid. The terminal ileum was stained in many parts with methylene blue and there were four perforations in the areas of blue staining. The terminal part of the ileum was thickened, white and found not viable. The terminal ileum with the perforations was resected and end to end anastomosis was done. She recovered slowly and was started on oral fluids after flatus was passed. She developed a small bowel fistula in the lower part of the abdominal wound on the 20th day. She was treated conservatively with NPO and IV fluids. Ultra sound examination of the abdomen did not show
any intra peritoneal collection or any other abnormality. The fistula closed spontaneously within a week. She was discharged home afterwards. Histopathological examination of the resected bowel showed severe diffuse inflammation of the small bowel with multiple perforations.
In the course of the next 6 months she had intermittent discharge of small bowel contents from the same area of previous small bowel fistula. Each time it closed spontaneously.
She underwent Ultrasound examination of the abdomen which did not reveal any abnormality. CT Abdomen also was normal. Fistulogram showed filling of the small bowel with the contrast. Large bowel was not filled with the contrast.
After these investigations she underwent an elective Laparotomy under GA. At laparotomy stricture of the terminal ileum beyond the fistulous opening was found. That part was resected and ileo caecal anastomosis was performed. The post operative period was uneventful.
DISCUSSION
Literature is very limited due to the rarity of the adverse reaction to the dye and only a few references are available. Various types of reaction to methylene blue dye like anaphylaxis8, methemoglobinemia6,7, pulmonary oedema09,10, chemical peritonitis1,2,3 or local skin reactions4,5 have been described. The patient in this report developed severe chemical peritonitis with multiple perforations of the small bowel. Formation of intraperitoneal adhesions in rats is reported in experimental studies11. To prevent adverse reactions to the dye, O’Sullivan advises the use of very dilute solution of the dye(1 ml of 1% methylene blue dye diluted in 100 ml of sterile saline). Aspiration of the dye from the peritoneal cavity and steroid wash to the areas of contact with the dye after completing the procedure might also help.
CONCLUSION
Adverse reaction to methylene blue dye is very rare. The reaction may be local at the site of application or general. The physician using the dye must take appropriate preventive steps like using very dilute solution, aspirating the dye after usage and giving steroid lavage. When adverse reaction occurs this should be treated promptly. The adverse reactions, the preventive measures and treatment are to be kept in mind whenever this dye is used.
Englishhttp://ijcrr.com/abstract.php?article_id=1081http://ijcrr.com/article_html.php?did=1081
Nolan DG. Inflammatory peritonitis with ascites after methylene blue dye
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Macia M, Gallego E, Garcia-Cobaleda I et al. Methylene blue as a cause of chemical peritonitis in a patient on peritoneal dialysis. Clin Nephrol 1995; 43: 136–137
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M Salhab, W Al sarakbi and K Mokbel Skin and fat necrosis of the breast following methylene blue dye injection for sentinel node biopsy in a patient with breast cancer International Seminars in Surgical Oncology 2005, 2:26 doi:10.1186/1477-7800-2-26
Stradling B, Aranha G, Gabram S. Adverse skin lesions after methylene blue injections for sentinel node localization. Am J Surg. 2002 Oct; 184(4):350-2
Mhaskar R, Mhaskar AM Methemoglobinemia following chromopertubation in treated pelvic tuberculosis. Int J Gynaecol Obstet. 2002 Apr;77(1):41-2. PMID:11929658 [PubMed - indexed for MEDLINE]
Bilgin H, Ozcan B, Bilgin T. Methemoglobinemia induced by methylene blue pertubation during laparoscopy.Acta Anaesthesiol Scand. 1998 May;42(5):594-5.PMID:9605379 [PubMed - indexed for MEDLINE]
Rzymski P, Wozniak J, Opala T, Wilczak M, Sajdak S. Anaphylactic reaction to methylene blue dye after laparoscopic chromopertubation. Int J Gynaecol Obstet. 2003 Apr; 81(1):71-2.
Teknos D, Ramcharan A, Oluwole SF Pulmonary edema associated with methylene blue dye administration during sentinel lymph node biopsy..J Natl Med Assoc. 2008 Dec;100(12):1483-4.PMID:19110921 [PubMed - indexed for MEDLINE]
Millo T, Misra R, Girdhar S, Rautji R, Lalwani S, Dogra TD. Fatal pulmonary oedema following laparoscopic chromopertubation. Natl Med J India. 2006 Mar-Apr;19(2):78-9. PMID: 16756195 [PubMed - indexed for Medline]
Gul A, Kotan C, Dilek I, Gul T, Tas A, Berktas M, Effects of methylene blue, indigo carmine solution and autologous erythrocyte suspension on formation of adhesions after injection into rats. Reprod Fertil. 2000 Nov;120(2):225-9
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241519EnglishN2013October19HealthcarePHYSIOLOGICAL JAUNDICE: ROLE IN OXIDATIVE STRESS
English6980Nitin PandeyEnglish Sushma GuptaEnglish Raj Kumar YadavEnglish Kumar SarvottamEnglishPhysiological jaundice is a common condition encountered in almost two third of neonates. It occurs due to complex interaction of many factors. In this review we have discussed mainly the physiological basis for its development. In newborns, if bilirubin level is more than physiological level, it may cause bilirubin encephalopathy (kernicterus), a deleterious neurological outcome. Then why nature has selected jaundice, a common condition in newborns. Perhaps nature has tried to use the antioxidant property of bilirubin and biliverdin to protect newborns that face storm of oxidative stress after birth.
EnglishPhysiological jaundice, neonatesINTRODUCTION
Jaundice is the visible manifestation in skin and sclera of elevated serum concentrations of bilirubin. Adult jaundice is generally a pathological consequence. Most adults are jaundiced when serum total bilirubin levels exceed 2.0 mg/dL. In neonates, the common causes of jaundice include hepatic immaturity, red cell incompatibility, infection, and breast feeding while some not so common causes are hypothyroidism, galactosaemia, viral hepatitis, and atresia of the bile ducts. The jaundice due to red cell incompatibility appears within 24 hours of birth, and is attributed to incompatible rhesus grouping and incompatible ABO grouping. The infective jaundice is a result of septicemia and urinary tract infection, and is suspected if the jaundice appears after the fourth day of life, though it may have other presentation as well. The jaundice due to hepatic immaturity is termed as physiological jaundice, and is reported in approximately 60% of normal full term infants and in 80% of the preterm infants. Infants, however, may not appear jaundiced until the serum total bilirubin concentration exceeds 5.0 to 7.0 mg/dL. The bilirubin levels gradually increase and reach peak by day 5-7, which can be as high as 12 mg/dL (moderate jaundice) in normal full term infants and up to 14 mg/dL (severe jaundice) in normal premature infants (1). Although neonatal jaundice is harmless, newborns are generally monitored for hyperbilirubinemia, acute bilirubin encephalopathy or kernicterus. However, onset of jaundice within first 24 hours of life, an increase of >5 mg/dL per day, direct bilirubin level > 1 mg/dL at any given time, or the persistence or new onset of jaundice in infants 2 weeks of older is warranted, and should be clinically investigated, especially in breast fed infants (2).
Causes and Presentation
As early as 1925, the animal studies at Rockfeller Institute indicated that the jaundice that develops after obstruction of common duct in the absence of complications, expresses the physiological wastage of corpuscles occurring from day to day (3). Later studies also indicated that physiologic hyperbilirubinemia in the neonate includes an increased bilirubin load because of relative polycythemia, wherein erythrocyte life span have
a shorter lifespan of 80 days compared with the adult erythrocyte life span of 120 days, immature hepatic uptake and conjugation processes, and increased enterohepatic circulation (4). Neonatal hyperbilirubinemia can occur due to bilirubin overproduction, decreased bilirubin conjugation, or impaired bilirubin excretion. Physiological jaundice is common both in preterm and in full term babies and occurs due to decreased bilirubin conjugation. Due to hepatic immaturity, there is a temporary deficiency of glucuronyl transferase enzymes, which reduces the rate of bilirubin conjugation resulting in a consequent retention of unconjugated bilirubin, however, it should not be confused with hereditary glucose-6-phosphate dehydrogenase deficiency. In full term infants the jaundice appears after the first 24 hours of life and reaches a peak on the 4th or 5th day while in preterm infants it usually begins 48 hours after 4th day of birth and may last up to two weeks. The average total serum bilirubin level generally ranges from 5 to 6 mg/dL on the 3rd to 4th day of life, gradually declining over the first week after birth (1). However, serum bilirubin may reach up to 260 and 360 µmol/L with < 2 mg/dL (34 μmol/L) of the conjugated form by 2nd or 3rd week of life in breast fed infants and may be asymptomatic. The levels gradually fall after a static phase of 3-4 weeks, and become normal by 4-16 weeks with continued breast feeding. In hepatitis-related jaundice, levels of conjugated bilirubin are high. Overall, a prolonged jaundice for >10 days should be thoroughly investigated.
Physiologic jaundice is caused by a combination of increased bilirubin production secondary to accelerated destruction of erythrocytes, decreased excretory capacity secondary to low levels of ligandin in hepatocytes, and low activity of the bilirubin-conjugating enzyme uridine diphosphoglucuronyltransferase (UDPGT).
Diagnosis
The diagnosis is established by examining the infant in a well-lit room and blanching the skin with digital pressure to reveal the color of the skin and subcutaneous tissue. During the examination, pathological jaundice should be ruled out. Physiological jaundice in healthy term newborns is characterized by an average total serum bilirubin level usually reaching 5 to 6 mg/dL (86 to 103 μmo/L) on the 3rd to 4th day of life and then declining over the first week after birth (1). However, there are chances that bilirubin can go up to 12 mg/dL, with less than 2 mg/dL (34 μmol/L) of the conjugated form. Maisels et al proposed criteria that can be used to exclude the diagnosis of physiologic jaundice as given in Table 1 (5).
Intrauterine Bilirubin Metabolism
Bilirubin appears in normal amniotic fluid after about 12 weeks of gestation, but it disappears by 36 to 37 weeks' gestation. Fetal liver is immature in conjugatory mechanism and removal of bilirubin from circulation. Between 17 and 30 weeks of gestation, uridine diphosphoglucuronosyl transferase (UDPGT) activity in fetal liver is only 0.1% of adult values, but it increases tenfold to 1% of adult values between 30 and 40 weeks' gestation. After birth, activity increases exponentially, reaching adult levels by 6 to 14 weeks' gestation. This increase is independent of gestation (6, 7). The major route of fetal bilirubin excretion is across the placenta. Because virtually all the fetal plasma bilirubin is unconjugated, it is readily transferred across the placenta to the maternal circulation, where it is excreted by the maternal liver. Thus, the newborn rarely is born jaundiced, except in the presence of severe hemolytic disease, when there may be accumulation of unconjugated bilirubin in the fetus. Conjugated bilirubin is not transferred across the placenta, and it also may accumulate in the fetal plasma and other tissues.
Bilirubin Production and Metabolism in Newborns
Bilirubin is produced at a rate of approximately 6 to 8 mg per kg per day in newborns, which is more than twice the production rate in adults and is attributed to polycythemia and increased red
blood cell turnover in newborns (8). In adults, the amount of bilirubin derived from sources other than the break-down of red cells is approximately 10-15% of the total, while in full-term infants it is 21-25%, and in premature infants, it is 30% of the total bilirubin load (9). The bilirubin production generally reaches a level similar to adults within 10 to 14 days postpartum (1). Bilirubin is the end product of the catabolism of heme. Newborns have a high rate of hemoglobin catabolism and bilirubin production because of their elevated hematocrit and red blood cell volume, and a shorter lifespan of the red blood cells. Major source of heme is degradation of senescent red blood cell (10). The formation of bilirubin from hemoglobin involves removal of the iron and protein moieties, followed by an oxidative process catalyzed by the enzyme microsomal heme oxygenase, an enzyme found in the reticuloendothelial system as well as many other tissues (11). The α- methane bridge of the heme porphyrin ring is opened and one mole of carbon monoxide (CO) and one mole of biliverdin and subsequently bilirubin are formed after each molecule of heme degradation (12). Biliverdin is reduced to bilirubin by biliverdin reductase. At this initial stage, bilirubin is lipid soluble and unconjugated (indirect-reacting). Bilirubin is a polar compound and at physiologic pH, it is insoluble in plasma and requires protein binding with albumin. After conjugation in the liver by glucuronosyltransferase to bilirubin diglucuronide (conjugated or direct-reacting), which is water soluble and eliminated by the liver and biliary tract (13- 16). If the albumin-binding sites are saturated, or if unconjugated bilirubin is displaced from the binding sites by medications (e.g., sulfisoxazole [Gantrisin], streptomycin, vitamin K), free bilirubin can cross the blood-brain barrier, which is toxic to the central nervous system (17). Some of the bilirubin may be converted back to its unconjugated form by a glucuronidase and reabsorbed by the intestine through enterohepatic absorption, which is known to be increased by breast milk (1).
Mechanism of Physiological Jaundice
The key causes for physiological jaundice are an increased bilirubin load on liver cell, decreased hepatic uptake of bilirubin from plasma, decreased bilirubin conjugation, and defective bilirubin excretion. An overview of pathophysiology of neonatal jaundice is presented in Figure 1.
