Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241517EnglishN2013September12General SciencesCOMPARISON OF CLASSIFICATION RULES FOR TWO UNIVERIATE POPULATIONS
English0109Hashimu BulusEnglishThree procedures for classifying an entity into one of the two predetermined univariate populations 1 and ?2 were derived, evaluated and compared. This paper proposes Unspecified structure of the variance, Regression Discriminant (RD) and Elongated Discriminant (ED) procedures for the classification using k repeated observations collected on each entity j at time t (t = 1,2,…, k;j = 1,2,…,ni; i = 1,2). Mean arterial pressure which is a function of systolic and diastolic blood pressures were collected sequentially in time from two sampled populations ?1(survivors) and ?2 (nonsurvivors),
of hypertensive patients admitted at the Jos University Teaching Hospital (J.U.T.H).Three techniques: re-substitution, leave – one out and partitioning of samples are used to construct and evaluate the sample based classification rules. Probabilities of misclassification obtained from the confusion matrices produced by these techniques are used to compare the performances of these rules. The analysis reveals that the procedures compare favourably with one another and the Fisher’s commonly used rule. The classification rule obtained using Elongated Discriminant procedure performs
better with lower error rates. This is followed by unspecified structure of the variance and regression discriminant procedure in that order.
EnglishClassification Rule, Elongated Discriminant, Regression Discriminant, Unspecified variance –covariance structure and univariate populationsINTRODUCTION
Consider the classification rule for classifying an entity into one of the two predetermined univariate normal populations ?1 and ?2 based on observations collected at a single point in time
Table 3: Probabilities of Misclassification (PM.C) for the Three Procedures (Partition of Sample Technique)
Procedures Unspecified variance Regression Discriminant Elongated Discriminant PMC 0.5333 0.5500 0.3667
CONCLUSSION
The analyses reveal that whichever technique is used to construct and evaluate the sample based classification rule, the Elongated Discriminant procedure out performs the other two, with minimum probability of misclassification. This is followed by the Unspecified Structure of the Variance and then the Regression Discriminant procedures. The Re-substitution Technique is found to be most appropriate when estimating the apparent error rate (APERA), as this gives the minimum error rate for all the procedures. When actual error rate is desired, the technique of Leave one out and partition of sample are most appropriate.
Englishhttp://ijcrr.com/abstract.php?article_id=1103http://ijcrr.com/article_html.php?did=11031. Bulus, H (2008). A Heuristic classification for Repeated Measure. Bagale Journal of Pure and Applied Sciences, Yola. Vol. 6, pages 38-46.
2. Ching-Tsao Tu and Chien-Pai Han (1982). Discriminant Analysis Based on Binary and Continuous Variables. Journals of the American Statistical Association.Vol.77, no 377, pages 447 – 454.
3. Hand, D. J. (1989). Discrimination and Classification. John Wiley and sons, New York.
4. Lachenbruch, P. A. (1975). Discriminant Analysis. Hafner press, New York.
5. Lawoko, C.R.O. and McLachlan, G.J. (1983). Some Asymptotic Results on the Effect of Autocorrelation in the error Rate of the Sample Linear Discriminant Function. Pattern Recognition, Vol. 16, pages. 119 – 121.
6. McLahlan, G. J. (1992). Discriminant Analysis and Statistical Pattern Recognition. John Wiley and sons Inc, New York.
7. Timm, N. H. (1975). Multivariate Analysis with Applications in Education and Psychology. Brooks / Cole Publishing Company, Monterey, California.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241517EnglishN2013September12HealthcareSERUM AMYLASE IN PATIENTS WITH CHRONIC KIDNEY DISEASE
English1015Bindu C. M.English Vidya Shankar. P.English H. V. ShettyEnglish Deepti GuptaEnglishIntroduction: Chronic kidney disease is a progressive loss in renal function over period of many months or years. There is decline in nephron function and number generally quantitated as reduction in glomerular filtration rate. As the GFR declines there is accumulation of metabolic end products excreted by Kidney. Amylase is one of enzyme that is rapidly excreted by kidney, thus patients in chronic kidney disease have elevated serum pancreatic enzymes. Aims and Objectives: The aim of present study was to determine changes in serum total amylase levels in patients with end stage renal disease on hemodialysis and non dialysed chronic kidney disease patients. Material and Method: Fifty patients with end stage renal disease coming for hemodialysis and fifty non dialysed chronic kidney diseases on outpatient follow up were included in this study. Fifty age and gender matched healthy individuals were included as control group. Blood samples were collected from patients as well as controls and were analysed for amylase, urea and creatinine using a fully automated analyzer. The results were analyzed statistically using student “t” test. Result: Present study has showed that serum total amylase levels were significantly higher in end stage renal disease and chronic kidney disease patients as compared to healthy controls (p value EnglishEnd stage renal disease, chronic kidney disease, serum amylaseINTRODUCTION
Chronic kidney disease (CKD) is associated with the decreased glomerular filtration rate over period of months to years. In the later stages of CKD, the glomerular filtration falls drastically eliding to the accumulation of metabolic end products. There is decline in nephron function and number generally quantitated as reduction in glomerular filtration rate (1)
Chronic kidney disease is identified by blood tests, creatinine and urea are two such substances routinely measured.
The National kidney foundation proposed a new classification system to classify chronic kidney disease in five stages, this system is known as Kidney disease outcome quality initiative (KDOQI)
Stage 1 being mildest with GFR 60 to 90 ml/min, Stage II is with GFR between 45 to 59 ml/min, Stage III patients having GFR of 30 to 44 ml/min, Stage IV are patients with GFR of 15 to 29 ml/min and stage 5 are patients with GFR of less than 15 ml/min. Patients with advanced CKD (Stage III, IV and V) have profound impaired GFR and accumulation of metabolic end products. End stage renal disease (ESRD) is group of patients on maintenance hemodialysis for CKD and requires dialysis to sustain life (2)
Amylase is one of the enzyme that is produced by exocrine pancreas and salivary gland that hydrolyses starch is rapidly cleared by kidney .Twenty percent of pancreatic enzymes is excreted by the kidney thus patients with end stage renal disease have elevated levels of serum pancreatic enzymes. The serum amylase and lipase are elevated in patients with end stage renal disease in absence of pancreatitis (3,4,5). The highest levels of amylase and lipase are noted in advanced CKD patients but marked elevations can also be seen in patients undergoing peritoneal dialysis (6,7).In one of study by Montalto et al found increase in serum pancreatic enzyme during chronic renal pathology is slight but frequently occurs(8).
The purpose of this study was to evaluate the changes of serum amylase levels in patients with end stage disease on hemodialysis and non dialysed chronic kidney disease patients in the Indian subcontinent.
METHODS
Study subjects
100 patients of age group between 18 to 70 years of either gender were enrolled in the study.
They were divided in to two groups as follows
(1) 50 patients with ESRD coming for maintenance hemodialysis to the department of nephrology.
(2) 50 nondialysed Chronic Kidney Disease patients on outpatient follow up.
Study controls
Control group comprised of 50 healthy voluntary adults in the Rajarajeswari medical college.
All patients and subjects showed no evidence of pancreatitis, alcoholic liver disease, acute infections and patients with HbsAg/Hcv positive and they were not on medications which may lead to pancreatitis.
Informed consent was obtained from these subjects. The study was approved by the institutional human ethical committee
SAMPLING
Blood samples (4ml) were drawn with proper aseptic precautions from these subjects using vacutainers containing clot activators. The blood was allowed to clot, centrifuged and serum was used to perform biochemical analysis on the same day.
ANALYSIS
Serum creatinine levels were estimated using modified Jaffes method.
Blood urea was estimated using Urease –GLDH (Glutamate Dehydrogenase) method.
Above parameters were estimated in hospital laboratory using fully automated analyser.
ESTIMATION OF AMYLASE
The method used to estimate amylase concentration in serum is by CNPG (2-chloro-4-nitrophenol β -1-4 galactopyranosylmaltotrioside) method .It is a direct substrate for determination of amylase activity .The rate of 2-chloro-4-nitrophenol formation can be monitored at 415 nm and is proportional to amylase activity.
Calculation of Glomerular Filteration Rate
GFR was estimated by CKD EPI (Chronic Kidney Disease Epidemiology Collaboration) equation.
CKD EPI Equation for Estimating GFR Expressed for Specified Race, Sex and Serum Creatinine in mg/dl (9)
EQUATION
GFR = 141 × min (Scr /κ, 1) α × max(Scr /κ, 1)-1.209 × 0.993Age × 1.018 [if female] × 1.159 [if black] where Scr is serum creatinine in mg/dl, κ is 0.7 for females and 0.9 for males, α is -0.329 for females and -0.411 for males.
Values for serum creatinine, Age in years were inserted in equation to give values of glomerular filtration rate.
STATISTICAL ANALYSIS
The comparison of mean and SD between two groups was done using students “t” test using Minitab software for windows. A p value of Englishhttp://ijcrr.com/abstract.php?article_id=1104http://ijcrr.com/article_html.php?did=1104
National kidney foundation 2002), K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification and stratification. Am j kidney dis.2002;39 (suppl 1):S1-S266.
National institute for health and clinical excellence.clinical guidelines 73: chronic kidney disease.London, 2008.
Royes VL, Jensen DM, Corwin HL. Pancreatic enzymes in chronic renal failure. Arch Intern Med 1987; 147: 537.
Vaziri ND, Chang D, Malekpour A, Radaht S. Pancreatic enzymes in patients with end stage renal disease maintained on hemodialysis. Am J Gastroentrerol.1988; 83:410.
Lin XZ, Chen TW, Wang SS, et al. Pancreatic enzymes in uremic patients with or without dialysis.Clin Biochem .1988;21:189
Kimmel PL, Tenner S, Habwe VQ, et al.Trypsinogen and other pancreatic enzymes in patients with renal disease a comparision of high efficiency hemodialysis and continuous ambulatory peritoneal dialysis.Pancreas.1995;10:325
Caruana RJ, Altman R, Fowler B, et al. Correlates of amylase and lipase levels in chronic dialysis patients.Int J Artif Organs.1988;11:454.
Montalto G, Carroccio A, SparacinoV, et al. Pancreatic enzymes in chronic failure and transplant patients.Eur J ClinChemClinBiochem .1997;35:237
Levey AS, Stevens LA, Schmid CH, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med. 2000;150;604-6
Collen MJ, Ansher AF, Chapman AB, et al. Serum amylase in patients in patients with renal insufficiency and renal failure. Am J Gastroentrerol.1990;85:1377
Aderstam B, Gracia-Lopez E, Heimburger O, Lindholm B. Determination of alpha amylase activity in serum and dialysate from patients using icodextrin based peritonial dialysis fluid.Perit Dial Int .2003; 23:146.
MasoeroG, Bruno M, GalloL, etal. Increased serum pancreatic enzymes in uraemia relation with treatment modality and pancreatic involvement .Pancreas.1996; 13:350-355.
Bastani B, MifflinTE, Lovell MA, Westervelt FB.Serum amylases in chronic and end stage renal failure: effects of mode of therapy, race, diabetes and peritonitis. Am J Nephro.1987; 7:292-299.
McGeachin RL, Hargan LA. Renal clearance of amylase in man .Journal of applied physiology.1956; 9:129-131.
Johnson SG, Ellis CJ, Levitt MD. Mechanism of increased renal clearance of amylase/creatinine in acute pancreatitis. New England Journal of Medicine.1976; 295:1214-1217.
Noda A.Renal handling of amylase: Evidence for reabsorption by stop flow analysis.Metabolism.1972; 21:351-355.
Hegarty JE, O’Donnell MD, Mcgeeney KF,Fitzgerald O.Pancreatic and salivary amylase /creatinine clearance ratios in normal subjects and in patients with chronic pancreatitis.Gut.1978;19:350-354.
Meroney WH, Lawson NL, Rubini ME, Carbone JV.Some observations of the behaviour of amylase in relation to acute renal insufficiency. New England Journal of Medicine.1956;255:315-
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241517EnglishN2013September12HealthcareAUTOIMMUNE RETINOPATHY-A REVIEW
English1623Devendra Pratap Singh RajputEnglish Priti SinghEnglish S. B. GuptaEnglish Samarth ShuklaEnglish Sourya AcharyaEnglish Rashmi KumarEnglishAutoimmune retinopathy is a rare autoimmune disease that primarily affects retinal photoreceptor function. It mainly presents in the fifth and sixth decades. Three main forms of autoimmune retinopathy (AIR) have been identified: cancer-associated retinopathy (CAR), melanoma-associated retinopathy (MAR), and non-neoplastic autoimmune retinopathy (npAIR). In this chapter, the term AIR will be used to encompass all three disorders. Patients typically present with a sudden onset of photopsia, rapid visual loss, and abnormal electroretinograms (ERGs). Different types of AIR present with similar clinical features and it requires extensive work up to rule out other differential diagnosis. Pt presents with poor visual prognosis that may be due to delayed diagnosis and delay in initiation of treatment. Different treatment modalities have been tried, including systemic immunosuppression with steroid and steroid-sparing agents, intravenous immunoglobulin, and plasmapheresis, with variable results. Different types of antiretinal antibodies have been found in these patients with autoimmune retinopathy such as antibodies to recoverin, α-enolase and transducin-α, but seronegative disease is also common. A lot of research work has been done in this field to understand the pathophysiological mechanisms that is responsible for autoimmune retinopathy, but than also understanding about this rare disorder is limited. In this review we have tried to summarize the pathogenic mechanism, clinical features, investigation, differential diagnosis, treatment and prognosis of autoimmune retinopathy.
EnglishAutoimmunity, Retinopathy, AutoantibodyINTRODUCTION
Auto immunity is a condition in which ones own tissues are prone to be affected by deleterious effects of the immunological system. Autoimmune retinopathy occurs when antigens trigger an immune response, which produces antibodies those cross reacts with a retinal protein. Autoimmune retinopathy represent an important cause of an otherwise unexplained acute or sub-acute vision loss in adults. These forms of retinal disease result from a presumed immunological process affecting the retina by auto antibodies directed against retinal antigens(1-3).
Autoimmune retinopathies can occur:
1. Rarely as primary autoimmune retinopathy.
2. More commonly as.
a. Cancer associated retinopathy (CAR)
b.Retinopathies secondary to various autoimmune reactions.
Cancer associated retinopathy is the term that has been used for the retinal degeneration first described by Sawyer and associates [4] in 1976 as a distant effect of cancer. Paraneoplastic retinopathy, a term first used by Klingele and associates in 1984(5) has become the more general term used for any of a number of autoimmune retinopathy associated with a malignant tumor. Autoimmune retinopathy is the preferred term for an acquired, presumed immunologically mediated retinal degeneration with symptoms resembling paraneoplastic retinopathy(2).
The etiology and source of antigenic stimulation vary but are largely unknown. It is possible that the disease is triggered by molecular mimicry between retinal proteins and presumed viral or bacterial proteins or by the acquired alteration of host tissues or antigen so that the autoimmunity is induced against retinal proteins. Multiple retinal proteins have been found to be antigen including recoverin , enolase , arestin , transdusin TUPL I , neurofilament protein , heat shock protein ,70 PNR and as yet unidentified bipolar cell antigen causing melanoma associated retinopathy (MAR syndrome)(6) .
Autoimmune retinopathies are ophthalmic disorders in which autoantibody damage retina and its components causing progressive vision loss. Autoimmune retinopathy typically presents in the fifth and sixth decades with rapidly progressive, bilateral, painless visual deterioration(7).
Specific forms of autoimmune retinopathies that have been identified include cancer associated retinopathy (CAR)(4,8), melanoma associated retinopathy (MAR)[6] , anti-enolase retinopathy[2], anti-carbonic anhydrase retinopathy and cancer associated cone dysfunction(9).
Some patients of secondary autoimmune retinopathy had associated systemic autoimmune diseases such as rheumatoid arthritis, grave’s disease, systemic lupus erythematosus and antiphospholipid antibody syndrome(10).
EPIDEMIOLOGY
Autoimmune retinopathy is an uncommon disorder, exact prevalence not known. It usually affect older adults, but patients as young as three years have been described with no sex predilection(11,12). Cancer associated retinopathy is most common form of autoimmune retinopathy. The malignancy most commonly associated with disorders is small-cell lung cancer, followed by gynecological breast cancers. Some cases have been reported with Hodgkin’s lymphoma, pancreatic and colon cancers (11,13). MAR appears to be increasing in frequency relative to CAR, perhaps because of a decrease in cases of lung cancer(11).
CLINICAL FEATURES
Autoimmune retinopathy typically presents in the fifth and sixth decades with rapidly progressive, bilateral, painless visual deterioration but an unremarkable fundus examination(7). Patients typically present with sudden onset of photopsia, rapid visual loss, and abnormal electroretinograms (ERG)(14). Bilateral vision loss as a result of both rod and cone dysfunction in CAR may occur over a period of months, visual symptoms may precede diagnosis of the systemic malignancy(15).
The triad of photosensitivity, ring scotoma, and a reduced caliber of the retinal arteriole along with undetectable signals in ERG are specific manifestations of CAR(16). MAR is characterized by shimmering, flickering or pulsating photopsias and usually occurs in the patients with cutaneous melanoma(16).
Besides glare sensitivity and flashing lights, a rapidly progressive, often asymmetric visual loss may occur. Although paracentral and mid-peripheral scotomas can be found frequently, visual field defects are often quite heterogeneous (17).
Individuals with cone involvement have
Photosensitivity (light sensitivity)
Prolonged glare after light exposure (hamarolopia)
Reduced visual acuity and loss of vision.
Patients with rod involvement have
Difficulty in seeing in dim lighting (Nyctalopia).
Prolonged dark adaptation.
Peripheral field vision loss.
Signs
Decreased central visual acuity
Visual field defects (central, paracentral or equatorial scotomas)
Alternate pupillary defect if asymmetric involvement.
Defective color vision.
Fundus Findings
Fundus can appear normal initially but with progression there is evidence of retinal degenerations (Retinal pigment epithelium RPE thickening and mottling, attenuation of the arterioles, optic nerve pallor. Cystoid macular edema (CME) has been reported in patients with non paraneoplastic retinopathy (npAIR) but is less common with CAR (18,19).
As reported by Keltner et al, fundus findings in 43 patients with MAR were as follows: 19 (44%) patients had normal fundus findings at presentation, 13 (30%) had vascular attenuation, and 12 (28%) had RPE changes. Vitreous cells were present in 13 (30%) patients, and 10 (23%) had optic disc pallor (11, 20)
Investigations and Diagnosis
All the patients who presented with unexplained loss of central vision, visual field defects, and/or photopsia are diagnosed with AIR based on clinical features, ERG findings, serum antiretinal antibody analysis and OCT testing for macula (10).
On OCT, patients show outer retinal abnormalities and/or decreased macular thickness. In Macular OCT reduced central macular, foveal thickness, loss of the photoreceptor layer or disruption of the photoreceptor outer and inner segment junction was noted(10)
Figure3
It should also be noted that antiretinal antibodies may be present in the normal population and their presence does not necessarily indicates retinopathy(10).For example, while anti recoverin autoantibody is not typically present in the normal population, the frequency of anti-α-enolase autoantibody is approximately 10% in healthy subjects; however this is not well defined for other anti-retinal auto antibodies(21,22).
It was found that autoantibodies against retinal proteins from patients with retinopathy were cytotoxic to retinal cells, in contrast to those from healthy subjects, probably through recognition of additional unique regions on their target retinal antigen(23).
Antibody Testing and their cytotoxic effects can be assessed with western blot, ELISA, immunocytochemistry, cytotoxicity assay for acute recovering antienolase antibodies assay[24].
The literature varies in diagnostic criteria for AIR and firm establishment of this diagnosis is challenging.
There have been different antibodies isolated against many specific retinal proteins in patient with autoimmune retinopathies. Patients with CAR possess autoantibodies, including recovering (23KDa), α-enolase(46KDa)(21,25). Other autoantibodies against retinal proteins have also been reported such as neurofilament proteins, heat-shock protein 70, TULPI protein, 40KDa insoluble protein(21,25-30).Auto antibodies binding to bipolar cells have been linked to the melanoma- associated retinopathy (MAR) syndrome(31-33)
Table 1
ELECTRORETINOGRAM
Typically, the responses in the ERG are markedly reduced, but normal ERGS are also described (17).Full field ERG are almost always abnormal, attenuated or absent photopic and scotopic response. IN CAR where mainly the cones are affected, full filed ERG could be normal but multifocal ERG will be abnormal.
DIFFERENTIAL DIAGNOSIS OF AUTOIMMUNE RETINOPATHY
Retrobulbar optic neuropathy.
Toxic nutritional optic neuropathy or hereditary optic neuropathy.
In malignancy unexplained visual loss may be due to infiltration of malignant cell around optic nerves metastasis to orbit and optic neuropathy due to chemotheraputic agents
Acute Zonal occult outer retinopathy (AZOOR).
TREATMENT
Treatment of primary disease should be done in conjunction with a physician and an oncologist. Long term immune suppression is the main therapy. Immunosuppression has been used to treat AIR with mixed results. Sawyer et al treated 1 of the original 3 patients with CAR with prednisone but saw no improvement34. Keltner et al reported the first patient with CAR responsive to corticosteroid therapy35. Since then, there have been numerous case reports in the literature using short-course high-dose intravenous methylprednisolone or oral prednisone. Plasmapheresis, when used alone, led to no improvement36, when used with prednisone, vision improved in 1 patient37. Guy and Aptsiauri reported improvement in 2 of 3 patients treated with intravenous immunoglobulin and stabilization in the third38. Espandar et al recently reported stabilization of CAR with alemtuzumab therapy39.
Various treatment modalities have been tried in patients with CAR, including oral and intravenous steroids, plasmapheresis, IVIg, rituximab, azathioprine, cyclosporine, and mycophenolate mofetil[40-43]. Despite treatment with these systemic medications, it is not unusual to have a progressive decline in vision with this disease 44. Serial intravitreal injection of triamcinolone may be beneficial for maintenance of vision in patients with CAR 44.
