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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241515EnglishN2013August17General SciencesSTUDIES ON THE SUB CULTURE AND MULTIPLICATION OF ANTHURIUMBICOLOUR PLANTLETS IN MURASHIGE SKOOG LIQUID MEDIUM
English0105Ancy D.English Bopaiah A.K.EnglishThis work was carried out to study the multiplication and growth of Anthurium bicolour (Agnihothri). Plantlets obtained earlier in the solid medium. The liquid culture method showed better growth and development of plantlets. The plantlets obtained were bigger in size with respect to leaf area and shoot height. The multiplication rate was enhanced due to faster absorption of nutrients. Rooting was also better in the liquid medium when compared to the solid medium. The study confirmed that liquid MS medium supplemented with 4 mg\L- BA and 1mg\L- NAA is found more suitable for the growth and multiplication of Anthurium bicolor plantlets.
EnglishAnthurium Bicolor (Agnihothri), In vitro, regeneration, plantlets.INTRODUCTION
Anthurium andreanum has many hybrids which are cultivated as ornamental and for cut flowers, one among them is Anthurium bicolor variety agnihothri with large brightly coloured spathe. It has a combination of blood red and grass green colour, Hence it is called bicolor. Though Anthuriums are cultivated through regenerative method, the regeneration capacity was found to be less among some of the hybrids. There is great demand for the planting material of Anthurium bicolor variety agnihothri both by the hobbyists and growers. The present work was initiated keeping in mind the demand and faster method for propagation of plantlets. The culture were initiated with solidified agar medium and an attempt was made to grow them using liquid medium supplemented with various concentration of growth additives (Table-1).The response was found to be good in the liquid medium when compared to the solid medium.
MATERIAL AND METHODS
Dry matured seeds were collected from the plant and then wash with running tap water, followed by soaking for 5-8 minutes with a mild liquid detergent (10% v/v) teepol. Again the seed were washed thoroughly with running tap water to remove the detergent trace. Then the seed were surface sterilized by dipping the seed in 0.1% v/v mercuric chloride solution for 10-15 minutes, followed by washing with sterile double distilled water 4 to 5 times inside the laminar air flow. They were again dipped in the hydrogen peroxide for 30 seconds and rinsed with sterile double distilled water, followed the standard procedure .These sterilized seeds were inoculated on the surface of solidified full strength MS (Murashige and Skoog 1962) medium supplement with 2 mg\L-BA and 0.5mg\L-NAA. The seed started germination resulting in multiple shoot formation (fig-2) when the shoots were subcultured in the MS full strength medium supplement with 4 mg\L-BA, 2mg\L-NAA, Myoinositol-100mg\L, thiamine HCl-4mg\L. The plantlets in the solid media was transferred to the liquid medium with same supplements as in the case of solid medium (fig-3). They were incubated at 25oC ±2 oC and (1599-2000 lux) in the growth room. These regenerated shoots formed cluster with bases adhere to one other (fig-5).The liquid medium was not agitated on the rotary shaker as it used to be done in earlier reports (Whei-Lan Teng 1997). Some of the regenerated shoots formed roots at the base, in the liquid medium (fig-7).
The individual shoots were transferred to MS rooting medium (fig-6), supplemented with Myoinositol, thiamine, glycine, NAA, sucrose, 2%-activated charcoal and agar (Table-1), later plantlets transferred to greenhouse.
RESULTS
The seed germinated in full strength MS medium supplemented with 2mg\L and o.5mg\L-NAA, in about 150 days of time the germinated seed showed multiple shoots (fig-2).The plantlets obtained were further subcultured in MS solid medium supplement with 4mg\L-BAP and 2mg\L-NAA. The shoot and roots regenerated in about 60 day of time in the MS liquid medium .Where as in the MS liquid medium, of the same composition as MS solid medium regeneration of plantlets were fast compared to the solid medium. The plantlets was transferred to the root inducing medium supplemented with 1mg\L-NAA, sucrose-3%, activated charcoal-2% (Table-1).
DISCUSSION
It is usual practice to multiply the anthurium plantlets using solidified medium .In the present work an attempt was made to deviate from the monotonous method of culturing them in solidified MS medium. The result was found very positive. The liquid medium was found to be more suitable than the solidified MS medium. This not only saves time in multiplying them. It also saved the cost of producing healthy plantlets, by not using agar in the medium, which is expensive .One more observation made in the is work was usage of, rotary shaker for liquid culture (Whei-Lan Teng 1997). In the present work rotary shaker was totally avoided. The culture were incubated keeping the media in a stagnant condition like the solid media. This also saves the cost of the production by not using extra power for the culture of anthurium plantlets .When the plantlets obtained were transferred to rooting medium (Tables-1), normal root formation was observed (fig-6). When the plantlets were hardened they grew into normal plants without showing any abnormalities (fig-7). This clearly indicates that, by using liquid medium in the later stages of growth, gives better result than the solid medium which is normally used in almost all commercial laboratories.
CONCLUSION
The above work suggest that liquid medium supplement with 4mg\L-BAP and 2mg\L-NAA was found to be better than MS solid media of the same composition for further regeneration and multiplication of plantlets.
ACKNOWLEDGEMENT
The authors wish to thank Dr. Fr. Daniel Fernandes S.J. for is support and encouragement
Financial disclosure: non Funded research work
Englishhttp://ijcrr.com/abstract.php?article_id=1198http://ijcrr.com/article_html.php?did=1198
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ABBREVIATIONS
6-Benzyl adenine (BAP), α-Napthaleneacetic acid (NAA), Indole-3-acetic acid (IAA), , Murashige and Skoog medium(MS) , Myoinositol(My.I), Glycine(Gly), Thamine (Thy) ,MS Liquid medium(LD),MS Solid medium(SD),MS Rooting medium(RD).
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241515EnglishN2013August17HealthcareCLINICALLY RELEVANT MORPHOMETRIC AND TOPOGRAPHIC ANALYSIS OF CORONARY OSTIA
English611Dattatray DombeEnglish Takkallapalli AnithaEnglish Sanjay KalbandeEnglish Thaduri NareshEnglishBackground: Accurate knowledge of coronary ostia is not only important for anatomists but also for radiologists and intervention cardiologists performing angiographies and shunt surgeries. The high prevalence, morbidity, mortality and enormous socioeconomic burden of coronary artery disease, has necessitated us to take up this study. We have made a sincere attempt to describe the normal and variant anatomy of the coronary ostia in 64 cadaveric hearts of Indian origin. The origin of coronary arteries, the number of coronary ostia, their location in relation to sinotubular junction and the diameter of coronary ostia were observed and their clinical implications are discussed. Aim: To study the variations in number, location of coronary ostia in aortic sinuses and measuring their diameter. Methodology: Sixty four cadaveric hearts with great vessels attached were analyzed in this study. The ascending aorta cut longitudinally at the posterior aortic sinus to visualize right and left posterior aortic sinus for analysis. Results: In all 64 heart specimens right coronary ostia was present in anterior aortic sinus and left coronary ostia in left posterior aortic sinus. Multiple coronary ostia were noted in 18.7% of cases. Conclusion: The great importance of coronary catheterization for diagnostic and therapeutic purposes has currently motivated the present study.
EnglishCoronary arteries, Coronary ostia, Aortic sinuses, Anomalous.INTRODUCTION
Coronary catheterization for diagnostic and therapeutic purposes has assumed significance in recent times, as the incidence of coronary artery diseases has seen an increasing trend in developing countries in the last few decades. Considering the hypothesis formulated by some authors [1,2] that changes in coronary flow may be due to changes in diameter, position and anatomic relations of the coronary ostia, this study provides data regarding the variations of coronary ostial origins, emphasizing the importance of such anatomic variants in the development of treatment.
In the vast majority of people, there are two main coronary arteries, right and left, which arise from separate ostia in the aorta. The bulbar aortic sinus and the proximal ascending aorta comprise the aortic root. A slight circumferential thickening, known as the sinotubular ridge (sinotubular junction) marks the separation of these two structures. The bulbous sinus and the three aortic cusps merge to form the sinuses of valsalva. The right sinus of valsalva lies right and anterior in the aortic root and contain the right aortic semilunar cusp, where as the left sinus of valsalva lies left and posterior in the aortic root and contains the left aortic semilunar cusp. The posterior sinus of valsalva lies posterior to the right sinus and contains the non coronary aortic semilunar cusp [3].
The coronary ostia are usually located below the sinotubular ridge within the sinus of valsalva, centrally located between the commissural attachments of the aortic cusps [4]. The ostium of each coronary artery tends to form a slight funnel, with the diameter of the left main coronary artery at its ostium slightly larger than that of the right coronary artery (mean 4.0 versus 3.2mm) [5].
MATERIAL AND METHODS
64 formalin fixed cadaveric hearts with their great vessels attached were used in this study, which was carried out in the department of Anatomy at Chalmeda Anandrao Institute of Medical Sciences, Bommakal, Karimnagar, India, over a period of 3 years i.e. 2010 to 2013. The hearts were dissected, the pericardium involving the root of the aorta was removed, and the origin of the right and left coronary arteries was isolated. Then, the ascending aorta was sectioned approximately 3cm above the commissures of the aortic leaflets. Next, the aorta was longitudinally opened at the level of posterior aortic sinus (non coronary sinus) to enable the visualization and analysis of the right and left aortic leaflets and their respective coronary ostia. In addition, the coronary arteries were sectioned at the level of their origins in the aortic wall (Juxta mural portion of the coronary arteries). The coronary ostia in relation to the right and left aortic leaflets were identified. The origin of coronary arteries, number of coronary ostia, their location in relation to the sinotubular junction and the diameter of coronary ostia using the vernier caliper were noted and tabulated.
RESULTS
The following criteria have been taken into consideration
1) Origin of right and left coronary arteries.
2) Number of coronary ostia in various aortic sinuses.
3) Location of right and left coronary ostia in relation to sinotubular junction.
4) Diameter of right and left coronary ostia.
DISCUSSION
The morphometric and topographical analysis of coronary ostia have been implicated in various clinical conditions and awareness of these anatomical variants may decrease the morbidity and mortality associated with various invasive procedures.
The aortic root is a frequent site of interventional procedures in both adults and children. Understanding the precise nature and relation of the anatomical structures composing the aortic root including coronary orifices is valuable in percutaneous and transcatheter therapeutic techniques for valve or device implantations as well as in various open heart procedures [6].
The origin of coronary artery is an important parameter in cardiac procedures. A single coronary artery occurs in 0.024% of people. It is usually benign but may be associated with congenital heart disease, such as transposition of the great arteries, tetralogy of Fallot, truncus arteriosus and coronary artery fistula [7]. Despite the anomalous origin, the peripheral coronary artery distribution is usually normal. This entity can be mistaken for two separate ostia originating from the same sinus of valsalva or for artesia of coronary ostium [8]. In 25% of patients with a single coronary artery, a major branch crosses the infundibulum, which can not only cause chest pain, myocardial infarction or sudden death but also has technical implications for the surgeon when exposing the heart, instituting extracorporeal circulation or when performing a right ventriculotomy.
The origin of right and left coronary arteries from the anterior aortic and left posterior aortic sinuses respectively is 100% in the present study and matches the standard books of anatomy[9] [Table No.1].
Presence of multiple anomalous ostia is rare and could cause certain clinical consequences. An abnormal location or an accessory origin of the coronary orifices may disturb performing an aortotomy incision for aortic exposure, preparing a coronary button in root replacement, direct delivery of cardioplegia through the coronary orifices and approach for aortic root enlargement [5].
Solitary coronary ostium giving rise to solitary coronary arteries can be a substrate for sudden cardiac death and carries the potential to precipitate severe ischaemic heart disease, including myocardial infarction in younger patients [10]. However, we could not find a solitary coronary ostium in the present study [Table No: 2].
When multiple ostia are observed in the anterior aortic sinus, the most common variation observed is an accessory orifice for right conus artery [11]. The third coronary artery usually forms an anastomosis with the likewise branch of left coronary artery. This anastomosis lies on the distal part of the pulmonary trunk and is known as the “vieussens arterial ring”. This may serve as collateral path between the right and left coronary arteries. Similar observation was made in our present study where 2 ostia arose from anterior aortic sinus in 11 cases (Fig: 2) [Table No. 2].
In approximately 8% of hearts, the openings were three or more in number. In such cases, one of the extra ostia may be that of SA nodal artery. In 50% of cases, the SA nodal artery arises as a branch of the initial part of the right coronary artery [11]. In the present study, three coronary ostia were seen in anterior aortic sinus in 2 cases. One heart had 3 separate ostia in the anterior aortic sinus for the right coronary, right conus artery and a vasa vasorum to the pulmonary trunk.
The present study reports 4 separate ostia (Fig: 3) in the anterior aortic sinus of a single heart. One of the ostia was for the right coronary and the three accessory ostia were for the right conus and SA nodal arteries and vasa vasorum to the pulmonary trunk [Table No.2].
Presence of multiple ostia is a hazard to heart surgeries as the ostia of small arteries like third coronary artery are usually very small and barely get opacified in angiographies, thus these arteries miss detection preoperatively and can get nicked during surgery [12].
The preoperative knowledge of location of coronary ostia in relation to sinotubular junction is important in the management of patients with different pathologies involving the aortic root and coronary arteries. Alexander et al [13] stated that the right and left coronary ostia arise normally within the aortic sinuses or at the junction of sinus and tubular portions of aorta. Such a location of ostium allows maximal coronary filling during ventricular diastole. Alexander described a record position of ‘High take off coronary artery’ as 2.5cm above the sinoaortic junction. The detection of such high originating coronary arteries is clinically significant because it can decrease the diastolic coronary arterial filling and such arteries can be missed while performing procedures like coronary angiography.
Vlodover et al [14] stated that both the coronary ostia were observed above the sinotubular ridge in 6% of randomly selected hearts. This becomes important to the operator attempting to perform coronary angiography, where selective intubation of the anomalous vessel may be extremely difficult, especially in the case of the right coronary artery with a high anterior ostium.
In our present study 3.1% of cases of both right and left coronary ostia were above the sinotubular junction [Table No.3].
The diameter of coronary ostia is also significant. The proximal segment of each coronary artery is intramural; it courses through the aortic wall and is usually tapered or funnel shaped. Jenny sales cavalcanti et. al. [15] reported 16% reduction in juxta mural diameter of RCA compared to the ostial diameter and in LCA the reduction was 11%. This needs to be considered when designing stents for aorto-ostial coronary lesion in order to achieve optimal results avoiding retrograde aorto coronary dissection and reducing restenosis. The smaller dimension of some coronary artery segments has important diagnostic and therapeutic implications since for any interventional procedure the absolute size of the coronary artery matters.
It has been reported that occlusion or thrombosis is more common in vessels less than 2.5mm in diameter. A moderate (60%) stenosis in a 2.5mm vessel would have more effects on flow than the same degree of stenosis in a 3.5mm vessel as the cross sectional area in the former would be reduced to 1.76mm2 as compared to 3.46mm2 in a larger vessel. Thus a moderate plaque would cause significant implications in coronary revascularization.
In our present study, the mean ostial diameter of left coronary artery was larger than right coronary artery [Table No. 4].
CLINICAL SIGNIFICANCE
Accurate knowledge of the locations of the coronary ostia in relation to the aortic root is critical for a number of interventional and surgical cardiovascular procedures, including cannulation or catheterization of the coronary arteries, aortic graft repair or root replacement and implantation of percutaneous aortic valves or transapical replacement. The recent advent of percutaneous aortic valves, providing a non-operative treatment of symptomatic aortic valve disease has necessitated continuing development of device, techniques and treatment protocols for optimization of percutaneous aortic valve procedures [16]. With the proximity of the coronary ostia to the aortic annulus and valve leaflets, a particularly challenging issue is the risk of obstruction of the coronary ostia during percutaneous aortic valve replacement.
Concerning percutaneous and transapical valve replacement, obstruction of the coronary arteries during and/or after implantation remains a risk that can have catastrophic consequences. Boudjemline and Bonhoeffer [17] point out that precise placement, with respect to height of percutaneous aortic valve is crucial. Locations too high above the valve annulus result in coronary ostial obstruction and locations too low can negatively impact left ventricular and/or mitral valve function.
CONCLUSION
Knowledge of variants in coronary anatomy is important as failure to recognize these anomalies may at times create challenges during radio diagnostic, various invasive and operative cardiac procedures.
Englishhttp://ijcrr.com/abstract.php?article_id=1199http://ijcrr.com/article_html.php?did=1199
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David M-Fiss-Normal coronary anatomy and anatomic variations. Supplement to applied radiology www.applied radiology.com January 2007, 14-26
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Baroldi G, Scomazzoni G. coronary circulation in the normal and the pathologic heart Washington DC, Armed forces institutes of pathology. 1967.
Parimala Sirikonda, Sreelatha S-Measurements and location of Coronary ostia – Int J Bio. Med. Res. 2012;3(4);2489-2496.
Memisoglu E, Hoblkoglu G, Tepe Ms. Congenital Coronary anomalies in adults; comparison of anatomic course visualized by catheter angiography and Electron beam CT. Catheter cardiovasc. interv. 2005;66:34-42.
Byrum CJ, Blackman MS, Schneider B et al. Congenital atresia of the left coronary ostium and hypoplasia of the left main coronary. Am Heart J. 1980;99:354-358.
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Koiumi,M, Kawai, k, Honma,s, kodma, k. Anatomical study of single coronary artery with special reference to the various distribution patterns of bilateral coronary arteries. Ann.ANAT 2000; 182:549-547.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241515EnglishN2013August17HealthcareCOMPARATIVE EVALUATION OF RADIOGRAPHIC FEATURES OF JAWS AND TEETH ON OPG (ORTHOPENTAMOGRAM) IN THALASSEMIA MAJOR PATIENTS AND NORMAL INDIVIDUALS
English1222Avinash L. KashidEnglish S.P. KumbhareEnglish R.S.SathawaneEnglish R.N. ModyEnglishIntroduction: The purpose of the present study is to make aware of serious disease, its radiographic features and its implications on dental care, especially for general dental practioners working in different communities. Material and Methods: For the present study, 50 Thalassemia major patients of the age of 6 years and above as group I and 50 Age and Sex matched control subjects were selected as Group II. Panoramic radiographs were taken using standard radiographic procedure on Orthopantomograph “PLANMECA PM 2002 EC Proline” Panoramic X-ray unit. Exposed Panoramic radiographs were processed manually. The processed radiographs were examined in subdued ambient light using transmitted light from a standard X-ray viewing box for radiographic features: spiky and short roots, enlargement of bone marrow spaces, thin lamina dura, identification of inferior alveolar canal, size of maxillary sinuses, taurodontism, and thickness of inferior mandibular cortex. Crown and root lengths were determined on panoramic radiographs by using Seow and Lai method. Results and Conclusions: Thus, it can be concluded from the present study that the results of this study suggest that following radiographic signs are evidence of thalassemia major: small / absent maxillary sinuses, spiky and short roots, taurodontism, enlargement of bone marrow spaces, identification of inferior alveolar canal, thin lamina dura, inferior mandibular cortex. Radiographic findings described above on orthopantamogram are not pathognomonic in itself but may be used in the field of dentistry as a diagnostic aid for thalassemia major.
Englishthalassaemia, panoramic radiography, jaw, teeth.INTRODUCTION
Thalassemia is a genetic disorder that involves the defective and decreased production of hemoglobin. Thomas B. Cooley, an American doctor, was the first person, who recognized and described β-thalassemia in 1925. The term “Thalassemia” was coined only in 1933 by G. Whipple and W. Bradford¹. It is derived from the Greek words “thalassa” which means the sea and “-haima” the blood; so meaning “sea in the blood”. Geographically the thalassemias are found in a broad belt extending from the Mediterranean basin to India and the orient.¹
The purpose of the present study is to make aware of serious disease, its radiographic features and its implications on dental care, especially for general dental practioners working in different communities2.
Radiological features of jaws and teeth include the appearance of spiky-shaped and short roots, taurodontism, attenuated lamina dura, enlarged bone marrow spaces, small maxillary sinuses, absence of inferior alveolar canal and thin cortex of mandible3.