The measurement of CO in normal newborn showed that newborn produces an average of 8 to 10 mg/kg (13.7 to 17.1 μmol/ kg) of bilirubin per day (18, 19). This is more than twice the rate of normal daily bilirubin production in the adult and is explained by the fact that the neonate has a higher circulating erythrocyte volume, a shorter mean erythrocyte lifespan, and a larger early labeled bilirubin peak. Bilirubin production decreases with increasing postnatal age but is still about twice the adult rate by age 2 weeks (18). The newborn reabsorbs much larger quantities of unconjugated bilirubin by enterohepatic circulation, than does the adult. Infants have fewer bacteria in the small and large bowel and greater activity of the deconjugating enzyme β-glucuronidase (20). As a result, conjugated bilirubin, which is not reabsorbed, is not converted to urobilinogen but is hydrolyzed to unconjugated bilirubin, which is reabsorbed, thus increasing the bilirubin load on an already stressed liver. Studies in newborn humans, monkeys, and Gunn rats suggest that the enterohepatic circulation of bilirubin is a significant contributor to physiologic jaundice (21- 23). In the first few days after birth, caloric intake is low, which contributes to an increase in the enterohepatic circulation (24, 25). The decreased hepatic uptake of bilirubin from plasma is generally associated with a decreased level of ligandin. Ligandin, the bilirubin-binding protein in the human liver cell, is deficient in the liver of newborn monkeys. It reaches adult levels in the monkey by 5 days of age, coinciding with a
fall in bilirubin levels, and administration of phenobarbital increases the concentration of ligandin (26). Although this suggests that impaired uptake may contribute to the pathogenesis of physiologic jaundice, uptake does not appear to be rate limiting. A decreased uridine diphosphoglucuronosyl transferase activity is generally a cause for reduced bilirubin conjugation. Deficient UGT1A1 activity, with resultant impairment of bilirubin conjugation, has long been considered a major cause of physiologic jaundice. In human infants, the early postnatal increase in serum bilirubin appears to play an important role in the initiation of bilirubin conjugation (27). In the first 10 days after birth, UGT1A1 activity in full-term and premature neonates usually is less than 1% of adult values (12, 28). Thereafter, the activity increases at an exponential rate, reaching adult values by 6 to 14 weeks of age (12). The postnatal increase in UGT1A1 activity is independent of the infant's gestation. A defective bilirubin excretion may precipitate jaundice due to impaired excretion. The absence of an elevated serum level of conjugated bilirubin in physiologic jaundice suggests that, under normal circumstances, the neonatal liver cell is capable of excreting the bilirubin that it has just conjugated. Nevertheless, the ability of the newborn liver to excrete conjugated bilirubin and other anions (e.g., drugs, hormones) is more limited than that of the older child or adult and may become rate limiting when the bilirubin load is significantly increased. Thus, when intrauterine hyperbilirubinemia occurs, it is not uncommon to find an elevated serum level of conjugated bilirubin (5).
Pathophysiological Consequences of Hyperbilirubinemia
If the serum unconjugated bilirubin level exceeds the binding capacity of albumin, unbound lipid-soluble bilirubin crosses the blood-brain barrier though even albumin-bound bilirubin may also cross the blood-brain barrier in case of asphyxia, acidosis, hypoxia, hypoperfusion, hyperosmolality, or sepsis in the newborn (29, 30). In such a situation kernicterus may occur, resulting in neurologic consequences of the deposition of unconjugated bilirubin in brain tissue causing damage and scarring of the basal ganglia and brainstem nuclei, developmental and motor delays, sensori-neural deafness, and mild mental retardation (31). Acute bilirubin encephalopathy is caused by the toxic effects of unconjugated bilirubin on the central nervous system, and is characterized by lethargy, high-pitched cry, and poor feeding in a jaundiced infant. If acute bilirubin encephalopathy is untreated, it may progress rapidly to advanced manifestations, such as opisthotonus and seizures. It has been recommended that the bilirubin levels above 25 mg per dL (428 μmol per L) should be taken as a warning by the treating physician, however toxicity can occur at a lesser value, depending upon the genetic and ethnic conditions (32- 35). Generally, in the absence of hemolysis such risk is negligible.
Effect of Breast Feeding on Jaundice
It has been postulated that substances in maternal milk, such as β-glucuronidases, and nonesterified fatty acids may inhibit normal bilirubin metabolism, and hence may precipitate jaundice (36- 38). Further, breastfed newborns may be at increased risk for early-onset severe physiological jaundice as there is an insufficient calorie intake during first few days (39). This renders breastfed newborns at a 3-6 times higher risk of moderate-to-severe jaundice versus formula-fed newborns (39, 40). In such a scenario, breastfeeding should be continued, and if indicated formula should be added/substituted. If breastfeeding is the cause of jaundice then serum bilirubin level should decline over 48 hours (32). Certain factors present in the breast milk of some mothers may also contribute to increased enterohepatic circulation of bilirubin (breast milk jaundice). β-glucuronidase may play a role by uncoupling bilirubin from its binding to glucuronic acid, thus making it available for
reabsorption. Data suggest that the risk of breast milk jaundice is significantly increased in infants who have genetic polymorphisms in the coding sequences of the UDPGT1A1 or OATP2 genes. Although the mechanism that causes this phenomenon is not yet agreed on, evidence suggests that supplementation with certain breast milk substitutes may reduce the degree of breast milk jaundice.
Management
Although jaundice in newborns is usually benign but it should be carefully monitored, and if needed, an intervention should be given. In case of infants with mild jaundice, and phototherapy is not indicated, increasing the frequency of feedings should be advised.
Newer Concepts: Role of Oxidative Stress
Oxidative stress occurs when the production of damaging free radicals (ROS) and other oxidative molecules overwhelms the capacity of the body's antioxidant defenses, and contribute towards maintaining redox homeostasis. The initiation of stress is generally a post-natal event, however, in certain cases this can preclude such as maternal pregnancy diseases like preeclampsia, eclampsia, and maternal infections, and preterm delivery. Generally body is equipped with an array of well integrated antioxidant defenses to prevent the overage of ROS, and is available in ample quantities to scavenge and control their concentration. However, a fully efficient antioxidant defense system is lacking in preterm newborn. This may result in compromised state in pre-term neonates and renders them to complications like bronchopulmonary dysplasia, retinopathy of prematurity, hypoxic/ischemic encephalopathy, and intraventricular hemorrhage (41). The key antioxidants in human body are vitamins A, E and C, selenium, and antioxidant enzymes (catalase, superoxide dismutase, and glutathione peroxidase). It has been shown that the mean plasma total nitrite and total serum bilirubin levels and blood reticulocyte counts of the study group were significantly higher in preterm infants with newborn jaundice than those of the control group. Also, the activity of erythrocyte antioxidant enzymes and the mean plasma levels of the antioxidant vitamins A, E, and C and selenium of the preterm infants with newborn jaundice were all found to be significantly lower than those of the control group (42). Also, the jaundiced newborns had significantly lower MDA but higher SOD, catalase and GPx levels (43). Besides these key antioxidants, G6PD plays an important role in maintaining the cytosolic pool of NADPH and henceforth the cellular redox balance. Since G6PD is an important antioxidant enzyme within the erythrocytes, it is plausible that its deficiency is associated with neonatal jaundice, hemolysis and hemolytic anemia. Additionally this disruption in redox homeostasis, can lead to dysregulation of cell growth and cell signaling, resulting in abnormal embryonic development, and increase in incidence of degenerative diseases (44).
Another important antioxidant in the pathophysiology of neonatal jaundice is heme-oxygenase enzyme, which has significant activity levels in the liver, spleen, and erythropoeitic tissue. In neonates, heme-oxygenase controls production of bilirubin and hemoprotein metabolism, and maintain concentration of intracellular heme. Heme is degraded by a synergistic activity of the microsomal enzymes, heme-oxygenase and NADPH-cytochrome C (P450) reductase, and cytosolic biliverdin reductase in the presence of oxygen and NADPH, and results in production of bilirubin and carbon monoxide as by-products. Since, enzymatic activity of heme-oxygenase produces NADPH and oxygen, an up-regulation of this enzyme may overwhelm the antioxidant defenses, which include stress, poor maternal nutrition, metalloporphyrins, hormones, starvation, toxins, and xenobiotics. Additionally, it may undergo due to an increased protein synthesis and gene transcription. It has been shown that the hepatic
heme-oxygenase activity and mRNA levels are elevated in fetus and neonate as compared to adults due to an increased transcription of the heme-oxygenase gene (45). Since research indicates that many severe diseases of the neonate are caused by oxidative injury and lipid peroxidation, it is important to identify its causes, implications, and measures to minimize this.
Phototherapy and Oxidative Stress
Phototherapy is a widely used treatment modality for unconjugated hyperbilirubinemia in newborn infants due to its non-invasive nature. However, it been demonstrated that phototherapy leads to oxidative stress in preterm newborns as marked by increased markers of oxidative stress, namely lipid peroxidation and DNA damage (46). Also, phototherapy resulted in a decrease in vitamin C, uric acid, total bilirubin and MDA concentration, while there was a significant increase in the levels of total oxidant status, oxidative stress index, and lipid hydroperoxide levels, and the levels of serum total bilirubin correlated positively with MDA (47). In this regards, studies have evaluated the contribution of doses and quality of phototherapy in oxidative damage (48). In a study, where a continuous day-light phototherapy was given to jaundiced term and preterm newborns for 72 hours, levels of serum vitamin E and the activities of red blood cell anti-oxidation enzymes (superoxide dismutase, catalase and glutathione peroxidase) were measured before and after 72 h of phototherapy. The results showed that there were no changes in levels in antioxidants measured in this study. These results suggested that day-light phototherapy was safe and efficient method of treatment for all neonates presenting with hyperbilirubinemia (49). However contrasting results were observed in another study assessed the effect of phototherapy on endogenous mononuclear leukocyte DNA strand in term infants exposed to intensive or conventional phototherapy for at least 48 hours due to neonatal jaundice, and a control group. The results showed that the mean values of DNA damage scores in both the intensive and conventional phototherapy groups were significantly higher than those in the control group. Further, total oxidant status levels in both the intensive and conventional phototherapy groups were significantly higher than those in the control group. Similarly, oxidative stress index levels in both the intensive and conventional phototherapy groups were significantly higher than those in the control group. Keeping these results in view, it is suggested that both conventional phototherapy and intensive phototherapy cause endogenous mononuclear leukocyte DNA damage in jaundiced term infants (50).
Antioxidant properties of bilirubin and biliverdin
Birth is state of sudden oxidative burst marked by a sudden exposure to oxygen, resulting in high oxidative load. Since the premature newborns do not have fully efficient antioxidant defenses as maturation occurs during the late gestation period, the newborns, especially premature infants, are extremely prone to oxidative damage (51, 52). This may also impact brain in lieu of limited oxidant scavenging capacity (53, 54). In this condition, heme-oxygenase-1 is considered as highly protective in various pathophysiological states such as cardiovascular and neurodegenerative diseases owing to its reactive oxygen and nitrogen species scavenging. Further, it has been shown that direct and indirect antioxidant properties of biliverdin and bilirubin has an important role in protection of endothelial cells along with heme-oxygenase-1 (55). Besides the regular antioxidant system of glutathione redox, the bilirubin-dependent redox cycle also seems to play a role in cell protection against oxidative stress in brain. Bilirubin, a reduction product of biliverdin by biliverdin reductase, is present in brain tissue under normal conditions in nanomolar (20–50 nM) concentrations. The bilirubin-dependent redox cycle and glutathione redox cycles work hand-in-hand. Heme-
containing proteins are broken down to biliverdin by heme oxygenases (HO). As discussed previously, heme-oxygenase-1is induced by oxidative stress, and this inducible form is expressed in glial cells (55, 57). The constitutive heme-oxygenase-2 on the other hand accounts for the enzymatic activity in brain, where it is expressed in neuronal populations in several regions (58, 59). heme-oxygenase-2 impairment results in a loss of bilirubin in cells and a higher susceptibility to different CNS damages (60). It has been shown that there is a correlation between activation of heme-oxygenase-2 in cultured hippocampal and cortex neurons (59). The reduction of biliverdin to bilirubin by the cytosolic enzyme biliverdin reductase strongly induces the apoptosis of cells cultured from hippocampal/cortical structures, which is neuroprotective (61). In a recent study it was shown that bilirubin may play an antioxidant role, both in vivo and in vitro, thereby protecting the preterm infant against these oxidative stress related disorders (62, 63). The role of bilirubin is further strengthened by the finding that plasma bilirubin had a significant negative correlation with MDA but positive correlation with antioxidant enzyme activities suggesting that neonatal hyperbilirubinemia is associated with lower oxidative stress (64). Biliverdin and heme-oxygenase genes are co-expressed in brain, and biliverdin acts by exhausting free SH groups and NADH or NADPH at pH of 6.8 and 8.7, respectively (65, 66). Biliverdin is involved in cell signaling, transports the transcription factor hematin from the cytoplasm to the nucleus, allowing hematin-dependent HO-1 gene transcription (67). Silencing biliverdin leads to a depletion of cellular bilirubin, increases cellular ROS and promotes apoptotic death in neuronal cultures (68). Additionally, biliverdin increases bilirubin production from heme degradation during oxidative stress (69). An intracellularly production of bilirubin is shown to act as ROS scavenger by quenching reactive radicals before being reoxidized to biliverdin (70, 71). However, results in this regard are contradictory where infants with significant hyperbilirubinemia had elevated oxidative stress and disturbed antioxidant enzyme activity, which calls for more scientific data (72).