PROGNOSIS
Treatment may provide mild to moderate transient visual acuity improvement. But overall the visual prognosis remains poor. In cases of CAR, systemic cancer treatment usually do not lead to visual improvement However prognosis depends on their underlying malignancy (16).
DISCUSSION
The diagnosis of autoimmune retinopathy remains extremly challenging. Patient has to undergo extensive neurological and neuro- ophthalmogical evaluation it also should be noted that antiretinal antibodies may be present in the normal population and their presence dose not necessarily indicate retinopathy.
Different mechanism of cell damage have been suggested for anti recoverin (45,46) and anti-enolase antibodies(47,48) predominantly resulting in apoptosis of retinal cells, therefore it appears that apoptosis may be a common pathway for retinal autoantibody induced retinal degeneration.
The evidence supporting the effects of antibodies on retinal cells are the following findings:
a) Autoantibodies against recoverin specifically labeled retinal photoreceptor cells and were internalized by cells causing their apoptotic death[ 49].
b) In CAR patients, autoantibodies against α-enolase induced the apoptotic death of retinal cells, and in glaucoma patients, autoantibodies against γ-enolase labeled retinal ganglion cells and induced their death through apoptosis [50,51]
Independent of specificity, autoantibody-induced apoptosis is a pathway to retinal death in AR.
However the pathogenic mechanisms of retinopathies are complex and our understanding of AR is still incomplete. Further studies are necessary to identify anti-retinal autoantibodies, to test their pathogenic potentials through in vivo and in vitro methods, and to define clinical and electrophysiological indicators for seropositive patients.
ACKNOWLEDGEMENT
Authors acknowledge the great help received from the scholars whose articles have been cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Authors are grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=1105http://ijcrr.com/article_html.php?did=1105
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Dr Kathryn L. Pepple, PhD, Dr Prithvi Mruthyunjaya OphthalmologyTimesEurope Volume 9, Issue 5.
Kimberly E. Stepien, MD,* Dennis P. Han, MD, Jonathan Schell, MD, Pooja Godara, MD, Jungtae Rha, PhD, and Joseph Carroll, PhD. Trans Am Ophthalmol Soc. 2009 December; 107: 28–33.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241517EnglishN2013September12HealthcareA STUDY ON GOITRE - IN A TERITIARY CARE HOSPITAL
English2427C. P. Ganesh BabuEnglish K. KarunakaranEnglishA total of 450 cases of Goitre is studied from January 2006 - October 2009 in a tertiary care hospital. Aim: To evaluate the cause and diagnosis of thyroid swelling in MAPIMS. Materials and Methods: All cases were evaluated by performing thyroid function tests, ultrasound neck, FNAC. Patients were classified according to age distribution, gender, according to symptoms of Hypothyroid, Euthyroid, Hyperthyroid Conclusion: More than 60% of the patients were suffering from Physiological Goitre. 15% were solitary nodule, 15% were Multinodular, 5% were Hashimotos, 5% malignancy. In our area most of the patients were suffering from Physiological Goitre due to low usage of iodized salt which is epidemiologically important.
EnglishGoitre, iodized salt.INTRODUCTION
Goitre is defined as enlargement of thyroid gland. Causes for goitre is wide open from benign to malignant conditions (table 1).(1). Even though national health programme has been initiated in India, still in many regions of India people use non -iodized salt only.
MATERIALS AND METHODS
A total of 450 cases of thyroid swelling were studied in MAPIMS from January 2006 to October 2009. Investigations performed were thyroid function tests, ultrasound thyroid, fine needle aspiration. Patients were classified according to age distribution, gender, and according to symptoms of Hypothyroid, Euthyroid and Hyperthyroid. And patients usage of iodized salt or not has also been used in the inclusion criteria.
RESULTS
Age distribution was from 10years to 70 years in our study. Most patients presented to our out - patient were in between 10 - 20 years of age (62%), next 21- 30 years (14.8%). (Table 2), (table 3). (R 2, R 3)
In female population alone 266 cases were reported in between age 10 -20 years , 54 patients were in the age 21 – 30 years. (table 4). In male population , more number of cases were reported in the age group of 31 - 40 years around 20 cases.(table 5).
According to the diagnosis, physiological Goitre cases were the commonest 271 cases(60.2%). next most common diagnosis is Thyroiditis.(table 6). Most of the patients were either Hypothyroid or Euthyroid. (table 7). (R 4). Comparing the usage of iodized salt , around 68.89% (310 cases) were not using iodized salt.( table 8).
DISCUSSION
Our study demonstrates the presence of significant amount of Physiological goiter in a particular geographical area inspite of the government agencies efforts in popularizing the use of iodized salt. 271 cases (60.22%) of Goitre in our area is Physiological Goitre due to lack of health education about iodized salt. 310 cases (69.89%) were not using iodized salt. In the 271 cases of physiological Goitre 250 cases were not using iodized salt and the remaining 21 cases inspite of usage of iodized salt usage they had Goitre due to low intake of salt. Even though majority of the population is not using iodized salt i.e, iodine deficiency prevalent in the community, why female patients are predominantly suffering from Physiological goiter.
Another paradox in our study, in the male population physiological goiter is more common in the age group of 31-40 years which is not a physiologically active age group when compared to the age group of 10-20 or even 20-30. These are few questions which have to be addressed or atleast debatable in suitable forums.
CONCLUSION
In our study we have concluded that area in and around hospital most of the people 60.22% were suffering from physiological Goitre due to lack of usage of iodized salt which is epidemiologically significant. Hypothyroidism can be prevented from usage of iodized salt.
Englishhttp://ijcrr.com/abstract.php?article_id=1106http://ijcrr.com/article_html.php?did=1106
Kabadi, Udaya. M, Abdaliah, Mouin, Goitre: a review of pathophysiology and management, march 2007.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241517EnglishN2013September12HealthcarePHENOTYPIC ASSAYS FOR DETECTION OF ESBL AND MBL PRODUCERS AMONG THE CLINICAL ISOLATES OF MULTIDRUG RESISTANT PSEUDOMONAS AERUGINOSA FROM A TERTIARY CARE HOSPITAL
English2835Kalaivani R.English Shashikala P.English Sheela Devi C.English Prashanth K.English Saranathan R.EnglishIntroduction: Pseudomonas aeruginosa has been a major nosocomial pathogen associated with nosocomial pneumonia, surgical site infections and UTI in patients admitted to intensive care units in the recent past(1). Major risk factors includes prolonged hospitalization, ventilation, underlying immunocompromised state and inadequate or irrational antimicrobial therapy(2). Despite improvements in therapy due to introduction of newer antimicrobials, P. aeruginosa is intrinsically resistant to number of antimicrobials, they aroused a major challenge to overcome the morbidity and mortality caused by multidrug and pan drug resistant P. aeruginosa(3). Drug resistance in turn leads to prolonged hospital stay and increased expenditure, which causes increased cross infections and poorer clinical outcomes. The present study investigated the prevalence of resistance mechanisms among Multi Drug Resistant Pseudomonas aeruginosa (MDRPA) clinical isolates from a tertiary care hospital. Methods: Seventy-five MDRP. aeruginosa isolates were obtained from 226 patients admitted in various wards. Antimicrobial susceptibility testing was performed by disk diffusion method and all these isolates were found to be MDR. All the isolates were subjected to different phenotypic assays to detect the production of enzymes such as ESBL, AmpC and MBL,. MIC determination was done by agar dilution method for Meropenem and Polymyxin B. Further, quantitative evaluation of biofilm production by was carried out by microtitre plate assay, since many studies have shown positive correlation between MDR and biofilm formation. Results: Of the 75 MDR P. aeruginosa, 36% were resistant to imipenem and 80% to meropenem. All the isolates were sensitive to polymyxin B. MBL production (38.67%) was found to be the predominant resistance mechanism followed by ESBL production (26.67%). None of them showed AmpC production. Ninety three percent (93%) of the strains produced abundant biofilms. Conclusion: P. aeruginosa was shown to be predominant nosocomial pathogen showing resistance to most of the available antibiotics including carbapenems. MBL is shown to be predominant mechanism for development of resistance in the present study.
EnglishMDR, Pseudomonas aeruginosa, ESBL, MBL.INTRODUCTION
Pseudomonas aeruginosa is one of the significant Gram-negative bacteria causing hospital-associated infections(4). Among the common multidrug resistant (MDR) nosocomial pathogens emerged in medical centers, P. aeruginosa is the most frequent pathogen causing life threatening infections markedly, respiratory tract infections, surgical site and urinary tract infections in patients from intensive care units (ICUs)(5). It has significant role in causing chronic debilitating respiratory infections in cystic fibrosis patients due to mucoid strains, which leads to increased mortality. Prolonged endotracheal intubation, associated with exposure to inappropriate antimicrobial therapies leads to colonization of the upper respiratory tract thereby complicates the eradication (6).
A major challenge has aroused regarding the treatment of infections caused by opportunistic pathogens, predominantly those with pan drug resistant P. aeruginosa and Acinetobacter baumannii strains, which has extreme ability to acquire resistance (7, 8). P. aeruginosa possesses the ability to acquire resistance genes from the environment as well as from other bacteria (4). High mortality may be attributable to the inherent virulence of the organism as well as the fact that it often occurs with immunosuppression and co morbidity conditions (9, 10). In addition, P aeruginosa is susceptible to a limited number of antimicrobial agents, which increases the likelihood of inappropriate empirical antimicrobial therapy. Reported rates of Multidrug Resistant Pseudomonas aeruginosa (MDRPA) varied from 0.6% - 32% according to various surveillance studies held in different geographic locations (11, 12). The prevalence of MDRPA has increased over the past decade and has become a major concern among hospitalized patients. Several mechanisms can contribute to resistance in P. aeruginosa, including β-lactamase production, up regulation of efflux systems, biofilm formation and decreased outer membrane permeability.
However, production of β- lactamases such as Metallo- β- lactamases (MBL) and Extended spectrum β-lactamases (ESBL) are the most common resistant mechanisms documented in P. aeruginosa. As carbapenems are the most potent β-lactams against P. aeruginosa, intensive use of carbapenems facilitated the emergence of carbapenem-resistant P. aeruginosa(14). Resistance to all antibiotics except polymyxins is now a reality in many medical centers. Despite of abundant literature, little is known about the prevalence of these mechanisms among the clinical isolates of P. aeruginosa from India. Hence, this study was carried out to understand the prevailing mechanisms of resistance among the clinical isolates of MDRPA from in-patients of a tertiary care hospital. This possibly will help to prevent the associated morbidity and mortality caused by this organism by implementing proper infection control measures, which can reduce the duration of hospital stay and expenditure.
MATERIALS AND METHODS
Study design
A descriptive study was conducted during the period of November 2009 to October 2010. Seventy-five MDR P. aeruginosa isolates were obtained from 226 patients admitted in various wards of the hospital. All the clinically significant MDRPA isolates collected in the Department of Clinical Microbiology laboratory from wound swabs, endotracheal aspirates, urine, blood, broncheoalveolar lavage, drain tip and tissue samples were investigated. Repeat isolates were excluded from the study. All the isolates were identified by standard microbiological techniques. ATCC P. aeruginosa 27853 strain was used as quality control reference strain for all experiments with satisfactory results.
Antibiotic susceptibility testing was performed by Kirby-Bauer disc diffusion method. All these isolates were found to be MDR and were responsible for clinically significant infections. Isolates were also tested for carbapenemase production, if they were found to be intermediate or resistant to either Imipenem or meropenem in disc diffusion method. MIC values were determined by agar dilution method for clinically relevant antibiotics such as meropenem (Astra Zeneca, Bangalore) and polymyxin B (Hi-Media, Mumbai) as per CLSI guidelines.
All the MDR P. aeruginosa were subjected to different phenotypic assays to detect the production of enzymes such as ESBL, AmpC and MBL, which are implicated for causing multiple drug resistance. Phenotypic confirmatory test for ESBL production was performed by placing ceftazidime (30 μg) and ceftazidime + clavulanic acid disc. Detection of Metallo-ß-lactamases was carried out by combined disc diffusion test. AmpC detection was done using AmpC discs method.
Microtitre plate assay for Biofilm production
Since many studies have shown positive correlation between biofilm and multiple drug resistance, quantitative evaluation of biofilm production by P. aeruginosa isolates was carried out by microtitre plate assay (16), (17). Biofilm negative E. coli isolate from our collection and ATCC P. aeruginosa 27853 were used as negative and positive controls respectively. Based on the OD values, the extent of biofilm formed by the clinical isolates were classified as follows,
OD ≤ ODc - Non adherent
ODc < OD ≤ 2 × ODc- Weakly adherent
2 × ODc < OD4 × ODc- Moderately adherent
4 × ODc < OD - Strongly adherent (20).
RESULTS
Among the seventy-five patients with MDRPA infection, males were found to be more predominant (66.7%) than females (33.3%). MDR P. aeruginosa infections were found to be 34.7% between 21 to 40 years of age group. MDR P. aeruginosa were mainly isolated from wound infections (43%), followed by endotracheal aspirates (19%), urine (16%), and blood (11%), bronchoalveolar lavage (BAL)( 7%,) drain tip (3%) and tissue (1%) respectively(Fig.1). Various risk factors for MDRPA infection were patients with prolonged hospitalization (52%), patients who are on Foley’s catheter (45%), patients with diabetes mellitus (37%), on ventilator (25%), on tracheostomy (21%), post operative patients (16%), on central line catheter (12%) and on steroids (1%). Thirty-three percentage of patients (n=25) were found to have more than two risk factors.
MDRPA isolates showed markedly high-level resistance towards ciprofloxacin (95%), tobramycin (92%), ceftriaxone and gentamicin, (83%). Forty-four isolates (59%) showed resistance to amikacin and 51% resistance was noticed for piperacillin + tazobactum. Among carbapenems, imipenem showed 36% resistance and meropenem 53% resistance. None of the isolates was resistant to polymyxin B. Among the 75 MDRPA isolates, 13 isolates, which were isolated from urine samples, showed 77% of resistance to norfloxacin and carbenicillin.
MIC for meropenem ranged from 0.5µg/ml to >64µg/ml. Forty out of seventy five (53.33%) isolates of MDRPA were found to be resistant to meropenem. The isolates were categorized resistant if the MIC value was more than 8µg/ml. Thirty two (42.67%) isolates showed sensitive MIC value (≤4µg/ml) and 4% (3) isolates showed intermediate MIC value (8µg/ml). All the isolates showed lower MIC of 0.5µg/ml to 1µg/ml for polymyxin B (Break point MIC for Pseudomonas aeruginosa ≤2µg/ml to ≥8µg/ml) and none of these isolates showed resistant or intermediate MIC values (Fig.2).
Thirty-nine percent of isolates were found to produce MBL and only, 27% isolates showed ESBL production, none of the isolates showed AmpC production. Twelve percent (9) of isolates were found to be negative for phenotypic production of all β-lactamases (fig.3). Almost all isolates (93%) from our collection were biofilm producers, wherein 75% of the isolates were strongly adherent, 8% moderately adherent and 11% weakly adherent. The percentage of non-adherent cells or biofilm negative isolates was found to be a meager of 7%.
DISCUSSION
P. aeruginosa is a leading cause of nosocomial infections, and it exhibits intrinsic resistance to almost all commercially available antimicrobial agents. However, acquired resistance to anti-pseudomonal β-lactam antibiotics such as ticarcillin, piperacillin, ceftazidime, cefepime, aztreonam and especially carbapenems can be a major challenge in managing MDRPA infections, mostly when it is associated with co-resistance with other classes of drugs namely aminoglycosides and quinolones. Acquired ESBL and metallo-β-lactamases are the major β-lactamases produced by P. aeruginosa.
The prevalence of MDR P. aeruginosa was found to be 33.2% in our investigation, which is in accordance with a similar recent study from India that showed the predominance rate of 44% (18). However, comparatively lesser prevalence of MDRPA (26.7%) responsible for burn wound infections in Iran (19). Likewise, one more investigation from India reported 22% MDRPA and 4% Pandrug resistant P aeruginosa (20), wherein, we recorded a higher level of MDRPA incidence. Factors such as age and sex among MDRPA infection were found to have significant association with MDRPA, wherein the incidence was more among the age groups between 21 and 40 (34.7%) and males being predominant (67%) which is the likely case in earlier reports (21). Possibly, it may be due to high incidence of road traffic accidents among males, leading to hospitalization thereby high incidence of P. aeruginosa infection through catheterization.
Earlier investigations have reported the major source of MDRPA to be sputum, tracheostomy specimen, pus, respiratory tract, surgical sites and endotracheal aspirate (22, 23 24, 25). In the present study, the major source of MDRPA was found to be wound swabs (43%), followed by endotracheal aspirate (19%) implying that wound infections and respiratory tract infections are most significant infections caused by MDRPA in most of the hospitals including our setup. The major risk factors were prolonged hospitalization followed by patients on Foleys catheter. Foot infections and surgical site infections were found to be common source of MDRPA among the diabetic patients.
MDRPA isolates showed markedly high-level resistance towards ciprofloxacin (95%), tobramycin (92%), ceftriaxone and gentamicin, (83%). Forty-four isolates (59%) showed resistance to amikacin and 51% resistance was noticed for piperacillin/ tazobactum combination. Among carbapenems, imipenem and meropenem resistance was observed to be 36% and 53% respectively. None of the isolates were resistant to polymyxin B. Among the 75 MDRPA isolates, 13 isolates, which were isolated from urine samples, showed 77% of resistance to norfloxacin and carbenicillin.
MIC for meropenem ranged from 0.5µg/ml to >64µg/ml. Forty out of seventy five (53.33%) isolates of MDRPA were found to be resistant to meropenem. The isolates were categorized resistant if the MIC value was more than 8µg/ml. Thirty two (42.67%) isolates showed sensitive MIC value (≤4µg/ml) and 4% (3) isolates showed intermediate MIC value (8µg/ml). All the isolates showed lower MIC of 0.5µg/ml to 1µg/ml for polymyxin B (Break point MIC for Pseudomonas aeruginosa ≤2µg/ml to ≥8µg/ml) and none of these isolates showed resistant or intermediate MIC values.
Among various mechanisms of resistance, MBL and ESBL enzymes were found to be more effective and the incidence of MBL production in P.aeruginosa has been reported to be 10-30% from different clinical setups in India (26). Recent studies have shown a very high incidence of MBL (47%), AmpC (50%) and ESBL (13.3%) among the MDRPA isolates tested (29). In our study, also we have observed a high prevalence of MBL (39%), ESBL (27%) producers and 22% of MDRPA isolates were found to produce both MBL and ESBL, which appears to be significant. Around 12 % of isolates did not show any of the mechanisms studied which might follow altogether different resistance mechanisms like formation of biofilms and/or cell wall permeability defects and efflux pump mechanisms (27)
High percentage of biofilm producers were observed in our study, which may be due to the increase number of MDRPA isolates encountered. Morten Hentzer et al. earlier reported the strong correlation between biofilm formation and multiple drug resistance in Gram-negative pathogens (29). Thus, biofilm formation appears to be one of the mechanisms among these strains to develop multi drug resistance, which is evident from the earlier reports from India (28).
CONCLUSION
In summary, MDR P. aeruginosa is a notable cause of hospital acquired infections and known to cause a wide spectrum of life threatening diseases. These organisms are resistant to almost all commonly available antibiotics with limited treatment options. Thirty-six percent of isolates showed resistance to imipenem and 53% to meropenem, which is an “alarming sign”, since carbepenems were the present drug of choice. Furthermore, 93% of isolates had the ability to form biofilm that might aid in the persistence of MDRPA thereby imparts resistance.
Englishhttp://ijcrr.com/abstract.php?article_id=1107http://ijcrr.com/article_html.php?did=1107
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241517EnglishN2013September12HealthcareEFFECTS OF SMOKING ON LIPIDS PROFILE
English3642Kavita S. GamitEnglish Meeta G. NanavatiEnglish Priyanka M. GohelEnglish R.N.GonsaiEnglishIntroduction: Smoking is an escalating public health problem in a developing country like India. WHO has recently introduced as fourth global health threat (1). Cigarette smoking is a dominant annually risk factor for premature or accelerated peripheral, coronary and cerebral atherosclerosis vascular disease. In the present study an attempt has been made to find out the effect of smoking on lipids profile in healthy smokers. Results are compared with that of same age groups healthy non smokers. AIMS 1. To study alteration in lipid profile in healthy smokers and compare the same with lipid profile of non-smokers. 2. To find out correlation between the numbers of cigarette smoked to the degree of alteration in profile in different age group. 3. To relate lipid profile alteration with duration of smoking. 4. To find risk stratification on the basis of dyslipidemia in smokers. Material and Method: The present study was carried out at B .J. Medical College, Civil Hospital Ahmedabad. The period of study was June 2012 to December 2012.Healthy smokers were selected mainly from hospital staff and relatives of patients of civil hospital Ahmedabad. A total 130 cases were studied for estimation of lipid profile. Conclusion: In the present study age wise prevalence of smoking is maximum in 30- 39 years group. Smoking causes alteration in lipid profile and risk of cardiovascular diseases. Amount and duration of smoking also influence dyslipidemia. The rapid reduction in risks of cardiac events after cessation of smoking implies that policies that prevent and reduce smoking will have large benefits for reducing cardiovascular mortality.