MATERIALS AND METHODS
For the present study, 50 Thalassemia major patients were selected from Department of Pediatrics, Medicine, Govt. Medical College and Hospital, Nagpur.
50 Age and Sex matched control subjects were selected from OPD of Oral Medicine and Radiology, Govt. Dental College and Hospital Nagpur which is situated in the same campus.
Inclusion criteria:
Group I: Thalassemia major patients of the age of 6 years and above.
Group II: Age and sex matched normal healthy individuals as controls.
A detailed case history was recorded and written consent of the patient / guardian of the patient for willingness to participate in the study was taken.
Panoramic radiographs:
Panoramic radiographs were taken using standard radiographic procedure on Orthopantomograph “PLANMECA PM 2002 EC Proline” Panoramic X-ray unit (Plate 1: fig-1). The unit was operated at 6-10 mA and 60-70 kVp (depending on patient) using KODAK T -MAT G films with Lanex regular intensifying screen (EASTMAN KODAK COMPANY, Rochester, New York). Exposed Panoramic radiographs were processed manually. The processed radiographs were examined in subdued ambient light using transmitted light from a standard X-ray viewing box for following radiographic features:-
Spiky and short roots
Enlargement of bone marrow spaces
Thin lamina dura
Identification of inferior alveolar canal
Size of maxillary sinuses
Taurodontism
Thickness of inferior mandibular cortex
In this study, spiky roots, enlargement of bone marrow spaces, thin lamina dura, identification of inferior alveolar canal and size of maxillary sinuses were determined by visual perception comparing with control.
Molar teeth were investigated for taurodontism as this was one of the findings noted by Tulensalo et al2. A tooth was classified as taurodontic when the distance between the baseline connecting the mesial and distal points of the cementoenamel junction and the highest point of the floor of the pulp chamber reached or exceeded 3.5 mm2.
The thickness of the inferior mandibular cortex in the molar region was defined as the distance between the inferior and superior borders of the cortex. Measurements were made using an electronic digital sliding caliper. The average of right and left side measurements were taken. All measurements were made three times by one examiner; the average was taken for the study. 2
Crown and root lengths were determined on panoramic radiographs by using Seow and Lai method. For determining the crown and root lengths, the mandibular first permanent molar was selected because the amount of distortion in panoramic radiograph of this tooth is known to be minimal. The method of Seow and Lai is as follows: Briefly, the outlines of the mandibular first molars were transferred to an acetate tracing paper using a sharp pencil rotring Tikky (2B, 0.35 mm) (Plate 1: fig-2). A line representing the long axis of the tooth was then drawn from the deepest pit traced and running through the furcation area. The crown length was determined by measuring the distance from the deepest occlusal pit to the furcation area along the long axis drawn. The root length was determined from the furcation area to the tip of the longer root along the long axis drawn before. Roots which were shorter by 2mm or more than the average root length in control group were considered as short roots2.
For the purpose of comparison and to determine the validity of the findings obtained from examining the panoramic radiographs of the study subjects, a total of 50 panoramic radiographs of the age and sex matched control group were taken from the Department of Oral Medicine and Radiology and reviewed under the same conditions.
To determine interobserver reliability in evaluation of above parameters the radiographs were evaluated by two experienced Oral Radiologists independently one of them interpreted the radiographs twice with two weeks interval between the two observations and intraobserver variability is determined.
The data obtained were analysed using the software, Statistical Package for the Social Sciences (SPSS) for Windows (Chicago, IL). Differences in radiological changes between the thalassaemic patients and control groups were tested using Chi-square (2) test. Differences in crown length, root length between the two groups were tested using the independent t-test. A statistically significant difference was considered to be present when p-values were less than 0.05.
Statistical analysis
Statstical analysis of the data was done using Statistical Package for the Social Sciences (SPSS Version10.0)
The Chi square test was used to compare the frequency of radiographic features in group I and groups II.
Student’s unpaired t-test was used to compare the measurements of group I and group II
Level of significance was judged by p-value. For statistical significance pEnglishhttp://ijcrr.com/abstract.php?article_id=1200http://ijcrr.com/article_html.php?did=1200
Manzon VS. Β-thalassemia: the anemia coming from the sea. Intensive course in biological anthropology 1st summer school of the European Anthropological association. 2007; June: 16-30; Prague, Czech Republic.
Hazza’a AM, Al-Jamal G. Radiographic features of jaws and teeth in thalassemia major. DMFR 2006; 35: p.283-288.
Lauren P. Hematologic diseases. In: Greenberg MS, Glick M, Ship JA, editors, Burkits Oral Medicine. 11th ed., Ontario: BC Decker Inc. 2008; p.385-411.
John PG, John F, George MR, Frixos P, Bertil G, Daniel A et al. The thalassemia and related disorders-Quantitative disorders of hemoglobin synthesis. In Wintrobes Clinical Hematology. 8th ed. Philadelphia (USA) 1981; Lippincott Williams and Wilkins. p.869-903.
Ghai OP, Gupta P and Paul VK. Hematological disorders. Ghai essential pediatrics Ed. 6th CBS publishers and distributers, New Delhi.
Olivieri NF, Gary MB. Iron-chelating therapy and the treatment of thalassemia. Blood. 1997 February; 89: p.739-761.
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Hattab FH, Alhaija-Abu, Yassin OM. Tooth crown size of permanent dentition in subjects with thalassemia major. Dental anthropology 2000; 14, No.3.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241515EnglishN2013August17HealthcareEVALUATION OF ANATOMIC VARIATIONS IN CORONARY ARTERY ON 64-SLICE COMPUTED TOMOGRAPHY ANGIOGRAPHY (CTA)
English2330Ritu MehtaEnglish Sanjeev AgarwalEnglishObjective: We retrospectively evaluated anatomic variants and anomalies of coronary arteries and found their incidence in 106 patients with the help of the 64-slice Computed Tomography Angiography (CTA). Materials and Methods: CT data of 106 patients who underwent 64-slice CT angiography (CTA) because of screening or suspected coronary artery disease were retrospectively reviewed in Department of Radiology, Geetanjali Medical College and Hospital, Udaipur. In each case, anatomic variants and anomalies were investigated. Results: The coronary artery system was right dominant in 85%, left dominant in 12% and co-dominant in 2.8 % of the cases. Ramus intermedius was present in 16.9%. Conus artery from Right coronary artery found in 72.6%, with a same ostium was observed in 10.3 % and in 16.9 % conus arteries originating with separate ostia were visualized. The sinus node artery (SNA) originated from the right coronary artery (RCA) in 66.9% and from the Left Circumflex artery (Cx) in 33%. LMCA was absent in 0.9%. Myocardial bridging was observed in 11.3%. Conclusion: Complex anatomy of the coronary artery tree can precisely be showed by 64-slice CTA. This technology is an appropriate substitute to conventional coronary angiography in distinguishing coronary artery variations and anomalies.
EnglishAnatomic Variations, Coronary ArteryINTRODUCTION
Coronary artery anomalies can be fatal during or subsequent to heavy physical activity, usually in young population. The information of coronary anomalies is also crucial for cardiologist before performing any invasive procedure in coronary artery disease patients. The coronary anomalies cause 11.8% deaths in young athletes in USA.(1) An another study depicted that 12% of sports-related sudden cardiac deaths and 1.2% of non-sports-related deaths were originated from coronary abnormalities in 14 to 40 year-old persons. (2)
Screening of coronary anomalies in population is becoming viable with Contrast-enhanced CT angiography. In comparison with Conventional angiography, coronary CTA has developed into an imperative non-invasive modality in the diagnosis of coronary artery disorders. High temporal and spatial resolution capabilities of multislice computed tomography (MSCT) scanners enable detailed 3D visualization of complex coronary artery anatomy without motion artefact. The introduction of new generation MSCT, making novel, detailed coronary artery studies possible. The origin, course, variations and anomalies of the coronary artery along with, the anatomy of the heart can now be meticulously studied with coronary CTA.(3,4) Furthermore, radiologists now have more skill in interpretation of images on normal anatomy in terms of anatomic anomalies and their cross-sectional images, which shows the way to improved diagnostic precision.(5) In this study, we aimed to recognize the 64-slice CTA appearance of the anatomic variations and anomalies of the coronary arteries and find out their incidence in a population of 106 patients.
MATERIALS AND METHODS
Population
CT data of 106 patients (91 male, 15 female, , range 31–78 years), who underwent 64-slice coronary CTA from January 2007 to December 2012 in Department of Radiology ,GMCH, Udaipur, were retrospectively assessed for anatomical variations and anomalies of coronary arteries. Patients were included who were advised by clinicians for coronary CTA screening or suspected coronary artery disease (CAD).The Institutional Review Board approved the study protocol.
CT scan and reconstruction parameters
All evaluations were carried out with a 64-slice CT scanner (Sensation 64, Siemens- Forcheim, Germany) with the subsequent parameters: slices/collimation 64/0.6 mm, rotation time 330 ms, effective temporal resolution (with 180° algorithm) 165 ms, 120 kv, 950 mAs, table feed/s 11.63 mm, effective slice thickness 0.6 mm, reconstruction increment 0.3 mm, field of view (FOV) 140–180 mm, isotropic voxel resolution of 0.4×0.4×0.4 mm.
Blood urea and serum creatinine levels were estimated before the procedure. Patients were premedicated with tablet propronalol (40 mg); those have a heart rate more than 75 beats/min one hour before the scan. Sublingual nitro-glycerine was also given to the patient just before the scan. After sensitivity test a bolus of 100 ml of high iodinated contrast material (350 mg/ml ultarvist German remedies) was injected with a flow rate of 5 ml/s, followed by a 40-ml saline chaser into an antecubital vein of the right arm. Synchronization between arterial route of contrast and coronary CTA was done with the help of bolus-tracking technique. Collection of data were done in end-diastolic phase (from -300 to -450 ms just prior the peak of the successive R wave) or end-sistolic phase by retrospective gating to get a clear image of the right coronary artery (RCA).
Image analysis
Image analysis was carried out to another workstation where the reconstructed Images at optimal phase were transferred. Interpretation of radiological images were done in axial projection initially with the following tools ,like Volume-Rendering Technique (VRT) with transparent background display, curved planar reformat (CPR), thin-slab maximum intensity projection (thin MIP) and multiplanar reconstructions (MPR).Evaluation of images starts from examining the dominance of the coronary artery , their branching pattern, the origin, course, and supplying region of the major coronary arteries were assessed. The origin of the posterior descending artery (PDA) is deciding factor for dominance pattern in coronary artery. Right dominance were defined as when PDA originating from the right coronary artery (RCA) in coronary artery systems and when PDA arising from the left main coronary artery (LMCA) were defined as left dominant. Coronary artery systems where PDA was come up from the RCA and most of part of the left ventricle’s posterior wall was supplied by posterolateral branches (PLB) from the circumflex artery (Cx) were termed as co-dominant. (6)
Coronary artery anomalies were classified according to Angelini et al. They classify coronary anomalies according to their origination, course, termination and anomalies of intrinsic coronary artery anatomy. (7)
RESULTS
Prevalence of normal variations and anomalies of coronary arteries observed in this study is demonstrated in Tables 1. Total 106 patients were screened through CTA. Right dominance was revealed in 90 patients (85.0%), left dominance in thirteen (12 %), and co-dominance in three (2.8%). The Most common origin of conus artery was from RCA in 77 out of 106 cases (72.6 %), the conus artery is also originated from same ostium or the right sinus valsalva in 13/106 cases (12 %), and it had a separate ostium origin in the remaining 18 cases (16.9%). The sinus node artery (SNA) originated from the RCA in 71 cases (66.9 %) and the left main coronary artery (LMCA) in 35 cases (33 %).The Ramus intermedius branch were found in 18 cases. The variation in LAD was found as type I in 26 cases (24.5%), type II in 37 cases (34.9 %), type III in 25 cases (23.5 %) and type IV in 18 cases (16.9%).Type I is described as not supplying the apex, type II partially supplying the apex and type III supplying entire the apex and type IV wraps around the apex.
Coronary artery anomalies were observed in a total of 13 cases (57.8%). One case (0.9%) had no Left Main Coronary Artery (LMCA). Left anterior Descending (LAD) and Left Circumflex (LCx) had outflows with separate ostia from the left sinus valsalva due to the absence of the LMCA. In this case LAD and LCx originated from the sinus valsalva between the aortic annulus and sino-tubular junction and blood flow was not low or high.
The LMCA trunk presented a variable length (mean 11.35±3.3 mm, range 1.2–18.7 mm, : Englishhttp://ijcrr.com/abstract.php?article_id=1201http://ijcrr.com/article_html.php?did=1201
Van Camp SP, Bloor CM, Mueller FO, et al. Nontraumatic sports death in high school and college athletes. Med Sci Sports Exerc. 1995; 27: 641–647
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Flohr T, Ohnesorge B. Heart rate adaptive optimization of spatial and temporal resolution for electrocardiogram-gated multislice spiral CT of the heart. J Comput Assist Tomogr 2001;25:907-23.
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Ko?ar P, Ergun E, Oztürk C, Ko?ar U. Anatomic variations and anomalies of the coronary arteries: 64-slice CT angiographic appearance. Diagn Interv Radiol 2009;15:275-83.
Zimmet JM, Miller JM. Coronary artery CTA: imaging of atherosclerosis in the coronary arteries and reporting of coronary artery CTA findings. Tech Vasc Interv Radiol 2006; 9:218–226.
Angelini P, Velasco JA, Flamm S. Coronary anomalies: incidence, pathophysiology, and clinical relevance. Circulation 2002; 105:2449–2454.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241515EnglishN2013August17HealthcareMORPHOMETRIC STUDY OF OCCIPITAL CONDYLES IN ADULT HUMAN SKULLS
English3134S. KavithaEnglish Shanta ChandrasekaranEnglish A. AnandEnglish K.C. ShanthiEnglishAim: The two bony projections that are present in the inferior surface of the occipital bone in the skull are called as Occipital condyles. They are present on either side of the foramen magnum in the base of skull. This study aims to document the dimensions of occipital condyles and its variations which are of paramount importance to neurosurgeons, orthopedic surgeons and radiologist when dealing with transcondylar surgical approaches and condylectomies. Methodology: The shapes of the occipital condyles were observed and the measurements like length, and breadth were measured. Results: The shape of occipital condyle varied from oval to crescent. Some shapes did not fit text book description. The mean length of occipital condyle of right side was 21.97 mm and left side was 22.34 mm. Conclusion: The documented parameters of the occipital condyles and its variations will serve as a guide line for surgeons in future.
EnglishCondyles, shape, occipital boneINTRODUCTION
The posterior part of the human skull is largely formed by the occipital bone. Adjoining the foramen magnum the occipital condyles are present. The superior articular facet of the atlas articulates with the occipital condyles to form the atlanto occipital joint. The occipital condyles are oval in shape and placed in an oblique manner so that its anterior end lies closer to the midline than its posterior end1. Occipital condyles are important element to maintain the head vertically. It is necessary for the stability of the craniovertebral junction. Occipital condylar fractures are a dangerous proposition due to the intimacy of the occipital condyles to the neurovascular structures abutting it 2.
Understanding the anatomical basis of craniovertebral anomalies is important when carrying out surgeries in the region. Lateral approaches during craniovertebral surgery require resection of the occipital condyles and In the Transcondylar approach, the Morphometry of the occipital condyles is a must 3. Symmetry of the occipital condyles does not pose any difficulty in flexion, extension and lateral bending but asymmetrical facets will give rise to altered kinematics in the atlanto occipital joint 4. Many patients who suffer a closed head injury are at risk for occipital condylar fractures 5. Hence the Morphometric analysis of occipital condyles and their facet is important clinically. So the present study will serve as a guideline for the dimensions of occipital condyles and their morphological variations in dry adult human skulls.
MATERIALS AND METHODS
About 145 human skulls were obtained from the department of Anatomy, Vinayaka Missions Kirupananda Variyar Medical College, Salem for the purpose of study. Damaged and pathological skulls were excluded from the study.
The equipments used for the purpose of study were
Vernier calipers,
Measuring scale
Digital photography equipment
The following parameters were measured on both right and left sides
Length – measured from the tip of the condyles in a vertical direction
Breadth – measured from the tip of the condyles in a horizontal direction
Shapes – all different shapes were documented
Statistical Analysis
Standard deviation, mean values and the range (Table -1) were calculated from the obtained results and parameters measured were evaluated by the paired sample t test (Table - 3) to differentiate between the right and the left sides. The resultant p value was less than 0.05 making it statistically significant.
RESULT
Of the 145 skulls studied the mean length of the occipital condyle on the right side was 21.97 mm and the mean length on the left side was 22.34 mm which was comparable with other studies. The mean width of the occipital condyle on the right side was 13.05 mm and the mean width on the left side was 13.30 mm which is significantly wider than other studies. The shape of the occipital condyles varied from being oval (Fig – 1) (R = 30.34% L = 31.03%), (Fig – 2) oblong (R = 29.65% L = 30.34%), (Fig – 3) crescent (R = 31.72% L = 30.34%) and (Fig – 4) rhomboid (R = 7.58% L = 8.27%). The commonest shapes were crescent and oval shapes on both sides. (Table – 2)
DISCUSSION
The dimensions of the occipital condyles in this study are significant and comparable with other studies of similar parameters. Atlanto occipital dislocation is a common cause of road accidents which are usually fatal, are undiagnosed and often not considered6. In such cases the dimensions of the occipital condyles and its shape will play an important role during a radiological assessment. A few research studies have documented the evidence of partition in the facets7. In the present study no condyles showed any such partition. A partitioned occipital condylar facet can be mistaken for fracture in an X-ray. Such morphological variations can produce clinical symptoms 7. In space occupying lesions of the posterior condylar fossa the preferred mode of approach is the dorsal approach through the foramen magnum 3 .This surgical approaches requires a thorough knowledge of occipital condyles and their adjoining structures. Other surgical approaches like transcondylar and the transjugular approach require surgical removal of occipital condyles 8. If occipital condyles have to be surgically removed, the geometrical configuration of the atlanto occipital joint will be disturbed and result in instability giving rise to clinical symptoms. Resection of condyles requires an in depth idea of measurements on how much to resect or how much to be left.
CONCLUSION
The occipital condyles are integral part of neck and the base of skull. Conventional text book description of occipital condyles does not mention many of the variations which are described here. Knowledge of approximate measurements of occipital condyles and variations in shape will serve as a ready reference when surgical interventions are needed in the region.
ACKNOWLEDGEMENTS
The authors sincerely wish to thank the management, administrators and the Professor and Head, Department of Anatomy of Vinayaka Missions Kirupananda Variyar Medical College, Salem for their whole hearted support and permissions to utilize their resources and conduct this study. The 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=1202http://ijcrr.com/article_html.php?did=1202
Susan Standring. Gray’s Anatomy, 40th Edition. Anatomical basis of clinical practice, Churchill Livingstone, London. 2008; 40:415.
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Wen HT, Rhoton AL Jr et al. Microsurgical anatomy of the transcondylar, supracondylar and paracondylar extensions of the far – lateral approach. J Neurosurg. 1997; 87(4): 555 – 85.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241515EnglishN2013August17HealthcareINCISIONAL HERNIA REPAIR - A CLINICAL STUDY OF 30 PATIENTS
English3541Nikhil Nanjappa B. A.English Alok MohantyEnglish S. Robinson SmileEnglishBackground: Incisional hernia is defined as any abdominal wall gap with or without bulge in the area of a postoperative scar perceptible or palpable by clinical examination or imaging [1]. Surgical management of incisional hernias has evolved over the last century, but consensus is lacking. Aims and objectives: This study aims to analyze the etiological factors of incisional hernia, modes of presentation, therapeutic modalities and the immediate postoperative complications. Materials and methods: The study is a prospective study conducted at a tertiary care teaching hospital for over 18 months. Thirty patients were studied and followed up for immediate post-operative complications. Observations and Results: Incisional hernia was found to occur more often in the 5th decade, females, and housewives, obese. The incidence was higher following gynecological operations, lower abdominal incisions, transverse incisions and when there was post-operative wound infection following the index surgery. Most patients noticed the incisional hernia only 1 to 3 years after the index surgery. A combination of mesh repair along with anatomical repair was carried out in 23 of the 30 patients, anatomical repair alone in 6 patients and one patient underwent laparoscopic mesh repair. Conclusion: Incisional hernias occur more often in females as they are more likely to undergo lower abdominal surgeries. Mesh repair was deemed superior to anatomical repair alone as post-operative complications were lesser. Placement of suction drain played an important role in reducing the likelihood of post-operative wound complications. There were no recurrences during our follow up period, albeit a longer follow up is required to draw definitive conclusions.