CONCLUSIONS
Physiological jaundice is a common condition seen in most of the newborns during their first week of life. The condition usually lasts 10 to 14 days. Here we have tried to explain the neonatal jaundice through the eyes of oxidative stress and antioxidants imbalance in neonates as an important physiological (or pathophysiological) factor.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241519EnglishN2013October19HealthcarePREVALENCE AND ANTIMICROBIAL SUSCEPTIBILITY PATTERN OF EXTENDED SPECTRUM BETA LACTAMASE PRODUCING KLEBSIELLA PNEUMONIAE ISOLATED FROM RESPIRATORY SAMPLES IN A SOUTH INDIAN TERTIARY CARE HOSPITAL
English8187Ranjan Basu English Raghav RaoEnglish Arijit SarkarEnglish Bidyarani KongbrailatpamEnglishObjective: Klebsiella pneumoniae is important in causing a classic form of primary pneumonia and the leading causes of nosocomial infection, being hard to eradicate due to development of multidrug-resistant strains that produce extended–spectrum beta-lactamase (ESBL) enzyme. The present study was conducted to find out the prevalence and antimicrobial susceptibility pattern of respiratory isolates of ESBL producing Klebsiella pneumoniae at our hospital . Methods: Respiratory samples of RTI patients from different IPDs and OPDs sent for culture and sensitivity prior to starting of any antibiotics, during January 2012 to June 2013 were included in the study. Klebsiella pneumoniae was identified by standard laboratory procedure as per CLSI guideline. Antimicrobial susceptibility testing was done by Kirby-Bauer’s disk diffusion method in Mueller Hinton Agar media. ESBL producing strains were confirmed by Double Disk Synergy test after initial screening with 3rd generation cephalosporins. Results: Out of 400 respiratory samples ,140 Klebsiella pneumoniae were isolated among which 38 ( 27.14 % ) were ESBL producers and 102 ( 72.86 % ) were non ESBL strains . A 131 ( 93.57% ) isolates were obtained from IPDs. and 9 ( 6.43 %) were from OPDs .Male to female ratio for ESBL producing K. pneumonia was 1.7 : 1. TBCD dept. and ICCU were the major contributors of those positive isolates. A 64% multi drug resistance were observed among ESBL isolates. Apart from 3rd generation cephalosporins, they were also highly resistant to common antibiotics like Ampicillin, Aztreonam, Gentamycin, Erythromycin and Co-trimoxazole. Imipenem was the most active antibiotics with 96.37% susceptibility rates. Conclusions: Regular monitoring on the judicious use of antibiotics helps in preserving the effectiveness and emergence of further resistance of the sensitive antibiotics among the ESBL producing K. pneumonia.
EnglishKlebsiella pneumoniae, susceptibility, ESBL producers , antimicrobial resistanceINTRODUCTION
Klebsiella pneumoniae is a Gram-negative, non-motile, encapsulated, lactose fermenting, facultative anaerobic, rod shaped bacterium found in the normal flora of the mouth, skin and intestines. In the recent years, klebsiella pneumoniae has become important pathogen in nosocomial infections. Klebsiella pneumoniae being the primary cause of respiratory tract infections, is most frequently recovered from clinical specimens and can cause a classic form of primary pneumonia. Klebsiella pneumoniae can also cause a variety of extrapulmonary infections, including enteritis and meningitis in infants, urinary tract infections in children and adults and septicaemia1. They are ubiquitously present and
reported worldwide. These bacteria have become important pathogens in nosocomial infections 2 which have been well documented in United States and India3. Epidemic and endemic nosocomial infections caused by Klebsiella species are leading causes of morbidity and mortality4. In the United States, Klebsiella accounts for 3-7% of all nosocomial bacterial infections, placing them among the eight most important infectious pathogens in hospitals. Klebsiellae have a tendency to harbour antibiotic resistant plasmids; thus, infections with multiple antibiotic-resistant strains can be anticipated.1
Multidrug resistant bacteria cause serious nosocomial and community acquired infections that are hard to eradicate by using available antibiotics. Moreover, extensive use of broad-spectrum antibiotics in hospitalized patients has led to both increased carriage of Klebsiella pneumoniae and the development of multidrug-resistant strains that produce extended–spectrum beta-lactamase (ESBL). The first ESBL producing strain discovered in Germany was Klebsiella pneumoniae in 1980s. Outbreaks of ESBL-producing Klebsiella pneumoniae infections have increased worldwide 5. Recently, World Health Organization also warned the community that multidrug resistant bacteria are emerging worldwide which is a big challenge to healthcare. If we don’t take immediate action then antibiotics may lose their power to cure diseases caused by this bacteria6.
Area-wise studies on antimicrobial susceptibility profiles are essential to guide policy on the appropriate use of antibiotics. The present study was conducted to find out the prevalence of ESBL producing Klebsiella pneumoniae in respiratory samples of patients with respiratory tract infections along with their antimicrobial susceptibility pattern at our hospital. The information would be useful in establishing empiric therapy guidelines to prevent the emergence of further resistance and to contribute data to larger more extensive surveillance programs.
MATERIALS AND METHODS
The present study was conducted in the department of Microbiology, GSL Medical College and General Hospital, Rajahmundry, Andhra Pradesh, India. Patients having symptoms of respiratory tract infections diagnosed provisionally in different IPDs and OPDs whose respiratory samples (sputum / throat swab / bronchial washings) were sent for culture and sensitivity prior to starting of any antibiotics, during the period from January 2012 to June 2013 were included in the study . Informed consent was taken from the patient and ethical clearance was obtained from the institute.
400 respiratory samples received during that period were inoculated in MacConkey’s agar, Blood agar and Nutrient agar media and routine standard operative procedures are followed in the laboratory in isolating and identifying the organisms from the sputum samples. Klebsiella pneumoniae was identified by typical mucoid, lactose fermenting colony, Gram stain morphology, motility test, oxidase test, urease production test, IMViC reaction, fermentation of sugars like glucose, lactose, sucrose, mannitol with production of acid and gas.
Antimicrobial susceptibility testing was done by Kirby-Bauer disk diffusion method in Mueller Hinton agar media and results are interpreted according to the Clinical and Laboratory Standards Institute (CLSI) guidelines 7. Standard antibiotics like ampicillin (10 mcg), amoxyclav (20/10 mcg), piperacillin/tazobactum (100 /10 mcg), ceftriaxone (30 mcg), cefotaxime (30 mcg), ceftazidime (30 mcg), cefepime (30 mcg), imipenem (10 mcg), aztreonam (30 mcg), ciprofloxacin (5 mcg) , levofloxacin (5 mcg) , co-trimoxazole (1.25/23.75 mcg) gentamycin (10 mcg), amikacin (30 mcg) and erythromycin (15 mcg)8 were tested (HIMEDIA, MUMBAI, INDIA)
Detection of ESBL
All Klebsiella pneumoniae isolates showing resistance to 3rd generation cephalosporins like cefotaxime, ceftazidime and ceftriaxone were screened initially for probable ESBL producing strains which were followed by the phenotypic confirmatory test for confirmation of ESBL producing isolates. The double-disk synergy test was used to confirm ESBL strains. In brief, ceftazidime (30 mcg), cefotaxime (30 μg) and ceftriaxone (30 μg) were placed at a distances of 30 mm from center to center and around a disk containing amoxicillin (20 μg) plus clavulanic acid (10 μg). The results were interpreted as positive when the difference in zones of inhibition of isolates was > 5 mm in combination with clavulanic acid than to ceftazidime, cefotaxime or ceftriaxone alone. Enhancement of the inhibition zone toward the amoxicillin-plus-clavulanic acid disk is suggestive of ESBL production. 9,10,7
The data obtained in this study was summarized by counts and percentages. Antibiotic Susceptibility rates were presented with the respective 95% confidence interval values.
RESULTS
Out of a total 400 respiratory samples (sputum and broncho-alveolar lavage) received in our central laboratory during the period from January 2012 – June 2013, 140 (35%) Klebsiella pneumoniae were isolated. Among the 140 K. Pneumoniae isolates, 38 ( 27.14 % ) were ESBL producing strains as confirmed by double disk synergy test and 102 ( 72.86 % ) were non ESBL strains; among them 107 (76.43%) were from male patient and 33 (23.57 %) were from females whereas 131 ( 93.57 % ) isolates were obtained from In Patient Dept. and 9 ( 6.43 %) were from OPDs; The distribution of ESBL and Non ESBL strains , sex wise and IPD / OPD wise are shown in Table – 1 . There was no significant age specificity noted in our study . Over all male to female ratio was 3.25 : 1 whereas the male to female ratio of ESBL producing isolates was 1.7 : 1 .
Most of the Klebsiella pneumoniae isolates from respiratory samples were received from the TBCD department ( 49 / 35.00 % ) followed by ICCU (36 / 25.71 % ) , General Medicine (27 / 19.28 % ) , Surgery (19 / 13.57 % ) and lowest from CTVS department ( 9 / 6.43 % ) ( Table – 2 ) .
The results of antimicrobial susceptibility of ESBL producing strains of Klebsiella pneumoniae to various antibiotics tested in this study are shown in Figure - 1 and Table – 3 . 95 % confidence interval data are also presented. Imipenem was the most active antibiotics with 96.37% susceptibility rates . The next best were Piperacillin plus Tazobactum Amoxyclav, Levofloxacin and Cefepime. Apart from the high resistance to all 3rd generation cephalosporins, they were also resistant to common antibiotics like Ampicillin , Aztreonam , Gentamycin , Erythromycin and Co-trimoxazole .
DISCUSSION
The present study reveals that the ESBL producing strains of K. pneumoniae is highly prevalent
(27.14 %) in respiratory isolates from mostly hospitalized patients / IPDs which once again proves them to be an important cause of infection in hospitalized patients . The admitted patients were the majority in contributing the ESBL producing K. pneumoniae as seen in 25.72 % IPD versus 1.42 % OPD patients among overall K. pneumoniae isolates from respiratory samples. The high rate of ESBLs among hospitalized patients is a global problem. It is generally thought that patients infected by an ESBL producing strains are at increased risk of treatment failure.
The prevalence of ESBL producers varies across continents and countries and also within hospitals11,12 . In India, the prevalence rate varies in different institutions from 28 to 84% 13. In our study the prevalence of ESBL producing K. pneumoniae in respiratory isolates was 27.14 %. Subha et al. in the study of various clinical isolates in Chennai from South India, found ESBL
production in 25.8 percent isolates 14. A study on ESBL producing K. pneumoniae in Kashmir by S. Ahmed et al showed a 16.7% prevalence of the same in samples from respiratory tract infection 15. Hadi Mehrgan et al showed that ESBL production was more often seen in K. pneumoniae isolated from respiratory specimens 16 .
The male to female ratio of ESBL producing isolates was 1.7 : 1 which was supported by a study at Gulbarga by Renuka R. et al revealing slightly higher prevalence in males than among females 17.
Other than the 3rd generation cephalosporins, the ESBL producing strains of Klebsiella pneumonia showed higher resistance with commonly used antibiotics like Gentamycin (60.53%), Co-trimoxazole (60.53%) , Aztreonam (57.89 %) , Ampicillin (57.89 %) and Erythromycin (55.26 %) . They were highly sensitive to Imipenem (97.36 %) followed by Piperacillin + Tazobactum (76.32 %) , Amoxyclav (73.68 %) , Levofloxacin (73.68 %) and Cefepime (65.78 %) . Among all ESBL producing K. pneumoniae , 64 % was multidrug resistance showing resistance to more than four drugs . All these observation are in tandem with various study by R. Rampure et al 18 , M. M. Faizabadi et al 19 , S. Ahmed et al 15 and A. Singh Sikarwar et al 20 .
The indiscriminate use of higher groups of antibiotics and plasmid mediated drug resistance are the probable contributors to the emergence of multi drug resistance strains of ESBL producing strains of Klebsiella pneumoniae. It has been discovered that the mutant gene for ESBL production also contributes for resistance to other drugs.
CONCLUSIONS
Incidence of respiratory tract infection caused by Klebsiella pneumoniae is increasing worldwide and is a common cause of primary pneumonia affecting all age group which is further complicated by rapidly emerging strains of multi drug resistant ESBL producing Klebsiella pneumoniae. The inadvertent and indiscriminate use of 3rd generation cephalosporins and other antibiotics has lead to the emergence of multi drug resistant ESBL producing Klebsiella pneumoniae. Regular monitoring on the judicious use of antibiotics helps in preserving the effectiveness of the sensitive antibiotics.
Our study aims to guide clinicians on starting empirical treatment and appropriate use of antibiotics which not only reduces the morbidity and mortality in the patients infected with ESBL producing Klebsiella pneumoniae but also controls the emergence of further resistance to the still sensitive drugs .
Englishhttp://ijcrr.com/abstract.php?article_id=1083http://ijcrr.com/article_html.php?did=1083
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241519EnglishN2013October19HealthcareTRAUMATIC RECTAL PERFORATION MANAGED BY SIMPLE CLOSURE WITHOUT COLOSTOMY
English8890A. SaravananEnglish G. GanesanEnglish K. Vivekananda Subramania NathanEnglishGenerally traumatic rectal perforations are managed by doing diverting colostomy along with simple closure. Here we are reporting a case of traumatic rectal perforation which is managed by doing simple closure alone without diverting colostomy. About 95% of rectal injuries are due to penetrating injuries. Rectal injuries due to blunt trauma are rare but have more disastrous outcome .Extraperitoneal perforations of the lower part of the rectum are usually due to blunt injury and access to the area of perforation and closure is extremely tough. Hence extraperitoneal perforation has a bad prognosis and always requires diverting colostomy. Large intraperitoneal perforations of the upper part of the rectum involving the anterior wall are commonly associated with concomitant injuries and always require diverting colostomy. Patients presenting late are usually associated with severe peritoneal contamination and have bad prognosis and always require diverting colostomy. But small intraperitoneal perforations of the posterior wall of the upper part of the rectum are not commonly associated with concomitant injuries like in the patient reported below and do not require diverting colostomy, if the patient presents early without serious peritoneal contamination.
EnglishRectal perforations, simple closure, diverting colostomy.INTRODUCTION
Rectal perforation is generally managed by doing diverting colostomy along with closure of perforation [1-9]. But so far there have been very few reports of managing rectal perforation by doing only simple closure without colostomy. Hence a case of rectal perforation managed by doing only simple closure without colostomy is reported here.
CASE REPORT
A thirteen year old boy had an accidental penetrating injury to his rectum by a wooden stick and presented within 18 hours of his injury with signs of generalized peritonitis, X-ray chest showed pneumoperitoneum (Fig-1).
Laparotomy was done immediately and 250ml of pus was found in the peritoneal cavity. A single small 1x1cm intraperitoneal perforation was found in the posterior wall of upper part of rectum (Fig-2) and was closed with single layer of interrupted 3.0 silk. The patient recovered uneventfully.