EnglishLipid profile, Smokers, Non smokersINTRODUCTION
Smoking is an escalating public health problem in a developing country like India WHO has recently introduced as fourth global health threat (1)
Tobacco smoking is one of the most potent and prevalent addictive habits, influencing behaviour of human beings. Smoking is now increasing rapidly throughout the developing world and is one of the biggest threats to currents and future world health. Furthermore, while the prevalence of tobacco use has declined among men in some high income countries, it is still increasing among young people and women. Cigarette smoking is the most common type of tobacco use. Tobacco continues to be the second major cause of death in the world. (2) By 2030, if current trends continue smoking will kill more than 9 million people annually. (3)
Cigarette smoking is a dominant annually risk factor for premature or accelerated peripheral, coronary, and cerebral atherosclerotic vascular disease. A one to three fold increase in risk of myocardial infarction has generally been noted among current cigarette smokers .several possible explanations have been offered for this association including arterial blood coagulation ,impaired of arterial wall ,changes in blood lipid and lipoprotein concentration. (4)
Plasma lipoprotein abnormalities are said to be the underlying major risk factor and may even be essential for the common occurrence of atherosclerotic vascular disease. Most of the epidemiological studies indicated a rise in plasma cholesterol, low density lipoprotein (LDL), very low density lipoprotein (VLDL), and triglyceride .While high density lipoprotein in significantly reduced. Most of the studies indicate a definite correlation between smoking and lipid profile in which there is definite dose response relationship between the numbers of cigarette smoking as well as the duration of smoking and changes in the lipid profile noted Tobacco smoke contain many constitutes ;nicotine is one of the main constitutes. Nicotine causes increase in triglyceride, cholesterol and VLDL levels and decrease in High density lipoprotein (HDL) levels .It has been described that nicotine increase the circulatory pool of atherogenic LDL via accelerated transfer of lipids from HDL and impaired clearance of LDL from plasma compartment therefore it increases the deposition of LDL cholesterol in the arterial wall(5 ) High density lipoprotein (HDL) appears to have an inverse relation to the risk of coronary heart disease, the lower concentration have higher risk of coronary artery disease.(6 )
In the present study an attempt has been made to find out the effect of smoking on the lipid profile in healthy smokers. Results are compared with that of same age groups healthy non smokers. Exclusively healthy smokers are selected to rule out the effects of any other parameters on alteration in lipid profile.
MATERIAL AND METHOD
The present study was carried out at civil hospital Ahmedabad. The period of study was June2012 to December 2012.healthy smokers were selected mainly from hospital staff and relatives of civil hospital Ahmedabad. A total 130 cases were studied for estimation of lipid profile.
Criteria for selection of cases (healthy smokers):
Age: ≥15 and ≤ 50 years
Body mass index (BMI) : 20 cigarette /biddi smoking and age also play important role in the HDL level in the blood of healthy smokers. There is significant decreased in serum HDL level in heavy smokers as compare with light, moderate and control group.
Table no 8 showing mean values of lipid profile analysis in smokers and non smokers.
Table no 9 shows comparison of lipid profile in smokers. Anova test was applied to find the significance of effect of chronicity of smoking on dyslipidemia .Results shows significant difference in lipid profile in between those who smoked for about 5-14 years, 15-19 years and more than 20 years. (P < 0.05)
DISSCUSION
In the present study age wise prevalence of smoking is maximum in 30 -39 groups. Cigarette smoking during adolescent has also increased.
In the present study, serum cholesterol values are found to be higher in healthy smokers compared to non smokers. In the 15-19 years values are within the normal range but towards the higher side. Maximum rise is in 40 -50 years age group. It is also affected by number of cigarettes smoked. These finding are in accordance with the finding of the other workers.
In the present study ,these is definite and significant
rise in serum triglyceride value in all the four age groups of healthy smokers, highest values (282.6 mg%) being in heavy smokers group, and in those who smoked for more than 15 years(262mg%).This established a direct relationship between the amount and duration of smoking and triglyceride level. The triglyceride levels among smokers are beyond normal range in 92% of smokers. Also very similar are given by other authors for triglycerides in smokers.
In the present study, serum LDL values are in the normal range in 15-19 years group .The increase in the LDL in 40-50 years age group is maximum and beyond normal range. While in middle age group it is borderline high. The LDL level also increased with numbers of cigarette smoked show direct dose response relationship. Thus age and chronicity of smoking effect on serum LDL level. And these observations are in agreement with those of other workers.
Serum VLDL concentration is found to be progressively increasing with increase in cigarettes consumption, highest being in heavy smokers in all the three age groups in present study.
Serum HDL concentration in smokers, a very consistent observations are made by all the workers establishing an inverse relationship. It is markedly decreased in old age increasing atherogenic risk.
Looking to the complete lipid profile , very significant observation are made in triglyceride and LDL values which are significantly high in smokers ,with increasing values in light to moderate heavy smokers as compared to non smokers. Cholesterol values are definitely higher than control group but as significant as triglyceride and LDL. The HDL concentration show remarkable decreased in smokers as compared to non smokers, making it a very valuable observation and effect of smoking on lipid profile.
CONCLUSION
In the present study age wise prevalence of smoking is maximum in 30 - 39 years group. Cigarette smoking during adolescent has also increased. Smoking causes alteration in lipid profile and increased risk of cardiovascular diseases. Amount and duration of smoking also influence dyslipidemia. Increased amount of smoking causes more of dyslipidemia. The rapid reduction in risks of cardiac events after cessation of smoking implies that policies that prevent and reduced smoking will have large benefits for reducing cardiovascular mortality.
Englishhttp://ijcrr.com/abstract.php?article_id=1108http://ijcrr.com/article_html.php?did=1108
Soleiman M .Haji Mahmoud, Jalali F – Lipid profile and morbidity risk in smokers and non smokers. Casp Journal Internal Medicine.2010;1(4):128-33.
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Kshitisk K, Sinha R,Bhattacharjee J A study of smoking on lipid and vitamin C metabolism International Journal of pharma and Bio Sciences.2010;1(4):106-13.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241517EnglishN2013September12HealthcareORGANOLEPTIC QUALITY OF LOW FAT DIETETIC FERMENTED DAIRY DRINK AT LOW PRICE
English4346Kirti SrivastavaEnglish Ramesh ChandraEnglishThe present study was undertaken with the objectives to develop suitable technology for preparation of low fat dietetic fermented dairy drink, to evaluate the organoleptic quality of dietetic fermented dairy drink as well as cost of the product. Three different percentage of milk fat 0.5%, 1.5%, and 3% indicated as F1, F2, and F3 respectively and four different levels of cornflakes powder 4%, 6%, 8% and 10% indicated as C1, C2, C3, and C4 respectively compared to each other. The sensory evaluation of the prepared dairy drink was carried out by using the nine point hedonic scale. Cost of the product was also worked out for different treatment combinations. The data obtained during investigation was statistically analyzed by using factorial design and critical difference between combinations. Amongst the different treatment combinations of dietetic fermented dairy drink, F3C3 having 3 percent milk fat and using 8 percent level of cornflakes powder was found to be superior in terms of flavour and taste, colour and appearance, consistency as well as overall acceptability over the other treatment combinations. The cost wise, dietetic fermented dairy drink prepared was also more economical as compared to the dairy drink available in present day market.
Englishcornflakes powder, milk fat, dairy drink, skim milk.
INTRODUCTION
Cultured buttermilk is economical, delicious and healthful. It is also an ideal beverage for weight watchers. It is so easy to digest that people with poor appetite can readily assimilate it. Cultured buttermilk has a high nutritive and therapeutic value. It is a good source of protein, riboflavin and calcium. Those with digestive problem are often advised to drink buttermilk rather than milk as it is more quickly digested. Many bakers use cultured buttermilk in biscuits, pancakes and other similar product because of the tangy flavour it imparts. Consumers need to be careful with cultured buttermilk because it is a soured product. Although harmful bacteria should not be able to thrive in it, if the flavour is slightly off, it is better to dispose of the buttermilk than to experience minor gastrointestinal distress as the result of bacteria or molds (Sinha and Sinha, 2000)
Maize (Zea mays L.) is an important coarse grain cereal crop holding third position in world production next to wheat and paddy. The pre-eminence of corn is due to its wide diversity of uses and highly useful products into which it can easily be transformed. Maize was domesticated in Central America 6,000 to 10, 0000 years ago. It spread to the rest of the world in the 16th to 18th centuries (FAO 1992 and CIMMYT, 1997). Maize crop has a special place in Indian agriculture and is staple food of people of Utter Pradesh, Punjab, Rajasthan, especially for low socio economic group (Deosthale and Pant, 1971; Reddy et. al. 1991). Maize is consumed mainly in the form of roti, sattu, dalia, phullae, etc. in India. It is used also as an important industrial ingredient for the manufacture of starch, glucose – syrup, dextrose, high fructose syrup, industrial alcohol, beer and whisky (Bhat and Puri, 1971). Maize flour is also used for the manufacture of cereal products, snack foods, cornflakes, instant foods, biscuits, wafers, crackers supplementary foods etc (Kent, 1976).
MATERIALS AND METHOD
The experiment was carried out in the Research Laboratory of Warner School of Food and Dairy Technology, Sam Higginbottom Institute of Agriculture, Technology and Sciences (Deemed-to-be-University), Allahabad. U.P. Skim milk was collated from student’s training Dairy Sam Higginbottom Institute of Agriculture, Technology and Sciences (Deemed-to-be-University), Allahabad. Corn flakes, Salt and other spices were purchased from the local market of Allahabad.
Dietetic fermented dairy drink was prepared by the method adopted for preparation of set curd, with the slight modifications. Quantity of variables such as skim milk, milk fat and stabilizer were optimized converted into curd. Which later was churned fifty percent water, salt and spices were added to it. For flavour enhancement, cornflakes powder was added to it. Dietetic fermented dairy drink composition made according to the method of the invention exhibit good organoleptic characteristics.
Sensory evaluation of low fat dietetic fermented dairy drink was done by a panel of five judges. The evaluation of the product was carried out by using hedonic score card based on “9 point Hedonic scale” allotted for various parameters. (Srilakshmi, 2002) The cost of the prepared product was calculated at the prevailing prices of raw materials purchased from the local market of Allahabad. The data obtained for various parameters was statistically analyzed for its validity by using factorial design and critical difference (C.D.) technique (Imran and Coover, 1983).
RESULTS AND DISCUSSION
Three different ratio of milk fat and four different levels of cereal i.e. cornflakes powder was used in the present experimental work. Dietetic fermented dairy drink prepared from different treatment combinations were compared with each other. The data collected on different aspect as per the methodology have been tabulated and analysis is presented and discussed in the following sequence.
Flavour and taste
Highest flavour and taste score of dietetic fermented dairy drink sample 8.68 was recorded in F3C3. The difference was found to be significant in most of the treatment combinations. Difference in flavour and taste of dietetic fermented dairy drink was probably due to the typical flavour of corn flakes powder added in dietetic fermented dairy drink.
On comparison, the mean values of fat level against the critical difference value, the average value of F3 (8.17) was highest and it differs significantly from all other fat levels. So it can be regarded as the best and on comparison, the mean values of cornflakes ratio against the critical difference value, the average value of C3 (8.52) was highest and it differs significantly from all other cornflakes ratio. So it can be regarded as the best.
Consistency
Highest consistency score of dietetic fermented dairy drink 8.48 was recorded in F3C3. The difference was found to be significant in most of the treatment combinations. The difference in the consistency noted in different treatment combinations was due to variation of cornflakes powder in dairy drink.
On comparison, the mean values of fat level against the critical difference value, the average value of F3 (8.16) was highest and it differs significantly from all other fat levels. So it can be regarded as the best and on comparison of the mean values of cornflakes ratio against the critical difference value, the average value of C3 (8.41) was highest and it differs significantly from all other cornflakes ratio. So it can be regarded as the best.
Colour and appearance
Highest colour and appearance score of dietetic fermented dairy drink samples 8.52 was recorded in F3C3. There was significant difference in most of the treatment combinations. The difference in the colour and appearance noted in different treatment combinations was due to variation of cornflakes powder and spices in dairy drink.
On comparison, the mean values of cornflakes ratio against the critical difference value, the average value of C3 (8.41) was highest and it differs significantly from all other cornflakes ratio. So it can be regarded as the best.
Overall acceptability
Highest overall acceptability score of dietetic fermented dairy drink samples 8.52 was recorded in F3C3 Overall acceptability score of dietetic fermented dairy drink differed significantly in most of the treatment combinations.
On comparison the mean values of fat level against the critical difference value, the average value of F3 (8.11) was highest and it differs significantly from all other fat levels. So it can be regarded as the best and on comparison, the mean values of cornflakes ratio against the critical difference value, the average value of C3 (8.42) was highest and it differs significantly from all other cornflakes ratio. So it can be regarded as the best.
Cost of the product
The average cost of production, one kg of dietetic fermented dairy drink samples i.e. F1C1, F1C2, F1C3, F1C4, F2C1, F2C2, F2C3, F2C4, F3C1, F3C2, F3C3, and F3C4, were Rs.30.05, Rs.35.29, Rs.40.34, Rs.45.21, Rs.31.36, Rs.36.57, Rs.41.60, Rs.46.45, Rs.32.67, Rs.37.86, Rs.42.86 and Rs.47.69 respectively. The cost of production of dietetic fermented dairy drink sample F1C1 (30.05) was much less then the other sample
CONCLUSION
From the findings of this study, it was concluded that among the different treatment combinations of fermented dairy drink, F3C3 having 3 percent milk fat and using 8 percent cornflakes powder level was found to be superior in terms of overall acceptability over the other treatment combinations. Therefore, it is concluded that for overall improvement in consistency, flavour, and taste in a level of 8 percent could easily be incorporated to produce good quality dairy drink. The cost wise dietetic fermented dairy drink treatment combinations were also more economical as compared to the dairy drink available in present day market. It is thus anticipated that dietetic fermented dairy drink will in future provide additional benefits to consumers with respect to convenience, price and health.
Englishhttp://ijcrr.com/abstract.php?article_id=1109http://ijcrr.com/article_html.php?did=1109
Bhat, C.M. and Puri, B.(1971): Nutritive value of maize as affected by home processing. Ind, J. Nutr. Dietet, 9:244 – 248.
CIMMYT. (1997): Science of sustain people and environment. Mexico, D.F: CIMMYT.ISSN: 0188-M9214.PP.38-39.
Deosthale, Y.G. and Pant, k.c. (1971): Nutrient composition and amino acid pattern of some high yielding maize varieties. Ind. J. Nutr. Dietet. 8: 244 – 248.
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FAO, (2009): Food and Agriculture Organization of the United Nations. Statistical Division. Maize, rice and wheat: area harvested, production quantity, yield
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Kent, N.L. (1976): Technology of cereals, Pergamon Press, England, p.210.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241517EnglishN2013September12HealthcareHISTOPATHOLOGICAL PATTERN OF MALIGNANT BREAST TUMOURS AND CORRELATION OF CLINICOMORPHOLOGICAL FEATURES WITH MOLECULAR PROFILE (HORMONE RECEPTOR STATUS) IN KASHMIR
English4753Naila NazirEnglish Ruby ReshiEnglish Sheikh BilalEnglish Summyia FarooqEnglishBackground: There is not much study done in our population group on the various types of breast tumours and the molecular profile (ER/PR status). Since Breast carcinoma incidence is increasing in our population the study was done to evaluate the different histopathological types, the hormone receptor status and there correlation with various clinicomorphological features in our population. Material and Methods: A two year prospective study was carried out on 50 patients with histologically confirmed invasive breast carcinomas which were further subjected to immunohistochemical assay (ER/ PR). Correlation with established risk factors age, tumour size, grade and histopathology were analysed. Results: ER and PR receptors determined by immunohistochemical method revealed ER+/PR+ in 52 %, ER+/PR- in 4 %, ER-/PR+ in 8% and ER-/PR- in 36% of the cases. Postmenopausal women showed a higher incidence of receptor positivity (77.27%) with increasing age. T2 tumours were more common (72%) as compared to T1 and T3 tumours. Receptor status was noted to be comparatively increased in larger sized tumours (88.9%). Infiltrating ductal carcinoma (NOS) was the commonest type (80%) with receptor positivity of 57.5%. Maximum tumours in the study were grade II (50%) which also showed maximum receptor positivity (64%) and the reactivity for the receptors was observed to decrease with increasing grade. Conclusion: ER/PR expression in breast cancers in the current study was found to be higher than the studies done in India/ Asia but still lower than studies done in west, even on Indian/ Asian immigrants to US and other western countries. This markedly lower receptor expression in Indian/ Asian studies is more likely due to preanalytic variables, threshold for positivity and interpretation criteria rather than genetic differences. So it is suggested that these variables need to be further identified and measures taken to rectify them so that a definite assessment of the receptor status can be done.
EnglishMalignant, Breast tumours, Molecular profile, ER, PR.INTRODUCTION
Breast cancer is a major medical problem in women and accounts for 22% of all female cancers with significant public health and social ramifications and is a leading cause of cancer death in women15,19. The number of cases worldwide has significantly increased since the 1970s, a phenomenon partly attributed to the modern lifestyles3,15. Breast cancer is the second most common cancer among women in India, following cancer of the uterine cervix. Presently, 75000 new cases are reported annually and account for 19-34% of all cancer cases among women nationally13,22. Breast cancer is a biologically heterogeneous disease and patients with the same diagnostic and clinical prognostic profiles can have markedly different clinical outcomes. Molecular profiling has provided biological evidence for heterogeneity of breast cancer through the identification of intrinsic subtypes. A crucial development in the evaluation of breast carcinoma has been the realization that the presence of estrogen and progesterone receptors (ER and PR) in the tumour tissue correlates well with response to hormone therapy and chemotherapy 2,11.
Since breast carcinoma is a common disease in this part of the country and a large number of breast carcinomas are diagnosed in our department, the present study was done to describe the morphology of malignant breast tumours- gross and histopathological types, study the molecular profile of breast tumours (estrogen receptor/ progesterone receptor expression) and the correlation between molecular profile of breast tumours and various clinicomorphological features.
MATERIAL AND METHODS
A two year prospective study was carried out from March 2011 to April 2013 on 50 patients in the post-graduate department of pathology, Government medical college Srinagar. Histopathologically confirmed invasive carcinoma cases were included in the study. Benign, in-situ lesions, sarcomas, and secondary lesions were excluded. Patient’s complete clinical data was recorded and the specimens received were fixed by keeping them in 10% formalin overnight. After fixing, gross examination of the specimen was done and findings recorded. Tissue sections about 1 cm apart were taken, put in stainless steel cassettes, labelled and kept in fixative for two to four hours. The tissue blocks were thoroughly washed with distilled water and the tissue was then dehydrated by passing through ascending grades of ethanol and then embedded in molten wax which was maintained in an oven at melting point of wax. A thin film of Mayer’s albumin was spread on clean glass slides and sections were placed on these slides and spread using hot water bath. After this, dewaxing was done by placing the slides in hot oven followed by passing through different grades of ethanol. The sections were stained routinely with Haematoxylin and Eosin and examined under the microscope. Grading of tumours was done according to modified Bloom-Richardson Grading System. IHC was performed by using the avidin-biotin complex peroxidase technique with the chromogen diaminobenzidine and antigen retrieval by heating specimen in microwave. For IHC Formalin fixed and paraffin embedded sections were cut and placed on a glass slides coated with 0.5% poly L-lysine. Endogenous peroxidase activity was blocked by placing slides in a mixture of methanol and hydrogen peroxide (9:1) for 20 minutes. Rabbit monoclonal antihuman estrogen receptor antibody - ER Clone SP1 and antihuman progesterone receptor antibody - PR Clone SP 2, Biocare were used. Sections were counter stained with Mayer’s Haematoxylin. ER and PR reactivity of invasive tumours was assessed. Sections from positive breast invasive ductal carcinomas were used as positive controls; negative controls were obtained by omitting the primary antibody. Scoring of ER and PR reactivity was done using Allred scoring system. All the data was subjected to statistical analysis.
RESULTS
The age of the patients ranged from 27 – 85 years. Average age of patients was 49 years. Maximum number of patients belonged to age group of 31 - 50 years (56%). There were 3 male patients in our study. Out of 50 cases 48 cases were Modified Radical Mastectomies and 2 lumpectomy specimens, with left breast involved in 30(60%) of the cases and 20(40%) involved the right breast. Out of 47 female patients majority i.e. 42 (89.3%) were multiparous, where as 3 were nulliparous, 2 patients were unmarried. Out of 47 female patients 25 (53.2%) cases were pre-menopausal; where as 22(46.8%) were post-menopausal. Mean size of lesion was 3.68 cm, ranging from 1.5 cm to maximum of 10 cm. Most of the tumours were of the size between 2-5 cm (72%). IDC (Infiltrating ductal carcinoma) NOS (-not otherwise specified) was the predominant morphological type constituting 40(80%) of total cases. There was 1 case of Infiltrating Lobular Carcinoma, 2 cases of IDC with Paget’s disease of nipple, 1 case of Carcinoid, 1 case of Squamous cell carcinoma, 2 cases of Medullary Carcinoma, 1 case of Mucinous Carcinoma, 1 case of Carcinosarcoma and 1 case of Adenoid Cystic Carcinoma. According to Modified Bloom-Richardson Grading 9 (18%) cases were grade I, 25 (50%) cases were grade II and 16 (32%) cases were grade III. In our study of 50 cases 28 (56%) cases were ER positive, 30 (60%) cases were PR positive, 26 (52%) cases were both ER and PR positive, 18 (36%) cases were both ER and PR negative, 2 (4%) cases were ER positive and PR negative and 4 (8%) cases were ER negative and PR positive. In our series 77.8% cases above 50 years were found to be ER+/PR+ as compared to only 36.8% cases below 40 years. Among 13 cases in the age group of 41-50 years 38.5% cases were found to be ER+/PR+ (Table 1). In our study 72.7% cases were found to be ER+/PR+ among the postmenopausal cases as compared to only 36% in the premenopausal patients. 80% cases with tumour size less than 2 cm were found to be ER+/PR+ (Table 2). Among Histological type majority of the tumours showing ER/PR positivity were infiltrating ductal carcinoma-not otherwise specified type. In our series 64% of Grade II tumours were ER+/PR+ and decreased to 31.25% in Grade III tumours.