EnglishIncisional hernia, ventral hernia, post operative hernia, mesh repair
INTRODUCTION
Incisional hernia is defined as any abdominal wall gap with or without a bulge in the area of a postoperative scar perceptible or palpable by clinical examination or imaging [1]. Incisional hernia is an iatrogenic hernia. Incisional hernia occurs in 5-11% of patients subjected to abdominal operations [2, 3]. Incisional hernias can occur early or late following the index surgery (the surgery done following which the hernia developed). If left unattended they can progress to massive sizes and cause discomfort to the patient. In some cases may even lead to strangulation of abdominal contents. Even worse may incarcerate, obstruct, perforate or can cause skin necrosis. An important factor in the etiology of incisional hernia is the type of suture used to close the wound. Other factors are associated with development of incisional hernia like increasing age, female sex, obesity, chest infections, type of suture material used, operative technique and most important wound infection [2]. The treatment of incisional hernia has evolved over the years. Starting from the days of anatomical repair to darning to patching to mesh repair. Now with the advent of laparoscopic technique of hernia repair, the treatment armory for incisional hernia has gained yet another dimension. This study tries to assess the magnitude of the problem, analyze the various factors that lead to the development of incisional hernia. The study also aims to evolve a consensus regarding the best possible management options.
AIMS AND OBJECTIVES
This study aims to analyze the etiological factors of incisional hernia, identify and ascertain various modes of presentation, to study therapeutic modalities (anatomical repair and meshplasty) and the immediate postoperative complications.
MATERIAL AND METHODS
The study is a prospective study carried at Mahatma Gandhi Medical College and Research Institute, Puducherry, between, October 2010 and March 2012. A total number of 30 cases were studied and the follow up period varied from 2 months to 4 months. All patients with incisional hernias during the study period who underwent surgical treatment were included in the study. Those with other abdominal wall hernias and aged above 70 years were excluded. A detailed history and thorough clinical examination was carried out in all patients. All patients underwent routine blood and radiology investigations to obtain fitness for surgery. Ultrasound abdomen was done for all patients to determine the size of the hernia defect. All patients underwent either anatomical repair alone or mesh repair based on the size of defect. Patients who underwent mesh repair had a suction drain left in situ. Patients were followed up for immediate post-operative complications. Data was tabulated and analyzed for statistical significance using univariate and multivariate analysis.
OBSERVATIONS AND RESULTS
Of the 30 patients studied, the youngest patient was 25 and the oldest was 60 years old. The mean age was 43.63 years. The highest incidence was in 5th decade (P: 0.0000). There were 23 females (76.7%) and 7 males (23.3%) with a P value of 0.0035. 16 were housewives (P: 0.0000).
Thirteen patients (43.33%) complained of a lower midline swelling (P: 0.0002) [Table 2]. The mean duration of the swelling was 32.2 months. The smallest swelling was 2*2 cm and the largest 10*10 cm.
Twelve of the 30 patients studied were overweight, 6 had chronic cough and 4 were grade 1 obese, 4 had voiding difficulty and 3 had constipation. However, 8 had no risk factors and 7 had more than one risk factor (P: 0.0081).
Six patients (20%) had lower segment caesarian section (LSCS) previously, 4 (13.3%) LSCS + tubectomy, 4 (13.3%) total abdominal hysterectomy + bilateral salpingo-oophorectomy, 3 (10%) Tubectomy, 3 (10%) duodenal ulcer perforation closure, 2 (6.7%) laparotomy for peritonitis, and 1 (3.3%) each ovarian cystectomy, left nephrectomy, truncal vagotomy and gastro-jejunostomy , open cholecystectomy, open appendectomy, and unknown procedure (P: 0.3944). 60% had undergone obstetrics and gynecology operations . 63.3% of the patients underwent emergency surgery . 66.7% of the 30 patients had undergone 1 index surgery, 16.7% underwent 2, 13.3% had 3 and 3.3% underwent 4 previous surgeries .
Only one patient noticed the hernia within a year of the index surgery. However, 15 patients noticed it between 1-3 years, 4 patients between 3-5 years and 10 patients after 5 years. Sixteen patients had swelling that reduced on manipulation, 12 were spontaneously reducible, 1 was irreducible and 1 patient had no swelling (P: 0.0004]. 56.7% patients had enterocoeles on clinical examination, 40% omentocoeles and 1 patient could not be evaluated (P: 0.0012).
Of the 30 patients, 17 (56.7%) patients did not have any post-operative complications, 11 (36.7%) had wound infection and 2 (6.7%) had wound dehiscence.
Twenty-one (70%) patients had lower abdominal incisions in the index surgery and 9 (30%) had upper abdominal incisions (P: 0.0285) [Table 1]. Fourteen (46.7%) had midline infra-umbilical incision, 6 (20%) upper midline incisions, and 5 (16.7%) had right infra-umbilical incision, 2 (6.7%) left infra-umbilical incision, 2 (6.7%) left lumbar and 1 (3.3%) right supra-umbilical (P: 0.0003). Eighty percent patients had transverse incisions during their index surgery and 20% had vertical incisions (P: 0.0121) [Table 2].
Sixteen patients (53.3%) had hernia defect of size between 1-10 cm2, 11 (36.7%) between 11 and 20 cm2 and 3 (10%) 21-30 cm2 (P: 0.0136). 73.3% patients had good abdominal muscle tone and 26.7% had poor muscle tone (P: 0.0106).
Twenty-three of the thirty patients underwent anatomical repair along with meshplasty (AR+MP), 6 (20 %) underwent only anatomical repair (AR) and 1 (3.3%) laparoscopic meshplasty (Lap MP). All 23 who underwent mesh repair had 1 suction drain placed after surgery. Fifteen (50%) of the thirty patients had spinal anesthesia (SA), 10 (33.3%) had general anesthesia (SA), 4 (13.3%) had spinal along with epidural anesthesia, 1 (3.3%) general anesthesia plus spinal.
Among the 30 patients, 17 (56.7%) had no post-operative complications, 8 (26.7%) developed seroma, 2 (6.7%) each had wound infection and dehiscence and 1 (3.3%) had serous discharge [Table 3]. Sutures were removed day 9.7 on an average among the patients studied. Average duration of hospital stay was 13.36 days. 29 patients followed up for at least 2 months and there were no recurrence. 1 patient was followed up for 6 weeks and had no recurrence
DISCUSSION
The peak age incidence of incisional hernia in our study was in the 5th decade. Age was found to be significant risk factor for incisional hernia by univariate analysis. Ellis et al in their study, reported a mean age of 49.4 years [4]. This was in tune with our findings. Our study showed a female preponderance with male to female ratio of 1: 3.29. This could be because of laxity of abdominal muscles due to multiple pregnancies and increased number of lower abdominal incisions in females. Ellis et al reported an incidence of 64.6% female population in their study of 383 patients [4]. Harding [5] and Milbourn et al [6] in their series showed a male to female ratio 1:1.17 and 1:1.25 ratios respectively. All studies allude to the fact that incisional hernias were more common in women. We found that the incidence was highest among housewives. This finding may have been incidental, as most of our patients were women.
About 43% of our patients presented with lower midline swellings and this was significant. This is comparable with the results by Milbourn et al [6], and Carlson et al [7]. This may be because of the following features:
• Intra-abdominal hydrostatic pressure is higher in lower abdomen compared to upper abdomen in erect position i.e., 20 cm of water and 8 cm of water respectively.
• Absence of posterior rectus sheath below arcuate line.
• This incision is used for mostly gynecological surgeries in patients who have poor abdominal wall musculature.
In our study 40% patients who developed incisional hernia were overweight, 13 % were grade 1 obese, 20 % had chronic cough, 10% had constipation, 13% had voiding difficulty and 23% had more than one risk factor. Only 27% patients had no risk factors. Average BMI in our study was 24.172 kg/m2. This is comparable with results published by Cameron et al., in which obesity (33/110-30%), chronic obstructive pulmonary disease (COPD) (23/110 – 20.90%) and stricture urethra (10/110 – 9.09%) was reported [8].
Sixty percent of our patients underwent gynecological procedures (lower abdominal surgeries). This may be because most of these procedures were done through lower midline incisions. Ponka [9] in his study noted 36% incidence and Milbourn [6] noted 28.76% incidence among gynecological procedures. Our numbers show a significantly higher incidence of incisional hernia in patients undergoing gynecological surgeries.
Thirty three per cent of our patients had undergone more than one surgery prior to the development of incisional hernia. In another study [10], 10% had undergone more than one operation previously. This also happens to be one of the significant risk factors in our study, which can be compared with Ellis’ [10] series (25%). Goligher [11] reported that repeated wounds in the same region or just parallel to each other will often lead to the development of hernia.
The incidence of incisional hernia was higher following emergency surgery. This could be attributed to the lack of pre-operative preparation, higher rates of wound infection and possibility of making larger incisions in an emergency situation. Similar claims have been made by two other studies [9, 12]. Wound infection following the index surgery puts the patients at increased risk for incisional hernia [12]. In our study 37% patients had wound infection and 7% had wound dehiscence following the index surgery.
In Akman’s series more than 65% of the incisional hernias occurred within 1 year after index surgery [13]. However, we found that half our patients noticed the incisional hernia only 1 to 3 years after the index surgery and only one patient noticed it before a year following the index surgery. These patients may have developed the hernia earlier but had not noticed it till the swelling was of an appreciable size.
In our study 70% patients with incisional hernia had infra-umbilical incisions. It was found to be a significant factor leading to incisional hernia. Of the 21 patients who had infra-umbilical incisions, 14 had midline incisions. This was also a statistically significant risk factor for development of incisional hernia. Lower abdominal incisions are at higher risk for incisional hernias [5, 6 and 7].
Meta- analyses comparing the rate of incidence of hernia following vertical and transverse incisions have found no significant difference between the two [14]. However, 80% of our patients with incisional hernia had transverse skin incisions. We found it to be a significant risk factor. But, we could not assess whether they had muscle cutting or muscle splitting incisions. It may also be because most of these patients with transverse incisions had infra-umbilical incisions, and that lower abdominal incisions are more prone to develop incisional hernia, as the rectus sheath is deficient below the arcuate line and the abdominal muscles may have to be divided [15]. Midline line incisions are more likely to result in incisional hernias compared to paramedian incisions. Of the two types of incision, the lateral paramedian incision takes longer to perform, requires a longer incision, rarely results in dehiscence, and does confer protection against incisional hernia [16]. Even we found that lower midline incisions were more prone to developing incisional hernias.
In our study, 73% patients had good abdominal muscle tone and had no significant systemic examination findings. This was significant. It hints that the incisional hernias could develop as easily in patients with good muscle tone compared to the ones with poor tone. It highlights the thought that the development of incisional hernia is related to factors related to the index surgery rather than the tone of abdominal muscles.
In our study polypropylene mesh and the suture material of the same type was used to repair the incisional hernias and the technique of the repair was decided by the size of the hernia defect, abdominal muscle tone, whether hernia defect could be approximated without tension and general condition of the patient. The choice of anesthesia was based on the location of the swelling, general condition of the patient and preference of the patient.
More than half of our patients had no post-operative complications. However, seroma formation was seen in 8 patients, wound infection and dehiscence in 2 each. Seroma formation was observed 4 each in patients who underwent meshplasty and anatomical repair alike. Wound dehiscence in one each in the both groups and were treated appropriately. Lall P. et al [17] reported seroma formation in 6 out of 35 patients and wound infection in 1 out of 35 patients. The lesser rates of seroma formation could be attributed to placement of suction drain in all patients who underwent meshplasty.
In our study the follow-up period was variable, ranging between 6 weeks to 4 months, and no immediate recurrence. Usher [18] reported zero recurrence in 48 patients who were treated by polypropylene mesh repair. Usher et al [19] also reported a 10 year cumulative rate of recurrence of 63% in anatomical repair and 32% in mesh repair. Suture repair should only be performed when the fascial edges are suitable for suturing and come together without any tension. There should also be no risk factors for wound failure. The recurrence rate thus varies in different studies but all studies favor mesh repair to decrease the rate of recurrence. Recurrence rates with mesh repair are much lower than with suture repair[i]. Laparoscopic repair is as effective as open prosthetic repair and complications are less likely and hospital stay is shorter [19].
With thorough patient evaluation, pre-operative skin preparation, meticulous operative technique, use of non-absorbable sutures for musculo- aponeurotic tissue, use of suction drain, use of peri-operative broad spectrum antibiotics, early ambulation and chest physiotherapy, complication rates in our study were minimized. With prosthetic mesh, defects of any size can be repaired without tension. The polypropylene mesh, by inducing inflammatory response sets up scaffolding that in turn induces the synthesis of collagen. Thus the superiority of mesh repairs over anatomical repair. Recurrence rates with mesh repair are much lower than with suture repair. Mesh repair is the technique of choice for most incisional hernias [19].
CONCLUSIONS
Incisional hernia was the second most common hernia following inguinal hernia. It was found to more common in the 5th decade; in females and in housewives. Almost all patients presented with a swelling involving a post-operative scar and lower midline swellings were commonest. The incidence was higher following lower abdominal incisions and in patients who underwent gynecological operations as they mostly had transverse incisions. Wound infection following index surgery was the most important risk factor associated with incisional hernia. The other major risk factors were obesity, chronic cough, constipation and difficulty voiding urine. More patients had enterocoeles and majority of them were reducible. The size of the hernia defect was less than 10 cm2 in over half the patients studied. The tone of abdominal muscles was good in about three quarters of the patients. Most patients underwent mesh repair. Spinal anesthesia was used in half the patients. Seroma formation was the commonest post-operative complication and occurred in about a quarter of our patients. However, more than half our patients had no post-operative complications. The use of suction drains was probably the reason for lower rates of seroma formation in patients who underwent mesh repair. The average duration of hospital stay in our patients was 13.36 days.
LIMITATIONS AND FURTHER RESEARCH
This study may not reflect all the aspects of incisional hernia including the treatment options as the series is small and follow up was for a short period in most of the cases. Also the details of index surgery, like what suture material was used, what technique was used to close the rectus sheath was not available as most patients had undergone their previous surgeries in other hospitals.
A randomized controlled study may be done to compare the outcomes of mesh repair and anatomical repair. Similarly a randomized controlled study may be carried out to judge the efficacy of suction drain tubes. A larger study spanning over longer time period is required to draw definitive conclusions.
ACKNOWLEDGMENTS
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
INFORMED CONSENT
An informed consent was sought from all the patients who were included in the study. The methodology of the study was explained to the patients individually in a language of their understanding. The patients were allowed to withdraw from the study at any point. The patients were also informed that the data collected from this study would be used for medical research and the material could be published, and they authors would take responsibility to protect the privacy of the patients. The format of the informed consent was approved by the institutional human ethics committee.
Englishhttp://ijcrr.com/abstract.php?article_id=1203http://ijcrr.com/article_html.php?did=1203
Korenkov M, Paul A, Sauerland S, Neugebauer E, Arndt M, Chevrel JP, Corcione F, Fingerhut A, Flament JB, Kux M, Matzinger A, Myrvold HE, Rath AM, Simmermacher RK (2001) Classification and surgical treatment of incisional hernia. Results of an experts’ meeting. Langenbecks Arch Surg 386:65–73. [PubMed]
George CD, Ellis H. The results of incisional hernia repair: a twelve year review. Ann R Coll Surg Engl. 1986 July; 68(4): 185–187.[PubMed]
Mudge M, Hughes LE. Incisional hernia: A 10 year prospective study of incidence and attitudes. Br J Surg. 1985;72:70–1. [PubMed].
Ellis H, Gajraj H, George CD. Incisional hernias: when do they occur?. Br J Surg. 1983 May;70(5):290–291. [PubMed].
Harding KG, Mudge M, Leinster SJ, Hughes LE. Late development of incisional hernia: an unrecognised problem. Br Med J (Clin Res Ed) 1983 Feb 12;286(6364):519–520.[PubMed]
Millbourn D, Cengiz Y, Israelsson LA. Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial. Arch Surg. 2009 Nov;144(11):1056-9. doi: 10.1001/archsurg.2009.189.[PubMed]
Carlson MA. New developments in abdominal wall closure. Chirurg. 2000 Jul;71(7):743-53.[PubMed]
Cameron AE, Gray RC, Talbot RW, Wyatt AP. Abdominal wound closure: a trial of Prolene and Dexon. Br J Surg. 1980 Jul;67(7):487–488. [PubMed].
Ponka JL. Hernias of the abdominal wall. Philadelphia, PA: WB Saunders, 1980: 82-90.
Ellis H, Heddle R. Does the peritoneum need to be closed at laparotomy? Br J Surg. 1977 Oct;64(10):733–736. [PubMed]
Goligher JC. Visceral and parietal suture in abdominal surgery. Am J Surg. 1976 Feb;131(2):130–140. [PubMed]
Jenkins TP. The burst abdominal wound: a mechanical approach. Br J Surg. 1976 Nov;63(11):873–876. [PubMed]
Akman PC. A study of five hundred incisional hernias. J Int Coll Surg. 1962 Feb;37:125–142. [PubMed]
Dunphy JE, Jackson DS. Practical applications of experimental studies in the care of te primarily closed wound. Am J Surg. 1962 Aug;104:273–282. [PubMed]
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Lall P, Khaira HS, Hunter B, Brown HJ. Repair of incisional hernias. Royal College of Surgeons Edinburgh. 2001; 46: 39-43.[PubMed]
Usher FC, Ochsner J, Tuttle LL., Jr Use of marlex mesh in the repair of incisional hernias. Am Surg. 1958 Dec;24(12):969–974. [PubMed]
Usher FC, Fries JG, Ochsner JL, Tuttle LL., Jr Marlex mesh, a new plastic mesh for replacing tissue defects. II. Clinical studies. AMA Arch Surg. 1959 Jan;78(1):138–145. [PubMed]
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241515EnglishN2013August17HealthcareROLE OF FINE NEEDLE ASPIRATION CYTOLOGY IN DIAGNOSING THYROID LESIONS - A RETROSPECTIVE STUDY
English4245Pratibha VyasEnglish Sulabh BansalEnglish Tarun OjhaEnglish Amit SinghalEnglish Suresh KumarEnglishBackground: One of the most common problems among patients attending ENT OPD (particularly female patients) is the thyroid enlargement. Though Thyroid cancer is not common; incidence of Thyroid nodule (Simulating thyroid cancer in appearance) is high. This study was conducted to evaluate efficacy of Fine Needle Aspiration Cytology (FNAC) at Mahatma Gandhi Medical College & Hospital, Jaipur in diagnosing thyroid lesions (benign or malignant) and to compare its advantages & results with histopathology. Method: This retrospective study was conducted in Department of ENT and Head-Neck surgery at Mahatma Gandhi Medical College and Hospital, Jaipur during the period January 2008 to January 2013. In all 282 cases were evaluated by detailed history, thorough clinical examination, ultrasonography (USG) of neck, complete thyroid profile (Serum T3, Serum T4 & Serum TSH) and histopathology of thyroid lesion. Results: In our study, sensitivity and specificity of FNAC was 70.2% and 97.3% respectively (in diagnosing thyroid lesions as benign and malignant). Conclusion: FNAC is safe, less expensive, less invasive and cost effective diagnostic tool in diagnosing thyroid lesions and distinguishing benign from malignant ones.