DISCUSSION
Perforation of the lower part of the rectum (extraperitoneal perforation) is extremely difficult to access by laparotomy and hence closure is extremely tough. But perforation in this patient was intraperitoneal lying at the upper most part of rectum and closure could be done easily. In addition, our patient presented within 18 hours of injury and there was no faecal contamination of peritoneal cavity. Hence a diverting colostomy was not done.
Patients with rectal perforation presenting early have good prognosis. But patients presenting late
are usually associated with very severe and serious peritoneal contamination and have bad prognosis [9] and always require diverting colostomy.
About 95% of rectal injuries are due to penetrating injuries [5]. Rectal injuries due to blunt trauma are rare [5, 8] but have more disastrous outcome [5]. Extraperitoneal perforations occurring in the lower part of the rectum are usually due to blunt injury [5, 8, 10], commonly associated with fracture of pelvic bones [5, 8, 10] and sepsis of perirectal tissues [5, 10] and pelvic abscess [10]. Access to the area of perforation and closure is extremely tough while doing laparotomy. Hence extraperitoneal perforation has a bad prognosis and always requires diverting colostomy [5].
Large intraperitoneal perforations of anterior wall of the upper part of the rectum are commonly associated with concomitant injuries to urinary bladder [ 2], seminal vesicles[3], uterus,small bowel mesentery [ 11], sigmoid mesocolon [3,11] etc. and sometimes even evisceration of the small bowel [4,12] and always require diverting colostomy.
CONCLUSION
Small intraperitoneal perforations of the posterior wall of the upper part of the rectum are not commonly associated with concomitant injuries like in this patient and do not require diverting colostomy, if the patient presents early without serious peritoneal contamination.
But all extraperitoneal perforations, large intraperitoneal perforations of the anterior wall associated with concomitant injuries and patients presenting late with very serious peritoneal contamination always require diverting colostomy along with closure of the perforation.
Englishhttp://ijcrr.com/abstract.php?article_id=1084http://ijcrr.com/article_html.php?did=1084
Emil Mammadov, Altan Alim, Mehmet Elicevik and Sinan Celayir., Self-induced penetrating rectal perforation by foreign body: an unusual event in childhood., Annals of Pediatric Surgery 2011, 7:25–26.
Mahmoud Aghaei Afshar, Foroogh Mangeli and Akram Nakheai., A Rare Case of Anorectal Injury with Ruptured Bladder and Rectum but Normal Anal Sphincter.,J Clin Case Rep 2012, 2:14.
Major D S Jackson., Accidental Impalement Injuries of the Intraperitoneal Rectum caused by the Barrel of the Self Loading Rifle., J R Army Med Corps 1985; 131: 164-166.
Neil R Price, S V Soundappan, Anthony L Sparnon and Danny T Cass., Swimming pool filter-induced transrectal evisceration in children: Australian experience., MJA?.Volume 192 Number 9. 3 May 2010; 534-536.
Isaac Chun-Jen Chen, Hsin-Chin Shih, Yi-Szu Wen., Extraperitoneal Rectal Perforation without Perineal Wound or Pelvic Fracture., J Chin Med Assoc 2004;67:637-639.
Ayeed Al-Qahtani ; Abdulkarim El-Wassabi ; Abdulrahman Al-Bassam .., Mercury-In-Glass Thermometer As A Cause Of Neonatal Rectal Perforations: A Report Of Three Cases And Review Of The Literature…, Annals of Saudi Medicine, Vol 21, Nos 1-2, 2001
Charles G. Roland, Arnold G. Rogers.., Rectal Perforations After Enema Administration, canad.M.A.J.nov.15,1959, vol.81.
Rachel M. Gomes, Jayesh Kudchadkar,Edwin Araujo, Trupti Gundawar,Anorectal avulsion: report of a rare case of rectal injury, Annals of Gastroenterology (2013) 26, 1
Aditya Yelikar ,Tejinder Singh Chhabda , Pravin Suryawanshi …,Laparoscopic Management of Rectal Perforation Secondary To Self Induced Foreign Body – A Rare Case Report …,IJSR - International Journal Of Scientific Research Volume :2 Issue :1 Jan 2013 .ISSN No 2277 – 8179.
J F Nolan., Delayed presentation of rectal perforation. , Journal of the Royal Society of Medicine Volume 83 November 1990; 744-745.
Karger B, Teige K, Bajanowski T. Bizarre impalement fatalities—where is the implement? J Forensic Sci 2002;47(2):389–391.
Naima Zamir, Ahmed Sharif, M.Aqil Soomro, Soofia Ahmed And Jamshed Akhtar, Rectal Perforation in Children, Journal of The College of Physicians and Surgeons Pakistan 2008, Vol. 18 (1): 66-67.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241519EnglishN2013October19HealthcareFERTILITY DESIRES AND CONTRACEPTION PRACTICES AMONG HIV POSITIVE WOMEN ATTENDING ANTIRETROVIRAL THERAPY CENTRE(A.R.T) OF A TERTIARY CARE HOSPITAL IN DAVANGERE
English9196Sarvamangala K.English ArshiyaEnglishBackground: Pregnancy among HIV positive women is an issue of public health importance because of poor maternal outcomes and paediatric HIV infections. The recent advances in Anti-Retroviral therapy and the focus on Prevention of Parent to Child Transmission (PPTCT) have radically changed HIV Positive Women's Fertility options. People with HIV infection may wish to plan pregnancy, limit their family, or avoid pregnancy. They may have a different outlook on future family planning but however, there is limited understanding of their reproductive needs. Objectives: 1. To determine the proportion of HIV positive women on ART using modern methods of contraception. 2. To assess the fertility desires and contraceptive choices and factors influencing these choices. Methods : ? Study Design: Cross-Sectional, descriptive study. ? Study Population: HIV positive women on antiretroviral therapy. ? Study Area: ART centre at CG Hospital Davangere. ? Study Period: 2 months (October 1st to 30th November 2012 ) ? Sample size: 150 HIV positive women. Statistical analysis: Percentage and chi-square Results: Use of any modern method of contraception was 52%. 48% of HIV positive women expressed a desire for a child in the future. Age, education status, parity and awareness about risk of transmission to baby had significant association with fertility desire (pEnglishfertility, contraception, HIV positive women.INTRODUCTION
The recent advances in Anti-Retroviral therapy and the focus on Prevention of Parent to Child Transmission (PPTCT) have radically changed HIV Positive Women's Fertility options1. HIV/AIDS may have either impact on their fertility desires as the fear of ill health may make them to consider stopping child bearing while family or community obligations make them to have desire for bear children. Hence fertility issues for them are becoming increasingly important. People with HIV infection may wish to plan pregnancy, limit their family, or avoid pregnancy2.
The desire of HIV-infected persons to have children in the future has significant implications for the transmission of HIV to sexual partners and newborns3. The risk of HIV transmission among individual couples is likely to increase as more infected individuals choose to have children with their HIV-negative partners. Despite the growing importance of fertility issues for HIV-infected men and women, little is known about their actual fertility desires and intentions.
They may have a different outlook on future family planning but however, there is limited understanding of their reproductive needs4.Therefore, the present paper tries to reflect the effect of HIV on fertility desire for children. Further, an attempt has also been made to give empirical evidences of desire for children and contraceptive use among HIV positive women.
Objectives:
1. To determine the proportion of HIV positive women on ART using modern methods of contraception.
2. To assess the fertility desires and contraceptive choices and factors influencing these choices.
METHODOLOGY
This is a facility based Cross-Sectional, descriptive study. The study population comprised HIV positive women on antiretroviral therapy who attended ART centre at Chigateri General Hospital, Davangere. The study was carried for over 6 months from June 1st to 30th November 2012.Sample size comprised 150 HIV positive women.
Data Collection:
Respondents were interviewed using pre-tested, semi-structured questionnaire about their fertility desires and contraception use while information about HIV/AIDS diagnosis, Anti-Retroviral therapy, CD4 counts and other details were collected from their records.
Statistical analysis was done using Proportions, Chi square test. HIV positive women aged between 15-45 years, sexually active, Non Pregnant and registered on ART at time of data collection and those consenting to participate in the study were included.
RESULTS
The mean age of study participants was 29 years with a standard deviation of 5.6 years. The highest and lowest ages were 42 and 19 years respectively (age range is 19-42 years). Majority (72%) were married followed by 12% who were divorced. About 9% were widow and 7% were single (not ever married but having or staying with a partner). Majority (60%) had no education or primary education while 30% had secondary education and only 10% had tertiary education (college or graduation). 60% were working while 40% were not working due to ill health.
Out of 150 study participants, 83% (n=124) have ever borne children. 53% (n= 79) had given birth before diagnosis of HIV while 30% (n= 45) had given birth after diagnosis of HIV. About 14 % (n=21) reported of having either spontaneous or induced abortions after diagnosis of HIV. 72% (n=142) of these women had either spouse or partner also HIV positive. Overall 48% (n=73) desired for more children while 52% (n=77) had no desire.
The current contraception use of all modern methods was around 52% (n=78).Relative’s pressure 17% to have a complete family was the most common reason given by most women who desired more children. 10 % reported they have single child so wanted to have at least one more child. About 9% had only daughter(s) so they want to have a son while 5% did not have any issues so they desired to have at least one child. Risk of transmitting HIV to the baby 32% emerged as the most common reason for not desiring to have more children.10% did not desire because of health concerns like already ill and won’t be able to take care of children. Another concern was baby born will also be not healthy so it will be extra burden on them. 8% were single parent while 2% reported financial constraints for not desiring more children.28% reported fear of side effect for not using contraceptives while 12% did not wanted to take too many drugs.6% reported that spouse were not willing/ allowing them to use. 2% reported they were ill or abstaining.
Table 3, shows that age, education status, parity and awareness about risk of transmission to baby had significant association with fertility desire (p< 0.05).While a positive trend was observed between HIV/AIDS stage, duration of ART, CD4 counts and Spouse status. DISCUSSION
In this study it was found that 48% of HIV positive women expressed a desire for a child in the future. Women, who desired a child were younger, married, in a sexually active relationship with no children, and had partners who desired a child. These proportions are similar to those found in others studies (Panozzo et al5., 2003, Loutfy et al6., 2009, Cooper et al7., 2009). Age is also a predictor for fertility desires. As the HIV epidemic has spread in developing countries, the highest rate of infection has occurred in women aged 15 to 29 [8,9] and coincides with the beginning and peak of their reproductive lives
This study showed that the number of children is associated with the desire for a child. Similar findings were found in many studies.10,11,12 Although there was a strong but not significant association in this study, preference for a male child was a common reason for wanting a child similar to studies in Asia regions.13,14
Higher education status of the couple and especially HIV positive women and awareness of the risk of transmission was very strongly associated with negative fertility desire. Our findings confirm those of other individual level studies: that awareness of HIV positive status leads desire to stop child bearing among married men and women (Nduna and Farlane15, Nattabi et. al.16)
There was no significant association between medical factors and fertility desires, except for use of contraception. Respondents who used contraception tended to be more likely to desire a child, although a similar study by Loutfy et al6 found no such association. In the present study, women who used contraception were more likely to desire a child than those who did not. The use of contraception did not necessarily indicate a desire not to have a child. Rather, the use of contraception was intended to control the timing of conception and birth. A partner’s/ spouses’ nonreactive state was found to be positively associated with desire for a child though it was not found to be significant. This is consistent with studies from Northeast Brazil.10,17
Women in stage 1 or 2 and higher CD4 count had desire for children as they were medically better while in stage 3 or 4 and lower CD4 count did not desire as they were generally ill. Women soon after initiation of ART were apprehensive about child bearing while after a year had positive desire as they may adjusted to the therapy. Women on longer duration of ART wanted to stop child bearing because of adverse effects of ART. Similar study conducted in the United States concluded that overall, 28-29 percent of HIV-infected men and women receiving medical care desire children in the future. These expressed differences in fertility desires could assist reproductive health services planners in designing programmes that address couples’ aspirations and needs.
Use of any modern method of contraception was 52% which was similar to the study in Malawi18. Condom use, especially among HIV positive couples, was lower than that reported in other studies (Panozzo et al5). However, more than one fifth of sexually active HIV infected couples were still not using any contraceptive method at the time of interview despite counselling. This finding is similar to the study conducted by Vimercati (1999).
CONCLUSION
The relationship between HIV and fertility desires is very complex and still it is not well understood. As far as desire for children is concerned, most of the study population wanted to have children but their HIV status limit them from resuming parenthood. Despite knowing their status a considerable proportion desired to have at least one child in future.
The fact that many HIV infected adults desire and aspirations to have children has waved way for interventions to prevent vertical and heterosexual transmission of HIV. Peer counselors, health care workers play a crucial role in decision-making about child bearing and childrearing by counseling on safe sex practices, use of contraception and the desire for child needs to be addressed timely and appropriately to the HIV infected clients. integration of reproductive health and family planning services into the programs should be made mandatory. Behavioral change researches regarding sexual behavior and contraceptive use involving HIV positive women and their spouses also need to be conducted.
Englishhttp://ijcrr.com/abstract.php?article_id=1085http://ijcrr.com/article_html.php?did=1085
Kalyanwala S, S Iyenger and S Janardhan. Factors influencing the fertility intentions of people living with HIV/AIDS in Karnataka. New Delhi: Population Council
Elizabeth K. Harrington, Sara J. Newmann, Maricianah Onono,Katie D. Schwartz et al. Fertility Intentions and Interest in Integrated Family Planning Services among Women Living with HIV in Nyanza Province, Kenya: A Qualitative Study.Infectious Diseases in Obstetrics and Gynecology.2012,22;8
Factors Influencing Reproductive Choices of HIV Infected Women in India
UNAIDS. Report on Global AIDS Epidemic. Geneva: UNAIDS; 2008
Panozzo L, Battegay M, Friedl A and Vernazza P. L. 2003. High risk behaviour and fertility desires among heterosexual HIV-positive patients with a serodiscordant partner--two challenging issues. Swiss Med Wkly, 2003, 133; 124-7.