DISCUSSION
The mean age at presentation was 49 years; younger age at presentation as compared to western population was seen in our series which was in concordance with studies done in India2,20,25. Information on Receptor status was done in all 50 cases of which 28 (56%) cases were ER positive, 30 (60%) cases were PR positive. 26 (52%) cases were both ER and PR positive. So our patients show much better receptor positivity as compared with studies done in rest of Asia (Desai et al5 2000, Fatima et al8 2005, Kuraparthy et al14 2007, Shet et al25 2009) where positivity for ER ranges from as little as 31.6% and PR ranges from as little as 25.3% to maximum of Englishhttp://ijcrr.com/abstract.php?article_id=1110http://ijcrr.com/article_html.php?did=1110
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241517EnglishN2013September12HealthcareVALUE OF REPEAT PLAIN X-RAY ABDOMEN IN DUODENAL PERFORATION
English5456M. PalaniappanEnglish C. P. Ganesh BabuEnglish M. BalachandarEnglishAim: To highlight the value of repeat plain X ray abdomen in duodenal ulcer perforation. Case report: 60 year old female patient was admitted with duodenal perforation with negative X-ray at the time of admission. Later the same investigation revealed pneumoperitoneum. Discussion: Pneumoperitoneum may not be evident in all duodenal ulcer perforations immediately after admission. In such occasions, repeat plain X ray abdomen may clinch the diagnosis. Conclusion: The value of repeat X-ray in suspected cases of perforation is stressed in this case scenario.
Englishduodenal ulcer perforation, repeat plain X ray abdomenINTRODUCTION
Duodenal ulcer perforation is one of the commonest emergencies done in general surgery. Clinical diagnosis is made by signs of peritonitis and liver dullness obliteration. Plain x-ray abdomen usually reveals air under diaphragm.In a few patients x-ray does not reveal pneumoperitoneum. In such patients, repeat x-ray turns out to be valuable.
CASE REPORT
Chellammal, 60 years lady presented with complaints of severe generalised abdominal pain of sudden onset of one day duration. She had no previous history of peptic ulcer. On examination, the clinical picture was that of peritonitis. Plain xray abdomen soon after admission showed no pneumoperitoneum. (Fig 1) Patient was put on drip, Ryles tube aspiration and antibiotics. In the course of resuscitation, after 4 hours, a second plain x-ray abdomen was taken which showed gas under the diaphragm.(Fig 2) Hence clinical suspicion of perforated hollow viscus was confirmed. At emergency laparotomy, a 2mm duodenal perforation was found(Fig 3) in the anterior wall of the first part of duodenum. This was closed by sutures with live omental patch reinforcement. In the subsequent post-operative course, patient did well. She was discharged early in the third week after complete wound healing.
DISCUSSION
Diagnosis of perforative peritonitis is usually straightforward. X-ray findings are confirmatory with pneumoperitoneum. In a few patients x-ray does not support the clinical findings. Small quantities of free gas, as little as 1cc are best detected on erect chest and left lateral decubitus films, according to Miller and colleagues in 1980(1) Air insufflation via Ryles tube has been advocated by some to reveal pneumoperitoneum in duodenal perforation. Gastrograffin dye instillation through Ryles tube and x-ray to reveal dye leak has also been suggested. (2) But in our opinion, these procedures carry the risk of reopening spontaneous seal of a perforation and adversely affecting the outcome. A simple repeat plain x-ray abdomen after 3 or 4 hours in the course of resuscitation is very safe, simple, easy to carry out and informative in patients with acute abdomen.
CONCLUSION
Various methods have been suggested for confirming pneumoperitonium in patients with negative X rays, like injecting air through the Ryle’s tube before X ray or taking contrast X ray. But simple repeat plain Xray abdomen after three or four hours is the safest and simplest method without risk of reopening spontaneously sealed perforations. In patients with peritonitis if the initial x-ray is not informative ,during the course of resuscitation repeat plain x-ray in 3 or 4 hours can be valuable. This article emphasises the value of simple repeat plain x-ray for diagnosis.
Englishhttp://ijcrr.com/abstract.php?article_id=1111http://ijcrr.com/article_html.php?did=11111. Miller RE, Becker GJ, Slabsugh RD: Detection of pneumoperitoneum, Optimum body position and respiratory phase; AJR 1980, 135:487.
2. Hugh TB, Perforated peptic ulcers in Maingot’s abdominal operations, Seymour I. Schwartz and Harold Ellis, 9th edition, vol-1, Appleton & Lange, 1990, p.633
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241517EnglishN2013September12HealthcareWORK POSTURE AND PREVALENCE OF MUSCULOSKELETAL SYMPTOMS AMONG WOMEN IN PACKING ACTIVITIES OF PHARMACEUTICAL INDUSTRY
English5764Prasuna VelagaEnglish Neeraja TelaproluEnglishThe pharmaceutical industry is one of the major industries of Andhra Pradesh. Huge number of women were employed in these industries to carry out packing activities manually. These packing activities being static and repetitive may give rise to fixed body positions, continued repetition of movements and concentrated force on hand or wrist with out sufficient recovery between the movements. A study was undertaken to determine the prevalence of musculoskeletal symptoms among women workers involved in packing activities of pharmaceutical industry. The sample consisted of 270 women workers randomly selected from nine pharmaceutical industries in Hyderabad. Work posture was evaluated by using RULA (Rapid Upper Limb Assessment) technique. A scale was developed to study the musculoskeletal symptoms in nine anatomical body regions. The musculoskeletal discomforts like pain, stiffness, swelling, spasms and so on experienced by women were explored. Correlation between the postural score obtained with the use of RULA and musculoskeletal symptoms was explored. There was a significant positive correlation between RULA posture score and prevalence of musculoskeletal symptoms. Further through ANOVA significant difference between the respondents with mild, moderate and severe musculoskeletal symptoms was found out. The results emphasized poor working postures of the workers in packing activities need to be changed soon.
EnglishMusculoskeletal Symptoms, Packing, Pharmaceutical industry, Posture, RULAINTRODUCTION
The Indian Pharmaceutical Industry is in the first rank among India’s science based industries with wide ranging capabilities in the complex field of drug manufacture and technology (APITCO, 2009, [1]). In pharmaceutical industry though the process of manufacturing is mechanized, the process of packing is still undertaken manually. Mostly the packing is done by women. The majority of packing activities are characterized by a sitting posture, worker’s head and trunk flexed forward and shoulders flexed and abducted. In this situation high rate of work related musculoskeletal disorders occurrence could be expected. Work related musculoskeletal disorders (WMSD) are a group of painful disorders of muscles, tendons and nerves. WMSD arise from ordinary arm and hand movements such as bending, straightening, gripping holding, twisting, clenching and reaching. These common movements are not particularly harmful in the ordinary activities of daily life. These movements become hazardous due to continuous repetition often in a forceful manner with lack of time for recovery between them (Canadian Centre for Occupational Health and Safety, 2005, [2]). The main objectives of present research were (i) Evaluate body postures of workers.
(ii) Determining the prevalence of musculoskeletal symptoms among workers. (iii) Finding out the relationship between body posture and musculoskeletal symptoms. MATERIALS AND METHODS Sampling procedure The state capital of Andhra Pradesh was selected to draw the sample for the present investigation. The women who were involved in the packing activities in pharmaceutical industries for a period of minimum three years and aged above 30 years were selected as the sample for the study. A sample of 270 women was chosen at random from nine pharmaceutical industries from the list procured from office of the Commissioner of Industries. Data collection Back ground information like age, number years of education, number of years work experience were collected by interview method. The prevalence of musculoskeletal symptoms was obtained by developing a scale and using it in the present study. Musculoskeletal symptoms are developed in the nine anatomical regions of the human body such as neck, shoulder, elbow, wrist/hand, upper back, lower back, hips/thighs/buttocks, knees and ankles/feet (Kuorinka et al., 1987, [4] and Dickinson et al., 1992 [5]). Upper limb consists of upper arm, elbow, fore arm, wrist, hand and fingers. The back region of the human body includes upper back and lower back. The lower limb part of the human body includes thigh, knee, ankle, feet and toes (Winwood and Smith, 1985 [6]). In the present investigation the nine anatomical regions were grouped as neck, shoulder, upper limb (upper arm, elbow, fore arm, wrist, hand and fingers), back (upper back and lower back), and lower limb (thigh, knee, ankle, feet and toes). The scale assessed the musculoskeletal symptoms like pain, stiffness, swelling, spasms, cramps, numbness and tingling sensations. The frequency of experiencing the musculoskeletal symptoms in nine anatomical body regions varied from never to always. The frequency of symptoms was assessed as never if symptoms may not present. The frequency of symptoms was assessed as rarely, some times, frequently and severe if prevalence of symptoms was few hours in a week, 1-2 days in a week, 3-4 days in a week and through out the week respectively. Higher the score indicated higher the prevalence of symptoms. The working position of women workers in packing activities of pharmaceutical industry was studied with RULA (Rapid Upper Limb Assessment) technique which is known as penpaper observational method (Mc Atamney and Corlett, 1993, [3]). According to this a score was calculated for the posture of each body part such as upper arm, lower arm, wrist, wrist twist, neck, trunk and legs. A score of 1 indicated the best or most neutral posture, e.g., arms by sides, elbows in approximately 900 flexion, wrist in neutral position, forearms mid- way between pronation and supination, neck in 100 flexion, trunk and legs sitting and well supported. A score of 4 indicated the worst position e.g., shoulder flexion above 900 or flexion between 450 and 900 and abduction. The combined individual scores for upper am, lower arm, wrist and wrist twist gave score A and those for neck, trunk and legs gave score B. Muscle use in each packing worker position were attributed a score of 1 and force exerted 0 or 1 because they were static postures with out loading or with loading of 2 to 10 kg. These scores were added to scores A and B to obtain scores C and D, respectively. And based on the design of the RULA method, each combination of scores C and D (a number of 1-7) called grand scores. Low grand scores (1 or 2) indicate acceptable working posture (action level 1). For grand scores of 3 or 4, further investigation is needed and changes may be required (action level 2). Prompt investigation and changes are required soon for scores of 5 or 6 (action level 3). Finally, immediate investigation and changes are required for grand score of 7 (action level 4) (Fig 1).
Statistical analysis
The interrelationship between RULA scores and presence of musculoskeletal symptoms was assessed through Pearson’s correlation coefficient. Analysis of variance (ANOVA) was computed between the RULA scores and musculoskeletal symptoms of the study to find out the significant mean differences. Step wise regression was carried out to find out the major contributing factor among all the variables.
RESULTS AND DISCUSSION
Subject demographic information The mean age of the employees was 39.23±4.55 years; mean number of years of education was 4.3±3.76 years. The mean number of years of work experience of packing workers at the time of assessment was 6.13±4.68 (Table 1).
RULA Scores
The possible upper arm scores are 1 through 6. The mean upper arm position score of women involved in packing activities was 1.79. This indicates upper arm position was slightly abducted with flexion 150 to 450 but however the movements were continuous. The possible lower arm score is from 1 to 3. The mean lower arm score was 2.12 indicate flexion less than 600 and up to 1000 . The possible wrist score varies from 1 through 4. The mean wrist score was 2.21 indicating many of them placed in extension status and made angle rather than 150 . The possible wrist twist score ranges from 1 to 2. The mean score was 1.68 indicating wrist twist at or near end of range rather than in mid range. The possible neck and trunk position scores are 1 through 6. The mean neck and trunk scores were 2.61 and 2.71. These scores indicate that the neck and trunk of the respondents were in flexion, rotation or side bending. The possible legs score are 1 and 2. The mean legs score was 1.19 (Fig 2).
RULA scores obtained by sample revealed that 79 per cent of the respondents scored 2 for upper arm. Majority of the respondents (88%) obtained lower arm score 2. Nearly eighty per cent of the respondents obtained wrist score 2 and 68 per centwrist twist score 2). Score 3 was obtained by majority of respondents for neck (61%) and trunk (71%). Maximum respondents (81%) obtained score 1 for legs (Table 3).
The possible muscle use scores are 0 and 1. All the respondents were working under static positions more than a minute with repetitive actions. This posture lead them to get score 1. The possible load scores vary from 0 to 3. In the present study majority of the respondents (75%) were carrying loads 2 to 10kg hence, scored 1. Only 25 per cent of the respondents were not involved in carrying loads/applying force and thus obtained score 0. The estimated mean for the arm and wrist score was 4.37. The estimated mean for the neck, trunk and legs scores was 5.41. The same results were depicted among VDT workers where the mean arm and wrist score was found to be 4 for men and women and neck, trunk and legs score 4.7 for women and 4.2 for men (Shuval and Donchin, 2005 [7]). The Grand RULA score denotes work posture of the worker while carrying out the work. This includes arm and wrist scores, neck, trunk and leg scores along with muscle use and load scores. The maximum score that can be obtained is 7 which indicate high risk. In the present investigation 33.7 per cent of the women scored 7 (action level 4) means that they had dangerous posture. In case of these respondents the work posture needs to be changed immediately. Scores 6 and 5 indicate medium risk (action level 3) and 43 per cent of the workers were found in this category. There is a need to change this posture soon. Scores 4 and 3 indicate low risk (action level 2). Only 18.9 per cent of the respondents were in this category. RULA scores 1-2 indicate an acceptable posture. But nobody obtained acceptable posture. The mean overall score was 5.7 indicated the need for change of workers’ posture while carrying out packing activities (Fig 2). The mean grand score in packing activities in pharmaceutical industry in Iran was 4.87 (Varmazyar et al., 2009 [10]) and while among truck drivers with posterior mechanism for rubbish collection and those of street cleaning vehicles were 4.71 and 4.53 respectively (Massaccesi et al., 2004[11]).The grand score 7 (action level 4) was calculated for saw mill occupation: saw filter workers (Jones and Kumar, 2007 [8]), grand scores 5 and 6 (action level 3) for carpet mending operation workers (Choobineh et al., 2004 [9]).
Prevalence of musculoskeletal symptoms
Majority of the respondents were experiencing the feeling of pain in neck (74%) followed by feeling of stiffness (56.3%) and appearance of swelling (55.93%). Among the respondents 74 per cent of the respondents were experiencing the feeling of pain in upper limb, 59.3 per cent in back and 60 per cent in lower limb (Table 4). Pharmacy packaging workers have a high relative prevalence of discomforts in terms of knees (44.7%), back (36.8%) and neck (31.6%) pain (Varmazyar et al., 2009).
Relationship between posture and self reported musculoskeletal symptoms
The relationship between upper arm score, lower arm score, wrist score with musculoskeletal symptoms in neck, shoulder, upper limb, back, lower limb and over all body were found to be non-significant. The wrist twist score showed significant positive correlation with musculoskeletal symptoms in neck (r=0.17), shoulder (r=0.17), upper limb (r=0.17) and over all body (r=0.13). Significant positive correlation was found between neck, trunk score with musculoskeletal symptoms in all musculoskeletal regions. Legs score showed significant positive correlation with musculoskeletal symptoms in shoulder (r=0.14), upper limb (r=0.14) and over all body (r=0.13). The arm and wrist score showed significant positive correlation with musculoskeletal symptoms in neck (r=0.23), shoulder (r=0.20), upper limb (r=0.14) and over all body (r=0.14). The neck, trunk and legs score showed significant positive correlation with musculoskeletal symptoms in neck (r=0.50), shoulder (r=0.51), upper limb (r=0.59), back (0.44), lower limb (0.44) and over all body (r=0.56). Body posture score showed significant positive correlation with musculoskeletal symptoms in neck (r=0.47), shoulder (r=0.46), upper limb (r=0.49), back (0.34), lower limb (0.33) and over all body (r=0.47) (Table 5).
Through ANOVA, the computed F values revealed significant mean difference between arm and wrist position score and musculoskeletal symptoms in neck (F=10.76**), shoulder (F=8.35**), upper limb (F=3.02*) and over all body (F=3.95*). The computed F values revealed significant mean difference at 0.01 level between neck, trunk and legs position score and musculoskeletal symptoms in neck (F=26.75**), shoulder (F=26.36**), upper limb (F=42.79**), back (F=19.86**) and lower limb (F=20.08**) and over all body (F=36.85**). The computed F values revealed significant mean difference between body postural score and musculoskeletal symptoms in neck (F=30.70**), shoulder (F=33.33**), upper limb (F=31.67**), back (F=15.89**), lower limb (F=12.12**) and over all body (F=13.47**). Significant differences were observed between RULA body part scores and the reported pain in neck and trunk in packing workers in pharmaceutical industry (Pourmahabadian et al., 2008 [12]). Survey revealed that among truck drivers RULA scores were significant particularly in neck (Massccesi et al., 2003) and similar among carpet menders (Choobineh et al., 2004) According to the results of the present study it can be concluded that the arm and wrist position of women workers in packing activities of pharmaceutical industry was at low to moderate risk. Respondents earned a score of 3, 4 and 5 were categorized as low risk group, moderate risk group and relatively high risk group. Multiple comparisons test was used to compare the risk groups. The women with arm and wrist at low and moderate risk position were sometimes experiencing musculoskeletal symptoms in neck, shoulder, upper limb and over all body. The women with arm and wrist at high risk position were frequently experiencing musculoskeletal symptoms in neck, shoulder, upper limb and over all body. Similar findings were reported by Varmazyar et al. (2008) among packing workers in pharmaceutical industry. The position of arm and wrist while at work play a major role in developing pain and other musculoskeletal symptoms. In the present investigation the neck, trunk, legs position scores less than or equal to 3 were categorized as low risk position, scores 4-6 as moderate risk and scores 7 and above 7 as high risk position. The women with neck, trunk, legs at low risk position were never experienced musculoskeletal symptoms in neck, shoulder and rarely experienced musculoskeletal symptoms in upper limb, back, lower limb and over all body. The women with neck, trunk, legs at moderate risk position were sometimes experiencing musculoskeletal symptoms in neck, shoulder, upper limb, back, lower limb and in over all body. The women with neck, trunk, legs at high risk position were frequently experiencing musculoskeletal symptoms in neck, shoulder, upper limb, back, lower limb and in over all body. According to Mc. Atamney and Corlet (1987) RULA final posture scores 1-2 are acceptable posture scores, scores 3-4 are low risk posture scores, scores 4-6 are moderate risk posture scores and scores 7 and above 7 are high risk posture scores. Women working with low risk body posture were rarely experiencing musculoskeletal symptoms in neck, shoulder, upper limb, back, lower limb and over all body. Women working at moderate risk posture were sometimes experiencing musculoskeletal symptoms in neck, shoulder, upper limb, back, lower limb and in over all body. Women working at high risk posture were frequently experiencing musculoskeletal symptoms in neck, shoulder, upper limb, back, lower limb and in over all body. Through step wise regression the determinants for musculoskeletal symptoms in neck, shoulder, upper limb, back, lower limb and over all body were found. It showed significant results that neck position was contributing for causing musculoskeletal symptoms in neck and trunk position for causing musculoskeletal symptoms in shoulder, upper limb, back, lower limb and over all body.
CONCLUSION
The postural problems were mainly due to awkward postures, repetitive movements and force exertion involved in the work and improper work seat, work table, arm reach in the workplace. Ergonomic interventions could be taken into account to lead the worker to reduce exposure to risk consequently preventing WMSD and hence to improve better health and enhanced productivity in the organization. The suggested ergonomic interventions included engineering controls like providing adjustable work seats and adjustable work tables or redesigning workplace layout; administrative controls like giving rest breaks, training and education in good ergonomic practices and work postures; personal controls like regular exercise for keeping health of the workers.
Englishhttp://ijcrr.com/abstract.php?article_id=1112http://ijcrr.com/article_html.php?did=11121. APITCO Limited, Engineering Growth, Draft Diagnostic study report, Pharmaceutical cluster, Hyderabad, Andhra Pradesh submitted to PMD Division, Small Industries Development Bank of India, 2009.
2. Canadian Centre for Occupational Health and Safety, OSH Answers: Work-related Musculoskeletal Disorders (WMSDs). 2005.
3. Mc. L. Atamney, E.N.Corlett, RULA: a survey method for the investigation of work related upper limb disorders. Applied Ergonomics, 24 (2), 1993, 91–99.
4. I.Kuorinka, B. Jonsson, A. Kilborn H. Vinterberg, , S.F. Biering, G. Andersson and K. Jorgensen, Standardized Nordic questionnaire for the analysis of musculoskeletal symptoms. Applied Ergonomics, 1987, 18, 233–237.
5. C.E. Dickinson, K. Campion, A.F. Foster, S.J. Newman, A.M.T.O. Rourke and P.G. Thomas. Questionnaire development: an examination of the Nordic Musculoskeletal Questionnaire. Applied Ergonomics, 23(3), 1992, 197-201
6. R.S. Winwood, Smith, J.L. Anatomy and Physiology for Nurses. (Education Academic and Medicinal Publishing Division of Hodder and Stoughton, London, 1985)
7. Shuval, K., Donchin, M. Prevalence of upper extremity musculoskeletal symptoms and ergonomic risk factors at a Hi-Tech company in Israel. Industrial Ergonomics, 35, 2005, 569-58.
8. T. Jones and S. Kumar, Comparison of ergonomic risk assessments in a repetitive high risk saw mill occupation: saw filter, Industrial Ergonomics, 37, 2007, 744-753.
9. A.Choobineh, R. Tosian, Z. Alhamdi and M. Davarzanie, Ergonomic intervention in carpet mending operation, Applied Ergonomics, 35, 2004, 493-496.
10. S. Varmazyar, A.S. Varyani, I.M. Zeidi and H.J. Hashemi, Evaluation Working Posture and Musculoskeletal Disorders Prevalence in Pharmacy Packaging Workers, European Journal of Scientific Research, 29(1), 2009, 82-88.
11. M. Massaccesi, A. Pagnotta, A. Soccetti, M. Masali, C. Masiero and F. Greco, Investigation of work-related disorders in truck drivers using RULA method, Applied Ergonomics, 34, 2003, 303-307.