EnglishThyroid, FNAC, Malignant, CytologyINTRODUCTION
Thyroid lesions are quite prevalent and globally thyroid enlargement affects 15% of the population.1But incidence of thyroid cancer is very low i.e. 3.6 per 100,000 population (.0036 percent)2
The most common indication for thyroid surgery is presence of Thyroid nodule which may be benign or malignant. Prevalence of thyroid nodule is about 4-7%.3 Because of very low incidence of thyroid cancer; thyroid nodules must be identified as benign or malignant; as treatment options in both the conditions are different. Thyroid cancers are treated surgically, while benign lesions must be followed strictly.4
FNAC was first reported in 1930 by Martin and Ellis.5 Since then, it has become reliable and cost effective method to distinguish benign from malignant lesion in neck. 6
FNAC is technically easy to perform, safe and inexpensive diagnostic tool. Sensitivity of FNAC in detecting malignancy in thyroid lesions is high.7 Any solitary or dominant nodule larger than 1 cm should be subjected for FNAC as smaller nodules carry very low risk of morbidity.8
Many studies show accuracy rate of FNAC more than 80%.9 Pitfalls of FNAC include false negative and false positive results, inadequate aspirate and suspicious results.10
Present retrospective study was conducted to evaluate efficacy of FNAC in diagnosis of thyroid lesions and to compare the results with histopathology after surgery.
MATERIAL AND METHODS
This study was conducted at Mahatma Gandhi Hospital and Medical College, Jaipur in the Departments of ENT and Head-Neck Surgery during the period between January 2008 and January 2013. Patients with features of hyperthyroidism, Hot and toxic nodule were excluded from the study. Patients with systemic diseases for example hypertension or hepatic or renal failure were also excluded from the study. A detailed history was taken followed by thorough clinical examination, thyroid profile, USG neck, and FNAC.
CT scan was advised in patients in whom malignancy was suspected to see the extent of tumour. After surgery the specimen was sent for HPE in 10% formaldehyde. The specimen was properly labeled.
RESULTS
In our series of 282 patients, 31 were male and 251 were females with male to female ratio being 1:9. Duration of thyroid swelling in the present study was from 4 months to 5 years. The average size of Goiter was 2-3 cm. The highest incidence of thyroid lesion was found in the age group of 20-40 years. On FNAC, 250 (87.6%) cases were benign as compared to 10 (6.1%) malignant cases.
DISCUSSION
To evaluate a thyroid nodule, a battery of investigations is needed including USG neck, thyroid profile, thyroid imaging, complimented by thorough clinical evaluation.
In diagnosing thyroid neoplasms, the highest rate of sensitivity and specificity is achieved by FNAC.2
A complication rate for FNAC is low. 2Complications include hematoma, tracheal puncture and transient laryngeal palsy.11 Tumour implantation following FNAC is reported only once.12
In our study, sensitivity and specificity of FNAC in diagnosing thyroid lesions is 70.2% and 97.3% respectively. Humberger reported sensitivity at 65.53% and specificity at 72-100%.13 In a study by Safirullah 94.2% sensitivity and 94% specificity in diagnosis of Malignant thyroid diseases was reported.
Results of this study are comparable with other data. Agrawal et. al. (1995)14 in Tata Memorial Hospital, Mumbai found accuracy of FNAC to be 90.9% in evaluating thyroid nodules, Kumar et.al. (2008) 15 reported accuracy of 97.7%. Both these findings are comparable with our study.
Reported sensitivity, specificity, and accuracy of Thyroid FNAC in detecting malignancies are between 65 – 98%, 72 – 100%, 65 – 95% respectively. 16, 17, 18
CT guided and US guided FNAC have a higher probability of accuracy along with any wet stain.8
FNAC has some very distinct advantages. It requires no preprocedural investigations or hospitalization. As a result, it is very easy to convince patients to give consent to it. Patients were also very willing as it reduced their expenditure, which otherwise they would have had to incur; had they opted for open biopsy. Post procedure complications are also very rare.
CONCLUSION
This study conclusively shows that FNAC could be first line diagnostic test in any case of thyroid swelling. FNAC of thyroid swelling is very safe, accurate, much less expensive, relatively simple and five minute OPD procedure. FNAC being much less expensive and quite painless is very well accepted by patients. With all these advantages, FNAC is very effective tool in diagnosis of thyroid pathology. Though FNAC is not the substitute for conventional open biopsy and subsequent histopathology, particularly in old patients but definitely should be first choice in diagnostic modalities in any case of thyroid swelling.
Englishhttp://ijcrr.com/abstract.php?article_id=1204http://ijcrr.com/article_html.php?did=1204
JA Franklyn, J Daykin, J Young, et.al.: Fine needle aspiration cytalogy in diffuse or multinodular goitre compared with solitary thyroid nodule, BMJ 1993; 307: 240
Theodar R. Miller, MD; John S., et.al.: Fine-Needle Aspiration Biopsy in the management of thyroid Nodules : West J Med 134: 198-205, Mar 1981
Wienke JR, Chong WK, Fielding JR, et.al.: Sonographic features of benign thyroid nodules. J Ultrasound Med 2003; 22:1027-31
Polyzos SA, Kita M, Avarmindis A. Thyroid nodules-stepwise diagnosis and management. Hormones (Athens) 2007; 6: 101-9
Martin HE, Ellis EB; Biopsy by needle puncture and aspiration. Ann Surg. 1930; 92: 169-81
Lowhagen T, Gargberg P.O., Ludell G, et.al.: Aspiration biopsy cytology (ABC) in nodules of the thyroid gland suspected to be malignant. Surg. Clin N Am 59: 3-18, 1979.
Mahar SA, Hussain A, Islam N. Fine needle aspiration cytology of thyroid nodule; diagnostic accuracy and pitfalls. J Ayub Med Coll Abbottabad 2006: 18 (4): 26-9
Arup Sengupta, Ranbir Pal, Sumit Kar, et.al. J. Natural Science, Biology, Medicine. 2011; 2(1) 113-118
Gharib H. Diffuse nontoxic and Multinodular goitre. Curr Ther Endocrinal Metab 1944; 5: 99-101
Baloch MN, Ali S, Ansari MA, et.al.. Contribution of Fine needle apsiration cytology in the diagnosis of malignant thyroid nodules Pak J. Surg 2008; 24(1) : 19-21
Wang C, Vickery A, Maloog F: Needle biopsy of thyroid. Surg Gynocol obs 143: 365-368, 1976
Sinner WN, Zajicek J; Implantation metastasis after percutaneous transthoracic needle aspiration biopsy. Acta Radial [Diagn] (Stockh) 17: 473-479, 1976
Humberger JI. Diagnosis of Thyroid nodule by fine needle aspiration cytology of thyroid nodules. J Clin Endorcinal metab 1994, 79:335-9
Agrawal A, Mishra SK. Completion total thyroidectomy in the management of differentiated thyroid carcinoma. Aust N Z J Surg 1996;66:358-60.
Kumar S, Aqil S, Dahar A. Role of fine needle aspiration cytology in thyroid disease. J Surg Pak 2008;13:22-5.
Gharib H. Fine needle aspiration biopsy of thyroid nodules: advantages, limitations and effects. Mayo Clinic Proc 1994;69:44-9.
Hamburger JI. Diagnosis of thyroid nodules by fine needle biopsy: Use and Abuse. J Clin Endocrinal Metab 1994;79:335-9.
Ali K. Ageep. Efficacy of Fine needle aspiration cytology in the diagnosis of thyroid swelling in Red Sea State, Sudan. Sudan JMS Vol 8 Issue 1, March 2013.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241515EnglishN2013August17HealthcareDETECTION AND IDENTIFICATION OF PRINTER INKS - A REVIEW REPORT ON LASER AND INKJET PRINTER INK ANALYSIS
English4651Rashmi SharmaEnglish T.R.BaggiEnglish Amit ChattreeEnglish Lav KesharwaniEnglish A.K.GuptaEnglishThe increased rate of crime involving the use of laser and inkjet printed documents is the motivation of writing this paper and to produce efficient analytical techniques for classification, identification, detection and analysis of laser and inkjet printed documents. A printed document is usually examined to determine whether or not it is forged or to determine its source of origin etc. The examination can be carried out either physically and chemically. The main aspiration of this paper is to collect and provide every useful and relevant information so that they can be implemented in a questioned document laboratory. This review paper indicates how the analysis of the printer inks can be used for the establishment of origin of a printed document.
Englishlaser and inkjet printer, analytical techniques, ink analysisINTRODUCTION
The technology of inkjet and laser printing has spread in past few decades and continue to develop due to the quality of print, reduced cost of inkjet and toner printers. The printers based on the laser and inkjet technology have occupied a strategic position for the commercial and personal use and thus are a target for criminal activities. With the increased number of forgeries involving printed documents there is a need of development of techniques which can help in detection of crime involving the printed documents. The investigations must be led as possible by minimizing the destruction of the questioned documents. Many publications make reference
to the forensic analysis of printing ink (laser printer toner and inkjet ink) involving both destructive and non destructive examination.
The scientific basis of all papers, presentations and posters isn’t validated by the authors of this review, as high number of references from the variety of sources was collected. This paper is essentially based on articles published in the major forensic science journals as well as presentations or posters presented at international forensic meetings to some extent. Many publications are available which describes the analytical methods giving information on the composition of these inks. The number of existing information and papers that can be useful for document examiners is huge. Although we tried to cover maximum number of information on the analysis of toner and inkjet ink still some lacks or omissions are possible.
This paper aims to provide an in-depth review of the technical advances in the field of laser and inkjet ink analysis. The main aim of this paper is to help FDE to choose good technical orientations for the examination and for the further development of the techniques. Keeping in consideration the need for printer ink analysis to fight against the forgeries involving printed documents many authors have given their contribution to this field which has briefly described below:-
Heuser (1987) used SEM-EDX for the analysis of photocopy toners and found the technique to be very useful in recognizing monocomponent process toners as they contain a magnetic carrier material usually magnetite that is detectable by this type of analysis. He was able to differentiate
easily between mono component and dual component process toners, because the dual component process does not result in magnetic carrier is continually recycled. Although Heuser was able to easily identify the presence of iron in some toner samples, interpretation of additional inorganic constituents was difficult due to the interference produced by the paper background.
Aginsky (1993) employed the ascending mode thin layer chromatography technique using a multiple development procedure. The purpose of study was to separate coloured components of computer printing Inks, artist's paints, copier toners, and colour pencils. The procedure used was able to separate pthalocyanine pigments and slightly soluble organic pigments. He analyzed 120
synthetic pigments and dyes used for commercial production of modern artist’s paints, toners for copying machines, printing and writing inks by TLC. After TLC the sample was taken by scratching writing material using razor and extracted by dimethylformamide. The three step TLC procedures were proved to give valuable information about inks, coloured organic components including the sparingly soluble ones.
Espadaler et al (1993) analyzed the organic and inorganic ink components of ink using the GC-MS and SEM-EDX respectively in order to explain the acidic behaviour and permanence of black colour in some inks. The inorganic components are the iron and copper sulphates. Their preparation is based on tannin extraction, with which the iron that yields the iron sulphate forms a black suspension that is retained and thickened by the gum arabic. One of the most important causes of degradation in ancient manuscripts is the acidity ink. The relationship between the important corrosion that some inks incite in the support and the fact that a strong black colouring remains in the ink has often been demonstrated. By contrast, no acidity is shown in light coloured or slightly dark inks.
Andrasko (1994) discussed a sampling technique using the metallic stubs for the removal of photocopy toner from the photocopied document by thermal transfer. The technique is simple and cause negligible destruction to the document. The toner samples were then analyzed by micro reflectance FTIR. The technique shows good reproducibility, is sensitive and applicable to small areas on the transferred material.
Jasuja et al (1997) analyzed different 20 green, blue, and red offset printing inks from Thin Layer Chromatography. The 5 sq mm sample of these inks was taken from the documents and extracted the ink from paper with few drops of mixture of pyridine and glacial acetic acid (3: 1). Studies reported that the number of spots, colour and Rf values inks could be taken into consideration for the differentiation of ink using TLC. They also reported different solvent systems for different colours of ink.
Doherty (1998) compared and studied ink samples from current and discontinued inkjet printer models for the classification and dating the formulations of ink. The black samples printed with 18 types of cartridges and unprocessed samples from 8 black ink cartridges were analyzed for their physical & chemical properties. The authors reported methanol and water (1: 1) as best solvent to dissolve ink from the printed document. They concluded that (a) processed and raw inks from the same model cartridges produced consistent chemical and different spectral results (b) many of the inks could be differentiated and classified and (c) the limited sampling of inks available for dating could be correlated to their respective introduction or reformulation date.
Pagano et al (2000) reported the separation of components of cyan, magenta, yellow and black inks after extracting with the solvent ethanol/water (1:1).Studies reported that ethyl acetate:ethanol:water(70:35:30) and water: acetic acid:butanol:butyl acetate(32:17:41:10) were the best solvent systems for separation of ink components. Authors suggested the creation of library with database of various original and refilled inks chromatograms will be helpful for the matching of the questioned inks with the standard inks. Besides, the authors also described the inkjet printing technology along with the composition of inkjet ink analyzed.
Sidhu et al (2000) analyzed 22 black and 17 colour ink writing samples of various models of inkjet printers using thin layer chromatography. The research concluded the samples of black and coloured inks could be separated and differentiated from each other. The solvent systems butanol:propanol: water(80:15:5) and butanol:ethanol:water (50:15:5) were found suitable for for the separation of black ink, whereas for the coloured inks the solvent systems butanol:propanol:glacial acetic acid (60:15:05) and chloroform:methanol: n-Hexane:Glacial Acetic Acid (70:20:5:0.5) were found most suitable.
Anglos et al (2001) reported the origin (and date of first use) of inorganic pigments as used in archeological inks, paints, and prints. The list of pigments also provides the elemental composition associated with a given pigment (i.e. Egyptian blue = CaCuSi4O10 and Naples yellow = Pb2Sb8O7, etc). From these pigments elements like Al, As, Ba, Ca, Cd, Co, Cr, Cu, Fe, Hg, K, Mn, Na, Pb, Sb, Se, Si, Sn, Sr, Ti, and Zn can be derived as the possible elemental composition. Laser Induced Breakdown Spectroscopy(LIBS) spectra for a group of the pigments has also been reported, although such spectra reported the basic pigment and not the pigment as part of an ink matrix where it will certainly be diluted by the other ink components would potentially more erratic LIBS spectra as compared the “clean” spectra presented in the reported work.
Merrill et al (2003)-I reported microscopical reflection absorption by infrared spectroscopy as a viable technique for analyzing the polymer resins contained in dry black photocopy and printed toners. The sampling technique involves a heat transfer of the toner from a document to the reflected surface of aluminum foil followed by analysis by R-A IR. The technique is fast, reliable and easily available to many forensic science laboratories. A searchable library was created that contains 807 toner samples analyzed by R-A IR.98 groups were establish based on spectral characteristics and a flow chart was developed to assist with group assignments. A blind study was conducted to compare 20 photocopied documents each paired to a test document to determine if the pair could have been produced from the same copier. The analyst obtains 100%
correct result in this study. Tests on 30 samples with the spectral library produced 90% first hits for the correct group. The three remaining samples were correctly determined by visual comparison of spectra for the top three hits. An actual case study was conducted where the investigation was narrowed from 400 possible machines to 8 based on a comparative study based on the photocopy toners.
Merrill et al (2003)-II utilized the reflection-absorption infrared microscopy (R-A-IR) technique for the analysis of copy toner samples. The copy toners were grouped into distinguished classes on visual comparison and computer assisted spectral matching and was then compared to that achieved by multivariate discriminant analysis. Out of data set of spectra of 430 copy toners, 90% (388/430) of the spectra were initially correctly grouped into the classifications previously established by spectral matching. Three groups of samples that did not classify well contained too few samples to allow reliable classification. Samples from two other pairs of groups were similar and often misclassified. Closer examination of spectra from these groups revealed discriminating features that could be used in separate discriminant analyses to improve classification. For one pair of groups, the classification accuracy improved to 91% (81/89) and 97% (28/29), for the two groups, respectively. The other pair of groups were completely distinguishable from one another. With these additional tests, multivariate discriminant analysis correctly classified 96% of the 430 R-A IR toner spectra into the toner groups found previously by spectral matching.
Merrill et al (2003)-III analysed copy toner samples using scanning electron microscopy with X-ray dispersive analysis (SEM-EDX) and pyrolysis gas chromatography/mass spectrometry (Py-GC/MS).the samples analysed were differentiated into 13 subgroups based on Principal component and cluster analysis of SEM data for 166 copy toners. The basis of grouping was the presence or absence of a ferrite base. When toners were compared for which both SEM and reflection-absorption infrared spectral data were available, 41% of the samples could be assigned to specific manufacturers. Py-GC/MS on poly (styrene:acrylate)-based toners produced eight peaks relevant to toner differentiation. One third of the toners clustered in a small group that contained five statistically different subgroups. Of the 57 toners for which both Py-GC/MS and SEM data were available, 31 could be differentiated using the combined analytical results. The synergy of the complementary information provided by Py-GC/MS and SEM narrows matching possibilitis for forensic investigations involving copied or laser printed documents.
Rasool et al (2004) successfully utilized the technique of micro-reflectance absorbance FTIR to differentiate the original and duplicate of inkjet printer ink cartridges on comparing the chemical composition of ink. On the basis of a comparison of spectra generated by micro-reflectance FTIR the original inkjet cartridge ink can be characterized and assigned representative fingerprint spectra.
Trzcinska (2006) classified 162 samples from 82 different types of cartridges produced by 21 manufacturers using fourier transform infrared spectroscopy and X-ray fluorescence spectrometry. They reported that if two samples are similar in polymer composition XRF analysis may discriminate both of them. The author successfully utilized the FT-IR technique and XRF to differentiate 82.5% and 90.8% pairs of examined samples.
Fittschen et al (2008) made use of LA-ICP-MS for the analysis of inkjet printer inks. Picoliter droplets of ink (HNO3 spiked with As, Co, Fe, and Ti) were delivered from an ink-jet printer onto acrylic glass, allowed to dry, and then analyzed. The technique proved to offer a potential quantification analysis for ink, provided that a matrix-matched standard can be produced.
Donnelly et al (2009) analysed inkjet inks by Laser Desorption Mass Spectroscopy to determine the number of inks used by a printer and the chemical composition of the colorants.
LaPorte et al (2009) used Direct Analysis in Real Time – Mass spectrometry (DART™ -MS) methodology for the identification of coloured inkjet ink. The technique is virtually non-destructive, involves very little sample preparation and allows creation of a spectral searchable database.
Szafarska et al (2009) emphasized on the chemical analysis of inkjet printer inks due to the wide spread extensive use of inkjet printers .He used the capillary electrophoresis technique, with simplified stages of extraction to differentiate between inkjet inks.
DISCUSSION
From the review of the researches discussed in this paper we can say that the examination of a printed document conventionally consist of the examination of the document for the indication of particular make or model of machine used which can be further improved by examination of them for their chemical characteristics by using various instrumental methods and finally their comparison with the standard document to identify the source of origin. Very less work has been reported in India on the examination of laser or inkjet printed document. There is a need to systemically work on the problem by employing various chromatographic, spectroscopic, computerized and other techniques to achieve good discrimination between printed documents.
CONCLUSION
The document examination expert now has an array of techniques such as chromatography (TLC, HPTLC,PyGC,HPLC),Spectroscopy(FT-IR,SEM-EDX,LDMS) for the analysis of ink including opining on the printer source of suspected document, to compare the suspected document with the admitted printed specimen, for the elimination or inclusion of suspected printer in the investigation etc. besides all these there is a need to develop ink libraries and to update them time to time along with the development in the printer ink advancements. The investigation of ink for the ink composition with the more sensitive and advanced techniques such as ICP-MS is required. Image processing of spectrum obtained by various instruments such as FT-IR could be a helpful approach for the comparative analysis of ink.
This is a need of the hour that image processing tools should be developed and be successfully employed for the discrimination of inks as reported by Djozen. The authors developed software in MATLAB based on the intensity profile of RGB characterstics for the discrimination of pen inks after TLC analysis. Such tools can successfully be employed for the examination of printing inks also.