M. R. Loutfy, T. A. Hart, S. S. Mohammed, et al., “Fer-tility Desires and Intentions of HIV Positive Women of Reproductive Age in Ontarrio, Canada: A Cross-Sectional Study,” PLos One, Vol. 4, No. 12, 2009, pp. 1-10. doi:10.1371/journal.pone.0007925
Cooper D, Moodley J, Zweigenthal V, Bekker L, Shah I and Myer L. 2009. Fertility intentions and reproductive health care needs of people living with HIV in Cape Town, South Africa: implications for integrating reproductive health and HIV care services. AIDS Behav.2009, 13 (1); 38-46.
UNAIDS, “PNG UNGASS Country Report,” 2010.http://data.unaids.org/pub/Report/2008/papua_new_guinea_2008_country_progress _report_en.pdf
National AIDS Council Secretariat and National Depart-ment of Health (NACS and NDOH), “The 2007 Estima-tion Report on the HIV Epidemic in Papua New Guinea,” Port Moresby, 2007.
A. Nobrega, A. F. Oliveira, T. M. Galvoa, et al., “De-sire for a Child among Women Living with HIV/AIDS in Northeast Brazil,” AIDS Patient Care and STDs, Vol. 21, No. 4, 2007, pp. 261-267. doi:10.1089/apc.2006.0116
L. Myer, C. Morroni and K. Rebe, “Prevalence and De-terminants of Fertility Intentions of HIV-Infected Women and Men Receiving Antiretroviral Therapy in South Af-rica,” AIDS Patient Care and STDs, Vol. 21, No. 4, 2007, pp. 278-285. doi:10.1089/apc.2006.0108
L. J. Chen, K. A. Phillips, D. E. Kanouse, et al., “Fertility and Intentions of HIV-Positive Men and Women,” Fam-ily Planning Perspectives, Vol. 33, No. 4, 2001, pp. 144- 152.
N. Ko and M. Muecke, “Reproductive Decision-Making Among HIV Positive Couples in Taiwan,” Journal of Nursing Scholarship, Vol. 37, No. 1, 2005, pp. 41-47. doi:10.1111/j.1547-5069.2005.00008.x
P. Oosterhoff, N. Anh Thu, N. Hnah Thuy, et al., “Hold-ing the Line: Family Responses to Pregnancy and the De-sire for a Child in the Context of HIV in Vietnam,” Cul-ture, Health and Sexuality, Vol. 10, No. 4, 2008, pp. 403-416. doi:10.1080/13691050801915192
NDUNA, M. and FARLANE, L. 2009. Women living with HIV in South Africa and their concerns about fertility. AIDS Behav, 13 Suppl 1, 62-5.
Nattabi, B., Li, J., Thompson, S. C., Orach, C. G. and Earnest, J. 2009. A systematic review of factors influencing fertility desires and intentions among people living with HIV/AIDS: implications for policy and service delivery. AIDS Behav, 13, 949-68.
R. A. da Silverira, G. A. Fonsechi-Carvasan, M. Y. Ma-kuch, et al., “Factors Associated with Reproductive Op-tions in HIV-Infected Women,” Contraception, Vol. 71, No. 1, 2004, pp. 45-50.
National Statistical Office (NSO)[MALAWI], A. O. M. 2010. Malawi Demographic and Health Survey 2010. Calverton, Maryland: NSO and ORC Macro.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241519EnglishN2013October19HealthcareSUPERNUMERARY RENAL ARTERIES
English97102Flossie JayakaranEnglish Sayee RajangamEnglishRenal arteries show a range of variations in origin and distribution to the kidney, with variable distributions and caliber of the vessels on each side. As these have serious implications in transplant surgery and renal imaging, it is imperative to examine the variations possible and also to have a common nomenclature for the variations seen. Standard textbooks note that variations are seen in about 30% of the population with a range of 9-76%1 and hence it was deemed necessary to add to the existing knowledge of variations in the patterns of the renal artery. 3 kidneys with variable arterial supplies have been described and the variations have been discussed here. A review of literature also showed that the nomenclature of the arteries varied from one study to another. An attempt has been made here to rationalize the terminology for ease of discussion and comparison.
EnglishSupernumerary arteries, polar arteries, renal segmental arteries, lateral splanchnic arteriesINTRODUCTION
Variations in renal vessels are expected, especially as the incidence of variation has been reported as 9-76%1. Variations are gaining greater importance due to MR angiography and transplantation of kidneys from live donors. Standard textbooks comment that while 70% of kidneys show a single artery, 30% of kidneys show supernumerary vessels2. This assumes importance for interpretation of radiological material, transplantation and in preventing erroneous interpretation of pyelogram among other serious consequences. Perusal of literature on the topic showed that a number of workers have reported variations of arterial patterns as well as variations in nomenclature of these arteries, using terms such as additional /anomalous /accessory /abnormal /aberrant arteries. The presence of kidneys with variable blood vessels, among the anatomy prosection specimens in the Department, triggered a review of literature and a study to investigate possible patterns of renal vessels.
MATERIAL AND METHODS
3 isolated kidneys, 1 right and 2 left kidney, which were used for student prosection showed renal vessels that could be termed ‘anomalous/aberrant/accessory’.
The 3 kidneys that made up this material were a pair of kidneys (1a and 1b) with an intact segment of the abdominal aorta and a segment of the inferior vena cava (Fig 1 and 2). The next specimen was an isolated left kidney with its vessels intact but not connected to an aorta or inferior vena cava (Fig 2). The specimens were photographed after clearing the connective tissue around the hilum and investigating the extra-hilar course of the arteries that supplied each kidney. The kidneys and the arteries entering it were not subjected to any further dissection.
RESULTS
Kidney 1a (Fig.1) was supplied mainly by the right renal artery which divided 2.5 cm from the aorta into 4 segmental branches before reaching the hilum of the right kidney (Fig.1: 1-4). 3 of these branches were anterior branches, (Fig.1: 1-3), and entered the hilum anterior to the pelvis of the ureter. One (Fig.1: 4) traveled behind the pelvis of the ureter to enter the hilum. An additional artery (Fig. 1: 5) arose from the aorta 2 cm above the right renal artery and entered the kidney at the upper end of the hilum, posterior to the upper part of the pelvis of the ureter.
Kidney 1b (Fig.2) was supplied by the left renal artery, which branched outside the hilum into 2 branches. Each of the 2 branches divided again into 2 arteries, but at varying distances from the hilum. All 4 branches entered the hilum behind the right renal vein and in front of the pelvis of the ureter. (Fig. 2: 3-6). 3 additional arteries branched from the aorta to supply the left kidney: two above and one below the left renal artery. The highest one (Fig. 2: 1) pierced the medial border of the kidney 0.5 cm above the hilum. The second one (Fig 2: 2) entered the upper part of the hilum behind the renal pelvis. The third additional artery (fig 2: 7) entered the kidney at the lower part of the hilum behind the renal pelvis. Altogether 7 arterial branches were noted.
Kidney 2 was an isolated left specimen. A single left renal artery divided before the hilum into 2 branches. The upper branch of the renal artery (Fig. 3: 1) after giving off a branch (presumably to the left suprarenal gland) pierced the anterior surface of the kidney below the upper pole. The lower branch (Fig.3:2) divided into 3 arteries (Fig 3: 2a, 2b, 2c), 2 of which, (2a and 2b), entered the hilum at the middle and lower end of the hilum respectively, while the last branch, (2c), given off posteriorly, entered the middle of the hilum behind the pelvis of the ureter.
DISCUSSION
Standard text books of Anatomy describe a pair of renal arteries that arise from the abdominal aorta at the level of the vertebral disc between L1 and L2. Each artery divides into 5 segmental arteries (superior, antero-superior, antero-inferior, inferior and posterior) that supply the 5 segments of the kidney3. The right artery is longer, often higher and runs behind the Inferior Vena cava (IVC) and behind the right renal vein. The left renal artery is slightly lower, behind the corresponding vein and crossed by the Inferior Mesenteric Vein. In 70% of cases, one artery branches to supply each kidney2. These arteries show variability of caliber, in the degree of obliquity and the precise relations.
The kidneys in this report had normal renal arteries as described in standard text books. They also had additional arteries arising from the aorta, above and below the renal artery (Kidney 1A and B). Kidney 1a had 4 arteries from the renal artery which entered the hilum to possibly supply 4 vascular renal segments, with the supernumerary artery (5) directly from the aorta (Fig.1: 1a:5) supplying the 5th vascular segment. Since no dissection was done this could be an informed comment on its area of supply. 5 vascular renal segments have been described in textbooks for each kidney2.
Kidney 1b had 7 branches supplying the left kidney of which one pierced the surface outside the hilum of the left kidney and could be called a polar artery2 (Fig 2: 1). The 6 vessels that entered the left hilum included the 4 branches of the left renal artery proper (Fig 2: 3-6) and 2 accessory vessels2 from the aorta (2 and 7) that may be supplying the posterior vascular segment. These (1, 2 and 7) would be the persistent lateral splanchnic arteries that supply the kidney as it ascends out of the pelvis during development2, though Hlaing et al8 reported this phenomenon as pertaining to arteries that supply the lower pole only.
Kidney 2 had a normal left renal artery from the aorta. However, the segmental branch to the upper pole was not through the hilum as is normally seen, but piercing the anterior surface of the upper pole and could be called Upper polar artery1 or Superior renal polar artery2. Polar arteries have been described as arising from anomalous/accessory arteries 6 or from the renal artery proper2. In this study, the artery supplying the upper pole in Kidney 2 arose from the normal left renal artery. 3 segmental branches of the left renal artery were seen entering the hilum instead of the expected 4 arteries. The possibility remains that further branching of the artery may occur within the kidney parenchyma.
Supernumerary arteries are relatively common (an incidence of 30%2), and had raised concerns that their narrow calibers may contribute to renal ischemia and increase the risk of hypertension – an event which has since been reported to show no statistical significance5. These arteries represent persistent embryonic lateral splanchnic arteries which grow in sequence from the aorta to supply the kidney as it ascends from the pelvis4. These arteries may arise from the aorta, coeliac trunk, superior mesenteric artery, inferior mesenteric artery and the aorta near its bifurcation2. Often called accessory renal arteries, the supernumerary arteries to the lower pole may be clinically important as they may obstruct the pelvi-ureteric junction resulting in hydronephrosis.
Supernumerary arteries are reported to be present in 30% of kidneys2, though other reports mention 40%6, 24%5, 20%7 and 4%8. It is reported to be more commonly seen on the left side1 where they enter the lower pole7. In kidney 2 of this report, there are 3 additional arteries to the left kidney, one of which pierces the anterior surface and 2 which enter through the hilum.
Variations in the renal arteries have serious consequences for surgeons and radiologists as has been elaborated in several reports1, 5-8. Consistency of nomenclature therefore is required in the description of variations. It is suggested that the following nomenclature for supernumerary arteries may be used to reduce confusion.
i) Hilar arteries enter the kidney at the hilum irrespective of their origin.
ii) Extrahilar do not enter the kidney through the hilum and irrespective of their origin, may be called (a)‘perforating’ if it perforates any surface of the kidney, or (b) ‘polar’, if it supplies the upper and/or lower poles7. Kidneys 1b and 2 may therefore be said to have a perforating polar artery each to the upper poles of the respective kidneys. Saritha et al called the extrahilar arteries as ‘accessory’ vessels, distinguishing polar accessory vessels from hilar accessory vessels.
Terms such as aberrant, abnormal and anomalous do not convey precise information and may therefore be unsuitable in a scientific context, as each artery, whether it arises from the aorta or other vessels, does supply a specific segment of the kidney. All segmental arteries are end arteries supplying a resectable unit/renal segment and do not show significant anastomosis with other vessels. They are therefore not aberrant, abnormal or anomalous1.
CONCLUSION
The present study has reported the presence of additional branches to the kidneys from the abdominal aorta and the renal artery. These variations in the organization of neurovascular structures at the renal hilum will provide valuable information to surgeons and radiologists before procedures are undertaken. A scheme for nomenclature of supernumerary vessels has also been suggested in this report.
Englishhttp://ijcrr.com/abstract.php?article_id=1086http://ijcrr.com/article_html.php?did=1086
Talovic E, Kulenovic A, Voljevica A, Kapur E. Review of Supernumerary Renal Arteries by Dissection Method. Acta Medica Academica 2007; 36: 59-69
Standring S, (ed) Gray’s Anatomy 40th ed. 2008. Churchill Livingstone Elsevier, UK
Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. 6th ed. 2010 Lippincott Williams and Wilkins, India
Snell R S. Clinical Anatomy by Regions. 8th ed. 2008 Lippincott Williams and Wilkins, USA.