12. M. Pourmahabadian, M. Akhavan and K. Azam, Investigation of risk factors of workrelated musculoskeletal disorders in a pharmaceutical industry, Journal of Applied Sciences, 8(7), 2008, 1262-1267.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241517EnglishN2013September12HealthcareEXTREME HEAT EVENTS: PERCEIVED THERMAL RESPONSE OF INDOOR AND OUTDOOR WORKERS
English6578P K NagEnglish Priya DuttaEnglish Anjali NagEnglish T. KjellstromEnglishBackground: With the changing climate in the tropical regions, millions of people in indoor and outdoor occupational situations are vulnerable to frequent heat episodes with health implications. Methodology: The study refers to behavioral responses of the men folks (N=999) to hot environment in indoor (iron work N=287, ceramics and pottery N=137, power loom N=143, pulp and paper mill N=31) and outdoor (stone quarry N=401) working conditions. Result: Wet bulb globe temperature (WBGT) values in power loom was highest (35.2±1.10C), followed by other respective occupations. The behavioral responses of workers differed significantly (pEnglishWBGT, heat stress, ceramic and pottery, power loom, pulp and paper mill, stone quarry workers.Introduction
Growing incidences of extreme heat events demonstrate the vulnerability to humankind with increased morbidity and mortality in different geographical regions1,3. Epidemiological research from case-control4, case-only and case-crossover studies5,6 elucidates susceptibility of the exposed population with reference to physiological and behavioral implications7. Despite projection that teeming millions in the tropics are expected to experience unprecedented extreme heat events in the coming years3,8. The public recognition of the community calamity in the vast Indian subcontinent remains subdued. The workers in informal occupations, farmers, construction workers, street venders, rickshaw pullers and others, including urban and rural poor dwellers in slums and pavement have daunting challenge to face impacts of heat events. Risks of heat induced human illnesses prevail with relative vulnerability to children, elderly, pregnant mothers, and those with pre-existing medical conditions such as obesity, cardiovascular and neurological diseases9. The workers in physically demanding jobs are also at increased risk of heat induced illness10. Since people with low adaptive capacity and lack of mitigation measures are at greater risk of morbidity and mortality11, the occupational characteristics, physical habituation to work, working capacity and state of heat acclimatization are the critical determinants to influence physiological and behavioral adaptations of population exposed to hot environment. This study targeted high heat exposed population to analyze their physiological and behavioral response as regard to perception of heat related stress and strain, and the possible differences of response among different occupational groups.
Materials and Methods
The study focused on indoor and outdoor informal working groups, such as ceramics and pottery, and iron works, power loom, pulp and paper mill and stone quarry works (Figure I). The iron works involve cutting of iron sheets, tubes, flats of desired size, folding, bending, drilling, punching, welding, riveting, assembling and spray painting. The ceramic and pottery works include manufacturing of products, such as ceramic tiles, sanitary ware, crockery items. Power looms are small scale textile manufacturing units in semi-urban environment. The workers in informal pulp and paper mill are engaged in making packaging materials, card board boxes, etc. Stone quarry works involve the process of excavation (digging, blasting or cutting) of rocks and minerals from open-pit mines.
The habitual perception of heat related stress and strain of nearly one thousand workers of rural and semi-urban environment were examined during the summer months (May and July), when the ambient temperatures reached to 45 to 500C, with relative humidity in the range between 50 to 80%. Direct measurements of the thermometric parameters ambient dry bulb (DB) and wet bulb (WB) temperatures, WBGT index were undertaken by Thermal Environment Monitor (QUESTemp, USA) and Relative Humidity/Temperature data logger (Lascar EL-USB-2-LCD, Sweden) throughout several hours of observation period, and continued for a number of days at each workplaces. Taking into account of WB and globe temperatures, the environmental warmth were expressed in terms of WBGT index.
The prevailing climatic conditions indicate that these occupational groups are potentially at risk of high heat exposures due to the work processes, in addition to thermal load during the peak summer months. During occupational engagement, as evident from the pictures shown in Figure I, the workers wore light clothing – shorts, trouser, or lungi / dhuti (a loose fabric wrapped around at the ankle length), and half-sleeve banian or t-shirt with insulation values ranging within 0.4 to 0.6 clo. Health risk surveillance was introduced among the men folks in the age range between 18 to 60 years, and their informed consent to participate in the study were taken, as per the ICMR (2000)12 ethical guidelines.
Human physiological and behavioral responses to environmental warmth manifest depending on the personal characteristics and other modifying variables. For example, heat stress and disorders are specific to one’s state of acclimatization and ability to respond to the level of heat exposure. Based on the WHO ICD-10 code T69, a checklist enquiry incorporated examining heat-related signs and symptoms. These were rated by the individual workers in a five point Likert’s attitude scale, referred to as strong disagreement (1) to strong agreement (5), the low score being the positive indicator of the absence of a problem. The self-reporting of perception of heat related symptoms has limitation, since the illiterate workers might not be much conversed with the relative Likert scoring method. Therefore, appropriate indoctrination of the workers and consistent recording by the field investigators are essential in order to establish the relationship between the perception of workers to stress symptoms and heat exposures.
Data analysis was performed using SPSS 16.0. Analysis included treatment of data for descriptive statistics, in addition to test of normality of distribution. The distribution characteristics of thermometric variables might serve as indicators to ascertain vulnerability of population to heat stress, and therefore, these variables were treated for statistical normality distribution in terms of kurtosis and skewness tests. Further, the behavioral responses were treated for one-way ANOVA to compare responses among the occupational groups. Also, the principal components analysis was applied to allow grouping of the behavioral responses into subscales, and to elucidate the component loading of the heat stress signs and symptoms.
Results
Table I includes the average physical characteristics of the workers. Different occupational groups had similar anthropometric dimensions. The sample size of workers selected from the pulp and paper mill (N=31) was small, in comparison to other groups. The workers in ceramic and pottery works were relatively younger, and older age groups were in power loom. Most other working groups were in the range of 30+ years of age.
The ambient temperature conditions recorded during the study (Table I) indicated that the DB temperatures exceeded 400C in all observations of powerloom, 3/4th in case of iron works, 1/4th in ceramic and pottery, and pulp and paper mill, and over 1/3rd of observations exceeding 400C of DB in case of stone quarry works. The WBGT index in power loom (35.2±1.10C) was highest, followed by ceramic and pottery (33.8±1.90C), stone quarry (33.1±2.40C), pulp and paper mill (32.7±1.10C), and iron works (31.6±1.50C) respectively. The thermometric variables treated for Kolmogorov-Smirnov test with Lilliefors significance correction indicated that the dimensions are normally distributed, with test statistics varied from 0.116 to 0.416 (pEnglishhttp://ijcrr.com/abstract.php?article_id=1113http://ijcrr.com/article_html.php?did=1113
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Brikowski TH, Lotan Y, Pearle MS. Climate-related increase in the prevalence of urolithiasis in the United States. 2008. Proc. National Acad Sciences 105: 9841-9846.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241517EnglishN2013September12HealthcareCOMPLETELY OSSIFIED SUPRASCAPULAR LIGAMENT - A CASE REPORT
English7981Pushpa N.B.English Roshni BajpeEnglish Shubha R.EnglishThe suprascapular notch is bridged by the superior transverse scapular ligament, (suprascapular ligament) which is attached laterally to the root of the coracoid process of the scapula and medially to medial limit of the notch. The ligament is sometimes ossified. The suprascapular nerve passes below the ligament and enters the supraspinous fossa, whereas the suprascapular vessels pass backwards above the ligament. During routine osteological class for I MBBS students we came across a scapula with completely ossified suprascapular ligament. Suprascapular nerve is mostly susceptible for entrapment at the suprascapular notch. A narrow notch or a calcified ligament has been shown to cause increased risk of injury to the suprascapular nerve.
EnglishSuprascapular notch, Transverse scapular ligament, Entrapment syndrome.INTRODUCTION
The superior transverse scapular ligament (suprascapular ligament) converts the scapular notch into a foramen or opening. It is sometimes ossified. The ligament is a thin and flat fasciculus, which is narrow at the middle than at the extremities. It is attached by one end to the base of the coracoid process, and by the other end to the medial end of the notch. The suprascapular nerve passes through the foramen and the suprascapular vessels passes above the ligament1 . After passing through the notch, the nerve enters the supraspinous fossa where it supplies supraspinatus and then shoulder capsule, glenohumeral and acromioclavicular joints. The nerve then supplies infraspinatous muscle after crossing the lateral margin of the scapular spine. Most suprascapular nerve entrapments occur at the suprascapular notch as a result of compression by the overlying suprascapular ligament2 . Case report: During routine osteology class for I MBBS students in the department of Anatomy at KIMS Bangalore, we came across a scapula with completely ossified superior transverse scapular ligament with very narrow scapular foramen [Fig1]. The ossified ligament’s dimensions are superior border – 8mm, inferior border – 3.64mm and thickness – 4.40mm. No other deformities were found in the bone.
DISCUSSION
In some animals the suprascapular notch is frequently bridged by bone rather than a ligament, converting the notch into a foramen3 . The incidence of bony foramen in scapulae varied from 0.3% to 13.6%, [where the superior transverse scapular ligament was completely ossified and scapular notch was closed]4 . Kopell and Thompson first described entrapment syndrome of suprascapular nerve at suprascapular notch. According to these authors the movement of abduction or horizontal adduction of the shoulder resulted in compression of the nerve against the ligament as quoted by Antoniadis G et al5 . Gray found foramen in 73 out of 1,151 scapulae (6.34%) but among 87 Indian scapulae none had foramen in them6 . Cohen et al. described a familial case of calcified superior transverse scapular ligament, affecting a 58 years old man and his son too, causing entrapment neuropathy of the suprascapular nerve, clinical symptoms of pain, weakness, atrophy of supraspinatus muscle as quoted by Khan. Khan also reported a case of completely ossified superior transverse scapular ligament in an Indian adult male3 . There are descriptions in the literature of bifid7 and trifid8 superior transverse scapular ligament, with former causing entrapment of suprascapular nerve. Compared to other painful conditions on the shoulder, suprascapular nerve entrapment is an obscure and uncommon syndrome causing severe shoulder pain and disability. It is easily cured if is recognised9 . An arthroscopic approach is a more sophisticated way of addressing the suprascapular nerve entrapment at suprascapular notch but a relative contraindication to arthroscopic release is transverse scapular ligament calcification or ossification10. The identification of the bony bridge is very important, because in these cases apart from dissecting the ligament the bony bridge must also be excised during the procedure, in order to achieve better post-operative results. Radiologists, Neurosurgeons and orthopaedic surgeons should be aware of ossified transverse scapular ligament, as it is necessary to identify and address it during the preoperative radiological examination or intra-operatively, since its existence alters the surgical technique during open or arthroscopic decompression of suprascapular nerve11 .
CONCLUSION
In the present case we are reporting a completely ossified superior transverse scapular ligament, with a very narrow scapular foramen in a south Indian adult which is significant in causing compression of suprascapular nerve.
ACKNOWLEDGEMENT
Authors are grateful to Department of Anatomy, KIMS, Bangalore and also to the authors whose articles are cited and included in the references of the manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=1114http://ijcrr.com/article_html.php?did=11141. Standring S, Borley NR, Collins P, Crossman AR, Gatzoulis MA, Healy JC, et al. Gray’s Anatomy: The Anatomical Basis Of Clinical Practice. 40thedition, London: Elsevier Ltd.,2008: 793, 795
2. Canale ST, Beaty JH, Linda Jones KD, et al. Campbell's Operative Orthopaedics. 11th edition, vol 3, Philadelphia: Elsevier Inc., 2008:2631
3. Khan MA. Complete ossification of the superior transverse scapular ligament in an Indian male adult. Int. J.Morphol., 2006; 24(2):195-6.
4. Polguj M, Jedrzejewski K S, Podgorski M, Topol M. Correlation between Morphometry of the suprascapular notch and anthropometric measurements of the scapula. Folia Morphol. 2011; 70(2):109-15.
5. Das S, Suri R , Kapur V. Ossification of superior transverse scapular ligament and its clinical implications sultan qaboos univ med j.2007;7(2)157-160
6. Gray DJ. Variations in the human scapulae. Am. J. Phys.Anthropol., 1942; 29:57-72.
7. Polguj M, Jedrzejewski K, Majos A and Topol M. Variations in bifid superior transverse scapular ligament as a possible factor of suprascapular entrapment: an anatomical study. International Orthopaedics (SICOT), 2012;36:2095–2100
8. Ticker JB, Djurasovic M, Strauch RJ, April EW, Pollock RG, Flatow EL et al. The incidence of ganglion cysts and variations in anatomy along the course of the suprascapular nerve. J. Shoulder Elbow Surg., 1998 7(5):472-8.
9. Priya R, Manjunath KY, Balasubramanyam V. Morphology of suprascapular notch. Anatomica Karnataka.2004; 1(5):32-35.
10. Millett P, Barton S: Suprascapular nerve entrapment: Technique for arthroscopic release. Techniques in Shoulder and Elbow Surgery. 2006; 7(2):89-94.
11. Natsis K, Totlis T, Gigis I, Vlasis K, Papathanasiou E, Tsikaras P. A bony bridge within the suprascapular notch. Anatomic study and clinical relevance. Aristotle University Medical Journal. February 2008: 35(1), 29-33.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241517EnglishN2013September12HealthcareSEASONAL GONADAL BIOCHEMICAL CHANGES, ASSOCIATED WITH THE REPRODUCTIVE CYCLE IN LABEO DYOCHEILUS (MCCLELLAND)
English8289Rakesh VermaEnglishSeasonality in reproductive cycles as well as testicular and ovarian biochemical changes is very common among teleost. Seasonal gonadal biochemical changes have potent effect on gonadal maturation and period of spawning. Determination of seasonal variation in percentage value of lipids, protein and water in gonadal tissue and establish the possible correlation with gonadal maturity was the objective of the study. Our study of Gonado-somatic index (GSI) reveals that Monsoon was the spawning season of fish. Gonadal tissue biochemical study showed that the lipid percentage was highest during resting phase of testis and spawning phase of ovary, while lowest during resting phase of ovary and spawning phase of testis. We also found that the monthly variation of lipid concentration in ovary was 1.79 times higher than that of the testis. Protein percentage was highest during spawning phase and lowest during resting phase in both gonads. Monthly variation of protein content in the testis and the ovary was almost equal in percentage. Water percentage was lowest during resting phase of testis and spawning phase of ovary, while highest during resting phase of ovary and spawning phase of testis, water concentration in ovary was 1.10 times higher than testis. Finally Gonado-somatic index correlate with gonadal lipid, protein and water percentage, this study show that the water content (R2 = 0.664) is more responsible for maturation of testis and lipid content (R2 = 0.601) for ovary, as compare to other factors.
Englishgonadal lipid, protein, water, gonado-somatic index, reproductive cycle, seasonal changes, Labeo dyocheilus.INTRODUCTION
It has long been documented that striking changes occur in gonadal biochemical composition in many species of fish during the normal annual sexual cycle. Seasonal reproductive cycles are common among tropical fishes (Robertson, 1990). Earlier investigations illustrate that there are substantial differences in the seasonal gonadal biochemical changes of different species of fishes and among individuals of the same species, with their age, sex and habitat. In general, they have a strong tendency to store the energy particularly, in the form of protein and fat during the active period of spawning. It has now been realized that these changes occur due to various physiological factors such as maturation, spawning and feeding. At any given time, the biochemical composition of an individual fish is the result of complex interactions between physical and biological characteristics such as size, sex, temperature, food availability and reproductive stage. Information of the magnitude of these fluctuations is an indicator of annual fish physiological changes. Various physiological and reproductive changes in fishes also depend upon coordinated actions of various hormones associated with brain-pituitary-gonadal axis (Evans, 1998).
Labeo dyocheilus has been categorized as vulnerable by National Bureau of Fish Genetic Resources (NBFGR) Lucknow, Dubey (1994), Prasad (1994) and CAMP (1998). Objectives of the present work were to determine the percentage value of three main constituents namely: lipids, protein and water in respect to gonadal development and spawning, as well as to establish the possible correlation between gonadal protein, lipids, moisture percentage and reproductive cycle of fresh water fish, Labeo dyocheilus. It is expected that these information will be useful for biologists to investigate various aspect of reproductive biology. This study will fulfill the gap in the literature, as lack of literature in biochemical composition of gonads.
MATERIALS AND METHODS
The sampling was carried out at Chaukhutia (Latitude: 29° 53' 55" N and Longitude: 79° 21' 22" E) in Uttarakhand state of India, annually between September 2009 to August 2012 for the period of three years. About 12 adult individual (25-30 cm in length) in each months were collected. Gonado-somatic index (GSI) is used to indicate gonadal maturation and spawning period. This includes the physical observation of fish and gonads, so as their length-weight was measured. The Gonado-somatic index value was calculated with the help of formula given below:
RESULTS
Gonado-somatic index: Minimum value of Gonado-somatic index for male is 0.008 ? 0.002 in October, whereas the maximum value 3.933 ? 0.665 in July. It can also be seen from the Gonadosomatic index data that it increases regularly from the month of October till July and then further decreases. Gonado-somatic index for female was minimum 0.099 ? 0.016 in month of October from which it increases regularly till a maximum value of 10.508 ? 1.881 in month of July. Thus, above result showed the Monsoon (Gonado-somatic index peak value in July) was the spawning season for both male and female fish. (Table1) Gonadal lipid percentage: Lipid percentage in testis varied from its minimum value of 14.84 % to that of the maximum value of 20.91 % in the month of July to January respectively. The lipid content gradually increased from the July to that of January and reached to its maximum and then decreased to July. Lipid percentage in ovary was minimum 26.66 % in January to the maximum 43.03 % in July. Lipid content gradually increased from January to July and reached to its maximum value and then further decreased to January. Lipid percentage is minimum in the testis and maximum in the ovary in the month of July. In the month of January the lipid percentage is found to be maximum in the testis whereas minimum in the ovary. We also found that the monthly variation of lipid concentration in ovary was 1.79 times higher than that in the testis. (Table 2 and Fig.1)
Gonadal protein percentage: Protein percentage in testis varied from its minimum 34.55 % to maximum 54.25 % in the month of January to July respectively. Protein percentage in ovary was minimum 30.22 % in January, maximum 52.31% in the July. In both gonads protein content gradually increased from January to July and reached to its maximum value and then further decreased to January. Monthly variation of protein content in the testis and the ovary was almost equal in percentage. (Table 3 and Fig. 2) Gonadal water percentage: Water percentage in testis has minimum value of 55.14 % to that of the maximum value of 79.75 % in the month of December to July respectively. The water content gradually increased from December to July and reached to its maximum value. Water percentage in ovary was minimum 69.77 % in July and maximum 88.06 % in January. Water content gradually increased from July to January and reached to its maximum value and then further decreased to July. Monthly variation of water concentration in ovary was 1.10 times higher than testis. (Table 4 and Fig. 3) Gonadal biochemical percentage and maturity: Since the gonadal maturity is explained by Gonado-somatic index (GSI), thus the percentage content of lipid, protein and water are plotted against Gonado-somatic index to find the effect of lipid, protein and water content on maturity. It is obvious from the plot that the water content (R2 = 0.664) is more responsible for maturation of testis in compare to lipid (R2 = 0.646) or protein (R2 = 0.264) content. For the maturation of ovary the lipid content (R2 = 0.601) is found to be more responsible as compare to protein (R2 = 0.172) or water content (R2 = 0.309). (Fig. 4 and Fig. 5)
DISCUSSION
Lipid helps in reproduction, maximize juvenile survivorship and growth Winemiller (1993). In the maturity phase of the male fish, spermatogenesis process was active; we observed that during the maturity period, the lipid concentration in testis has its minimum value. It is supported by a study in Clarias batrachus, in which the lipid concentration in testis had its minimum value in the spawning phase by Singh and Singh (1983). Henderson and Tocher (1987) Singh and Singh (1984) and Love (1970), obtained the similar observations that lipid concentration decreases as the maturity phase progress in testis. We observed that, lipid percentage in ovary has its minimum value in January (resting month) from where it increases continually to maximum in July (spawning month). It was also reported by Singh and Singh (1979), Shreni and Kalpana (1980) that there is an increase in the ovarian lipid during maturity phase in Hereropneustes fossilis. MacFarlane et al., (1993) Okuda (2001) and MacFarlane et. al. (1993), investigated the accumulated lipids in the developing ovaries. Shreni (1980) stated that the protein cycle in fishes synchronized with maturity of fishes. During maturity phase of fish, gonads increase many fold and attain large size and thus, in this period the protein concentration increases in the testis and ovary. In present study, during pre-maturity or resting phases the protein percentage was low while maximum during maturity phase in gonads (testis and ovary). These observations correlate positively to the results of Love (1970), John and Hameed (1995) who observed that resting gonads has minimum protein percentage. Bano (1977) studied that during the maturing phase protein is found to be increased and reached maximum which attributed to low metabolic activity. Macay and Tunison (1936), Jafri (1968) also noted the increased protein content in muscle which also attributed in increment with gonad maturity. Declining of protein in post-spawning phase was also reported by Somavanshi, (1983) in Garra mullya, and Luzzana et. al, (1996) in Coregonid bondella. In present study we observed that water percentage in testis was lowest in the resting month and highest during spawning month. Kingston and Venkataramani (1994) observed that he water content of testis in Selaroides leptoepis is higher during the peak maturity phase. Kumar et al., (2001) also found that there is an increase in water percentage of testis during active phase of reproductive cycle in Labeo rohita. Water percentage in ovary was highest in the resting month and lowest during spawning month. Similar study was done by Singh et. al. (2004) that the water content in ovary of female of Labeo rohita is decrease during the active reproductive phase. Singh and Nauriyal (1990) also found out the decrease ovarian water content and increase testicular water contain associated with maturity of cold water fishes Schizothorax richardsonii and Glypthorax pectinopterus.
CONCLUSIONS
In summary, we were able to find the July (Monsoon) was the spawning month of fish as well as monthly and seasonal variation of lipid, protein and water content in testis and ovary. We also obtained the months having minimum as well as maximum percentage value of these variables in testis and ovary. It was concluded that the lipid and water percentage was higher in ovary in compare to that of testis, while the protein content is almost same in both gonads. We also found that water content in testis and lipid content in ovary are more responsible for maturation than rest of the factors.