Englishhttp://ijcrr.com/abstract.php?article_id=1205http://ijcrr.com/article_html.php?did=1205
Heuser HG. Methods concerning classification and identification of photocopies. In proceedings of International Symposium on Questioned Documents. Federal Bureau of Investigation: 1987; Washington DC.
Aginsky VN. Comparitive Examination Of Inks by Using Instrumental thin layer Chromatography and Microspectrophotometry. Journal of Forensic Science JFSCA. 1993; 38(5):1111-1130.
Espadaler I, Sistach MC, Cortina M, Eljarrat E, Alcaraz R, Cabañas J, Rivera J. Organic and Inorganic Components of Manuscript Inks. ICOM Committee for conservation.10th Treennial meeting Washington,DC,USA. 1993 August 22-27.
Andrasko J. A simple method for sampling photocopy Toners for Examination by Microreflectance Fourier Transform Infrared Spectrophotometry. Journal of Forensic Sciences JFSCA.1994; 39(1):226-230.
Merrill, R.A., Bartick,E.G.,and Mazzella ,W.D.,”Studies of Techniques for Analysis of Photocopy Toners by IR,” journal of Forensic Sciences, JFSCA, Vol.41,No.2,March 1996,pp.246-271.
Jasuja OP, Sharma R. Thin layer Chromatographic Analysis of Some Printing Inks. International Journal of Forensic Document Examiners. 1997; 3(4):356-359.
Doherty P. Classification of Inkjet Printers and Inks. Journal of the American Society of Questioned Document Examiner. (1998). 1(2): 88-106.
Pagano LW, Surrency MJ and Cantu AA. Inks: Forensic Analysis by Thin Layer (Planar) Chromatography. Encyclopedia of separation science. 2000; 7: 3101-3109.
Sidhu TK.Thin Layer Chromatographic Analysis of Inkjet Printer Inks. A Report submitted to Punjabi University, Patiala (Unpublished Work).
Anglos D. Applied Spectroscopy 2001; 55:186-205A.
Merrill RA,Bartick EG,Taylor JH III.Forensic discrimination of photocopy and printer toners, part I. Anal Bioanal Chem 2003;376:1272-8.
Merrill RA,Bartick EG,Taylor JH III.Forensic discrimination of photocopy and printer toners, part II Anal Bioanal Chem 2003;376:1279-85.
Merrill RA,Bartick EG,Taylor JH III.Forensic discrimination of photocopy and printer toners, part III Anal Bioanal Chem 2003;376:1286-97.
Rasool SN, Varshney KM, Sudhakar P. Forensic Examination of ink in inkjet printer cartridges by FT-IR-Micrscopy. The forensic Scientist OnLine Journal, 2004; 7: 1-7.
TrZcinska BM. Classification of Black Powder Toners on the Basis of Integrated Analytical Information Provided by Fourier Transform Infrared Spectrometry and X-Ray Fluorescence Spectrometry. Journal of Forensic Science. 2006; 51:4
Fittschen UE, Bings NH, Hauschild S, Forster S, Kiera AF, Karavani E, Fromsdorf A, Thiele Anal Chem J. 2008; 80:1967-1977.
Donnelly S, Marrero JE, Cornell T, Fowler K, Allison J. Analysis of pigmented inkjet printer inks and printed documents by laser desorption/mass spectrometry. Journal of Forensic Science. 2009; 55(1):129-135.
LaPorte GM, Wilson JL, Houlgrave SM, Stephens JC. The classification of inkjet inks using accuTOF DART (Direct Analysis in Real Time) mass spectrometry. American Academy of Forensic Sciences -Denver - 2009, XV (J17).
Szafarska M, Solarz A, Poluszny RW, Wozniakiewicz M, KoscieIniak P. Optimization of extraction of inkjet inks from paper for forensic purposes .5th European Academy of Forensic Science Conference.2009; QD 05.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241515EnglishN2013August17HealthcareSERRATUS POSTERIOR MUSCLES: ANATOMICAL PROPERTIES, FUNCTIONAL AND CLINICAL SIGNIFICANCE
English5254Sachin PatilEnglishThere is significant paucity in the literature regarding serratus posterior superior and inferior muscles. Most standard textbooks mention conflicting views on the role of serratus posterior superior and inferior muscles in respiration. This study was aimed at providing a more accurate review about the serratus posterior superior and inferior muscles and their functional importance. For the preparation of this paper we consulted scientific articles published in English and textbooks. The articles were accessed from a basic search in PubMed database. Recent studies have shown that there is no electromyographic evidence supporting a role for either the serratus posterior superior and inferior muscles in respiration. These muscles may function primarily in proprioception and are clinically important.The serratus posterior superior and inferior muscles are considered to be source of myofascial pain, which presumably originates from trigger points within the muscles. Both muscles are implicated in chronic pain syndromes like idiopathic myalgia or painful shoulder syndrome and scapulocostal syndrome. Further investigation need to be done on these muscles to confirm their functional and clinical importance.
Englishserratus posterior, scapulocostal syndrome, trigger points, myofascial painINTRODUCTION
Serratus posterior superior (SPS) is a thin quadrilateral muscle, which arises by a thin aponeurosis from the lower part of the nuchal ligament, the spines of the seventh cervical and upper two or three thoracic vertebrae and their supraspinous ligaments.1 But study by Satoh describes origin of SPS as high as third cervical vertebrae while lower limit of origin is upto second thoracic vertebrae.2 Textbook of anatomy by Cunningham’s mentions inferior limit of origin upto fourth thoracic vertebrae.3 SPS is inserted as four digitations attached to the upper borders and external surfaces of the second, third, fourth and fifth ribs, just lateral to their angles. Serratus posterior superior is innervated by the second, third, fourth and fifth intercostals nerves.1
Serratus posterior inferior (SPI) arises from the spines of the lower two thoracic and upper two or three lumbar vertebrae and their supraspinous ligaments by a thin aponeurosis that blends with the lumbar part of the thoracolumbar fascia.1 Textbook of anatomy by Cunningham’s mentions thoracolumbar fascia as only origin of this muscle.3 But study by Satoh describes origin of SPI as high as eleventh thoracic vertebrae.4 It ascends laterally, and its four digitations pass into the inferior borders and outer surfaces of the lower four ribs, a little lateral to their angles. Serratus posterior inferior is innervated by ventral rami of the ninth, tenth, eleventh and twelfth thoracic spinal nerves.1
There is no electromyographic evidence supporting a role for either the SPS or SPI in respiration. Thus, the main evidence suggesting such a role is one the basis of their attachments. The clinical importance of these muscles is that both are implicated in chronic pain syndromes like idiopathic myalgia or painful shoulder syndrome and scapulocostal syndrome.
Figure 1- Serratus posterior superior (SPS) and serratus posterior inferior (SPI) muscles
MATERIALS AND METHODS
For the preparation of this paper we consulted scientific articles published in English and textbooks. The articles were accessed from a basic search in PubMed database (http://www.ncbi.nlm.nih.gov/pubmed), using terms like serratus posterior superior, serratus posterior inferior and scapulocostal syndrome. The data concerning anatomy, function and clinical significance of serratus posterior superior and inferior muscles was collected and analysed.
DISCUSSION
The standard textbook of Anatomy mentions conflicting views on function of these muscles.The British edition of Gray's Anatomy indicates that the role of the serratus posterior superior is uncertain in man whereas the American edition describes a specific function for this muscle, namely, elevating the ribs during deep inspiration. Similarly, for the presumably related muscle, serratus posterior inferior , the British edition indicates that the muscle's action is to draw the lower ribs downward and backward, although possibly not in respiration. In contrast, the American edition of this text states that the muscle is active during forced expiration.5 Hollinshead’s Anatomy mentions the serratus posterior muscles as inspiratory muscles which is similar to that stated in clinical anatomy by Moore and Dalley .6,7 But Snell anatomy indicates that the SPS is active in inspiration and the SPI in expiration.8
Regarding the function of muscles other different views are present in previous literatures. Travell and Simons suggested that the SPI functions synergistically with the ipsilateral iliocostalis and longissimus for rotation (unilateral) and extension (bilateral) of the spine while in respiration, the muscle acts synergistically with the quadratus lumborum.5
Vilensky et al suggested that the SPS and SPI have reflex connections with the respiratory muscles such that overstretching results in compensatory movements. The muscles may function to measure stress levels at the superior and inferior limits of the thoracic spine. Considering, the ambiguous relationship between muscle spindle density and presumed proprioceptive function, they suggested that better electromyographic recordings and electroneurography of the motor and sensory nerves of these muscles, rather than further histological analysis, would be the best approach to understanding their function. Authors further stated that until there is supportive evidence, no respiratory function be attributed to either the SPS or the SPI, and that the possible clinical importance of these muscles as generators of pain, especially shoulder pain, which is one of the frequent locations of myofascial pain, should be mentioned in gross anatomy courses and textbooks.5
The scapulocostal syndrome, an insufficiently understood condition was clinically studied in 201 cases by Fourie LJ in 1991. The pain was the presenting symptom in all cases and important cause was from an enthesopathy of the serratus posterior superior muscle. The operation of 'serratotomy' (severing the serratus posterior superior muscle) was performed with excellent results in 6 patients in whom conservative treatment failed. This study supports that SPS is one of the cause of painful shoulder syndrome and scapulocostal syndrome.9
Recent study by Loukas M et al supported that SPS and SPI have role in role in respiration based on their findings that no morphometric difference exists between the SPS and SPI of COPD patients versus controls.10
Further investigation need to be done on these muscles to confirm their functional and clinical importance.
CONCLUSION
We undertook this study with the aim of providing a more accurate report about the serratus posterior superior and inferior muscles, because of interesting relationship with chronic pain syndromes like idiopathic myalgia or painful shoulder syndrome and scapulocostal syndrome. Finally, this study shall be useful for clinicians, surgeons and academics that manipulate and keep particular interest for these mysterious muscles .
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/ publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=1206http://ijcrr.com/article_html.php?did=1206
Standring, S. (Ed). Gray's Anatomy: The Anatomical Basis of Clinical Practice 40th ed. New York: Churchill Livingstone.2008;2729-31.
Satoh JI. The serratus posterior superior in certain catarrhine monkeys and man, in particular the structure of the muscular digitations and their nerve supply. Okajimas Folia Anat Jpn. 1969; 46:65-122.
Sinclair DC. Muscles and fasciae, In: Romanes GJ (ed) Cunningham’s textbook of anatomy. 12th eds. Oxford: Oxford University Press, 1981; 352.
Satoh J I. The serratus posterior inferior in monkey and man, in particular the structure of the digitations of this muscle and their nerve supply. Okajimas Folia Anat jpn. 1970; 47:19-61.
Vilensky JA, Baltes M, Weikel L, Fortin JD, Fourie LJ. Serratus posterior muscles: anatomy, clinical relevance, and function. Clin Anat. 2001 ;14(4):237-41.
Hollinshead WH,Rosse C( eds). In: Textbook of anatomy. 4th ed. Philadelphia.1985;309-310
Moore KL, Dalley AF II. Clinically oriented anatomy. 4th ed. Baltimore: Lippincott Williams and Wilkins. 1999; 80.
Snell RS. Clinical anatomy for medical students. Baltimore: Lippincott Williams and Wilkins. 2000; 58.
Fourie LJ. The scapulocostal syndrome. S Afr Med J 1991; 79:721-724.
Loukas M, Louis RG Jr, Wartmann CT, Tubbs RS, Gupta AA, Apaydin N, Jordan R. An anatomic investigation of the serratus posterior superior and serratus posterior inferior muscles. Surg Radiol Anat. 2008;30(2):119-23.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241515EnglishN2013August17HealthcareLOW PREVALENCE OF DENTAL CARIES IN CHILDREN WITH PERINATAL HIV INFECTION
English5561Sahana SrinathEnglish Srinath S.K.English Vishwanath S.K.English Ritu SinghEnglish Pravesh BharadwajEnglishObjective: The objective is to assess the prevalence of caries in children with perinatal HIV infection. Methods: Oral examination was performed on Children aged 2-12 years with perinatal HIV infection who stayed at ‘Calvary Chapel home of hope for special children’ in Bangalore, to assess dmft/DMFT. Results: Prevalence of tooth decay in primary teeth (dmft) for the age group 2-6 years was 57.15%, for age group 7-12 years was 20.0%. Prevalence of tooth decay in permanent teeth (DMFT), for the age group 7-8 years was 16.60%, for age group 10-12 years was 21.42%. Of the 27 children examined 59.25% were caries free, in which 40.0% were male children and 70.58% were female children. Conclusions: Based on these results we can conclude that oral hygiene can be maintained with a favorable dental behavior
EnglishCaries, Diet, Dental HealthINTRODUCTION
In worldwide it is estimated that there are 2.3 million HIV positive children from 0 to 14 years infected by mothers (1). In children, the quality of life related to health should be considered differently from adults (2). The high prevalence of HIV infection reinforces the need of dentists and his staff to update the prevention and treatment of diseases and the promotion and maintenance oral health of individuals with HIV/ AIDS (2).
Prior to 1992, informationabout dental caries in HIV-infected children was verylimited (3). Of the published articles on the oral manifestationsof AIDS, virtually all addressed this issue only in anadult population. In one of these studies, HIV-infected adultshad a lower prevalence of dental caries than a comparison groupof healthy adults from the same region of Zaire (4).Another adultstudy found that there was an association between dental cariesand Capnocytophagakeratitis (5). A Russian study found a highincidence of dental caries in symptom free HIV-infectedadults (6). It was not until the late 1980s that investigators startedto turn attention to the oral manifestations of HIV-infectedchildren, but none of those earlier writings reported on thedisease of dental caries (7-9). Between 1992 and 1996 there werethree published cross-sectional studies of dental caries in theprimary teeth of HIV-infected children (10-12).These studiesshowed that there was a higher prevalence of dental caries (including ECC) in the primary dentition of HIV-infectedchildren as compared to healthy children. However, in a 1996case control study of caries prevalence in a group of childrenaged 1.5 to 12 years, Teles, G et al. reported a lower dmft for HIV-infected children as compared tohealthy children, as well as a higher DMFT (13). Vieira, et al., reported that HIV-infectedchildren (aged 2-12 years), who were more immunologicallyaffected (CD4:CD8 < 0.5 ratio) showed a greater DMFT/dmfindex than HIV-infected children who were immunocompetent (14).
Standard antibody testing is now available to determine a person’s HIV status at an early age. However because of the expense of the complex technology, health workers in developing countries – where 95% of the world’s paediatric AIDS cases are found – must rely on early clinical manifestations of HIV infection (15). Moreover, the use of disease markers prevalent in adult HIV infection is not necessarily effective in the paediatric AIDS population. CD4 lymphocytes, for example, where HIV primarily resides and multiplies, decline with the progression of HIV disease in infected adults; in children, however, a CD4 count alone is not as reliable a marker of progressive disease because children tend to have higher and less consistent CD4 levels than do adults (16,17).
In the light of the above factors the aim of this study was to assess the prevalence of dental caries in children with perinatal HIV infection.
HYPOTHESIS
Null Hypothesis (H0): The prevalence of dental caries in children with perinatal HIV infection is not different from that of normal children residing in the same region.
Alternative Hypothesis (H1): The prevalence of dental caries in children with perinatal HIV infection is higher than that of normal children residing in the same region.
MATERIALS AND METHODS
Source of data
Children aged 2-12 years staying at Calvary Chapel home of hope for special children in Bangalore, with perinatal HIV infection were chosen as subjects.
Method of data collection
27 subjects with perinatal HIV infection fulfilled the criteria and were included in the study. The participation of the subjects in the study was voluntary, and a written informed consent was obtained at the beginning of the study.
Inclusion criteria
1. Children with perinatal HIV infection
2. Children stayed at ‘Calvary Chapel home of hope for special children’
3. Age group: 2- 12 years
Exclusion criteria
1. Children with any oral lesions
2. Children on medications other than anti viral therapy
3. Chronic inflammatory diseases like Rheumatoid arthritis which require Medication
TRAINING AND CALIBRATION
The investigator was trained in the department of Pediatric dentistry, Government Dental College and Research Institute Bangalore, on 10 subjects. Calibration was done on 10 subjects, who were examined twice using diagnostic criteria on the same day with a time interval of one hour between the two examinations, and then the results were compared to diagnostic variability. Agreement for assessment was 90 percent.
EXAMINATION
The examination procedure was carried out at the calvary chapel home of hope for special children under natural light by single investigator. The children were made to sit on a cement bench. The oral examination was performed according to World Health Organization guidelines for oral health surveys. The diagnosis of developmental enamel defects was done according to the modified developmental defects of enamel index.
Examination was carried out using 27 mouth mirrors and 27 periodontal probes. Examination of children was undertaken to determine caries prevalence using dmft/DMFT, and developmental enamel defects. The examiner started with the upper left central incisor and continued distally through the second molar in the same quadrant. The same sequence was followed for the upper right, lower left, and lower right quadrants. Tooth surfaces were examined in the following order: lingual, labial, mesial, and distal for anterior teeth, and occlusal, lingual, buccal, mesial, and distal for posterior teeth. (Image 1)
Guardians were interviewed to obtain information on their children’s dental health behaviors such as tooth-brushing, diet, fluoride; oral medication and dental attendance were explored.
Data collected was used to estimate the mean number of teeth, the number of teeth with carious lesions, number of missing/extracted teeth and number of teeth with restorations. Caries was defined by presence of decayed or filled teeth, and was categorized as present or absent.
As the subjects stayed in the special home for children with HIV infection, a suitable control group was not found. Hence the prevalence of dental caries (dmft and DMFT) in children with perinatal HIV infection was compared with the prevalence of dental caries in normal children residing in the same city, which was found in a large study conducted in Bangalore city (18).
RESULTS
The study population was composed of 27 children, there were 62% (n=17) female children and 38% (n=10) male children. 27 children ranged in age from two to twelve (2-12) years, with a mean age of 8.407 years. Developmental enamel defects nor the discrepancies in the average number of teeth for their age were found. All the twenty seven children brushed their teeth twice daily with a tooth brush and tooth paste to clean their teeth.
CARIES
Prevalence of tooth decay in primary teeth (dmft) for the age group 2-6 years was 57.15%, for age group 7-12 years was 20.0%. 50.0% of male children were free of decay in the primary teeth, however 82.36% of female children were free of decay in the primary teeth (Table 1).
Prevalence of tooth decay in permanent teeth (DMFT), for the age group 7-8 years was 16.60%, for age group 10-12 years was 21.42%. 20.0% of male children had caries in their permanent teeth, and 20.0% of female children had caries in their permanent teeth (Table 2).
Of the 27 children examined 59.25% were caries free, in which 40.0% were male children and 70.58% were female children (Table.3).
The dmft found in these children was 0.55 with a standard deviation of 1.088 and the DMFT was 0.733 with a standard deviation of 1.10. The dmft found in children with perinatal HIV infection was low and was marginally significant (p=0.072, p > 0.05 however p < 0.10,) compared with that of normal children. However no significant differences were found in DMFT of these children when compared with that of normal children (p= 0.238) (Table.4).
DISCUSSION
Oral health care is an important component of all round care for people withHIV infection (19).The lack of healthy, functioning dentition can adversely affect the quality of life, complicate the management of medical conditions, and create or exacerbate nutritional and psychosocial problems (20).Some anti-retroviral drugs are sucrose based in the form of a syrup or suspension, such as Zidovudine, and others may lead to decreased salivation, which makes them potentially cariogenic (21).
In South Africa an oral examination was performed on 87 HIV positive children ranged between 3.2 and 7yrs, who were not receiving antiretroviral treatment. Rampant caries early in childhood was found in 19 (21.8%) children, with 5 children suffering severe pain from multiple carious teeth (22).The study in Romanian population consisted of 173 children at age range 6 to 12 years noted severe dental caries in the majority of children (dmfs/dmft 16.9/3.7 and DMFS/DMFT 8.1/3.1) (23).