Gupta A, Tello R. Accessory Renal Arteries Are Not Related to Hypertension Risk: A Review of MR Angiography Data. Am J of Roentgenology 2004; 182: 1521-1524
Madhyastha S, Suresh R, Rao R. Multiple Variations of Renal Vessels. Indian J of Urology: Case Report 2001; 17 (2):164-65
Saritha S, Jyothi N, Praveen Kumar M, Supriya G. Cadaveric Study of Accessory Renal Arteries and its Surgical Correlation. Int J Res Med Sci 2013; 1 (1): 19-22
Hlaine KPP, Das S, Sulaiman IM, Latiff AA, Ghafar NA, Suhaimi FH, Othman F. Accessory Renal Vessels at the Upper and Lower Pole of the Kidney: A Cadaveric Study with Clinical Implications. Bratisl Lek Listy 2010; 111(5): 308-10
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241519EnglishN2013October19HealthcareAN INTERVENTIONAL TRIAL TO EVALUATE EFFICACY OF NUTOOL THERAPY IN CONTROL OF PRIMARY INSOMNIA AMONG ELDERLY USING INSOMNIA SEVERITY INDEX
English103109Muhib J.English Arish M. K. ShervaniEnglish Najeeb J.English Kouser F. F.English A. Nasir AnsariEnglish Muneeb J.EnglishBackground and objectives: Insomnia is a unique and complex problem in geriatric population. As many as half of the elderly population between 60 to 79 years of age complain of disturbed sleep, which includes increased sleep latency, decreased quality of sleep, awaking symptoms, excessive daytime sleepiness, mental stress / depression which may result in disturbed intellect, impaired cognition, confusion, psychomotor retardation the whole syndrome of complaints can compromise patient’s quality of life and create social and economic burden for caregiver. Considering the wide spread prevalence of insomnia in geriatrics, compounded with lack of wholesome drugs in the treatment, an interventional study was carried out with the objectives to evaluate the efficacy and safety of Nutool therapy in control of geriatric insomnia. Methods: A total of 30 elderly primary insomniacs, diagnosed for primary insomnia by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, were randomly assigned to test and control groups, comprising 15 patients in each group, respectively. In the test group, Nutool was performed with Roghan e Banafsha (500ml) and Roghan e Gul (500ml), both mixed in equal ratio while Nutool was done with liquid paraffin in control group. The therapy was scheduled on alternate days for one month. The change in the severity of insomnia was evaluated on the basis of scores of Insomnia severity index. Statistical analysis was done using student t-test (paired) for comparison in intra group and t-test (unpaired) for inter-group comparison. Results: Nutool therapy showed statistically significant improvement in all the parameters of Insomnia Severity Index, when pre and post interventional values of the parameters were assessed in intra as well as inter group comparisons. Interpretation and conclusion: This intervention proves the efficacy and safety of Nutool therapy in control of insomnia among elderly.
EnglishInsomnia, geriatrics, Nutool therapy, Insomnia severity index.INTRODUCTION
Insomnia is a common complaint throughout the world, and is characterized by difficulty in initiating or maintaining sleep or non-restorative sleep, associated with significant morbidity1. Insomnia in the geriatric patients is commonest among sleep complaints reported by population more than 60 years of age. It is consistently associated with significant reduction in the quality of life, higher risk of depression, and increased use
of health care services3. An epidemiological study reports that individuals with insomnia have a 4.5 folds higher probability of presenting with depression compared with those with normal sleep pattern. In addition, primary insomniacs have an elevated risk of manifesting depression within 3.5 years after onset, even in absence of psychological disturbances4.
Primary insomnia is a specific disorder, defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) as a condition of at least 1 month’s duration, not caused by a medical or psychiatric disorder. In addition, a symptom of insomnia (disturbed sleep initiation or sleep maintenance, or early morning awaking) must present and be associated with complaints of daytime dysfunction.
Pharmacological treatment is the most practical approach to insomnia management; however, adverse events most commonly perceived by the insomniacs include alteration in cognitive function, memory and psychomotor activity, with negative effect on routine daily activities, the so-called hangover is a common manifestation. Moreover, rebound insomnia can occur after abrupt withdrawal of hypnotic therapy. National Institute of Health and Clinical Excellence recommends that doctor should consider using non-drug therapy before starting hypnotic drugs5, as side effects and risks associated with long-term use of the drugs are often major reasons for abetting the patients to discontinue their use despite their perception of continued efficacy4. With these limitations in pharmacotherapy there is a growing interest in non-pharmacological interventions for older adults6. Considering this unconvincing scenario regarding the use of drugs and their side effects, researchers are turning to the nature and the traditional pathies. Unani medicine axiomatically comes to the fore as Seher (Insomnia) has successfully been treated since ancient times without considerable obnoxious side effects on the body.
MATERIAL AND METHODS
The study was designed as Single blind, randomized, placebo-controlled, concurrent parallel group interventional trial, conducted at National Institute of Unani Medicine Hospital, Bangalore. Ethical clearance was obtained from the Institutional Ethical Committee, NIUM, Bangalore. The study spanned from March 2009 to February 2010. Thirty eligible cases of either sex, above 60 years of age, with primary insomnia and ISI higher than 7, were selected and randomly assigned to Group A (Control Group) and Group B (Test Group), each comprising 15 patients. Group A had been administered liquid paraffin, a placebo drug, under identical conditions as those for test group. Group B was treated with Roghan Banafshan and Roghan gul, mixed in equal quantity of 500 ml each. Efficacy of the drug was evaluated with a Score of Insomnia severity index. Nutool therapy was performed on every alternate day for one month divided in fifteen sittings. Pre and post treatment values of the parameter were assessed statistically.
Patients were advised to observe abstinence from all sorts of hypnotic drugs or measures one week prior to starting the therapy, and no concomitant treatment for insomnia was allowed during the treatment.
Patients were selected on the basis of DSM-IV-TR- Diagnostic criteria for primary insomnia which includes the predominant complaint of difficulty in initiating or maintaining sleep, or non restorative sleep, for at least one month and this sleep disturbance is associated with day time fatigue and may cause clinically significant distress or impairment in social, occupational or other important area of functioning.
Insomniacs associated with secondary medical problems such as Acute fevers or painful conditions, known cases of chronic obstructive pulmonary disease, patients with Obstructive sleep apnea syndrome, Central sleep apnea syndrome, known cases of Restless leg syndrome, Periodic Limb Movement Disorders, Idiopathic Insomnias
or lifelong insomnia, known cases of narcolepsy, sleep disorders associated with diagnosed mental, neurologic and other medical disorders, history of glucocorticoids consumption, known cases of Parkinson, chorea, epilepsy, dementia, Huntington disease, poor mental health, alcohol or drug abuse with in past six months, patients who do not agree to give consent and adhere to protocol were excluded from the study. Ancient Unani physicians used Nutool as an efficient regimen in the treatment of insomnia, as Nutool produces Tarteeb (moistness) in the organ.7, 8
The test drugs, Roghan e banafshan (oil of Viola odorata) and Roghan e gul (oil of Rosa centifolia), used for the Nutool possess properties like Munnawim, Murattib and Muqavvi etc.
Administration of oil: Before starting the therapy, clean gauze was tied just behind the eye brows to avoid spilling of oil over the face. Eyes were protected by keeping a cotton swab soaked in plain water over the closed eye lids. Oil was sterilized and cooled to luke warm to start the therapy. The oil was continuously poured in a rhythmic stream from a distance of half feet 7over the fore head of a patient lying in supine position. The oil flowing down the head was collected in a container placed beneath the outlet of the nutool table. The collected oil was reused to maintain an uninterrupted flow of oil over head for duration of 30 minutes.
Statistical analysis
Results on continuous measurements are presented on Mean ± SD (Min-Max) and results on categorical measurements are presented in Number (%). Significance is assessed at 5 % level of significance, unpaired Student t test ( two tailed, independent) has been used to find the significance of study parameters on continuous scale between two groups (Inter group analysis) and paired Student t test (two tailed, dependent) has been used to find the significance of study parameters on continuous scale within each group.
DISCUSSION
The purpose of test drug in one group and liquid paraffin in other group is to assess the efficacy of Nutool therapy, because Roghan banafshan with Roghan gul being sedative may relieve insomnia and with liquid paraffin, it would not relieve the symptom. But the present study is the first of its kind evaluating the efficacy of procedure of Nutool therapy, as no satisfactory data is available, suggesting Nutool is effective therapy in management of insomnia. This trial had also been studied in a manner of psychological/behavioral studies, multimodal therapies like cognitive and behavioral studies, where studies had been evaluated the pre and post changes and thus p values were observed within group (intra group comparison as opposed to between groups) by comparing p value of two groups (inter group) we had evaluated the variation of therapy in those groups, furthermore, if inter group comparison showed any significant improvement in outcome, this can be considered as the superiority of the test oil over pharmacological inert liquid in improving the variable, sleep latency, mental depression and day time somnolence. Hence pre and post interventional changes within both the groups are evaluated to prove the efficacy of Nutool therapy as a whole.
The Intra group comparisons were made and findings were significant in both the groups with p value1.20 considered as very large effect statistically.
However, variation in pre intervention and post intervention values was significant in
both groups (PEnglishhttp://ijcrr.com/abstract.php?article_id=1087http://ijcrr.com/article_html.php?did=1087
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241519EnglishN2013October19HealthcareINTERACTION OF EMBLICA OFFICINALIS WITH FAMOTIDINE AND PANTOPRAZOLE IN PYLORUS LIGATION INDUCED GASTRIC ULCERS IN RATS
English110120Kanani Neeta J.English Bhave Amol L.English Bhatt Jagatkumar D.EnglishBackground: Emblica officinalis (EO) is widely used in Ayurveda for various ailments on account of it’s medicinal properties of which it has stood test of time for its use in peptic ulcer. However currently there is no report in literature about combining it with allopathic anti-ulcer agents used in peptic ulcer. Objective: To study interaction of EO with antiulcer agents, famotidine and pantoprazole in pylorus ligation induced gastric ulcers in rats. Materials and Methods: Gastric ulcers in rats were induced by method of pyloric ligation as described by Shay et al. Effects of different doses of famotidine, pantoprazole and EO on volume, pH, acidity, and ulcer index were observed. Also effects of EO in combination with famotidine or pantoprazole were studied for the same. Results: Famotidine (4mg/kg i.p.), pantoprazole (4mg/kg i.p.) and EO (100mg/kg p.o.) produced significant anti-ulcer effects in terms of reduction in acidity and ulcer index. Famotidine (1mg/kg i.p.), pantoprazole (1mg/kg i.p.) and EO (50mg/kg p.o.) did not alter the above parameters significantly.Simultaneous administration of (50mg/kg) and famotidine (1mg/kg) showed significant anti-ulcer effects which were apparent from reduction in acidity and ulcer index without causing any change in pH value. Similarly, pantoprazole (1mg/kg) combined with EO (50mg/kg) showed significant anti-ulcer effects on similar lines but with significant rise in volume of gastric secretion. Conclusion: EO produced pantoprazole with EO may be recommended for management of peptic ulcer with an advantage of minimizing side effects and drug interactions of former drugs while getting benefits from EO like its antioxidant property.
EnglishCombined Therapy, Emblica officinalis, famotidine, pantoprazole, pyloric ligation
INTRODUCTION
Peptic ulcer has become a major health problem, both in terms of morbidity and mortality and accounts for a vast amount of drug consumption in many developing countries. Though multifactorial etiology has been implicated, an ulcer is thought to be formed when there is an imbalance between aggressive factors i.e. the digestive power of acid and pepsin and defensive factors i.e. the ability of the gastric and duodenal mucosa (intact gastric mucosal barrier) to resist this digestive power.[1] In majority of patients with ulcer, damage to the gastric mucosal barrier is necessary to facilitate the damaging effect of acid and pepsin and this damage is found to be provoked by factors like NSAIDS, H. pylori, alcohol and stress.
It appears that exposure of the involved tissue to acid is essential for the development of clinical symptoms in most instances of the disease.[2] On this basis, control of gastric acidity is a cornerstone of therapy in peptic ulcer disease, even though this approach may not address the fundamental pathophysiological process. Antacids were the only affordable medication for the treatment of peptic ulcer disease in developing countries; but its long term use was associated with pneumonitis, potential drug interactions and a very poor compliance to two hourly administrations.[3] After years of use of antacids, considerable advances in understanding the pathogenesis as well as the treatment of acid peptic disease have culminated in the discovery of H2- blockers, proton pump inhibitors and anti-H. Pylori regime.[2] Though used quite successfully, reports on clinical evaluation of these drugs show that there are incidences of relapses, adverse effects and dangers of drug interactions during therapy. Tolerance to the acid-suppressing effects of H2-receptor antagonists is well described and may account for a diminished therapeutic effect with continued drug administration. Tolerance can develop within 3 days of starting treatment and may be resistant to increased doses of the medications.[4] Increased bacterial counts in the upper gastrointestinal tract have been reported as a consequence of continuous inhibition of acid secretion by proton pump inhibitors.[5] This is associated with increased incidence of Campylobacter jejuni enteritis.[6] Nonetheless cessation of treatment in peptic ulcer disease is associated with relapse rates of 50 – 80% per year.[7]
Recent advances have stressed on prevention of gastroduodenal ulceration by measures directed at strengthening the mucosal defense system rather than attenuating the aggressive factors i.e. using a gastric mucosal protective agent.[8] However the efficacy of these drugs is debatable as far as permanent cure is concerned. Peptic ulcer disease therapy is more or less a success, but the quest still continues for better drug and now the limelight has shifted to alternative medicine. Ample references are available in Ayurveda and Unani medicine about the utility of Musa paradisiaca (Vegetable banana), Azadirachta indica (Neem), Ocimum sanctum Linn (Tulsi), Emblica officinalis (Amla) and the list is endless, in treating patients of peptic ulcer but they lack inadequate scientific data. Of these, few scientific studies have been done to evaluate antiulcer activity of Emblica officinalis (EO). Study with methanolic extract of EO against ulcers have showed significant ulcer protective and healing effects in various gastric ulcer model of rats.[9] This might be due to its effects both on defensive and offensive mucosal factors. Study by Rajeshkumar et al,[10] on antiulcerogenic activity of fresh fruit juice of EO and its methanolic extract evaluated in various experimental models of ulcers in rats have showed a dose dependent protective effect against gastric mucosal damage. This protection afforded by EO was found to be better than that of ranitidine.
However at present there is no report in literature regarding the combination study of EO with conventional antiulcer drugs. Therefore Loading...Please wait while the content of the page loads the present study was undertaken to demonstrate the antiulcer effects of EO as well as its interaction with a H2-blocker famotidine and a proton pump inhibitor pantoprazole in pylorus ligated (PL) gastric ulcer model in rat.
MATERIALS AND METHODS
Wistar strain albino rats of either sex weighing 200-250 g were kept in the departmental animal house at room temperature (25oC to 30oC) and were given regular laboratory diet with water ad libitum. Principles of laboratory animal care and use were followed throughout the study. The study was designed with due permission of animal ethics committee.