ACKNOWLEDGMENTS
The author acknowledges the LSRB-DRDO (R&D) New Delhi organization for financial assist and FRDL for Laboratory as well technical support.
Englishhttp://ijcrr.com/abstract.php?article_id=1115http://ijcrr.com/article_html.php?did=11151. Bano, Y. (1977). Seasonal variation in the biochemical composition of Claris batrachus L. Proc. Ind. Acad. Sci., 85: 147-155.
2. CAMP (1998). Conservation assessment and management plan for freshwater fishes of India. Workshop report Zoo Outreach organization, Coimbatore/ CBSG and NBFGR, Lucknow, India, 1-158
3. Evans D.H. (1998). The physiology of fishes 2nd ed. CRC Press.Boca roton, New York. 441-464.
4. Folch, J., Lees, M. and Stanley, G.H.S (1957). A simple method for the isolation and purification of total lipids from animal tissues. J. Biol. Chem., 226: 497-509.
5. G.P. Dubey (1994). Endangered, vulnerable and rare fishes of west coast river systems of India. In: Threatened Fishes of India, P.V. Dehadrai, P. Das and S.R. Verma (Eds.). Natcon publication, India. 4: 77-95.
6. Henderson, R. J. & Tocher, D. R. (1987). The lipid-composition and biochemistry of freshwater fish. Progress in Lipid Research 26: 281-347.
7. Jafri A. K. & Khawaja D. K. (1968). Seasonal changes in biochemical composition of fresh water murrel Ophiocephallus punctatus (Bloch). Hydrobiologia, 32 (1-2): 206-218.
8. Jonh T. Sophy and Hameed M. Shanul (1995). Boichemical composition of Nemipterus japonicus and Nemipterus leptilepis in relation to maturity cycle. Fishery Tech 32(2): 102- 107
9. Kingston, S. and Venkataramani V.K. (1994). Biochemical composition yellow stripe scad, Selaroides leptoepis as a function of maturity stage and length fishery Tech., 31: 159-162.
10. Kumar, A., Singh I.J. and Ram R.N. (2001). Correlative cyclicity of certain biological indices and testicular development in Labeo rohita (Ham.) under tarai condition of Uttranchal. The Indian journal of Animal sciences (ICAR, New Delhi Publication), 71(11):1085-1087.
11. Love, R.M. (1970). The Chemical Biology of Fishes. Academic Press, Inc., London. 547.
12. Lowry, O.H., Rosebrough, N., Farr, A.L. and Randall, R.J. (1951). Protein measurement with Folin Phenol reagent. J. Biol. Chem., 193: 265-285.
13. Luzzana U. Serrini, G. Moretti V.M. Grimaldi P. Paleari M.A. and Valfre F. (1996). Seasonal variations in fat content and fatty acid composition of male and female Coreganid bondella from Lake Maggiore and Land locked shad from Lake Cemo (North Italy). J. Fish Boil. 48(3): 352-366.
14. Macay M. and Tunison A.V. (1936). Cortland Hatchery Report No. 5. N.Y. State Cons. Deptt. Us Bur of fish and Cornell Univ.
15. MacFarlane, R.B., Norton, E.C. and Bowers, M.J. (1993). Lipid dynamics in relation to the annual reproductive cycle in yellow tail rockfish, Sebastes flavidus. Canadian Journal of Fisheries and Aquatic Sciences, 50: 391- 401.
16. Okuda, N. (2001). The costs of reproduction to males and females of a paternal mouth brooding cardinalfish, Apogon notatus. Journal of Fish Biology, 58: 776-787.
17. P.S. Prasad (1994). Status paper on endangered, vulnerable and rare species of Bihar. In: Threatened Fishes of India. (P.V. Dehadrai, P. Das and S.R. Verma Eds.). Natcon publication, India. 4: 25-29.
18. Robertson, D. R. (1990). Differences in the seasonalities of spawning and recruitment of some small neotropical reef fishes. J. exp. mar. Biol. Ecol., 144: 49-62.
19. Shreni, D. Kalpana (1980). Seasonal variations in the chemical composition of cat fish. Heteropneustes fossilis (Bloch). Proc. Ind Acad Sci. (anim. Sci.), 89: 191-196.
20. Singh, A.K. and Singh, T.P. (1979). Seasonal fluctuation in total lipid and cholesterol content of ovary liver and blood serum in relation to annual sexual cycle in Hereropneustes fossilis (Bloch). Endocrinologie, 73: 47-54.
21. Singh, A.K., Kumar A., Singh I.J. and Ram R.N. (2004). Lipid and water content profiles in ovary and liver in a freshwater teleost, Labeo rohita during annual reproductive cycle in the tarai condition of Uttaranchal. Journal of Aquaculture in Tropics. 19(2): 137-144.
22. Singh, H.R. and Nauriyal, B.P. (1990). A comparative study of some biochemical constituents in the reproductive cycle of hill stream teleosts. Schizothorax richardsonii (Gray) & Glypthorax pectinopterus (Meleod). Proc. Natl. Acad. Sci., India, 16: 117-123.
23. Singh, I.J. and Singh, T.P. (1983). Annual changes in total gonadotropic potency in relation to gonadal activity in fresh water, Clarias batrachus. J. Inter Disci. Pl. Cycle. Res., 4: 227-239.
24. Singh, I.J. and Singh, T.P. (1984). Chang in gonadotropin, lipid cholesterol levels during annual reproductive cycle in the fresh water teleost, Cirrhinus mrigala (Ham.) Annales’D Endocrinologie, Paris, 45: 131-136.
25. Somvanshi (1983). Seasonal changes in biochemical composition of Hill stream fish Garra mullya, Ind. J. Fish. 30 (1).
26. Winemiller, K. O. (1993). Seasonality of reproduction by livebearing fishes in tropical rainforest streams. Oecologia, 95: 266-276.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241517EnglishN2013September12HealthcareA STUDY OF PREVALENCE OF HYPERTENSION AMONG BUS DRIVERS IN BANGALORE CITY
English9094Satheesh B. C.English Veena R. M.EnglishBackground: Growing evidence suggests that hypertension is an important public health problem worldwide that constitutes the basis for the cardiovascular disease epidemic. Hypertension has become significant major health problem because of the major changes in the lifestyles, aging population, urbanization and socioeconomic changes. The percentage increases when selected occupational groups are screened. Transport drivers are one such group of people who are at risk of developing hypertension due to nature of their profession. The related impacts are not only harmful for driver’s health, but also may endanger others. Very few studies in this regard prompted to take up the present study. Objectives: To study the prevalence of hypertension among the city bus drivers and study its association with certain risk factors. Methods: A structured personal interview using questionnaire and physical examination which includes height weight and blood pressure recordings were done in 500 bus drivers who were enrolled to this cross sectional study Results: The prevalence of hypertension among the bus drivers was 16% (80/500). A significant positive correlation was seen between hypertension and increasing age, tobacco chewing and BMI. However, in this study hypertension was not found to be significantly associated with smoking, alcohol consumption, diet and salt intake. Conclusion: Considering the high prevalence of hypertension in bus drivers and its association with risk factors, necessary education programme to raise the awareness has to be conducted. The findings of this study should be reconfirmed by other large scale studies to identify the role of known and unknown factors in hypertension in this community.
EnglishPrevalence, Hypertension, Bus driversINTRODUCTION
India, the world's largest democracy, is undergoing a rapid economic growth accompanied by demographic, lifestyle and cultural changes.1 For a developing nation as India which is in a socio-economic and epidemiological transition, hypertension a common cardiovascular disorder, poses a major public health challenge as hypertension is one of the major risk factors for cardiovascular mortality, accounting for about 20-50% of all deaths.2 The percentages of hypertensive’s increase more when selected occupational groups are screened. Transport drivers are one such group of people who are at the risk of developing hypertension due to nature of their profession. In the 1960s, Morris and his colleagues reported that the incidence of coronary heart disease among London bus drivers was almost twice that of bus conductors.3 These findings are supported by a more recent prospective study in Copenhagen that reported higher heart disease mortality among bus drivers when compared with the general population.4 Several cross sectional designs suggest that driving a bus in a modern urban transit system may carry increased health risk. There has been a spurt in the vehicle population in cities due to opening of the Indian economy adding woes to the bus drivers causing high levels of stress and fatigue. The possibility of increased health risk associated with the bus driving is of importance not only to the health and safety of drivers in urban transit systems, but to the vast public that interacts with these systems. Screening of hypertension will help to detect the risk factor early and will help to control better, if counseling and treatment are instituted early. Because many factors associated with the disease cannot be modified, emphasis should be given to those risk factors that are amenable to intervention. Thus, there is an ideal opportunity to screen the baseline health status of drivers to detect the risk factors for hypertension early and to help control better. Very few studies have been undertaken in this population group in India. With this background, the present study was taken up among bus drivers to study the prevalence of hypertension and some risk factors associated with hypertension in Bangalore city.
MATERIAL AND METHODS
This study is a cross-sectional, conducted for a period of 1 year in 2003. Before initiating the study, a pilot study was conducted among 50 drivers. 44% of the bus drivers were found to be hypertensive. Based on the prevalence, the sample size was calculated at 5% significance level and 10% allowable error. To calculate the sample size the following formula was used, The sample size was 489, rounded up to 500. The sample size selected was systematically done by stages where 5 depots were selected in the first stage among 23 depots by using systematic cyclic random sampling method. Subjects were selected proportionate to driver’s strength in the selected depots to get 500 units by using simple random sampling method. The study subjects included were 500 male bus drivers aged 30 years and above with a minimum of 5 years experience as bus drivers that exclusively work in Bangalore city. Demographic and anthropometric data including height, weight, and blood pressure were recorded by a structured personal interview using questionnaire. Measurement of blood pressure Hypertension is defined as diastolic blood pressure greater than 140mmHg and systolic blood pressure greater than 90mHg. Blood pressure was measured following a five minute resting period in a sitting position on the right hand repeated two times with at least five-minute interval. The first and the fifth Korotkoff sounds were recorded as systolic and diastolic blood pressures. The mean value was taken in to consideration as the blood pressure value of the study. Data Analysis Chi-Square test of significance was used to test the association between hypertension and various risk factors.
RESULTS
All the study subjects were exclusively male (as it is common for professional drivers in India). 226(45%) out of 500 drivers were in 40-49 year age group followed by 217(43%) and 57(17%) in 30-39 and ≥50 years age group respectively. 233(47%) of the bus drivers had the high school education, whereas 24(5%) had pre-university and above. In the present study, out of 500 drivers, the prevalence of hypertension was found in 16% (80) (table 1, figure1). In the drivers, hypertension was found in 21(26%) participants between 30-39 years, 42(53%) participants between 40-49 years and 17(21%) participants in 50 years or more (χ2 =15.683; DF=2; P0.05) (Table3). The prevalence of hypertension is high 73(91%) among the drivers who were consuming mixed diet as compared to vegetarians 7(9%) (χ 2 = 0.344; DF=1; P> 0.05) but statistically was not significant (Table3). The observed differences were not statistically significant in drivers who consumed alcohol, smoked, and consumed extra salt (Table3). Among the study population, 34 were obese (30- 35). Out of 34 obese drivers, 12(15%) were hypertensives (χ2 = 12.068; DF=1; P< 0.05). The observed differences were found to be statistically significant (Table4).
DISCUSSION
The prevalence of hypertension among bus drivers was 16% (80/500). In other words more than one out of every 10 person had hypertension. In this study, the various risk factors that were associated with hypertension are increasing age, habit of tobacco chewing, increased body mass index. According to NHANES-III, the prevalence and severity of hypertension increases substantially with advancing age across the full human lifespan;5 High association of hypertension with tobacco chewing habits is supported by a study by Nanda and Sharma et al which noted increase in heart rate and blood pressure following tobacco chewing supporting the result of this study.6 Our study demonstrated significant correlation between hypertension and obesity. National cohort study in United States found BMI was a risk factor for hypertension.7 Evans County Georgia (1991) indicated that those obese are at 6 times higher of becoming hypertensives.8 B. S. Deswal et al reported that the relative risk of developing hypertension among obese subjects was found to be 5.25 times more as compared to non-obese persons which is highly significant (PEnglishhttp://ijcrr.com/abstract.php?article_id=1116http://ijcrr.com/article_html.php?did=11161. Bhansal SK, Saxena V, Kandpal SP, et al. The prevalence of hypertension and hypertension risk factors in a rural Indian community: A prospective door-to-door study. J Cardiovasc Dis Res. 2012; 3(Pt 2): 117–123.
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4. Netterstrom B, Laursen P. Incidence and prevalence of ischemic heart disease among urban bus drivers in Copenhagen. Scandinavian Journal of Social Medicine 1981;2:75-79
5. Burt VL, Whelton P, Roccella EJ. Prevalence of hypertension in the US adult population. Results from the Third National Health and Nutrition Examination Survey, 1988- 1991.Hypertension. 1995; 25(3):305-13.
6. Nanda PK, Sharma MM. Immediate effect of tobacco chewing in the form of 'paan' on certain cardio-respiratory parameters. Indian J Physiol Pharmacol. 1988; 32(Pt 2):105-13.
7. Ford ES, Cooper RS. Risk factors for hypertension in a national cohort study. Hypertension. 1991; 18(5):598-606.
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9. Deswal BS, Satyamoorthy TS, Dutta PK. An Epidemiological Study Of Hypertension Among Residents In Pune. Indian Journal of Community Medicine.1991;1:21-28
10. Kannel WB. The Framingham study. J.Atheroscler Throw.2000;6(Pt 2):60-6
11. Swain JF, Rouse IL, Curley CB. Comparison of the effects of oat bran and low-fiber wheat on serum lipoprotein levels and blood pressure. N Engl J Med. 1990 Jan 18; 322(Pt 3):147-52.
12. Sciarrone SE, Strahan MT, Beilin LJ. Ambulatory blood pressure and heart rate responses to vegetarian meals. J Hypertens. 1993;11(Pt 3):277-85.
13. Malhotra SL. Studies in arterial pressure in the North and South India with special reference to dietary factors in its causation. J Assoc Physicians India. 1971; 19 (Pt 3):211- 24.
14. Baldwa VS. Prevention of hypertension in a rural community of Rajasthan. JAPI 1984; 32 (12): 1045.
15. Intersalt: an international study of electrolyte excretion and blood pressure. Results for 24 hour urinary sodium and potassium excretion. Intersalt Cooperative Research Group. BMJ. 1988. 30; 297:319-28.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241517EnglishN2013September12HealthcareA STUDY OF COMPLICATIONS OF THYROIDECTOMY
English95101Sudarshan Babu K. G.English Lakshmi ShantharamEnglishIntroduction: Thyroid surgeries are the most common endocrine surgeries performed today. This procedure has been through tremendous evolution to make it a safe procedure. In spite of improved techniques, every thyroid surgeon has come across complications associated with this surgery. This study aims to understand various complications after thyroid surgeries and the factors responsible for complications and discuss management techniques for those complications in brief. Materials and Methods: 50 patients admitted in our hospital for various thyroid surgeries were followed up from pre operative evaluation to post operative period for appearance of complications. Those with postoperative complications were followed up and managed. Results: 12% patients had transient hypoparathyroidism, 2% had permanent hypoparathyroidism, 4% had temporary RLN palsy and 2% had permanent RLN Palsy. Other rare complications were Superior laryngeal nerve palsy, hematoma, and wound infection. Conclusion: In our study, temporary hypoparathyroidism was the most common complication (12% of the patients operated). Improved surgical techniques during thyroid surgery and efficient methods of complication management have reduced the postoperative morbidity and mortality. In spite of all measures, keen observation in postoperative period is important to look for complications for early intervention.
EnglishThyroidectomy, Recurrent Laryngeal Nerve palsy, Hypocalcemia, ComplicationsINTRODUCTION
Thyroid surgery is one of the common endocrine surgeries performed today. Thyroid gland is situated in a critical area in the neck surrounded by many vital structures. The complications related to the surgery were very high in olden days. This surgery did not find ready acceptance by Germans and French initially who called these operations “Foolhardy Performances”. 1 Any discussion on thyroid surgeries will be incomplete without the mention of “Theoder Kocher” a magnificent surgeon who reduced the mortality of thyroid surgeries from 50% to less than 4.5% by advocating methodical surgical dissection of the gland.2 Kocher received Nobel prize in the year 1909 for his pioneer work.1 Despite continuous efforts by surgeons all over the world for making this essential surgery free of morbidity, it continues to be an enigma and some kind of complication has become a rule rather than an exception. This study aims to identify various complications arising in thyroid surgery and literature review for factors predisposing for complications and methods of preventing and managing those complications.
MATERIALS AND METHODS
The present study was conducted at Kempegowda Institute of Medical Sciences, Bangalore and includes 50 patients admitted in the department of surgery wards for various thyroidectomy procedures. The patients requiring thyroid surgery and those willing to undergo surgery and attend follow up were included in the study. It was a prospective observational study. Informed written consent was obtained from all patients, which was approved by the institutional ethics committee. Patients who had complications prior to surgery and those who were lost for follow up were not included in the study. A detailed history was taken and thorough clinical examination was done. Vocal cords assessment was done preoperatively using Videolaryngoscopy and documentation done. Pre operatively the thyroid profile, ultrasound of thyroid and fine needle aspiration cytology of the thyroid nodule was done along with routine urine and haematological examinations. Depending on the need of the clinical condition the thyroid surgery was planned. The procedures were done under general anaesthesia. All the operations of the present study were done by the same team of surgeons headed by the most senior surgeon of the unit to exclude surgeon related and experience related variables. During surgery effort was made to identify and preserve all the Parathyroid glands. When excision was inevitable, it was planted in the sternocleidomastoid muscle. The recurrent laryngeal nerves were not dissected for identification in all cases. Soon after the procedure at the time of extubation, the anaesthesiologists using the videolaryngoscopy demonstrated the mobility of the vocal cords. Patients were followed up for 2 months. If any complication was noticed, that patient was followed up for 1 year. RESULTS 50 patients undergoing various thyroid surgeries were included in the study. Out of them 42 were females and 8 were males constituting 84% and 16% respectively. Majority of the patients were in 4th decade with 19 patients constituting 38%. Benign solitary nodule was the commonest condition in our patients study with 23 patients (46%) in that category. Most common malignant condition detected was papillary carcinoma of thyroid. Surgical procedures performed were hemithyroidectomy, subtotal thyroidectomy, isthmusectomy and total thyroidectomy. Hemithyroidectomy was the commonest procedure done. The same team of surgeons performed all procedures in order to avoid the surgeon related variability. Complications of surgery were looked for during the postoperative visits till 2 months after surgery in all patients. 16 out of 50 patients had one or more complications that amounted to 32%. Those with complications were followed up for 1 year. The commonest complication in our study was hypoparathyroidism. (Table 1) Out of total 50 patients 7 showed features of hypoparathyroidism amounting to total 14% among which 6 had transient hypoparathyroidism(12%) and 1(2%) had permanent hypoparathyroidism. Patient complaints included perioral numbness, tetany of hands (Fig 1) and spasm of calf muscles. They were treated with intravenous Calcium Gluconate injection followed by oral calcium with vit D3 supplements three times a day for 10 days. One patient had symptoms in spite of many days of calcium supplement who was asked to take daily calcium supplement. Recurrent laryngeal nerve (RLN) palsy was noted in 3 patients. 2 had unilateral and 1 patient had bilateral palsy. (Fig 2) Both the patients with unilateral RLN Palsy recovered by 6 months. All the patients with recurrent laryngeal nerve palsy were treated with Inj dexamethasone 8 mg three times a day and speech therapy for vocal cord exercises. One patient had bilateral abductor palsy. He was a patient of thyroiditis with extensive fibrosis and neovascularization. Vocal cords were immobile at the time of extubation and patient developed stridor. Tracheostomy was done. Patient was followed up regularly for recovery of vocal fold movements. After 1 year when there were no signs of recovery of vocal cords, Laser arytenoidectomy was done and patient was decannulated from the tracheostomy tube. Haematoma was seen in 2 (4%) patients. In one patient who underwent isthmusectomy, the drain was not kept as there was a good operative field with very minimal bleeding. Thyroid bandage was applied to approximate the flaps. The haematoma noticed on 1st postoperative day was cleared by wide bore needle aspiration and releasing one suture. One patient (2%) had superior laryngeal nerve palsy and he presented with vocal fatigue and frequent throat clearing. On Videolaryngoscopy, bowing of vocal cords noted. (Fig 3) Patient was treated with steroid injections and vocal exercises were taught. After 15 days, patient showed recovery of vocal cords. 3 patients (6%) had wound infection, which was treated with appropriate antibiotics and regular dressing. One patient developed hypertrophic scar that was treated with intralesional Triamcinolone injection and scar thinning was achieved partially.