According to Howell et al (24). The prevalence of caries in HIV children was very high, especially with deciduous dentition. Tofsky et al.(25) found a mean dmft average of 8.3 for children with HIV, while for children not infected with HIV this average was 3.1 teeth, which showed, according to the authors, the need of guidance and treatment for those infected patients. A comparative study of the prevalence of caries, by Souza et al (26).In HIV infected children and children without evidence of immunosuppression, showed statistically significant difference between the average mean dmft (5.29; 2.59) and DMFT (2.36; 0.74) of the two groups, respectively. Other recent studies showed that the high prevalence of caries in infected children seems to be greater in those that are in advanced stage of disease and with more severe degree of immunosuppression (27).
Poorandokht et al., found that 54 children of the 100 children examined had rampant caries and rampant caries was the most common oral manifestations of AIDS in those children (54%) sfollowed by periodontal disease (44%), further authors suggested that Rampant caries and severe periodontal diseases (mean CD4 count, 523±297) might have caused tooth loss and dentures use in some patients with severe immunosuppression, resulting in not being categorized as rampant caries (28).
Beena JP et al, found that the primary dentition group had a mean deft of 5.07 ± 5.29 and a caries prevalence of 58.62%; in the mixed dentition group the mean deft was 3.81 ± 3.41 and the mean DMFT was 1.40 ± 2.03 with caries prevalence of 86.20%. In the permanent dentition group the mean DMFT was 3.00 ± 2.37 with a caries prevalence of 76.47% (29).
It was however observed that the prevalence of dental caries recorded in the present study was lower than those previously reported. Dental caries prevalence in these HIV positive children although lower than that seen in other studies was however did not differ significantly when compared to reports of healthy children residing in the same city.
Although the exact reason for the low levels of dental caries prevalence recorded in this study was not apparent, it may be attributable to the general high level of oral health awareness and the diet they consumed which completely eliminated the added sugars, which leads to good oral health and restorative care. (Image 2)
(Image -2 Diet chart of Calvary chapel home)
CONCLUSIONS
Children with perinatal HIV infection who stayed at Calvary chapel home of hope had a favorable dental behavior and the caries experience was low.
IMPORTANCE OF THIS PAPER
Survival rates for children born with HIV who receive antiretroviral therapy are more than double those for children who do not. However Some anti-retroviral drugs are sucrose based in the form of a syrup or suspension, such as Zidovudine, and others may lead to decreased salivation, which makes them potentially cariogenic.
Many recent studies have demonstrated high caries prevalence rates in these children; however in the present study we found a group of children taking ART with low prevalence of caries.
Englishhttp://ijcrr.com/abstract.php?article_id=1207http://ijcrr.com/article_html.php?did=1207
United Nations Programme on HIV/AIDS (UNAIDS). AIDS epidemic update. Special report on HIV/AIDS. Geneva: Joint United Nations Programme on HIV/AIDS (UNAIDS), World Health Organization (WHO); 2006. [cited 2009 Aug 31]. Available from: http://data.unaids.org/pub/EpiReport/2006/2006_EpiUpdate_en.pdf
Sílvia Helena de Carvalho Sales-Peres, Marta Artemisa Abel Mapengo, Patrícia Garcia de Moura-Grec, Juliane Avansine Marsicano, André de Carvalho Sales-Peres, Arsenio Sales- Peres. Oral manifestations in HIV+ children in Mozambique. Ciência and Saúde Coletiva . 2012;17(1):55-60
Moyer I, Kobayashi R, Cannon M, Simon J, Cooley R, Rich K: Dental treatment of children with severe combined immunodeficiency. Pediatr Dent. 1983;5:79-82.
Murray P, Grassi M, Winkler J: The Microbiology of HIVassociated periodontal lesions. J Clin Periodont. 1992;16:636-42.
Ticho B, Urban R, Safran M, Saggau D: Capnocytophaga keratitis associated with poor dentition and human immunodificiency virus infection. Am J Ophthalm. 1990;109:352- 53.
Kharchenko OI, Pokrovskii VV: The state of the oral cavity in persons infected with the human immunodeficiency virus. Stomatologiia. 1989;68(5):25-8.
Leggott P, Robertson P, Greenspan D, Wara D, Greenspan J: Oral manifestations of primary and acquired immunodeficiency disease in children. Pediatr Dent. 1987;9:98-104.
Tucker B, Schaeffer D, Berson R: A combination of HIV antibody and HIV viral findings in blood and saliva of HIV antibody-positive juvenile hemophiliacs. Pediatr Dent. 1988;10:283-86.
Falloon J, Eddy J, Wiener L, Pizzo P: Human immunodeficiency virus infection in children. J Pediatr 1989;114:1-23.
Howell R, Jandinski J, Palumbo P, Shey Z, Houpt M: Dental caries in HIV-infected children. Pediatr Dent. 1992;14:370-71.
Valdez I, Pizzo P, Atkinson J: Oral health of pediatric AIDS patients: A hospital-based study. J Dent for Children.1994; 61: 114-18.
Madigan A, Murray P, Houpt M, Catalanotto F, Feuerman M: Caries experience and cariogenic markers in HIV-positive children and their siblings. Pediatr Dent.1996;18:129-36.
Teles G, Perez M, Souza I, Vianna R: Clinical aspects of human immunodeficiency virus (HIV) infected children. J DentRes.1996;75:316 (abstract #2386).
Viera AR, Ribeiro IP, Modesto A, Castro GF, Vianna R: Gingival status Of HIV+ children and the correlation with caries incidence and immunologic profile. Pediatr Dent 1998;20:3169-72.
Falloon J, Eddy J, Wiener L, Pizzo P: Human immunodeficiency virus infection in children. J Pediatr.1989;114:1-23,
Howell R, Jandinski J, Palumbo P, Shey Z, Houpt M: Dental caries in HIV- infected children. Pediatr Dent 1992;14:370-71.
Valdez I, Pizzo P, Atkinson J: Oral health of pediatric AIDS patients: A hospital-based study. J Dent for Children.1994; 61:114-18.
Pramila M, S. S. Hiremath. Oral health status of handicapped children attending special schools in Bangalore city. Int. J.of Cont. Dent 2011;2(1):55-581
S. G. Damle, A. K. Jetpurwala, S. Saini, P. Gupta. Evaluation of Oral Health Status as an Indicator of Disease Progression in HIV Positive Children. Pesq Bras Odontoped Clin Integr, João Pessoa 2010;10(2):151-156
Baccaglini L, Atkinson JC, Patton LL, Glick M, Ficarra G, Peterson DE. Management of Oral lesions in HIV-positive pati ents. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 103 Suppl:S50.e1-23.
Charles Mugisha Rwenyonyia, Annet Kutesaa, Louis Muwazia, Isaac Okulloa, Arabat asangakia, Addy Kekitinwab. Oral Manifestations in HIV/AIDS Infected Children. Eur Jou of Dent 2011; 5:291-298
Blignaut E. Oral health needs of HIV/AIDS orphans in Gauteng, South Africa. AIDS Care 2007; 19(4):532-538.
Flaitz C, Wullbrandt B, Sexton J, Bourdon T, Hicks J. Prevalence of orodental findings in HIV infected Romanian children. Pediatr dent. 2001; 23(1): 44-50
Howell RB, Jandinski J, Palumbo P, Shey Z, Houpt M. Dental caries in Hiv-infected children. Pediatr Dent 1992;14(6):370-371.
Tofsky N, Schoen D, Jandinski J, et al. Dental caries in children with Aids. J Dent Res 1995; 74:191.
Souza IPR, Teles GS, Castro GF, Guimarães L, Viana RBC, Peres M. Prevalence of dental caries in HIV-infected children. Rev Bras Odontol 1996; 53(1):49-51.
Castro GF, Souza IP, Chianca TK, Hugo R. Evaluation of caries prevention program in HIV+ children. Braz Oral Res 1997; 15(2):91-97.
Poorandokht Davoodi, Mina Hamian, Reza Nourbaksh, Fatemeh Ahmadi Motamayel.Oral Manifestations Related To CD4 Lymphocyte Count in HIV-Positive Patients. J. of Dent Research, Dental Clinics, Dental Prospects. 2010;4(4):115-119 Beena JP.Prevalence of dental caries and its correlation with the immunologic profile in HIV-Infected children on antiretroviral therapy.Eur J Paediatr Dent. 2011 Jun;12(2):87-90
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241515EnglishN2013August17HealthcareENDOCRINE DYSFUNCTION IN β THALASSEMIA - A CLINICAL REPORT
English6265Swati Bhattacharyya English Sanghamitra ChakrabortyEnglish Sharmistha ChatterjeeEnglishHypoparathyroidism is one of the rare endocrinopathy in β thalassemic patients as a consequence of iron overload. Hypogonadotropic hypogonadism, hypothyroidism are still prevelant in β thalassemic patients inspite of intensive chelation therapy. Though regular blood transfusion may increase the life expectancy, yet growth disturbances and growth hormone defects in these children may be noticed. We present a rare case of multiple endocrinological defects following splenectomy in a known case of β thalassemia noted during biochemical investigations. The literature regarding the prevalence of hypoparathyroidism has been reviewed. Moreover, literature survey depicts that serum concentration of ferritin does not predict the occurrence of hypoparathyroidism, thus the case being reported.
EnglishHypoparathyroidsm, Endocrinopathy, ? Thalassemia, Hypogonadotropic HypogonadismINTRODUCTION
The inherited disorders of haemoglobin are the commonest single-gene disorders, with an estimated carrier rate of 7% among the world population.1 Though regular blood transfusion and intensive chelation therapy may increase the survival of thalassemia affected child, yet growth disturbances and endocrinopathy like hypogonadotropic hypogonadism,diabetes mellitus, hypothyroidism and rarely hypoparathyroidism in these children may be
noticed.2,3,4Hypoparathyroidism may or may not be associated with hypocalcemia and present with neurological symptoms like tetany, carpopedal spasm, paresthesia.5,6, Majority of the hormonal defects like growth hormone-insulin like growth factor axis, hypogonadotropic hypogonadism is solely from iron overload and later age of initiation of chelation therapy. So, regular hormonal profile assay in thalassemic patients is warrented.
CASE REPORT
A 14 year old girl, known case β thalassemia, presented to the outpatient department of Medical College Hospital, Kolkata with carpopedal spasm and fever for last two months. About 1 year back she had a history of splenectomy because of increased requirement of blood transfusion and hypersplenism. She was diagnosed to be suffering from β thalassemia major by clinical symptoms and HPLC of Hemoglobin at the 2nd year of birth. She received repeated monthly blood transfusions there after till next 10 years. There was no family history of haemolytic anaemia. Both the parents of the girls were found to be thalassemia carrier on screening by HPLC.
On general examination, the girl was of thin built with height 90cm and weight 18 kilograams (expected 22kgs). The girl was having moderate degree of pallor with mild icterus. The facies was with high arched palate, prominent malar prominences and frontal bossing. There was severe bowing of both the legs and a scar of splenectomy in the left hypochondrium. The left axillary lymph node were enlarged. Fine needle aspiration cytology, however, suggested reactive hyperplasia of lymph node due to infection. On systemic examination, the liver was just palpable and other systems were within normal limit. The girl had no pubertal changes (Tanner I) and did not attained menarche till then.
As admitted with carpopedeal spasm she was treated with 2gm intravenous calcium gluconate injection. The investigations before admission revealed 2.56million/cmm of RBC, 6.7 g/dl of haemoglobin and 3% reticulocyte count. The peripheral blood showed hypochromic and microcytic red blood cells with target cells. The serum electrolytes were found to be Na-132 meq/L, K-3.4 mg/dl, PO43—4.4 mg/dl and Mg+2-1.6mg/dl measured by ISE. Both free calcium (5.1mg/dl) and ionised calcium (1.6mg/dl) were found to be low. Both serum vitamin D3 8.265 nmol/l (recommended reference interval 36-144nmol/l) and parathyroid hormone iPT= 3pg/ml (the recommended reference interval 10-65pg/ml) were estimated by ELISA and found to be reduced. The fasting plasma glucose was 79mg/dl. On laboratory investigation for hypogonadism, gonadotropins (3 pooled serum assay) were estimated by ELISA. Serum FSH concentration was 1.37mIU/ml, lower than the cut off 2mIU/ml as per IAP recommendation. Thyroid profile ( serum TSH, fT4,fT3) and cortisol at 8.a.m was determined to exclude other causes of delayed property. As the patient was on chelation therapy (desferrioxamine), monitoring of the ocular examination was normal with visual acuity of 6/6, but the audiometric system showed central perforation with mild sensorineural deafness. Serum insulin like grow factor 1 was estimated to determine the cause of retarded growth and found to be74ng/ml (286-660ng/ml). Hepatic enzymes showed transient rise of transaminases and hepatitis serology was within normal limits. The renal functions were normal but the urinary calcium excretion increased from 83.2mg/dl to 206 mg/dl and serum calcium raised to 8.4mg/dl after treatment with calcium gluconate suggested severe parathyroid hormone deficiency. Serum ferritin was many folds higher than the threshold, about 2213.8 mg/dl suggesting iron overload.
DISCUSSION
In our present case, the 14 year girl is suffering from iron-overload due to repeated blood transfusion, as reflected by her serum ferritin status. It has already been established that the iron overload is the prime cause of endocrinopathy in such patients.6 The growth retardation in the girl is mainly due to a dysfunction of the growth hormone-insulin like growth factor axis. It is well known that bone metabolism and skeletal consolidation are dependent on a variety of hormonal factors like GH, IGF-I, sex hormone and their receptors. 7Growth hormone insensitivity at the post receptor level, rather than growth hormone reserve may be more important in IGF-I deficiency in β thalassemia patients. This finding has been seen in case series reports where the basal insulin like growth factor levels significantly increased after administration of human growth hormone.9 As in this case, transfusion dependent thalassemia major patients, chelation therapy may also be an important cause of growth retardation. Desferrioxamine though reduces hemosiderosis, may also lead to bony lesions like genu-valgum, metaphyseal changes and impaired spinal growth.10 The underlying cause of hypogonadotrophic-hypogonadism may be due to pituitary dysfunction attributed by iron toxicity. Hypogonadism, bone marrow expansion, increased iron store and desferrioxamine toxicity may also lead to osteoporosis and osteopenia in such transfusion dependent thalassemia patients. 11,12,13 Osteopenia may also result from hypocalcaemia and Vitamin D deficiency. The increased serum ferritin due to increased iron overload may be a cause of reduced parathyroid secretion and this may lead to Vitamin D deficiency.
CONCLUSION
From the above discussion it is evident that endocrinopathy is still a clinically significant cause of morbidity despite the newer advent of chelation therapy, so this case has been reported. But the proper cause effect relationship between endocrinopathy and transfusion associated iron overload is yet to be established in these patients. This can be done only by conducting further case series in such patients in this part of the subcontinent. These studies may be helpful for clinicians for effective management of transfusion dependent patients.
ACKNOWLEDGEMENT
The authors of this article acknowledge the inspiration and help received from the scholars whose articles have been cited in the reference section. The authors pay their gratitude to authors/editors/publishers of all those articles/journals/books from where the reviews and literatures for the discussion have been collected.
Abbrebiations Of Terminology Used In The Case Report.
HPLC- High Performance Liquid Chromatography
ELISA- Enzyme Linked Immunosorbent Assay
ISE-Ion Selective Electrode
iPT- Intact Parathyroid Hormone
FSH-Follicle Stimulating Hormone
TSH- Thyroid Stimulating Hormone
IGF-I – Insulin Like Growth Factor I
GH-Growth Hormone
Englishhttp://ijcrr.com/abstract.php?article_id=1208http://ijcrr.com/article_html.php?did=1208
Weatherall DJ, Clegg JB. Inherited haemoglobin disorders: an increasing global health problem. Bull World Health Organ. 2001;79(8):704-712.
Olivieri NF, Nathan DG, MacMillan JH, Wayne AS, Liu PP,McGee A, Martin M, Koren G, Cohen AR (1994) Survival in medically treated patients with homozygous ß-thalassemia. N Engl J Med 331:574–578.
Abdollah Shamshirsaz A, Bekheirnia MR, Kamgar M, Pourzahedgilani N, Bouzari N, Habibzadeh M, Hashemi R, Abdollah Shamshirsaz AH, Aghakhani S, Homayoun H, Larijani B (2003) Metabolic and endocrinologic complications in beta thalassemia major: a multicenter study in Tehran. BMC Endocr Disord 3:4.
Italian Working Group on Endocrine (1995) Multicentre study on prevalence of endocrine complications in thalassaemia major. Complications in nonendocrine diseases. Clinical Endocrinology (Oxford) 42:581–586.
Aloia JF, Ostuni JA, Yeh JK, Zaino EC (1982) Combined vitamin D parathyroid defect in thalassemia major. Arch Intern Med 142:831–832.
De Sanctis V, Vullo C, Bagni B, Chiccoli L (1992) Hypoparathyroidism in beta-thalassemia major. Clinical and laboratory observations in 24 patients. Acta Haematol 88:105–108.
Lasco A, Morabito N, Gaudio A, Crisafulli A, Meo A, Denuuzzo G et al.Osteoporosis and beta-thalassemia major: role of the IGF-I/IGF-III axis: Journal of Endocrinological Invesigation. 2002 Apr; 25(4):338-44.
Pincelli AI, Masera N, Tavecchia L, Perotti M, Perra S, Mariani R, Piperno A, Mancia G, Grassi G, Masera G. GH deficiency in adult B-thalassemia major patients and its relationship with IGF-1 production: Pediatric Endocrinology Review. 2011 Mar;8 Suppl 2:284-289.
Soliman AT, Abushahin A, Abohezeima K, Khalafallah H, Adel A, Elawwa A, Elmulla N. Age related IGF-I changes and IGF-I generation in thalassemia major. Pediatric Endocrinology Review. 2011 Mar;8 Suppl 2:278-83.
De Virgiliis S, Congia M, Frau F, Argiolu F, Diana G, Cucca F, Varsi A, Sanna G, Podda G, Fodde M, et al Deferoxamine-induced growth retardation in patients with thalassemia major: J Pediatr. 1988 Oct;113(4):661-9.
Chiabotto P, Di Stefano M, Isaia GC, Garofalo F, Piga A(1998) Bone density and metabolism in thalassemia. Journal of Pediatric Endocrinol Metab 11:785–790
Domrongkitchaiporn S, Sirikulchayanonta V, Angchaisuksiri P,Stitchantrakul W, Kanokkantapong C, Rajatanavin R (2003) Abnormalities in bone mineral density and bone histology in thalassemia. J Bone Miner Res 18:1682–1688.
Wonke B, Jensen C, Hanslip JJ, Prescott E, Lalloz M, Layton M,Erten S, Tuck S, Agnew JE, Raja K, Davies K, Hoffbrand AV(1998) Genetic and acquired predisposing factors and treatment of osteoporosis in thalassemia major. J Pediatric Endocrinological Metabolism:11:795–801.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241515EnglishN2013August17HealthcareEVALUATION OF PRIMARY IMMUNIZATION COVERAGE AND REASONS FOR PARTIAL / NON IMMUNIZATION IN MAHARASHTRA
English6672Sanjay WaghEnglish Ashok MehendaleEnglish Mohan RautEnglish Santoshi WaghEnglish Diwakar SharmaEnglishBackground: The complete immunization is cost effective method to prevent vaccine preventable diseases. In many areas complete immunization is not achieved due to various reasons. The partial or non immunization can be converted in to complete immunization if situation analyzed. Objective: 1) To find out the immunization coverage in 12- 23 months children. 2) Assess the factor associated with partial / non immunization 3) To find out various reasons for partial / non immunization. Methodology: A cross sectional study was conducted in field practicing area of Dept Community Medicine in Three PHC area of Wardha district Maharashtra by house to house survey. Study period: April 2009 to November 2010. A total 1199 children were included in the study Chi square test was applied for statistical analysis. Result: 84.90% children were fully immunized to primary vaccine. The immunization coverage for BCG (96.7%) Vaccine was highest and lower for Measles (84.9%). Most common reason for partial immunization was unaware about the schedule of vaccine (36.5%), out of station (17.7%) and child was ill (14.9%). Parent’s education plays significant role in immunization status of children. IEC activities should be in community to avoid non immunization in children.
Englishimmunization, partial immunization, various reasons.