Rats were divided into various groups viz., Control(saline treated), DMSO (vehicle) treated, famotidine treated (1mg/kg and 4mg/kg), pantoprazole treated (1mg/kg and 4mg/kg), EO powder treated (50mg/kg and 100mg/kg) and finally a combination treatment of EO powder (50mg/kg) with famotidine (1mg/kg) and EO powder (50mg/kg) with pantoprazole (1mg/kg). Drugs were administered intraperitoneally (i.p.), 1 hr prior to pyloric ligation (PL) for all groups except EO which was administered orally twice a day with food for seven days. Control group received normal saline while vehicle treated two groups received DMSO i.p.4 hr and 1 hr prior to PL. The volume of all the above injections was in the range of 0.2 to 0.4 ml.
Pyloric ligation was performed as described by Shay et al.[11] The gastric contents were collected and subjected to centrifugation at the rate of 3000 rpm for 10 minutes for estimation of volume, pH, free acidity and total acidity.
pH was estimated by using Indikrom pH strips [Glaxo India Limited] with pH range of 2.0 – 4.5 and 5.0 – 8.5 with range difference of 0.5. Free acidity and total acidity were estimated by titrating one ml of centrifuged sample with 0.01 N NaOH using Topfer’s indicator and Phenolphthalein indicator respectively. Acidity was expressed in clinical units i.e. the amount of 0.01 N NaOH base required to titrate 100 ml of gastric secretion. For estimation of ulcer index, the stomach was cut open along the greater curvature and the inner surface was examined for ulceration with the help of simple dissecting microscope. Usually, circular lesions were observed but, many times, linear lesions were also seen. Ulcer index was calculated by using the formula;
Drugs Used
Fresh solutions of famotidine and pantoprazole [Sun Pharmaceutical Industries, Vadodara] were prepared daily in DMSO. Dry powder of EO fruit was obtained from Amlaki Capsule [500 mg; Intel Pharmaceuticals, Calcutta]
Statistical Analysis
All data are expressed as Mean + Standard error of mean (S.E.M.). For comparison amongst different groups, post hoc one way ANOVA was performed. Value of P less than 5% (PEnglishhttp://ijcrr.com/abstract.php?article_id=1088http://ijcrr.com/article_html.php?did=1088
Friedman LS, Peterson WL. Peptic ulcer and related disorders. In: Fauci AS, Braunwald E, Isselbacher KJ, Wilson JD, Martin JB, Kasper DL, Hauser SL, Longo DL, editors. Harrison's Principles of Internal Medicine.Vol.2. 14th ed. USA: McGraw Hill. Health Professions Divison; 1998. p. 1596-99.
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Bafna, PA; Balaraman R. COPYRIGHT 2008 Urban and Fischer Verlag. This material is published under license from the publisher through the Gale Group, Farmington Hills, Michigan. All inquiries regarding rights or concerns about this content should be directed to customer service. (Hide copyright information) Anti-ulcer and antioxidant activity of DHC-1, a herbal formulation. J Ethnopharmacol 2004;90(1):123-127
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241519EnglishN2013October19HealthcareDIMENSIONAL CHANGES OF TRACHEA IN SECOND AND THIRD TRIMESTER FETUSES -AN ANATOMICAL STUDY
English126131Anne DsouzaEnglish Vrinda Hari AnkolekarEnglish Mamatha HosapatnaEnglish Antony sylvan DsouzaEnglishIntroduction: Advances in neonatal medicine have led to the early diagnosis and treatment of respiratory diseases, and the recent development of fetal airway surgery. Data on the growth of the trachea and bronchi are not readily available to the anesthesiologist and bronchoscopist in spite of the obvious clinical interest. The aim of this study was to determine the anatomical development of tracheal structures during the fetal periods and to correlate these observations with other fetal biometric parameters to estimate developmental particularities of the fetal airway. Materials and methods: The study was carried out in the department of Anatomy, on 28 human fetuses of known gestational age (GA) from spontaneous abortions or stillbirths, aged 16–37 weeks of gestation which were categorized into second and third ( trimesters. Following parameters were noted prebifurcation length (PL), birfurcation length (BL), bifurcation-to-prebifurcation length ratio (BL/PL), Upper external transverse diameter (UD), Lower external transverse diameter (LD), Circumference (C) of trachea at the level of last tracheal cartilage. Results: The mean and standard deviations were calculated for second and third trimester and values were compared using student t-test. There was significant difference in means for PL, UD and LD between second and third trimesters. The various parameters were correlated with GA using Pearson’s correlation test. SPSS version 16 was used for the statistical analysis. No significant correlation was found for LD (r=0.2, p=0.2) and for C (r=0.19, p=0.3). Conclusion: Authors conclude that the tracheal length increases significantly proportional to the GA, but not the diameter.
Englishtrachea, prebifurcation length, bifurcation lengthINTRODUCTION
Advances in neonatal medicine have led to the early diagnosis and treatment of respiratory diseases, and the recent development of fetal airway surgery1. Data on the growth of the trachea and bronchi are not readily available to the anesthesiologist and bronchoscopist in spite of the obvious clinical interest2. Advances in neonatal medicine have contributed to the survival of extremely preterm infants. Because of their respiratory immaturity, long-term tracheal intubation is often necessary. Practical determination of endotracheal tube size in the premature population is classically based on clinical report3,4,5,6,7. Changes in tracheal dimensions occur in a variety of conditions. For example, generalized widening is a characteristic feature of tracheobronchomegaly and tracheomalacia; generalized narrowing is seen in tracheobronchopathia osteochondroplastica and may be a feature of relapsing polychondritis8. The study of the development of the fetal trachea provides information on the functional morphology of this organ9. The aim of this study was to determine the anatomical development of tracheal structures during the fetal periods and to correlate these observations with other fetal biometric parameters to estimate developmental particularities of the fetal airway. The parameters measured in the present study will help in placement of endotracheal tube of accurate size in premature infants. These measurements should be useful in the detection of tracheal abnormalities, problems in respiratory physiology and in endotracheal intubation, endoscopy and tracheostomy.
MATERIAL AND METHODS
The study was carried out in the department of Anatomy, Kasturba Medical College, Manipal, on 28 human fetuses of known gestational age (GA) from spontaneous abortions or stillbirths, aged 16–37 weeks of gestation which were categorized into second (N=10) and third (N=18) trimesters. The specimens were immersed in 10% formalin solution. The fetuses with any external malformations were excluded from the study .The part of respiratory tract from the level of cricoid cartilage up to the hilum of lung of each foetus was resected. After clearing the soft tissues tracheal rings were visualized and the following parameters were noted using vernier calipers as shown in fig 1,
Prebifurcation length (PL), corresponding to the distance between the superior border of the first tracheal cartilage and the inferior border of the last tracheal cartilage
b) Bifurcation length (BL), corresponding to the distance between the inferior border of the last tracheal cartilage and the tracheal bifurcation
c) Bifurcation-to-prebifurcation length ratio (BL/PL)
d) Upper external transverse diameter (UD), measured at the level of the first tracheal cartilage
e) Lower external transverse diameter (LD), measured at the level of the last tracheal cartilage.
f) Circumference (C) of trachea at the level of last tracheal cartilage.
The mean and standard deviations were calculated for second and third trimester and values were compared using student t-test. The various parameters were correlated with GA using Pearson’s correlation test. SPSS version 16 was used for the statistical analysis.
RESULTS
The present study included 10 second trimester and 18 third trimester fetuses. The mean and standard deviation of various parameters measured is shown in table 1. Student t-test was used to determine the significance between the means of second and third trimester. There was significant difference in means for PL, UD and LD between second and third trimesters.
Pearson’s correlation test was done to correlate the various parameters with GA. There was a positive correlation for PL (r=0.58, p=0.001), BL (r=0.39, p=0.036) and for UD (r=0.55, p=0.002). The correlation is denoted in graphs 1, 2 and 3. No significant correlation was found for LD (r=0.2, p=0.2) and for C (r=0.19, p=0.3).
DISCUSSION
There are few studies in literature published on the anatomical measurements of the airway in pediatric populations or premature populations10, 11, 12. Tracheal dimensions undergo considerable change according to GA14. As the mid trachea is approached there is an antero-posterior flattening which yields a more elliptical section. From the mid-trachea to carina the section rounds out again and flares into right and left bronchi2. Different methods have been described to illustrate observations of fetal measurements and to estimate age-specific reference intervals for these measurements15, 16. According to Szpinda et al no significant male–female differences for any of tracheal parameters were found17. Most authors reported that both length and diameters of the trachea increased with advanced fetal age in a proportional fashion. According to Szpinda et al, the PL ranged from 8.14 ± 1.90 to 20.77 ± 0.50 mm, BL ranged from 2.23 ± 0.25 to 5.77 ± 0.76 mm, the external transverse diameters of the trachea were found to increase from 2.39 ± 0.04 to 5.20 ± 0.17 mm and from 2.42 ± 0.20 to 4.93 ± 0.08 mm for proximal and distal ends of the trachea, respectively17.A study done by Harjeeth et al showed the average length of fetal trachea was 33.07 ± 1.44mm and the average UD was 5.83 ± 1.18mm18. In the present study the PL ranged from ranged from 20.6±5.66 to 25.16±3.68 mm, BL was ranged from 3.04±0.95 to 3.66±0.97mm, UD ranged from 3.75±0.63 to 4.5±.7mm and LD ranged from 4.2±0.82m to 4.94±0.87mm, which were consistent with values obtained by Harjeeth. In the present study the length and upper diameter of trachea increased significantly in third trimester. Whereas the tracheal diameters did not increased significantly with gestational age. Few studies have been published on the anatomical measurements of the airway in either pediatric population or premature population19, 20.
CONCLUSION
Authors conclude that the tracheal length increases significantly proportional to the GA, but not the diameter. Generalized widening is a characteristic feature of tracheobronchomegaly and tracheomalacia; generalized narrowing is seen in tracheobronchopathia osteochondroplastica. Hence the study of the development of the fetal trachea provides information on the functional morphology of this organ.
ACKNOWLEDGEMENT
The authors sincerely thank the post graduate students and non-teaching staff of Anatomy, KMC Manipal for their valuable contribution to the work.
Englishhttp://ijcrr.com/abstract.php?article_id=1090http://ijcrr.com/article_html.php?did=1090
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241519EnglishN2013October19HealthcareDISTRIBUTION OF VAGUS NERVES TO STOMACH AND ITS VARIATIONS
English132142Ch. D. SukumarEnglish Mahalakshmamma V.English Udaya Kumar P.English Gajendra (Late)EnglishIntroduction: It is a well established fact that “vagotomy” in varying degrees is a decisively relieving surgical procedure in peptic ulcer patients. Failure of vagotomy or recurrence of paptic ulcer symptoms is due to the variations in the pattern of distribution of the gastric nerves to stomach. Complexity of varying pattern of the gastric nerves supplying the stomach compels a thorough investigation in this context. Materials and Methods: Total of 30 Stomachs with lower part of esophagus and pylorus were utilized for the study from the department of anatomy of Narayana Medical College, Nellore, and Andhra Pradesh. Each specimen was labeled soon after collection and then preserved in a small tank containing 10% formalin. The nerve trunks and their branches were traced by standard dissection methods. Results and Conclusion: In the present study of 30 specimens in 20% of gastric nerves variation were found in its course, pattern and communication; which can produce secretion of acid inspite of conventional vagotomy. It could be suggested that high selective vagotomy can a method of choice for treatment of specific cases of paptic ulcer because of the variations found in the distribution of vagi to the stomach.
EnglishStomach, Vagus nerve, Vagotomy.
INTRODUCTION
It is a well established fact that “vagotomy” in varying degrees is a decisively relieving surgical procedure in peptic ulcer patients. However there have been instances of recurrent or persistent pain, which is due to an incompletely sectioned vagus nerve. Complexity of varying pattern of the vagus nerves supplying the stomach and necessity of highly selective vagatomy in specific cases compels a thorough investigation in this context.
NORMAL ANATOMY
Vagal trunks above the level of the diaphragm:
Richard Gentry Jackson8 described four types of anterior and posterior vagal trunks above the level of the diaphragm. In type A, Vagus is single trunk above and below the diaphragm. In type B it becomes a single trunk some distance above the diaphragm but divides into two or more trunks before passing through the esophageal opening of the diaphragm. Vagus becomes a single trunk only at the diaphragm but some distance above the diaphragm it has multiple trunks as in type C whereas it never becomes single trunk at or above the diaphragm in type D
Diagram No. 1 Showing different types of anterior and posterior vagal trunks
Vagal trunks below the level of esophageal opening of the diaphragm
The Anterior vagal trunk passes through the diaphragm and gives off hepatic, gastric, pyloric and celiac branches which supply the liver, biliary apparatus, duodenum, Pancreas, and the pyloric antrum through Celiac plexus or hepatic plexus. The most medial of the gastric branch, which runs parallel to lesser curvature, is known as nerve of the latarjet or principle anterior nerve of lesser curvature.
The posterior vagal trunk gives off hepatic, gastric and celiac branches below the diaphragm. The hepatic branches reach the hepatic plexus either independently or by joining the hepatic branch of anterior vagal trunk. The gastric and coeliac branches of the posterior vagal trunk are same as anterior vagal trunk.
MATERIALS AND METHODS
Total 30 Stomachs, with intact lower part of esophagus and pylorus, were collected for the study from the department of anatomy of Narayana Medical College, Andhra Pradesh. All the specimens collected belonged to cadavers of adult south Indians of unknown profession and food habits.
The collected specimens were labeled and subsequently preserved in 10% formalin. The Specimens had not been subjected to any operative procedures before death. Vagal trunks were traced from lower part of esophageal plexus to the level of the diaphragm carefully. The dissection was continued till the branches of vagal trunks reached the wall of the stomach. Gastric and pyloric branches, Nerves of latarjet, Anterior and posterior vagal trunks with their communications were also traced.
The vagi and its branches were colored and photographed from the lower end of oesophageal plexus. Small thin fibres which were torn during dissection were not seen in the photographs. The length of the vagal trunks was measured from the level of the diaphragm to the lower end of the oesophageal plexus using an ordinary scale. Communicating branches and nerves of latarjet were also observed and measured.