DISCUSSION
Thyroid surgery is the most common endocrine surgery performed. Most of the multinodular goiters require excision of both the lobes of thyroid with the isthmus. Subtotal thyroidectomy was a standard practice, but recurrence rate with this procedure is as high as 10-30%. 3 Total thyroidectomy is free of this problem but poses potential high risk of complications. Major complications of thyroidectomy are Hypocalcaemia, Recurrent Laryngeal nerve (RLN) Palsy and postoperative bleeding. Less common complications are surgical site infections stitch sinus, granuloma, keloid formation, wound infection and chylous fistula.2 The prevalence of complications varies from 5-27.5% in various studies. 1 Transient Hypoparathyroidism is the most common complication. (Table 2) 4,5,6,7 Factors responsible for complications: 8,9,1 ? Extended thyroidectomy (total thyroidectomy) ? Revision surgery ? Patients older than 50 years ? Graves disease ? Surgeon`s experience ? Dissection extended to identify the recurrent laryngeal nerve ? Central node neck dissection ? Extended Operating time10 ? Weight of the gland10 ? Substernal goiter with tracheal compression 7 Special surgical training and expertise is required while operating on high-risk conditions like total thyroidectomy and graves disease. The risk of hypocalcemia after thyroid surgery varied in different studies with a range of 2.43% to 35.49%.1 At least two parathyroid glands should be identified and preserved.9 Postoperative Hypoparathyroidism commonly occurs due to removal or devascularization of the parathyroid glands. Parathyroid autotransplantation helps to restore the parathyroid function and avoids the need for prolonged pharmacological support. Overall success rate with the immediate parathyroid autotransplantation into the sternocleidomastoid muscle ranges from 85- 95%.11 Routine supplementation with Oral calcium and vitamin D prevents symptomatic postoperative hypocalcemia without inhibiting the parathormone secretion and thereby facilitating short hospital stay.12 Postoperative vocal cord palsy is defined as the presence of an immobile vocal cord or the decreased movement of the vocal cord during phonation. Postoperative RLN palsy has the potential for recovery with a rate ranging from 50- 88%. The RLN palsy is regarded as permanent if it persists for more than 1 year after the surgery. 10The risk of permanent vocal cord paralysis varies from 0.2-5% in literature.1 Various mechanisms have been suggested for vocal cord palsy associated with thyroidectomy. Compression of the RLN and its blood supply, stretching of the nerve, inflammation or edema of RLN as in thyroiditis are suggested to be the aetiological factors.13 Vocal cord examination is mandatory pre-operatively and postoperatively during extubation. There are different schools of thought for the visualization of recurrent laryngeal nerve during surgery. Some surgeons advocate that intraoperative verification of anatomical and functional integrity of the RLN is important to avoid potential nerve injury and vocal cord palsy. 14 Wade advocated that the RLN is very vulnerable and the nerve should not be visualized or touched.15 Intraoperative nerve monitoring device helps to monitor RLN during surgery by providing both auditory and visual evoked waveform information.14 However the nonrecurrent laryngeal nerve on the right side is always a threat to indirect injury because of its rare occurrence.10 For those nerves cut unintentionally, recognized intraoperatively, endto-end anastomoses of the nerve or Ansa-RLN anastomoses may be tried. Teflon injection and Isshiki type I Thyroplasty are other treatment methods.16 Postoperative hematoma is another complication that can be fatal. Close postoperative monitoring of patient for hematoma is essential. Early exploration and evacuation of hematoma in all patients who develop postoperative hematoma is important, however a conservative approach may be tried in minimal hematoma without progression.17 A Precise tracking of the complications in a thyroid surgery helps surgeon in taking quick remediable action. This analysis helps patients to get correct information prior to surgery to make a conscious and informed decision about the surgery. When residents under training perform thyroidectomy, it can be made safe when done under close supervision of experienced faculty.18
CONCLUSION
Temporary hypoparathyroidism is the most common complication in the literature including our study. R L N Palsy and Haematoma are other dreaded complications. It has been a century since the great surgeon “Theodore Kocher” received Noble prize for his contribution in taking this surgery to a new safe level, but still this procedure continues to pose challenges for the most experienced surgeons also. It is essential to keep in mind the possible complications in this procedure and be prepared to mange them. Good surgical expertise is essential to avoid complications. Keen postoperative monitoring of patient is invaluable and helps in early detection and management of those complications.
Englishhttp://ijcrr.com/abstract.php?article_id=1117http://ijcrr.com/article_html.php?did=11171. Sumit Gupta, C Vasu Reddy, Shyam TC, Smriti Karki. Clinicopathological features and complications of thyroid operations: A Single centre experience. Indian J Otolaryngol Head Neck Surg (April-June) 2013; 65(2):140-145.
2. Tariq wahab khanzada, Abdul Samad, Waseem Memon, Basanth Kumar. Postthyroidectomy complications: The Hyderabad experience. J Ayub Med Coll Abbottabad 2010; 22(1): 65-68.
3. Antorio RZ, Jose Rodriguez, Jaun Riquelme, Teresa Soria, Manuel Canteras, Pascual Parrilla. Prospective study of Postoperative complications after Total Thyroidectomy for Multinodular goityers by surgeons with experience in Endocrine surgery. Ann Surg. 2004 July; 240(1): 18-25.
4. Lodovico Rosato, Nicola Avenia, Paolo Bernante, M Aurizio De Palma, Giuseppe Gulino, Pier Giorgio Nasi et al. Complications of Thyroid surgery: Analysis of a multicentric study on 14,934 patients operated on in Italy over 5 yrs. World Journal of Surgery; March 2004; Vol 2893): 271-276.
5. Shaha A, Jaffe BM. Complications of thyroid surgery performed by residents. Surgery. 1988 Dec; 104(6): 1109-14.
6. JG Fillo, LP Kowalski. Surgical Complications after thyroid surgery performed in a cancer hospital. Otolaryngology- Head and Neck Surgery. Mar 2005; Vol 132(3): 490-494.
7. Wen TS, Electron Kebebew, Quan-yang Duh, Orlo HC. Predictors of Airway Complications After Thyroidectomy for Substernal Goiter. Arch Surg.2004; 139(6): 656-660.
8. Y Erbil, U Barbaros, H Issever, I Borucu, A Salmaslioglu, O Mete et.al. Predictive factors for recurrent laryngeal N plasy and hypoparathyroidism after thyroid surgery. Clinical otolaryngology; Feb 2007; Vol 32(1): 32-37.
9. Oliver Thomusch, adreas machens, Carsten Sekulla, Michael Brauckhoff, Henning Dralle. The impact of surgical technique on postoperative hypoparathyroidism in bilateral thyroid surgery: A multivariate analysis of 5846 consecutive patients. Surgery; Feb 2003; Vol 133(2): 180-185.
10. Chung-Yau Lo, Ka-Fai Kwok, Po-Wing Yuen. A Prospective Evaluation of Recurrent Laryngeal Nerve Paralysis during Thyroidectomy. Arch Surg. 2000; 135(2): 204-207.
11. Christakis I, Constantinides VA, Tolley NS, Palazzo FF. Parathyroid Autotransplantation during Thyroid Surgery. World J Endocr Surg, Sept-Dec 2012;4(3):115-117.
12. Bellantone R, Lombardi CP, Raffaelli M, Boscherini M, Alesina PF, De Crea C et al. Is Routine supplementation therapy (Calcium with Vitamin D) useful after Total thyroidectomy? Surgery. 2002 Dec; 132(6): 1109-12.
13. Deependra NS, Amit Agarwal, Sushil Gupta, Manoj Jain. Benign thyroid Disease causing RLN Palsy. World J Endocr Surg, May-Aug 2011; 3(2):65-68.
14. Poveda MCD, Dionigi G, Sitgesserra A, Barczynski M, Angelos P, Dralle H etal. Intraoperative Monitoring of the Recurrent Laryngeal Nerve during Thyroidectomy: A Standardized Approach part 2. World J Endocr Surg 2012; 4(1): 33-40.
15. JSH Wade. Vulnerability of the recurrent laryngeal nerves at thyroidectomy. Br j Surg, 43(1955), pp 164-179.
16. Feng-Yu Chiang, ling-Feng wang, Yin-Feng Huang, ka-Wo Lee, Wen-Rei Ko.Recurrent laryngeal nerve palsy after thyroidectomy with routine identification of the recurrent laryngeal nerve. Surgery. Mar 2005; Vol.137 (3): 342- 347.
17. Ashok RS, Bernard MJ. Practical management of post thyroidectomy hematoma. Journal of Surgical Oncology. Dec 1994; Vol 57(4): 235- 238.
18. Maisie LS, Uttam KS, Dale H Rice. Safety of thyroidectomy in residency: A review of 186 consecutive cases; Nov 1995; Vol 105(11): 1173-117
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241517EnglishN2013September12HealthcareIMPLICATION OF PROJECT ON UPGRADATION OF SAFETY IN HEALTH CARE (PUSH) AMONG GOVERNMENT SECTOR IN TAMILNADU
English102111Manimekalan ArunachalamEnglish Vetrivel Chezian SengodanEnglishBackground: During the past few years, there has been an increase in public concern about the management of health care waste on a global basis. Due to public awareness and litigations, health care Waste collection and proper disposal have become a social issue in India. Objectives: The objective of the study is to analyze the implication of Project on Up gradation of Safety in Health care (PUSH) in health care waste management among government sector in TamilNadu. Methods: The amount of health care waste generated and the expenditure incurred among government sector from primary care level to tertiary care in Tamilnadu were studied. The study period was from 2009-10 to 2011-12.It is a cross sectional study. Results: There was a reduction of biomedical waste generated from 2009-10 to 2011-12. There was a reduction of health expenditures to CTF operators from 2009-10 to 2011-12. Conclusion: It was found that there was reduction of biomedical wastes generated and the reduction of expenditure to CTF operators due to Project on Up gradation of Safety in Health care (PUSH) in health care waste management among government sector in TamilNadu and this type of project can be followed in other part of India.
EnglishBiomedical waste, TamilNadu, hospital, PUSH Project, government.INTRODUCTION
A modern hospital is a complex, multidisciplinary system which consumes thousands of items for delivery of medical care and is a part of physical environment. All these products consumed in the hospital leave some unusable leftovers i.e. hospital waste. The last century witnessed the rapid mushrooming of hospital in the public and private sector, dictated by the needs of expanding population. Lack of awareness has led to the hospitals becoming a hub of spreading diseases rather than working toward eradicating them. The advent and acceptance of “disposable” have further increased the generation of hospital waste in the current scenario. Medical waste is a special category of waste because it poses potential health and environment risks, typically including sharps, human tissues or body parts and other infectious materials. Hospital waste is a potential health hazard to the health care workers, public and flora and fauna of the area. India participated in the United Nation?s Conference on human environment held at Stockholm in June 1972, where decisions were taken to take appropriate steps for protection and improvement of human environment. Therefore, the Environment (Protection) act 1986 was formed by the Ministry of Environment and Forest, which is the most comprehensive Act on the Indian statute book relating to Environment protection. In July 1998, the Government of India Environment (protection) act 1986 (Rule 29 of 1986) issued a Notification on Biomedical waste (Management and Handling), rules 1998, indicating the rules for management and Handling for the management and handling of biomedical waste. The Government of India (notification 1998) specifies hospital waste management is part of hospital hygiene and maintenance activities. Despite the fact that current medical waste management practices vary from hospital to hospital, the problematic areas are similar for all healthcare units and at all stages of management, including segregation, collection, packaging, storage, transport, treatment and disposal. Biomedical waste means any waste, which is generated during the diagnosis, treatment or immunization of human beings or animals or in research activities pertaining thereto or in the production or testing of biologicals, and including categories as mentioned in Schedule I[1] [Table 1]. It was long thought that proper handling of health care wastes were not done in developing countries, due to lack of scientific methods of segregation. In Tamilnadu, proper segregation and disposal of wastes had taken place even before 3800 years in Adichanallur. [2] According to the Archeological survey of India, the inhabitants of Adichanallur used an ingenious method to bury their dead human bodies in an urn on a hillock, where they could not be flooded by the nearby river or the lake [Figure 1, 2]. It was the method of segregation, which was practiced in Tamilnadu, even on 5th century B.C [2] . Poor management of Health care waste exposes healthcare workers, waste handlers and the community to infections, toxic effects and injuries [3]. The management of health-care waste is an integral part of a national health-care system. A holistic approach to health-care waste management should include a clear delineation of responsibilities, occupational health and safety programs, waste minimization and segregation, the development and adoption of safe and environmentally sound technologies and capacity building. Recognizing the urgency of this problem, the Government of Tamilnadu have implemented health care waste management plan through Health System Development Project (HSDP) with World Bank assistance in 2008. A major component of the plan is professional training of all the stake holders to ensure the understanding of proper disposal of bio medical waste, safety of the health personnel and people. Under the health care waste management plan, Bio-Medical Waste (BMW) generated from the health care sector will be segregated as per the colour coding prescribed by the bio medical waste handling rules [Table 2] and to generate a massive awareness in the community about the need for the safe disposal of bio medical waste. [4]
MATERIALS AND METHODS
All the health care providing centres in the government sector of Tamilnadu from the primary to tertiary level were in the study group (Table 3, figure-3). The period of study was from the year 2009-10 to 2011-12. The total number of bed strength was 55014. The biomedical waste generated in the above centers and the expenditures incurred for biomedical waste management were studied. It is a cross sectional analysis evaluating the generation of biomedical waste per bed per day among government sector in tamilnadu
RESULTS
Biomedical waste generated in Tamilnadu for the year 2009-10 is 531896 kilograms, in 2010-11 it was 429395 Kilograms and in 2011-12 it was 282485 kilograms for the total bed strength of 55014[figure-4]. There was also a reduction of expenditure to CTF operators from 2009 to 2011 [Table 4, figure-5].
DISCUSSION
The objective of BMW management are mainly to reduce waste generation, to ensure its efficient collection, handling, as well as safe disposal in such a way that it controls infection and improves safety for employees working in the system. Seventy five to ninety percent of the waste generated by the health care providers is non toxic or general waste[1] . It comes from administrative and housekeeping functions of the health care establishments are taken care by the local bodies. The remaining 10-25% is health care waste is hazardous and creates a variety of health risks [1]. According to WHO report 85% of hospital waste is non-hazardous waste, around 10 % are infectious waste and around 5% noninfectious but hazardous waste.[5] It is estimated that annually about 0.33 million tons of hospital waste is generated in India and, the waste generation rate ranges from 0.5 to 2.0 kg per bed per day. The solid wastes from the hospitals consists of bandages, linen and other infectious waste(30-35%), plastics (7-10%), disposable syringes(0.3-0.5%), glass(3-5%) and other general wastes including food(40-45%) [6] . Effective management of biomedical waste is not only a legal necessity but also a social responsibility. [5] In 2006, Gupta S. Boojh did a study on biomedical waste management attitudes in Northern India. The study revealed that the infectious and non-infectious wastes are dumped together with in the hospital premises and disposed with municipal waste. The results of the study revealed the need for strict enforcement of legal provisions and a better environmental management system for the disposal of bio medical waste.[7] In 2006, N. Mathar Mohideen did a study to assess the knowledge, attitude and performance of nurses on Bio Medical Waste management in selected hospitals in Karnataka. The study showed that very negligible percentage of the nurses had high knowledge (1.7%) and more than seventy five percent of the nurses had below average knowledge. The study revealed the necessity for a training programme on biomedical waste management.[7] Deepali Deo et al in 2006 have concluded that the objective of Biomedical Waste Management are mainly to reduce waste generation, to ensure its efficient collection, handling as well as safe disposal in such a way that it controls infection and improves safety for employees working in the system. The study concluded that it will be apt to remember recommendations of WHO „Human element is more important than technology?. [8] A study in 2011 by Ketan V. Lakahtria conducted in Ahmedabad has observed that there is a gap between biomedical waste rules and inadequate state of waste management. Safe and effective management of waste is not only a legal necessity but also a social responsibility. [5] KAP study conducted in Northern India by Vanesh mathur et al in 2011 have insisted on compulsory continuous training for the healthcare personals in accredited training centers.[9] A study conducted by Boss U J et al in 2009 in puducherry government general hospital have concluded that in India, not much attention has been paid to the management of biomedical waste (BMW) and recommended the establishment of standards and periodic monitoring along with effective training of personnel. [10]. According to WHO (biomedical waste 2004) the human element is more important than the technology alone. Almost any system requiring treatment and disposal that is operated by well trained and well-motivated staffs provide more protection for staffs, patients and the community than an expensive or sophisticated system that is managed by staffs who do not understand the risks and the importance of their contribution (Biomedical waste2004). Although education about health care waste management is included in undergraduate medical courses, it may be essential to make it a part of continued professional education and strictly implemented with 100% compliance. According to the biomedical handling rules the state governments were made responsible for effective implementation. In Tamilnadu, Biomedical waste awareness program was started by the Government of Tamilnadu in 2008 through a “project for upgrading safety in health care”(PUSH).This programme is monitored by the Tamil nadu health system project(TNHSP) in collaboration with National rural health mission, Tamil nadu pollution control board and Tamilnadu AIDS prevention and control society. The aim of the project is to establish 11 regional training centers to train 150 health care providers as trainers in bio medical waste management. Trainers will in turn train 40,000 health care providers in the state of Tamilnadu. Doctors, medical students, nursing staff, laboratory technicians, and radiographers were involved in this program and the essentials of biomedical waste management were summarized to them by experts. This program was made compulsory for all the health care professionals due to the importance of proper segregation of biomedical wastes at the site of their production.[4, 11, 12]. The biomedical wastes are segregated as per the colour coding issued by the government of India and transported to the storage room available in the health care centers.[8] The effective segregation of biomedical waste at the site of their production will help in the prevention of hazards of biomedical waste. The nursing supervisors are fixed with the responsibility to supervise biomedical waste registers regarding segregation maintained by the staff nurses available in all the work stations namely wards, outpatient services, casualty, labour room and operation theatres on day to day basis. The colour coding charts are provided in the regional language and pasted near the colour coded baskets in all work stations for immediate reference. With private public partnership the common treatment facility (CTF) is taken care by the private operators. Consent for operating CTF facility was given by the government of Tamilnadu to eight operators located at Chengalpattu, Sriperumpudur, Vellore, Salem, Tanjavur, Arupukottai, Tirunelveli and Coimbatore covering thirty districts of Tamilnadu. It is the responsibility of these agencies to take away the biomedical wastes from the storage room of health care centers till safe disposal in the common treatment facility.[11, 12] To monitor effective implementation of biomedical waste management, State level, district level and hospital level monitoring committees have been formulated (Table 5). In the state and district level committees NGO, Indian medical association are included apart from government officials from Tamilnadu pollution control board and municipal department. From our study it is evident that the expenditure on CTF operators have also been declined every year from 2009 to 2011. [Table 4].This is possible only through segregation of health care waste at the source of generation, implemented by the Project on Up gradation of Safety in Health care (PUSH) plan of government of Tamilnadu for health care waste management among government sector in Tamilnadu.
CONCLUSION
Wherever hospital waste is generated, a safe and reliable method for handling of biomedical waste is essential. Segregation of Biomedical Waste is considered the most important steps in Biomedical Waste Management. It is the responsibility of the occupier to segregate biomedical wastes at source. From our study it?s evident that right investment of resources and commitment has resulted in a substantive reduction in health expenditures to CTF operators. [Table 4]. Continuous training, monitoring, periodic evaluation are the key points for the successful implementation of Project on Up gradation of Safety in Health care (PUSH) plan of government of TamilNadu executed by TamilNadu Health System Development Project. Effective management of biomedical waste is not only a legal necessity but also a social responsibility which is achieved by proper segregation of health care waste at the source of generation in the health care centres among government sector in TamilNadu. Project on Up gradation of Safety in Health care (PUSH) plan of government of TamilNadu can be adopted in other parts of India for better implementation of health care waste.
ACKNOWLEDGEMENT
Authors acknowledge the great help received from the scholars whose articles cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Authors are grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=1118http://ijcrr.com/article_html.php?did=11181. Park K. Hospital Waste Management. Park?s Textbook of Preventive and Social Medicine. 20th Edn, 2009: 694-699.
2. The Hindu, Urn burial site discovered in Tamil Nadu district, Available from:http://www.hindu.com/2004/03/14/stori es/2004031400151100.htm , [Accessed 10th January 2013]
3. Rutala WA (1987). Infectious waste - A growing problem for infection control. Asepsis, 9: 2-6
4. Tamilnadu state level committee for hospital waste management , Available from: (http://www.tn.gov.in/gorders/eandf/environ7 2-e.htm), [Accessed 10th January 2013]
5. Ketan V. Lakahtria: Biomedical Waste Management Systems for Urban Hospital: institute of technology, nirma university, Ahmedabad – 382 481, 08-10 December, 2011
6. Patil AD, Shekdar AV. Health-care waste management in India. J Environ Manage. 2001; 63:211–20. [PubMed]
7. Mrs.Seshamba kandanala: a study to assess the knowledge and attitudes on biomedical waste management among staff nurses at s.n.r. district hospital, Kolar: 2010
8. Deepali Deo, Tak S B, Munde S. A Study of Knowledge Regarding Biomedical Waste Management among Employees of a Teaching Hospital in Rural Area. Journal of ISHWM. 2006 April; 5(1): 12-5.
9. Vanesh Mathur, S Dwivedi, MA Hassan, and RP Misra Knowledge, Attitude, and Practices about Biomedical Waste Management among Healthcare Personnel: A Cross-sectional Study: Indian J Community Med. 2011 AprJun; 36(2): 143–145.
10. Boss UJ, Moli GP, Roy G, Prasad KV, Biomedical waste generation in Puducherry Government General Hospital and its management implications, J environmental health 2009 May;71(9):54-8.
11. Health & family welfare department, government of tamilnadu, Available from:(http://www.tnhealth.org/mehospitals.ht m), [Accessed 10th January 2013]
12. Ministry of Environment and forest notification on the Bio-Medical Waste (Management and Handling) Rules. 1998,Newdelhi.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241517EnglishN2013September12HealthcareAN ANOMALOUS CORACOBRACHIALIS MUSCLE - A CASE REPORT
English112115Surwase Ramdas GopalraoEnglish Lakshmi RajgopalEnglishCoracobrachialis a muscle of flexor compartment of the arm is usually attached proximally to the tip of the coracoid process of scapula along with short head of biceps brachii and distally attached to the medial border of middle of shaft of humerus. During routine dissection of the upper limb, an anomalous coracobrachialis muscle was found on the left arm of a male cadaver. Its proximal attachment was from the fibrous band of medial intermuscular septum of arm. Its distal attachment was to the medial epicondyle of humerus and to the antebrachial fascia. Median nerve and brachial artery were seen passing deep to this muscle. This variation is important for clinicians and radiologists.