INTRODUCTION
Protection through immunization against vaccine preventable diseases, disabilities and death is the right of every child. Vaccines remain one of the most cost-effective public health initiatives1. In India, immunization services are offered free of cost at government hospitals still the coverage remains low. According to the National Family Health Survey (NFHS-3), only 44% of 1to 2 years old children had received the basic immunization, which is much less than the desired goal of achieving 85% coverage2. However it is not an easy task to achieve. In a developing country like India, the sheer logistics of the numbers of the target population that stretches across geographically diverse regions make universal immunization of children a herculean task3. Because of increased accessibility of health care services in both urban and rural areas, an increase was expected in the utilization of the services; however, studies reveal low utilization of health care services 4. It is known that fully immunization status can only protect the children at maximum. Percentage of protection may be reduced in partially immunize child5.
Parents show various reasons for discontinuing or non immunizing their children. Success of immunization coverage depends upon clear understanding of reasons for partial immunization of a child. Hence the present study was planned with the following objectives.
OBJECTIVE
To find out immunization status among the children in the age group 12-23 months
To assess the factor associated with immunization
To find out various reasons for partial immunization
METHOD
Study Design: The cross sectional descriptive study
Study area: Three PHC area of Wardha District (Mahrashtra) Namely Anji, Goul and Talegaon including 67 villages.
Study Population: Children in the age group of 12-24 months.
Study period: April 2009 - November 2010
Data collection technique and tools
Three PHC’s (Population 88131) were selected as it comes under field practice area of the Department of Community Medicine, MGIMS, and Sevagram Wardha district. List of children in the age group of 12-23 months was prepared by house to house visit, separately for each village. In all the families with a child in the age group of 12-23 months, a pre-tested and pre-designed questionnaire was administered to the mother of the child to find out if the child has been immunized with all the vaccines in the national immunization schedule. If she was not available at the time of survey; father, grandmother, grandfather or any care taker more than 18 years of age was asked to provide the information. The respondents were asked whether they had a vaccination card of the child. If the vaccination card was available in the family, particulars about each vaccine was noted. For vaccinations not recorded on the card, the respondent's report that the vaccination has or has not been given the vaccine was accepted. If a house was found locked, the investigator visited the household two more times.
However, if the house was found locked during all three visits, no further visits were paid to the household. For all children, who had not received the full course of the primary immunization, in-depth interview was conducted to find out the cause of non-immunization or partial immunization. The in-depth interview was based on a semi-structured format. The details about the missed dose of partially/ non immunized child was noted. A child was classified as fully immunized if he had received one dose of BCG, three doses of DPT and one dose of measles vaccine. Partially immunized any one of the dose or vaccine was dropped. Unimmunized child means who had not given any vaccine. BCG scar was looked for history of immunization.
Data entry and Analysis: The data for primary dose were entered and analyze in SPSS 16 -Version. P value was generated, p value 0.05 was taken as non significant.
RESULT
Table 1: A total no 1199 children in the age group of 12-24 months were included in the study. (84.90%) children’s were fully vaccinated against all six vaccine preventable diseases. When compared between gender, the proportion of fully immunize children was higher in male (64.04%) than in female (35.92%), however the difference was highly significant (p-value=Englishhttp://ijcrr.com/abstract.php?article_id=1209http://ijcrr.com/article_html.php?did=1209
Inamdar M, Piparsania S, Inamdar S, Singh K. Exploring the causes of low immunization status in school going children. Journal of Health and Allied Sciences. 2011;10(4):1-4.
Vikaram A, Amarjir S, Vijaylakshmi ,S Coverage and quality of immunization services in rural Chandigarh. Indian Pediatrics. 2012;49:565-567.
Varsha C, Rajiv K, Arawal VK, Joshi SH, Sharma M, Evaluvation of Primary immunization coverage in urban area of bareilly city using cluster sampling technique. JIRM.2010;1(4): 10-15.
Sharma R, Desai VK, Kavishavr A. Assessment of immunization status in slums of surat by 15 cluster multi indicator cluster technique. Indian J community Med. 2009;32(2):152-155.
Govindarajan PK, Senthilmugan TK. Study on immunization coverage in urban population in Tamilnadu. Nat.J.Res.Com Med.2012;1(4):220-222.
Dalal A, Silveira MP. Immunization status of children in Goa. Indian Pediatrics. 2005;42:401-402.
Punith K, Lalitha K,Suman G,Pradeep BS, Jaynath Kumar K. Indian J community Med. 2008;33(3) 151-155.
Maj RM Joshi, Lt Col (Mrs) Bala. Immunization Coverage at a Military Station. MJAFI,2003; 59(3):223-225.
Chopra H, Singh AK, JV Bhatnagar,M Garg,SK Bajpai SK. Status of routine immunization in urban are of Merrut. Indian J community Med. 2007;19(1):91-92.
Chturvedi M, Nandan D, Gupta SC. Rapid assessment of immunization practice in Agra district. Indian Journalof Public Health. 2007;51(2):132-134.
Khokhar A, Chitkara A, Talwar R, Sachdev TR, Rasania SK. A study of reasons for partial immunization and non immunization among children aged 12-23 months from an urban community of delhi . Indian J.Prev.Soc.Med.2005;36(4):84-86.
Prabar KM, Kousik C, Debasis D, Debidas G. Child Immunization Coverage o f Some Rural Belt in Relation to Socioeconomic Factors of Jalpaiguri and Darjling district of west Bengal. J Life Sci 2009;1(2):91-95.
Sharma V, Sharma A. is female child being neglected? Immunization in India. 2010
Yadav S, Mangal S, Padhiyar N, Mehata JP, Yadav BS. Evaluvation of immunization Coverage In Urban Slums in Jamnagar. Indian J community Med. 2006;31(4) 300-3001
Nirupam S, Chandra R, Shrivastav VK Sex bias in immunization coverage in urban area of UP. Indian Pediar.1910;27(4):388-4.
Bhola N, Singh JV, Shally A, Vidya B, Vishwajeet K, Singh SK. KAP Study on Immunization of Children in a City of North India. Journal of Health and Allied Sciences.2008;7(1):1-6.
Devivanayagam N, Nedunchelian K, Ashok TP, Mala N. Reasons for Partial /non Immunization With Oral Polio /Triple Antegen Umong Children Under Five Year.Pediatrics.1992;29:1347-1351.
Tushar P, Niraj P. Why infant Miss Vaccination During Routine Immunization Session? Study in a Rural Area of Anand District, Gujrat. Indian Journal of Public Health.2011; 55(4):321-32.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241515EnglishN2013August17HealthcareCADAVERIC STUDY OF ARTERIAL PATTERN OF CAECUM AND VERMIFORM APPENDIX - RESEARCH ARTICLE
English7375Sivanageswara Rao Sundara SettyEnglish Raja Sekhar KatikireddiEnglishAim: Knowledge of normal and abnormal arterial supply of the caecum and appendix is very important to surgeons to perform the abdominal operations. The present study was carried out to know the arterial pattern of caecum and appendix. Materials and methods: The study was done on total number of 80 specimens, 30 were adult cadavers and 50 foetuses. Results: In all adult and foetal specimens, the ileo colic artery was arising from right side of superior mesenteric artery, anterior and posterior caecal arteries were arising from inferior division of ileo colic artery. Single Appendicular artery was arising from inferior division of ileo colic artery in all specimens expect one foetuse, which seen accessory appendicular artery. Conclusion: In the present cadaveric study observed majority normal pattern of arterial supply of caecum and appendix except one accessory appendicular artery observed in foetuse.
EnglishVermiform Appendix, Fotuses, Appendicular arteryINTRODUCTION
The caecum is a large blind sac which seen in the right iliac fossa, proximal to ascending colon. Vermiform appendix is narrow tube like structure which arises on posterio medial side of caecum at the level of the ileal opening. The inferior division of the ileocolic artery is the source of blood supply to the caecum and appendix, which arises from the right side of the superior mesenteric artery, branch from the abdominal aorta. Anterior and posterior caecal arteries are branches of inferior division of the ileocolic artery which supply the caecum. The appendix is supplied by appendicular artery which is usually branch from the inferior division of iliocolic artery [1].
METERIALS AND METHODS
The present work was carried out to study the pattern of arterial supply of caecum and appendix in human cadavers and fetuses. The total number of specimens studied was 80, out of this 30 were adult cadavers (male and female) and 50 were fetuses (male and female). The specimens were collected from department of anatomy and Gynecology and obstetrics, Guntur and Bhaskar medical colleges, Andra Pradesh, India. The cadavers and fetuses were preserved by injected preservative fluids. Dissected the specimens by giving the vertical incision from xiphisternum to pubic symphysis, later separated the peritoneum and traced the superior mesenteric artery and ilio colic artery, anterior and posterior caecal arteries, then appendicular artery in meso appendex.
RESULTS
The arterial supply of caecum and appendex was studied in detail. In all adult and foetal specimens iliocolic artery was arising from right side of superior mesenteric artery. Anterior and posterior caecal arteries were originated from inferior division of iliocolic artery (Figure: 01). All 30 adult and 49 foetal specimens were noticed single Appendicular artery which arising from inferior division of iliocolic artery except one foetal specimen observed accessory Appendicular artery along with main artery, which arising from inferior division of iliocolic artery (Figure: 02).
DISCUSSION
Skawina studied the vermiform appendix in human fetuses, observed that in most of the cases vermiform appendix is supplied by single branch, which arising from ileo colic artery [2]. According to Shahand Shah, the appendix received two branches from either the anterior or posterior caecal artery or one branch from each of these in 30% of cases [3]. According to Arindom Banergy studies on 25 specimens, in all cases caecum was supplied by ilio colic artery which arises from right side of superior mesenteric artery and out of 25 cases 23 apendixes were supplied by single appendicular artery and 2 cases supplied by accessory appendicular artery [4]. Beaton et al studied 200 specimens, observed that 48.5 % of cases the main appendicular artery arose from the ileocolic artery, from the ileal branch 35 % and in 5 % from the posterior caecal branch of the ileocolic artery [5]. Kelly and Hurdon noticed that, 66.0% of cases, the main appendicular artery supplied distal three-quarters of the appendix, but proximal fourth of appendix was supplied by accessory appendicular artery [6]. According to Schaeffer, the main appendicular artery and an accessory artery, both were branches arise from the posterior caecal branch of the ileocolic artery [7]. Bruce [8], Koster [9] observed that appendix was supplied by a single appendicular artery.
CONCLUSION
Knowledge of the accessory appendicular artery and its course is important for surgeons while performing the laparoscopic surgeries to avoid damage of them and prevent the hemorrhage. This kind of arterial variations may also misguide the surgeon while ligating the appendicular artery especially in appendicectomy.
ACKNOWLEDGEMENTS
I wish to express that, I am greatful to my teachers Dr. K.Anasuya. Professor, Dr. K. Krupadhanam. Professor, Dr. K.V. Vijaya Saradhi. Professor and HOD and previous authors, publishers, editors of all of those articles, journals and books from where the literature of this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=1210http://ijcrr.com/article_html.php?did=1210
Susan standring. Gray’s Anatomy. Anatomical basis of clinical practice. 39th ed. Churchill Livingstone, 2005; 1189-1190.
Pitynski K, Skawina A, Gorczyca J, Kitlinski M, Kitlinski Z. Arterial vascularization of the vermiform appendix in human fetus. Folia Morphol (Warsz). 1992; 51: 159–164.
Shah MA, Shah M. The arterial supply of the vermiform appendix. Anat Rec. 1946; 95: 457–460.
Arindom Banergy, Anil kumar, Arunabha Tapadar, M Prany. Morphological variations in the Anatomy of caecum and appendix- A cadaveric Study. National journal of clinical Anatomy. 2012; 1: 30-35.
Beaton, Anson, Swigart, Johnson. Quoted by B. J. Anson and W. G. Maddock in Callender's. Surgical Anatomy. Philadelphia: Saunders. 953; 3 ed: 478.
Kelly, H. Aand Hurdon, E. The Vermiform Appendix and its Diseases. Philadelphia:W. B. Saunders. 1905; 189.
Schaeffer, W. J. Morris, Human Anatomy. Toronto Blakiston.1953; 11th ed: 709.
Bruce J, Walmsley R, Ross JA. Manual of Surgical Anatomy. Edinburgh, London, E and S Livingstone. 1964; 377.
Koster H, Weintrob M. The blood supply of appendix. Arch Surg. 1928; 17: 577–586
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241515EnglishN2013August17HealthcareCHANGING MICROBIOLOGICAL TRENDS IN CASES OF CHRONIC SUPPURATIVE OTITIS MEDIA PATIENTS
English7681Bansal SulabhEnglish Ojha TarunEnglish Kumar SureshEnglish Singhal AmitEnglish Vyas PratibhaEnglishBackground: Chronic Suppurative Otitis Media (CSOM) is a common infectious chronic ear disease in India.The present study was aimed to identify bacterial isolates associated with CSOM and their Antibiogram in patients attending ENT OPD of Mahatma Gandhi Medical College & Hospital, Jaipur. Materials and Methods: Samples were taken from 190 patients (both male and female) in all age groups during the period of Jan 2012 to June 2012 suffering from CSOM and having active ear discharge. Their Gram staining, Direct microscopy with KOH, Culture sensitivity, and Biochemical tests were carried out to identify the organisms and to know their sensitivity pattern. Drug susceptibility testing was conducted using a modified Kirby Bauer disk diffusion method. Results: The most common causal organisms isolated were Pseudomonas aeruginosa 80 (45.9%) followed by Staphylococcus aureus 46 (26.4%) amongst the 167 (87.9%) bacterial isolates (including 10 isolates of MRSA). Fungi accounted for 7 (3.7%) of the isolates while 16 (8.4%) were culture negative isolates. The antimicrobial profile of the major isolates i.e. Pseudomonas and Staph. Aureus revealed maximum sensitivity to Piperacillin / Tazobactum against 90% isolates. Conclusion: Pseudomonas aeruginosa is the most common isolate followed by Staphylococcus aureus. Both of these are sensitive to Piperacillin / Tazobactum. The study of microbial pattern and their antibiotic sensitivity determines the prevalent bacterial organisms causing CSOM in local area and to start empirical and more targeted treatment of otitis media and its complications for successful outcome, thus to prevent the emergence of resistant strains.
EnglishChronic Suppurative Otitis Media, Ear Discharge, Methicillin – resistant Stphylococcus aureus, Microbiology, SensitivityINTRODUCTION
Otitis Media is and inflammation of the middle ear cleft irrespective of etiology and pathogenesis. Sources of infection in Otitis Media is mainly dependent on the route by which the infection reaches the middle ear and the chief route by which this occurs is the Eustachian Tube.(1) Causes in such cases is nasopharyngeal disease and in children it is usually the adenoids. The causative infection may be in the nose, paranasal sinuses, or in the oropharynx. (2)
Chronic Suppurative Otitis Media (CSOM) is a persistent disease of middle ear, which is capable
of causing severe destruction and sequelae with manifestation of Deafness, Discharge and Perforation .(3)Disease is more common in children belonging to lower socioeconomic group.(3) Most common organism found in CSOM are Pseudomonas aeruginosa, Staphylococcus aureus, Proteus mirabilis, Klebsiella pneumonae, E.coli, Aspergillus sps. and Candida.(4)The disease is mainly classified into two types: Mucosal and Squamosal type depending upon whether the disease process affects the Pars tensa or the Pars flaccida of the tympanic membrane.(5)
However, due to increased and irrational use of wide?spectrum antibiotics, the resistance in the bacterial isolates has become very common along with emergence of multiple strains of bacteria. (6) Changes in the Microbiological flora following the use of sophisticated synthetic Antibiotics have increased the relevance of the reappraisal of the modern day flora in CSOM and their in vitro antibiotic sensitivity pattern is very important for the clinician to plan a general outline of Treatment. (7)
The present series deals with study of the Bacterial flora in cases of CSOM who attended the ENT Department OPD with complaints of chronically discharging ear.
MATERIAL METHODS
The study was carried out at ENT Outdoors of Mahatma Gandhi Medical College and Hospital, Jaipur from Jan 2012 to June 2012. A total of 190 patients of all age groups and both genders were included. Only those were selected who had not taken any treatment either systemic or local in the form of eardrops for the last seven days. The ear discharge from each diseased ear taken on a sterile swab in ENT OPD and sent to the Microbiology Department for their Gram staining, Direct microscopy with KOH, Culture sensitivity, and Culture Sensitivity testing. Swabs were taken from the deeper part of External Auditory Canal were inoculated on MacConkey’s, Blood, Chocolate and Sabouraud’s Dextrose agar and incubated aerobically at 37 degree for 24-48 hrs. Antimicrobial susceptibility testing was performed on Muller Hilton agar using the modified Kirby Bauer disc diffusion method. The antibiotics tested were: Amikacin, Gentamycin, Ciprofloxacin, Ceftazidime, Ceftriaxone, Imipenem, Augmentin (Amoxycillin/Clavulanic Acid), Tazocin (Tazobactum/Piperacillin), Levofloxacin, Vancomycin.
RESULTS
The study included 190 patients in the Age ranged from 6 month to 80 Years, with Peak age group being 15-30 years was noted in 108 cases (56.84 %).(Table 1) The male and female distribution was 62.1 % and 37.9 % respectively .Out of the 190 swabs, 174 showed growth giving an Isolation Rate of 91.6 %. The analysis by sex and age did not show a predominance of any particular group of patients related to any aetiological agents. Result of sensitivity pattern of organisms isolated from Chronic Suppurative Otitis Media patients are showen in table no 2. TaZobactum / Piperacillin-TZ (80%), Levofloxacin - LEV (73.1%) and Ceftazidime - CAZ (72.9 %) showed maximum activity to most of isolated organisms.
In 190 patients, mild Degree of hearing loss were found in 71 (37.%) patients, moderate Degree of hearing loss in 86 patients (45.2 %), while in 33 patients (45.7 %) sever to profound of hearing loss were observed.(Table 3).
DISCUSSION
Chronic Suppurative Otitis Media (CSOM) is a major public-health problem, and India is one of the countries with high-prevalence where urgent attention is needed.(8) The otologist and paediatrician are commonly observing CSOM and its various complications such as facial palsy, unalterable local destruction of middle ear structures, serious intracranial and extracranial complications. (8) Early diagnosis of etiological microbes can avoid these complications, however it also facilitate rapid and successful treatment.
High prevalence of culture positive cases of CSOM (91.18%) was seen in the present study. We found that the CSOM was more prevalent in first and second decade of life and accounted for 51% of the cases. This finding agrees well with the observations made by other researchers. (9,10) Children are more prone to upper respiratory tract infections (URTIs). Furthermore, cold weather pre-disposes children to URTI. Both of these two reasons contribute well to high-prevalence of CSOM in children. (11)
The male is to female ratio was found to be 1.2:1. Cases of CSOM were more common in females than in males.This study was comparable with the outcome of few authors (10,12)nd in difference with other researchers.(13)
Pseudomonas aeruginosa the most common isolate (45.9%) in our study was 100% sensitive to Tazocin (Tazobactum/Piperacillin), 92 % to Imipanum and 88.7% to Levofloxacin. P. aeruginosa resistance against Quinolones may be due to irrational use, wrong dosage, easy accessibility and developing enzymatic resistance of organism against Quinolones.(14) Similar differences have been noted in literature regarding activity of Aminoglycosides against P. aeruginosa.(14)Pseudomonas, however, is the predominant cause of CSOM in tropical region does not usually inhabit the upper respiratory tract, its presence in the middle-ear cannot be ascribed to an invasion through Eustacian Tube other researches from India,(9) and Pakistan(10) demonstrated similar trends as Pseudomonas was the most prevalent organism and this could be due to regional and effect of climatic difference may results the variation in micro-organisms. Staphylococcus aureus (other than MRSA) the second most common isolate (20.6 %) in our study was 100% sensitive to Tazocin (Tazobactum/Piperacillin), 72.2% to Levofloxacin and 52% to Amikacin. The susceptibility pattern of Staphylococcus aureus found in our study against most of the antibiotics is almost consistent with the one reported in few other local studies this observation was in line with diversity of microbial flora of CSOM infection in colder regions as reported in studies by Ettehad, et al. (16) from Iran (31.15%) and Singh, et al.(17) from India (36%).