RESULTS
In the present study of 30 specimens, on an average, Type-A (simple pattern) was found in 59.9% and Type-B (intermediate pattern) in 18.3%. Type-C and Type-D were found in 9.9% and 21.6% of the specimens respectively. The average lengths and percentage of AVT and PVT of all types were shown in Table no.1. The length of the lower limit of esophageal Plexus measured from the upper limit of diaphragm are shown in Table no.2.
Single trunks were measured for their shape and position which varied with reference to the midline on the esophagus. They are shown in the table no.3 and diagram no.2 respectively.
Communicating branches between anterior and posterior vagal trunks were measured and described as low, mid, high and long communicating branches which are shown in table no.4
Variations observed in the branching pattern of anterior vagal trunk:
Normally anterior vagal trunk passes through the diaphragm as a single trunk and gives off gastric, pyloric and celiac and hepatic branches.
In 4 specimens the upper gastric branches arose at or above the level of oesophageal hiatus of the diaphragm. There were no gastric branches in the 3 specimens. The nerve of latarjet was present in 76.6% percent of specimens. In 50% of specimens it was found to communicate with recurrent branch of the hepatogastric nerve. In 2 specimens it divided at its origin about 3 to 4 cms in common with the pyloric nerve. The length of the nerve varied from 2.5 cms to 9 cms.
It was observed that the coeliac branches of the anterior vagus nerve reach the coeliac plexus by at least 3 routes.
Fibres ascended to the coeliac plexus via Hepatic plexus and hepatic artery.
Fibres joined the sympathetic fibres running along the left gastric artery from pyloric branches.
Fibres given off directly from the anterior vagus nerves to coeliac plexus.
Pyloric branches of the anterior vagus were present in 8 specimens. In 7 specimens it was from lower hepatic branches or branches of nerve of latarjet.
The hepatic branches were observed to run 1.5 cm to 2.5 cm away from the lesser curvature. Some branches arose in common with pyloric branches. A few hepatic branches arose in common with the nerve of latarjet.
Variations observed in the branching pattern of posterior vagal trunk:
The variations of PVT were seen as follows:
It was given off above the level of oesophageal hiatus.
It arose with the nerve of latarjet.
In 2 specimens there was no clear division and it descended directly to coeliac plexus and numerous fine gastric branches sprang from it.
In one specimen the main stem descended directly towards the coeliac plexus.
In one specimen the anterior vagus nerve was thin and the posterior vagus nerve supplied both the surface of the stomach.
The hepatic branches were traced to hepatic plexus via the coeliac plexus and the hepatogastric ligament. In 10 specimens hepatic branches accompanied, the hepatic branches of the left gastric artery. The gastric branches originated at the level of the oesophageal hiatus of the diaphragm or in the thorax. The posterior vagus also gave off extra anterior gastric or hepatic branches. The coeliac branches comprised the major portion of the posterior vagus which formed plexus around the left gastric artery.
DISCUSSION
A large variety of surgical procedures were introduced for the treatment of peptic ulcer. The introduction by dragstedt1, 2 and his associates of the complete division of the vagus nerve supply to the stomach have been accepted as a method of choice. Grimson3 and Moore4 reported that vagotomy was not the final answer to the treatment of peptic ulcer even though in a vast majority of the cases there has been a relief of gastric pain following vagotomy.
1. Pattern of Anterior vagal trunk (AVT) and posterior vagal trunk (PVT) above the diaphragm.
The anatomic description of vagus nerve and their branches between anterior and posterior vagal trunks above the level of diaphragm have been described by Mitchell5, Chamberllein6, Ruckley7, Jackson8, E and D’arcy McCrea20
Mitchell5 observed that there were no constant numbers of trunks above the diaphragm. Kollman, as quoted by E. D’arcy McCrea, observed anterior trunks to be where as posterior trunk to be single. Chamberllein6 classified the vagus nerve into Simple pattern (60%), Intermediate pattern (16%) and Complex pattern (24%). Ruckley7 observed that in about 66.6% of specimens there was a single anterior trunk. In 91.6% cases PVT was single. Jackson8 described 4 types of AVT and PVT as type A, B, C and D and measured the average lengths of the vagal trunks and also observed that a greater proportion of the posterior communicating branches are of the long type than are the anterior branches.
In the present study of 30 specimens: Type-A (simple pattern) was found in 59.9%. Type-B was (intermediate pattern) was found in 18.3%. Type-C was found in 9.9% and Type-D in 21.6%. The average length of Type-A AVT was 5.36 cms and PVT was 3.68 cm. Type-B AVT was 6.23 cm and PVT was 3.6cms. Type-C AVT was 6.7 cm and PVT was 4.1 cm. Type-D AVT was 6.6 cm and PVT was 4.2 cm. 80% of AVT and 76.6% of PVT were single trunks.
Analysis of AVT showed, Type-A in 53.3%, Type-B in 26.6%, Type-C in 6.6% and Type-D in 13.3% of specimens. Analysis of the PVT showed Type-A 66.6%, Type-B 10%, Type-C 13.3% and Type-D in 10% of specimens.
AVT became single farther above the diaphragm when compared to PVT. More AVTs than PVTs divide before passing through the diaphragm. In type-B the AVT was single for a longer distance before dividing, than the PVT. It was noted that not a single posterior vagal trunk measured more than 5 cm in length above the diaphragm.
II. Pattern of Multiple trunks below the diaphragm
Jackson8 observed that, below the diaphragm, multiple trunks of AVT in 15 specimens (30%) and multiple trunks of in PVT in 4 specimens (8%) of out of 50 specimens. Ruckley7 observed multiple trunks of AVT in 3 specimens (25%) out of 12 and PVT in 1 specimen (8.3%). In the present study, the pattern of multiple trunks below the diaphragm was found in 12 (40%) out of 30 specimens in AVT and 6 (20%) out of 30 specimens in PVT.
III. Communicating Branches
According to Mitchell5, there were no constant number of communicating branches between AVT and PVT. Chamberllein6 found that the communicating branches were prominent in 70%, moderately prominent in 16% and obscure in 14%. According to Ruckley7 AVTs and PVTs were linked by number of long and short communicating strands. According to Jackson8 mid communicating branches were more seen posteriorly than anteriorly (40%) and high communicating branches were seen more anteriorly (33.3%) than posteriorly.
In the present study it was observed that communicating branches from posterior to anterior vagus were passing around the oesophagus or through its muscle fibres. Communicating branches were not seen in all dissections. The communicating branches were classified as mentioned in the results (table no.4). Middle and long communicating branches were more from the posterior vagal trunk (30% and 26.6% respectively).
IV. Position of AVT and PVTs on the oesophagus
The distal end of the oesophagus was usually fixed in position. The position of the AVT and PVT were not constant in relation to the distal end of the oesophagus.
Mitchell5 observed the position of AVT and PVT on distal portion of the oesophagus in relation to anterior and posterior aspects respectively. The anterior vagus nerve was found to pass mainly to the posterior aspect of oesophagus and posterior vagus was found to passes to the anterior aspect of oesophagus occasionally. Chamberllein6 observed that the position of the AVT on the oesophagus was normal in 88% and abnormal in 12% of specimens whereas the position of PVT was normal in 82% and abnormal in 18% of specimens. According to Jackson8 66% of AVT were in normal position and 30% were in abnormal position 38% of PVT were in normal position and 29% were in abnormal position. Walters9, 10 in his studies noted that PVT was not always posterior so it was named right gastric nerve and AVT was named as left gastric nerve. In his study of AVT he found that 32% were towards the right side and 62% were towards the left side. On the posterior aspect 44% of PVTs were towards the right side and 18% were on the left side of oesophagus.
In the present study it was found that distal end of the oesophagus was mostly fixed in position. AVTs were closely applied to the oesophagus and slightly to the left of distal esophagus. The PVTs were on the right of the midline and separated from oesophagus by loose areolar tissue. AVTs were in normal position in 84% and in abnormal position in 16%. The PVTs were in normal position in 33.3% and in abnormal position in 66% (Diagram No.1).
Terminal branches of AVT and PVT
Mitchell5 described that the AVT divided into 4 branches gastric, pyloric, hepatic and coeliac below the diaphragm. The nerve of latarjet may be a branch from pyloric or gastric branch of AVT. E. D’Arcy McCrea20 stated that presence of anterior gastric plexus is variable, either may be present or absent. Jackson8 traced the gastric branches, Hepatic branches, pyloric branches and coeliac branches arising at different levels from AVT. PVT gave gastric, hepatic and coeliac as terminal branches. The anterior nerve of laterjet was the continuation of AVT or pyloric branches and posterior nerve of latarjet follows the continuation of coeliac branches or PVT posteriorly. Jackson8 also noted in two cases that there were no gastric branches anteriorly and in those cases gastric branches of PVT supplied the anterior surface of the stomach. In the study reported by waltman walters 9, 10 the AVT and PVT divided into its terminal branches 3 cm below the level of diaphragm. Johnstone11, 12 and Carter13 observed that the AVT gave off hepatic branches at oesophago gastic junction. AVT continued as anterior nerve of Latarjet. The PVT gave off gastric branches and the posterior nerve of latarjet was the continuation of PVT. According to K C Shanthi14, et al, 11 out of 12 cadavers showed branching of nerve of latarjet forming plexus over anterior surface of stomach, except one in which no branching was observed.
In the present study, the AVT gave off four branches, 3 cms below the diaphragm, as hepatic, gastric, pyloric and coeliac branches. These branches were multiple, the numbers varying from 2-5 branches. The most medial of the gastric trunk was the anterior nerve of latarjet. It was parallel to lesser curvature and ended in the antrum and its length varied from 2.5 to 6 cm from pylorus. The anterior nerve of latarjet was present in 76.6% of specimens. There were no gastric branches in three specimens.
Coeliac branches entered the coeliac plexus via the hepatic branches of the coeliac plexus and along with the hepatic artery. Fibres from pyloric branches or from anterior nerve of latarjet were found to run along the left gastric artery to the stomach. Pyloric branches were often hepatic branches or anterior nerve of latarjet.
The PVT gave hepatic, gastric and coeliac branches. The number varied from 2-3 branches. The most medial branch of gastric nerve was the posterior nerve of latarjet. The PVT was thick and in a few specimens it divided into two divisions and then gave off branches.
In the present study there were no gastric branches in 3 specimens. In 4 specimens upper gastric branches arose at or above the level of the oesophageal hiatus or from the posterior nerve of latarjet which was present in 73.3% of specimens. In one specimen AVT was very thin and the posterior vagus also supplied the anterior surface of the stomach.
The variations of the coeliac division of PVT were as follows:
It arose at or above the oesophageal opening.
It arose along with the nerve of latarjet.
In one specimen the main stem descended directly towards the coeliac ganglia or plexus.
SUMMARY
Vagotomy is the usual procedure followed for treatment of peptic ulcer for many years. W.J. Merle Scott15 observed that recurrence of peptic ulcer symptoms after vagotomy can occur in some cases due to variations in distribution of vagus nerve.
In the present study, of 30 specimens, it was concluded that distinct majority of vagal trunks followed a normal pattern. However about more than 20% showed variable patterns of distribution.
In this study AVT divided at higher level when compared to PVT above the diaphragm. No single PVT trunk measured 4.2 cm above the level of the diaphragm but AVT trunks measured 6 cm.
Multiple trunks were present in 43.3% of specimes above the diaphragm and in 40% of specimens below the diaphragm. Therefore 3.3% more multiple trunks were found above the level of diaphragm when compared to multiple trunks below the level of the diaphragm. Multiple trunks were found more from the PVTs above the diaphragm and more from AVTs below the diaphragm. Majority of Type-A vagal trunks present no technical difficulty for vagotomy, whereas in Type- B, C and D surgeon have to search carefully for all the branches and locate the primary trunks then division has to be made, which poses more technical difficulty but failure of which may lead to recurrence of peptic ulcer symptoms.
Long and middle communicating branches between AVT and PVT were found more in number posteriorly rather than anteriorly. High communicating branches were found more anteriorly..
The distal end of the oesophagus was mostly fixed in position. The AVTs are closely applied to the oesophagus and PVTs are separated from oesophagus by loose areolar tissue. Therefore it is easier to palpate PVTs than AVTs. Common location of vagal trunks was found to be within the area just above the diaphragm right of the anterior midline of the oesophagus for AVTs and right of the posterior midline for PVTs. If the vagus nerve were found located outside these areas they were considered as abnormal in position. Abnormal position of AVTs was in 16% and in PVTs 20%. It was noted that AVTs and PVTs were found within a fairly limited area.
It is preferable to divide the AVT above the diaphragm, because it is usually single and is higher than PVT. The PVT could be divided just below the diaphragm because it was found that it does not become single until it reaches the diaphragm.
CONCLUSION
It is difficult to perform complete vagotomy in Type-C and Type-D vagal trunks. In the present study 10% Type-C and 4.9% Type-D were found. Amdrup, Jenson and wilkison16 introduced the highly selective vagotomy(HSV) where the aberrant fibres supplying the stomach were identified and resected. T F Gorey17, et al and Falk GL18, et al, concluded that HSV is a definitive operation in complicated and chronic duodenal ulceration that allows preservation of the pylorus.
The knowledge of the variations of gastric branches of vagus nerve will help the surgeons to perform better. So, it could be concluded that HSV is method of choice for treatment of peptic ulcer in specific patients because of the variations found in the distribution of vagi to the stomach in the present study.
Competing Interests
The authors declare that we have no competing interests
Ethical committee clearance
As the study included only human cadavers, ethical committee clearance was not taken into consideration. Authors will take the responsibility of any further allegations regarding ethical clearance that arise from the study.
ACKNOWLEDGEMENTS
I thank Dr. Vimala (Late) and my colleagues for their precious suggestions and I extend my gratitude to all the scholars / authors / editors / publishers whose articles, journals are reviewed, cited and included in the references of this manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=1091http://ijcrr.com/article_html.php?did=1091
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