Englishcoracobrachialis inferior muscle, Wood’s muscle, musculocutaneous nerve, brachial artery, median nerve, fibrous tunnel.INTRODUCTION
Coracobrachialis is a muscle of the flexor compartment of the arm. It is attached proximally to the tip of the coracoid process of the scapula together with the tendon of short head of biceps brachii. It ends on an impression, 3-5 cm in length, midway along the medial border of the middle of the humeral shaft between the attachment of triceps and brachialis, where the nutrient foramen of the bone is usually located. It is supplied by the musculocutaneous nerve (C5, C6 and C7), a branch from the lateral cord of the brachial plexus. This nerve supplies the muscle before piercing it and then courses further between biceps brachii and brachialis 1, 2 . Many variations regarding the origin of coracobrachialis, course of related arteries and the positioning of the neurovascular bundle behind the muscle have been described which may result in compression of the neurovascular bundle 3 . These variations remain unnoticed during life, until they become symptomatic and receive the attention of the surgeons or noticed by anatomists during dissection. Several variants of insertion of coracobrachialis muscle have also been described in literature. Coracobrachialis has been reported to insert as an accessory slip to the lesser tubercle, medial epicondyle or medial intermuscular septum. Wood in 1867 and El-Naggar and Zahir in 2001 have described coracobrachialis having distal attachment to the medial epicondyle of humerus or to the medial intermuscular septum of arm, blending with the medial head of the triceps muscle 4, 5 . According to Bergman et al, coracobrachialis muscle actually consists of three parts: i) A proximal part arising from the coracoid process of the scapula and inserted onto the humerus close to the lesser tubercle; ii) A middle part of intermediate size; iii) A distal part, which is the largest and the most superficially placed 6 . In human beings, the proximal and the middle parts are the most constantly present. Distal portion is sometimes present in the form of coracobrachialis inferior or longus (according to Wood, 1867)4 and may be attached to the humerus or to a fibrous band of medial intermuscular septum or even to the medial humeral epicondyle. Knowledge of such variation is of considerable importance during invasive and non-invasive investigative procedures or during orthopedic and reconstructive surgical procedures7 .
CASE REPORT
During routine dissection of cadavers, in one left arm, an anomalous coracobrachialis inferior muscle was found. In this specimen, the proximal attachment of coracobrachialis was to the tip of coracoid process along with the short head of biceps brachii and its distal attachment was to the medial border of middle of shaft of humerus. It was seen that musculocutaneous nerve supplied and then pierced the muscle (Fig. 1). Distal to the normal coracobrachialis muscle, an accessory coracobrachialis muscle was found having a proximal attachment to the humerus distal to the insertion of normal coracobrachialis and also to the fibrous band of medial intermuscular septum of arm (Fig. 2). Its distal attachment was to the medial epicondyle of humerus and to the antebrachial fascia. This muscle fits in with the description of coracobrachialis longus or coracobrachialis inferior as described by John Wood in 1867 4 . In this case, it was found that coracobrachialis inferior was supplied by a nerve branch arising directly from the medial cord of brachial plexus (Fig. 3). Deep to the coracobrachialis inferior, there was a fibrous tunnel [which was formed by the medial intermuscular septum from which this muscle was arising] through which the median nerve and the brachial artery were passing (Fig. 4).
DISCUSSION
Variations of the insertion of coracobrachialis are classified by James Doyle et al as proximal and distal 8 . Proximal insertional variation may be to i) Surgical neck of humerus; ii) Capsule of the shoulder joint; iii) Bicipital ridge of humerus about 1 cm distal to the lesser tubercle. The latter variation is called as coracobrachialis superior or coracobrachialis rotator humerii or Gruber’s muscle. Embryologically, this may be the superior portion of the coracobrachialis muscle. Of the proximal insertions, some may be additional slips extending to various structures in the shoulder area like the tendon of latissimus dorsi, the tendon of teres major or the lesser tubercle of humerus. Of these, an accessory slip of coracobrachialis arising from the coracoid process, crossing the radial nerve in the axilla and inserting into the tendon of latissimus dorsi has been named as coracobrachialis minor or le court coracobrachialis of Cruveilhier 8 . Variant distal insertions may be to i) Distal medial margin of humerus / Medial supracondylar ridge; ii) Medial epicondyle; iii) Fibrous band of medial intermuscular septum (Internal brachial ligament); iv) Anomalous supracondylar process; v) Ligament of Struthers; vi) Antebrachial fascia. An anomalous coracobrachialis muscle which is inserted farther distally than usual is referred to as coracobrachialis longus or coracobrachialis inferior or Wood’s muscle 8 . In the case under discussion, the coracobrachialis muscle had a normal origin and a normal insertion and an additional slip was found to prolong into distal arm covering median nerve and brachial artery and getting inserted on to the medial epicondyle and antebrachial fascia. This additional slip is coracobrachialis longus or inferior or Wood’s muscle. This muscle also had an independent nerve supply directly from the medical cord of brachial plexus and such a finding is so far not reported.
CLINICAL SIGNIFICANCE
From clinical viewpoint, the muscle insertion into the medial epicondyle and antebrachial fascia would create a narrower anterior compartment during contraction of coracobrachialis muscle and could produce proximal median neuropathic symptoms and brachial artery compression. Entrapment of median nerve and brachial artery by tendinous arch of coracobrachialis has been reported recently 9 . This additional muscle may cause musculocutaneous or high median nerve paralysis 10, 11, 12 . The coracobrachialis muscle is used as a transposition flap in the reconstruction of soft tissue defects of infraclavicular and axillary areas and in post-mastectomy reconstruction 10. It can be used in graft surgeries as an accessory muscle and its removal may not cause any functional problem 13. It is also a guide to the axillary artery during surgery and anesthesia. Anatomic variations of coracobrachialis muscle may easily be confused with other muscle and pathologic conditions at CT and MRI scans 13. So, surgeons and radiologists should be aware of variations of this muscle.
EMBRYOLOGICAL BASIS
The morphologic variation of the coracobrachialis may be explained on the basis of the embryogenesis of the muscles of the arm. The muscles of the upper limb differentiate in situ from the limb bud mesenchyme. The muscle primordia within the different layers of the arm fuse to form a single muscle mass, thereafter, some muscle primordia disappear through apoptosis. Failure of muscle primordia to disappear during development may account for the presence of the accessory insertion of coracobrachialis muscle reported in this case 14.
CONCLUSION
Surgeons and radiologist should keep in mind about such variations of coracobrachialis muscle while doing the surgeries and any radiological procedure. If this variation present it can be used as transpositional flap in postmastectomy reconstruction and also can be used in graft surgeries. If such variation present clinician should keep in mind that embryological basis of such variation.
ACKNOWLEDGEMENT
The authors wish to acknowledge with gratitude the permission given by Dr. Pritha Bhuiyan, Professor and Head of Anatomy, Seth GS Medical College and K.E.M. Hospital, Mumbai for publishing this article.
Englishhttp://ijcrr.com/abstract.php?article_id=1119http://ijcrr.com/article_html.php?did=11191. William PL, Warwick R, Dyson M, Bannister LH: Gray’s anatomy 37th edition, Edinburgh, Churchill Livingstone, 1989; 614-615.
2. McMinn RMH. Editor Last’s Anatomy: Regional and Applied. 8th ed. Edinburgh, Churchill Livingstone, 1990 ; 79.
3. Kumar N, Shetty SD, Somayaji SN, Nayak SB: Presence of accessory coracobrachialis and its clinical importance – A case report, Int. J. Anat. Var. (IJAV). 2012 ; 5:27-28.
4. Wood J.: On human muscular variations and their relation to comparative anatomy, J. Anatomy Physiol. 1867; 1:44-59.
5. El-Naggar MM, Zahir FI: Two bellies of coracobrachialis muscle associated with a third head of the biceps brachii muscle, Clin.Anat.2001; 14(5): 379-82.
6. Bergman RA, Thompson SA, Afifi AK, Saadeh FA: Muscles In Compendium of Human Anatomical Variation Text, Atlas and World Literature. Baltimore, Urban and Schwarzenberg, 1988; 10-11.
7. Ray B, Rai A.L, Roy T.S.: Unusual insertion of coracobrachialis muscle to the brachial fascia associated with high division of brachial artery, Clinical Anatomy, 2004; 17:672-676.
8. Doyle J, Bottle M, Krames C, Roselius E.: Editors Muscle Anatomy In: Surgical Anatomy of the hand and upper extremity. Baltimore, Lippincott, Williams and Wilkins, 2003; 97-98.
9. Rodrigues V, Nayak S, Nagabhodshana S, Vollala VR: Median nerve and brachial artery entrapment in the tendinous arch of coracobrachialis muscle, Int. J. Anat. Var. (IJAV). 2008 ; 1:28-29.
10. Kopuz C, Icten N, Yildirim M.: A rare accessory coracobrachialis muscle: A review of literature, Surgical Radio Anat.2003; 24: 406-410.
11. El-Naggar MM, Al-Saggaf S: Variant of coracobrachialis muscle with tunnel for median nerve and brachial artery. Clin.Anat.2004; 17: 139-143.
12. Potu BK, Rao MS, Nayak SR, Vollala VR, Mandava AK, Thomas H: Variant insertion of coracobrachialis muscle in a south Karnataka cadaver, Cases Journal.2008; 1:291.
13. Kumar N, Shetty SD, Somayaji SN, Nayak SB: Presence of accessory coracobrachialis and its clinical importance –a case report, Int. J. Anat. Var. (IJAV),2012; 5:27-28.
14. Guha R, Satyanarayana N, Reddy CK, Jayasri N, Nitin V, Praveen G, Sunitha P, Datta AK: Variant insertion of coracobrachialis musclemorphological significance, embryological basis and clinical importance, JCMSNEPAL.2010; 6(2):42-46.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241517EnglishN2013September12HealthcareTHE NERVE SUPPLY TO EXTENSOR CARPI RADIALIS BREVIS MUSCLE - A STUDY
English116123Jayakumar V. R.English Roshni BajpeEnglish Shubha R.EnglishAim: To study the nerve supply to extensor carpi radialis brevis muscle. Materials and methods: 50 upper limbs of adult human cadavers irrespective of sex were studied in the Department of Anatomy at Kempegowda institute of medical sciences, Bengaluru, Karnataka, the nerve supply to extensor carpi radialis brevis (ECRB) muscle was observed. Study was done by dissection method. The following parameters: source of nerve to ECRB, site of division of radial nerve in relation to lateral epicondyle were noted and the distance between origin of nerve to ECRB and point of entry into the muscle was measured. Results: In 29 specimens the nerve supply to extensor carpi radialis brevis was from posterior interosseus nerve (PIN), in 12 specimens from superficial branch of radial nerve and in 9 specimens from the angle of bifurcation of radial nerve and none of the specimens showed innervation from the radial nerve trunk. In 33 specimens, radial nerve divided at the level of lateral epicondyle, in 15 specimens it was above the level of lateral epicondyle and in 12 specimens showed division below the level of lateral epicondyle. Average length of nerve to ECRB on right and left side was found to be 4.4 cm and 4.1 cm respectively. Conclusion: In 24% of specimens the nerve supply to extensor carpi radialis brevis was from the superficial branch of radial nerve, the knowledge of which is clinically important for surgeons and orthopaedicians before undertaking surgical procedures such as free functional muscle transfer, tenotomy etc.
EnglishRadial nerve, posterior interosseus nerve, lateral epicondyle, tenotomy.INTRODUCTION
Extensor carpi radialis Brevis (ECRB) is one of the superficial muscles of the extensor compartment of the forearm. It arises from the lateral epicondyle of the humerus by a tendon of origin along with other forearm extensors, the radial collateral ligament of the elbow joint, from a strong aponeurosis which covers its surface and adjacent intermuscular septa. The tendon passes under extensor retinaculum and is attached to the dorsal surface of the base of the third metacarpal on its radial side, distal to styloid process and on adjoining parts of the second metacarpal bone1 . The muscle acts to extend and radially abduct the hand. It also stabilises the wrist when the fingers are flexed2 . The extensor carpi radialis brevis is innervated by posterior interosseus nerve (PIN) C7 and C8. Branches to ECRB may arise from the main trunk of radial nerve or from the beginning of the superficial branch of radial nerve1 . The radial nerve, a continuation of the posterior cord of brachial plexus consists of fibres from C6, C7, C8 and sometimes T1. It is primarily a motor nerve that innervates the triceps; the supinators of the forearm; and the extensors of the wrist, fingers, and thumb. This nerve is injured most often by fractures of the humeral shaft. Gunshot wounds are the second most common cause of radial nerve injury. Other causes include lacerations of the arm and proximal forearm, injection injuries, and prolonged local pressure. Roles and Maudsley emphasized that entrapment of the posterior interosseous nerve can cause chronic and refractory tennis elbow. Such entrapment is called radial tunnel syndrome and one of the potential compressive anatomical structures is the origin of the extensor carpi radialis brevis muscle. When entrapment is caused by other conditions, however especially in the forearm, surgical exploration and decompression of the nerve usually are beneficial3 . Previous studies done by Salisbury (1938) showed that nerve to ECRB arises most frequently from the superficial branch of radial nerve in 56% limbs4 ; Al-Qattan (1996) reported 48% from superficial branch and 20% from the radial nerve trunk2 . In a recent report by Sharadkumar et al (2012) 42% of specimens were innervated by superficial branch of radial nerve5 . It is a universally accepted axiom that the variation in nerve supply to any muscle, particularly in an extremity is of definite surgical importance.
MATERIALS AND METHODS
The present study was done on 50 upper limbs (26 right sides and 24 left sides) of adult human cadavers irrespective of sex in the Department of Anatomy, Kempegowda institute of medical sciences, Bengaluru, Karnataka. The study was done by dissection method. The nerve to extensor carpi radialis was identified in all the specimens and its length was measured with maximum accuracy using a measuring scale. The following observations were recorded. i. Site of division of radial nerve in relation to lateral epicondyle ii. Number of terminal branches of the radial nerve iii. Source of the nerve to ECRB i.e. radial nerve trunk above its division, angle of its bifurcation, deep branch or superficial branch of radial nerve iv. Distance between origin of nerve to ECRB and point of entry into the muscle
RESULTS
The nerve to extensor carpi radialis brevis arose most commonly from the deep branch of radial nerve in 58% specimens, followed by superficial branch in 24% and from the angle of bifurcation of radial nerve between superficial and deep branch in 18% of the specimens. None of the specimens showed innervation from radial nerve trunk before dividing into terminal branches (Table-1 / Fig: 1, 2, and 3). The radial nerve divided most commonly at the level of lateral epicondyle in 66% limbs, followed by its division below the level of lateral epicondyle in 24% limbs and in the rest 10% it divided above the level of lateral epicondyle (Table-2 and 3). In 82% of the limbs the radial nerve divided into two branches, superficial and deep; in the remaining 18% limbs it showed three divisions, the third being the nerve to ECRB arising from the angle between the superficial and deep branches of radial nerve (Table- 4). Average length of nerve to ECRB from its origin to point of entry into the muscle on right and left sides were 4.4 cm and 4.1 cm respectively. Maximum and minimum length of the nerve was found to be 7.7 cm and 2 cm on the right side and 7.4 cm and 2.3 cm on the left side respectively (Fig: 4).
DISCUSSION
The source of origin of nerve to ECRB has presented many variations in the previous studies, originating either from radial nerve trunk, superficial branch of radial nerve or deep branch of radial nerve or from angle of bifurcation of radial nerve between its superficial and deep branches (Table-5).
The incidence of the nerve supply to ECRB from superficial branch of radial nerve has been reported by Salisbury (1938) in 56% limbs and AlQattan (1996) in 48% of the limbs2, 4. The present study showed that this was the case in 24% of the specimens. The variation in the incidence of innervation of ECRB by superficial branch of radial nerve in different studies may be due to racial factors6 . Dhall et al. (2001) studied 60 specimens and reported the origin of nerve to ECRB from superficial branch in 35% limbs and from deep branch in 50% and from the angle of bifurcation in 15% specimens7 . S.R Nayak et al (2009) studied 72 limbs the origin, nerve supply to ECRB and its role in lateral epicondylitis. In their study, 11 specimens (15%) showed nerve to ECRB arising from radial nerve trunk, in 36 specimens (50%) it arose from deep branch and in 25 specimens (34%) from the superficial branch of radial nerve8 . Among 60 upper limbs that were studied by Meenakshi Khullar et al (2012), the nerve to ECRB arose from deep branch in 50% specimens, 30% from superficial branch and remaining 20% from the angle of bifurcation of radial nerve6 . Sharadkumar et al (2012) recently studied 100 specimens and found that nerve to ECRB arose mostly from the superficial branch in 42 specimens, from deep branch in 36 specimens and from the angle of bifurcation in 22 specimens5 . Division of radial nerve trunk with respect to lateral epicondyle was observed. In studies done by Dhall et al, Meenakshi Khullar et al and Sharadkumar et al the division of radial nerve trunk occur most commonly above the level of lateral epicondyle. In present study it was found to divide at the level of lateral epicondyle in most (66%) specimens5, 6, and 7 . In the present study, we measured the length of the nerve to ECRB as an average of 4.4 cm and 4.1 cm on the right and left sides respectively. S.R Nayak et al observed the above distance at an average of 4.3 cm and 4 cm on right and left sides which is similar to our study. The data regarding the length of the nerve will help the surgeons while exploring the elbow region during the surgical decompression of the posterior branch of radial nerve in between the ECRB and Extensor carpi radialis longus (ECRL) muscles8 . Number of terminal branches of radial nerve has been studied previously. The radial nerve terminated as either 2 branches (superficial and deep branch) or as 3 branches (superficial branch, deep branch and nerve to ECRB from the angle between the superficial and deep branch). Dhall et al reported 85% showed two branches and 15% presented with three branches8 . Meenakshi et al found that nerve divided into two branches in 80% and into three branches in 20% specimens6 . Sharadkumar et al. reported 78% specimens with two branches and 22% with three branches. Present study showed radial nerve termination into two branches in 82% limbs and 3 branches in 18% limbs5 . Variations in the origin of the nerve to extensor carpi radialis brevis muscle are clinically important. ECRB muscle may be spared in injuries to the posterior interosseus nerve thereby explaining the preservation of some wrist function clinically after penetrating injuries which may otherwise result in a complete wrist drop6 . Lacerations of the radial aspect of the proximal forearm resulting in injury to the superficial radial nerve may also involve the nerve to ECRB. Preoperatively, isolated paralysis of ECRB is difficult to detect on clinical examination in the acutely injured patient because weakness of wrist extension may be attributed to pain. Surgical exploration of these cases should therefore include identification of the motor nerve to ECRB2 . Traumatic transection of the superficial radial nerve in the distal forearm may result in a painful neuroma. One of the options is to transect the superficial radial nerve in the proximal forearm and to bury the proximal nerve stump in muscle. If this option is chosen, transection of the superficial radial nerve should be performed distal to its motor branch to ECRB2 .
Recently, ECRB has also gained importance for use in ‘free functional muscle transfer’ i.e. transfer of a muscle with its motor nerve and vascular pedicle from one site of the body to another site in order to restore the motor function. So knowledge of the variations in the origin of its nerve supply is thus important while this muscle is being harvested6 . The normal origin and the course of the nerve to ECRB lie very close to the posterolateral aspect of the radius, a frequent site of pathology, trauma and surgical procedures. The anterior approach to the elbow and the variations in this approach are used frequently in the surgical management of proximal radial fractures as well as variety of other pathologies. Such manoeuvres involve the separation of the ECRB distally with resultant exposure of radial nerve and its branches. Hence the knowledge of variations of nerve supply to the ECRB will assist the surgeon in avoiding an inadvertent injury due to placement of retractors5 . Repeated contraction of wrist extensor muscles especially the ECRB which may compress the deep branch of radial nerve at the elbow during pronation leading to lateral epicondylitis or tennis elbow8 . In tennis elbow muscle involved is ECRB. The non-inflammatory, chronic degenerative changes occur in the origin of ECRB. The surgeons performing ‘Z’ shaped tenotomy on tennis elbow to lengthen the tendon of ECRB must be aware of this variation in order to avoid unwanted complications5 .
CONCLUSION
Our study emphasizes that the nerve supply to ECRB from the superficial radial nerve is not a rare occurrence. The awareness is clinically important for surgeons dealing with compressive neuropathies and orthopaedicians operating on the fractures of the lower end of humerus and plastic surgeons performing free functional muscle transfer. A lack of knowledge of such variations might prove to be a hindrance to the operating surgeons.
ACKNOWLEDGEMENT
The author is thankful to the Department of Anatomy, Kempegowda institute of medical sciences, Bengaluru, for giving an opportunity to do the study. All the authors are grateful to the authors and publishers of those articles or books that are cited in references from where the literature has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=1120http://ijcrr.com/article_html.php?did=11201. Standring S, Borley NR, Collins P, Crossman AR, Gatzoulis MA, Healy JC, et al.Gray’s Anatomy : The Anatomical Basis Of Clinical Practice. 40th ed. London: Elsevier Ltd; 2008;P.849,856.
2. Al-Qattan M.M. The nerve supply to the extensor carpi radialis brevis. J Anat 1996;188:249-50.
3. Canale ST, Campbell’s Operative Orthopaedics. 10th ed. Mosby Ltd; 2003; vol 4: p. 3257.
4. Salisbury CR. The nerve to the extensor carpi radialis brevis. Brit J Surg 1938;26:95– 98.
5. Sawant SP, Shaikh ST, Lele SD, et al. Study of nerve supply of extensor carpi radialis brevis muscle. International Journal of Analytical, Pharmaceutical and Biomedical sciences 2012;1(4):63-70.
6. Khullar M, Kalsey G, Laxmi V, Khullar S. Variations in the nerve supply to the extensor carpi radialis brevis. Journal of Clinical and Diagnostic Research 2012;6(1):13-16.
7. Dhall U, Kanta S. Variations in the nerve supply to extensor carpi radialis brevis. J Anat Soc India 2001;50(2):134-136.
8. Nayak SR, Ramanathan L, Krishnamurthy A, et al. Extensor carpi radialis brevis origin, nerve supply and its role in lateral epicondylitis. Surg Radiol Anat 2010;32(3):207-211.