Coliforms including Proteus and Escherichia coli were isolated from 8.0% and 6.8% cases respectively, and these findings were tandem to the reports by Mansoor, et al. (10) who reported the same to be 8% and 4% .
The most commonly found fungi in CSOM are Candida species and Aspergillus species. (18) In the present study, fungal etiology was found in 7 (12.25%) cases .In a study from Haryana, India, fungal etiology was found in 15% of cases. (19) Fungal infections of the middle-ear are common as fungi thrive well in moist pus.
Antimicrobial susceptibility test (AST) was carried out for all the aerobic isolates (except for 10 isolates of Diptheroids). AK was found to be most effective drug followed by CAX, GEN and ciprofloxacin (CIP). These findings were parallel to the reports by other authors. (10,19,20) For the antibiotics commonly available as topical ear drops, GEN, and CIP showed good activity for most of the commonly isolated organism and can be used as effective first line topical antibiotic in the treatment of CSOM. Studies have revealed that quinolones like CIP are safe and effective particularly against S. aureus and Pseudomonas aeruginosa.(21,22)
Isolation of various aerobic, anaerobic, and fungal isolates shows that different conditions of CSOM could be differentiated on microbiological grounds. Thus, for better management of CSOM, microbial classification of infection as well as drug sensitivity test of organism recovered are essential for making appropriate decision of antimicrobials that will effectively eradicate the pathogen.
CONCLUSION
Pseudomonas aeruginosa is the most common isolate followed by Staphlococcus aureus from the culture specimens of Chronic Otitis Media. Both of these are sensitive to Tazobactum/Piperacillin, except MRSA. Pseudomonas aeruginosa was 100% sensitive to Tazobactum/Piperacillin combination. Pseudomonas is increasingly becoming more resistant to the common drugs like Quinolones. Vancomycin is 100% effective against MRSA.
Therefore, evaluation of microbiological pattern and their Antibiotic Sensitivity pattern in local area become helpful in prescribing empirical antibiotics for successful treatment of Otitis Media and thus minimizing its complications and emergence of resistance strains.
Englishhttp://ijcrr.com/abstract.php?article_id=1211http://ijcrr.com/article_html.php?did=1211
Ahmadaa, Usman J, Hashim R. Isolates from CSOM, their antimicrobial sensitivity. Armed Forces Med J, 1999, 82-5.
Vartianien E. Effect of aerobic bacteriology on clinical presentation and treatment results of CSOM. J Laryngo-Oto, 1996, 315-8.
Altuntas A, Aslam A, Eren A. Susceptibility of microorganisms isolated from CSOM to Ciprofloxacin. Eur Arch Otorhino Laryngology, 1996, 364 -6.
Jakimovska F, Cakarm, Lazareveskia, et.al. CSOM –Microbiological findings. Balkan j otolneuro –otol, 2002, 104-6.
A Mathur, M Bradoora. Bacteriology of CSOM without cholesteatoma. Indian Practitioner Journal, 2002, 426-28.
Sabella C. Management of otorrhoea in infants and children. Paed infectious dis J, 2000, 1007-8.
Indudharan R, Haq JA, Aiyar S. Antibiotics in chronic suppurative otitis media: A bacteriologic study. Ann OtolRhinolLaryngol1999;108:440-5.
Acuin J. Global burden of disease due to chronic suppurative otitis media: Disease, deafness, deaths and DALYs Chronic Suppurative Otitis Media-Burden of Illness and Management Options. Geneva: World Health Organisation; 2004. p. 9-23. (Accessed August 29, 2012, at http://www.who.int/pbd/deafness/activities/hearing_care/otitis_media.pdf).
Shyamla R, Reddy SP. The study of bacteriological agents of chronic suppurative otitis media-aerobic culture and evaluation. J Microbiol Biotechnol Res 2012;2:152-62.
Mansoor T, Musani MA, Khalid G, Kamal M. Pseudomonas aeruginosa in chronic suppurative otitis media: Sensitivity spectrum against various antibiotics in Karachi. J Ayub Med Coll Abbottabad 2009;21:120-3.
Gordon MA, Grunstein E, Burton WB. The effect of the season on otitis media with effusion resolution rates in the New York Metropolitan area. Int J Pediatr Otorhinolaryngol 2004;68:191-5.
Loy AH, Tan AL, Lu PK. Microbiology of chronic suppurative otitis media in Singapore. Singapore Med J 2002;43:296-9.
Poorey VK, Lyer A. Study of bacterial flora in csom and its clinical significance. Indian J Otolaryngol Head Neck Surg 2002;54:91-5.
Mirza IA, Ali L, Arshad M. Microbiology of chronic suppurative otitis media-experience at Bahawalpur. Pak Armed Forces Med J 2008; 58:372-6.
Vishvanath S, Mukhopadhyay C, Prakash R, Pillai S, Pujary K, Pujary P. Chronic suppurative otitis media: Optimizing initial antibiotic therapy in a tertiary care setup. Indian J Otolaryngol Head Neck Surg 2012;64:285-9.
Ettehad GH, Refahi S, Nemmati A, Pirzadeh A, Daryani A. Microbial and antimicrobial susceptibility patterns from patients with chronic otitis media in Ardebil. Int J Trop Med 2006;1:62-5.
Singh AH, Basu R, Venkatesh A. Aerobic bacteriology of chronic suppurative otitis media in Rajahmundry. Biol Med 2012;4:73-9.
Ibekwe AO, al Shareef Z, Benayam A. Anaerobes and fungi in chronic suppurative otitis media. Ann Otol Rhinol Laryngol 1997;106:649-52.
Kumar H, Seth S. Bacterial and fungal study of 100 cases of chronic suppurative otitis media. J Clin Diagn Res 2011;5:1224-7
Gulati SK. Investigative profile in patients of chronic suppurative otitis media. Indian J Otol 1997;3:59-62.
Kardar AA, Usman M, Tirmizi S. Topical quinolones versus topical aminoglycosides in the medical management of chronic suppurative otitis media: A comparative trial. J Sur Pak 2003;8:6-9.
Macfadyen CA, Acuin JM, Gamble C. Topical antibiotics without steroids for chronically discharging ears with underlying eardrum perforations. Cochrane Database Syst Rev 2005;4:CD004618.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241515EnglishN2013August17HealthcareSTUDY OF SERUM LEVELS OF URIC ACID IN CORONARY ARTERY DISEASE AND DIABETES MELLITUS
English8286Suvarna T. JadhavEnglish Ajit V. SontakkeEnglish Bipin M. TiwaleEnglishCoronary Artery Disease (CAD) leads to Angina and Myocardial Infarction (MI). Premature mortality on Coronary Heart Disease (CHD) is more common in diabetic atherosclerosis. In the present study serum Uric Acid level was estimated in patients of CAD with DM, CAD without DM, DM without CAD and CAD with DM and other risk factors compared to healthy normal subjects. The level of Uric Acid was significantly increased in all four groups of patients as compared to control group. Conclusion: On the basis of our results we conclude that high circulating uric acid levels may be indicator that the body is trying to protect itself from harmful effects of free radicals by increasing the production of endogenous antioxidants like uric acid. Hence uric acid may act as non conventional marker to predict the risk of Coronary Vascular Disease (CVD) complication in Diabetes Mellitus (DM).
EnglishCoronary Artery Disease, Diabetes Mellitus, and Uric Acid.
INTRODUCTION
Coronary Artery Disease (CAD) leads to Angina and Myocardial Infarction (MI). Premature mortality on Coronary Heart Disease (CHD) is more common in diabetic atherosclerosis (1).
Cardiovascular diseases (CVD), comprising coronary heart disease (CHD) are currently the leading cause of death globally, accounting for 21.9 per cent of total deaths, and are projected to increase to 26.3 per cent by 2030. The factors that coalesce to increase the risk of developing atherosclerotic Coronary Heart Diseases were demonstrated in Framingham in the mid - 20th century and have subsequently been shown to be pervasive across ethnicities and regions of the world. These are not new risks, but the ubiquity of smoking, dyslipidaemia, obesity, diabetes, and hypertension has been gradually escalating, and is thought to be the driving influence behind the epidemic of heart disease faced today (2).
Of the risk factors, diabetes, and its predominant form, type 2 diabetes mellitus (T2DM), has a distinctive association with Coronary Heart Disease. Those with diabetes have two- to four-fold higher risk of developing coronary disease than people without diabetes, and cardiovascular diseases accounts for an overwhelming 65-75 per cent of deaths in people with diabetes. More significantly, however, the age- and sex-adjusted mortality risk in diabetic patients without pre-existing coronary artery disease was found to be equal to that of non-diabetic individuals with prior myocardial infarction (MI). These remarkable findings regarding higher risk of mortality have led to suspicion that common precursors predispose to diabetes and Coronary Heart Disease, with subsequent implications that insulin resistance, visceral adiposity, and excess inflammation (2).
However, a great controversy arose as to whether elevated uric acid was an independent risk factor for Coronary Artery Disease or it was merely a marker of co-existing conditions such as hypertension, abdominal obesity, diabetes mellitus, hyperlipidaemia, inflammation, impaired renal function and diuretic treatment (3).
The contradictory data obtained in the studies have been analysed and reviewed by independent research groups. Although different potential mechanisms explaining the associations between high serum uric acid and CAD have been proposed, a well- established pathophysiological link is still missing (4-6).The concentration of uric acid, as well as other risk factors for the development of CAD, is strongly influenced by different genetic factors and lifestyle habits. Traditionally, elevated serum uric acid (SUA) is linked to gout. Recent investigations have shown that there may be a relationship between hyperuricemia, ischemic heart disease and metabolic syndrome, which is characterized by obesity, dyslipidaemia, diabetes and hypertension. Although a direct relationship between Serum uric acid and cardiovascular disease is difficult to prove due to confounding factors like hypertension and diabetes, Strasak et al have recently demonstrated that Serum uric acid is an independent predictor of mortality due to congestive heart failure and stroke( 7).
MATERIALS AND METHODS
The present study was carried out in the Department of Biochemistry, Dr. D. Y. Patil Education Society’s Medical College and Hospital, Kolhapur. This study was approved by Institutional ethical committee.
In this study a total number of 200 subjects between age 40 yrs to 60 yrs matched with age and sex were included. They were distributed in controls and four study groups.
Controls
Normal Healthy controls- 100 cases
Group- I
Patients with CAD and DM- 25 cases
Group- II
Patients with CAD – 25 cases
Group- III
Patients with DM – 25 cases
Group- IV
Patients with CAD and DM + Other risk factors- 25 cases
All controls were from the same age groups as patients, not showing any clinical signs and symptoms suggestive of CAD. They were having normal blood pressure (BP), ECG, blood sugar level and apparently no other cardiac risk factors. Group-I contained patients diagnosed to have CAD (based on angiography) with confirmed DM and were receiving treatment for the same. Group- II contained patients with CAD but no DM. Group-III contained Type II DM patients receiving treatment for DM, and were not showing any complications of DM, and had normal ECG and BP. Group- IV contained patients with CAD and DM along with other risk factors (such as smoking, hypertension, family history of Coronary Artery Diseases, obesity etc.)
Sample collection-3ml of venous blood sample was collected in plain bulb and was allowed to clot. Serum was separated by taking necessary precautions to avoid haemolysis. This serum was
Used for the estimation of uric acid. Uric acid was estimated of Dynamic extended stability with lipid clearing agent modified Trinder method, End point (8).
Inclusion Criteria: A) Control group: 100 age matched healthy subjects were included in the control group. The subjects were selected after screening for any prior history of cardiovascular disease or any other disease. B) Coronary Artery Disease Patients: Angiographically proven patients by the cardiologists with relevant coronary artery disease showing greater than 50% stenoses in at least one major coronary artery at the time of diagnostic catheterization were enrolled in this study. Each subject was screened by a complete history, physical examination and laboratory analysis. C) Diabetic Patients with Coronary Artery Disease: Clinically diagnosed patients whose fasting blood glucose level was above 125 mg/dl.
Exclusion Criteria:-The patients with hemodynamically significant valvular heart disease undergoing catheterization, surgery or trauma, known cardiomyopathy, known cancer, abnormal hepatic and renal function, past or concurrent history of any disease and taking any medication that could influence the oxidant and antioxidant status and endothelial functions were excluded from the study group.
RESULT-
Showing the levels of Uric Acid in (mg/dl) in control subjects and different study groups
Groups
Uric Acid (mg/dl)
Control
4.6 + 2.43
Group I (CAD with DM )
6.0 + 2.7 #
Group II (CAD with out DM )
6.4 + 3.06 #
Group III (DM with out CAD )
5.2 + 3.04 ♣ ♦
Group IV (CAD with DM with other risk factors)
6.8 + 2.62 * ♠ $
Values are expressed as mean + SD
* PEnglishhttp://ijcrr.com/abstract.php?article_id=1212http://ijcrr.com/article_html.php?did=1212
V.K.Bali, Sandeep Seth. Management of coronary Artery Disease in patients with Diabetes Mellitus Department of Cardiology ‘All India Institute of Medical Sciences, New Delhi. Indian Heart Journal.53:147; 2001, 157-162.
Mohammed K Ali, K.M. Venket Narayan, Nikhil Tandon. Diabetes and Coronary Heart Disease: Current Perspectives. Indian J Med Res. 2010 November; 132(5): 584-597.
Alderman, M. H. Uric acid and cardiovascular risk. Curr Opinion Pharmacol, 2002, 2, 126 – 130.
Johnson, R. J., Kang, D. H, Feig, D. Is there a pathogenetic role for uric acid in hypertension and cardiovascular and renal disease ? Hypertension 2003, 41, 1183 – 1190.
Barker J, Drishanan. E., Chen, L, Schumacher, H. R. Serum uric acid and cardiovascular disease.Recent developments, and where do they leave us? Am. J. Med., 2005, 118, 816 – 826.
Hayden, M. R, Tyagi S. C. Uric acid; A new look at an old risk marker for Cardiovascular disease, metabolic Syndrome, and type 2 diabetes mellitus: The Urate redox shuttle. Nutr. Metab (Lond.), 2004, 1 – 10.
Strasak A, Ruttmann E, Brant L. Serum Uric Acid Risk of Cardiovascular Mortality: A Prospective Long – Term study of 83 683austrian Men. (E pub. ahead of print).
Shepard M.D, Mezzachi R.D, Clin Biochem Revs, 1983 ; 4; 61 – 7
Mohan M, Halkin H, Karasik A, Lusky A. Elevated serum uric acid. Facet of hyperinsulinemia. Diabetologia, 1987; 30; 713 – 718.
Facchini F, Chen YDI, Hollenbeek CB, Reaven G M. Relationship between resistances of insulin mediated glucose –uptake, urinary uric acid clearance and plasma uric acid concentration. JAMA, 1991; 266: 3008 – 3011.
Brand F N, Mc Gee Dl, Kannel WB, Stokes J, Castgelli WB Hyperuricemia as a risk factor of coronary heart disease: The Framingham study. Am J Epidemiol 1985; 121, 11 – 18.
Bengtsson C, Lapidus L, Stendahl C, Waldenstorm J. Hyperuricaemia and risk of cardiovascular disease and overall death: a 12 year follow up of participants in the population study of wimeni Gothenburg, Sweden, Acta Med Scand 1988; 224: 549 – 555.
Levine W, Dyer A.R, Shekelle R.B, Schoengerger J.A, Stamler J. Serum uric acid and 11.5 year mortality of middle – aged women: findings of the Chicago Hest Association Detection Project in Industry.Clin Epidmiol., 1989; 42 : 257 – 267.
Zavaroni I, Bonora E, Pagliara M, Dall’ Aglio E, Luchetti L, Buonano G, Bonati PA, Risk factors for coronary artery disease in healthy persons with hyperinsulinemia and normal glucose tolerance. N Engl J Med., 1989; 320: 702 – 706.
Lee J. Sparrow D, Vokonas P.S, Landsberg L, Weiss S.T. Uric acid and coronary heart disease risk: evidence for a role of uric acid I the obesity – insulin resistance syndrome: the Normative Aging Study. Am J Epidemiol. 1995; 142: 288 – 294.
Gertler M. M., Garn S. M. and Levine S. A. Serum Uric acid in relation to age and hysique in health and in coronary heart disease. Ann Intern. Med, 1951, 34, 1421 – 1431.
Duk- Heekang. Potential Role of Uric Acid as a Risk Factor for Cardiovascular Disease. Korean J Intern med. 2010 March; 25(1): 18-20.
Becker BF, Towards the physiological func, 1993; 14: 615 – 631.
Baynes J W Role of oxidative stress in the development of complications in Diabetes mellitus. Diabetes, 1991; 40: 405 – 412.
Suvarna C, Dean RT, May J, Stocker R. Human atherosclerotic plaque contains both oxidized lipids and relatively large amounts of alpha – tocopherol and ascorbate. Arterioscler ThrombVasc Biol, 1995; 15: 1616 – 1624.
Fuster V, Badimon L, Badimon JJ, Chesebro JH. The pathogenesis of coronary artery disease and the acute coronary syndromes. N Engl J Med, 1992; 326: 310 – 318.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241515EnglishN2013August17HealthcareGLOBAL HEALTH AND INFANT MORTALITY: APPLICATION OF VERBAL AUTOPSY TOOL TO CATEGORIZE INFANT DEATHS, ASCERTAIN THEIR CAUSES AND IDENTIFY THE GAPS IN HEALTH MANAGEMENT INFORMATION SYSTEM IN INDIA
English8794Vijay KumarEnglish B.S. GargEnglishObjective: To see the usefulness of verbal autopsy and in assessing the cause of deaths among infants and identify gaps in reporting system in 4 PHCs in India. Methodology: The study incorporated all the infant deaths, which occurred in a one-year period from 2nd Jan 2004 to 1st Jan 2005 in Yavatmal district in Maharashtra. This data was compared with the corresponding district data and the gaps in reporting were identified site-wise. Results: Medical certification of cause of death was done in only 12% of deaths. Under reporting was more than 50% in 2 PHCs and the IMR was found to be 59 per 1000 live births in contrast to 38 per 1000, given by the district authorities. Prematurity and LBW contributed for the 47% deaths during the early neonatal period. In post neonatal period mostly infectious causes like ARI contributed for 35% followed by CNS infections (12%). Majority (73%) of the 90 infant deaths were delivered at home and were attended by unskilled personnel (72%). Overall there were 63% deaths which occurred in the early neonatal period, 13% in late neonatal period and 23% in post neonatal period. Conclusions: Verbal autopsy can be used to give information for the health planners to prioritize health services based on the mortality pattern of an area and for collecting information for action at the local level.
EnglishInfant mortality, low birth weight, Neonatal period, prematurity, verbal autopsyIntroduction
Global health is the health of populations in a global context and transcends the perspectives and concerns of individual nations. In global health, problems that transcend national borders or have a global political and economic impact are often emphasized. Thus, global health is about worldwide improvement of health, reduction of disparities, and protection against global threats that disregard national borders. Information on causes of death is extremely important for policy-making, planning, monitoring and evaluation of health programmes, as well as being necessary for field research, comparisons and epidemic awareness. In developing countries, where most deaths are neither attended by doctors nor medically certified, this crucial information is often incomplete and of poor quality. Since this situation is not likely to change in the near future, there is an urgent need to search for alternative methods of obtaining information on causes of deaths. This is particularly important for childhood deaths, which constitute a major portion of all deaths, and which many intervention programmes are currently attempting to reduce 1.
Specific targets for reducing the infant mortality rate (IMR) have been set by many governments and international organizations .The Millennium Development Goal is to reduce infant mortality rate to 35 per 1000 and under-five mortality to 45 per 1000 live births by 20152.The goal of National Health Policy-2002 is to reduce IMR to 30 per 1000 live births by 20103and the Tenth Plan goal is to reduce IMR to 45 per 1000 live births by 2007 and to 28 per 1000 live births by 2012.4 Since 1996, India’s IMR has stagnated at 72, which is far above the “Health For All” goal set by the government of India of an IMR of 60 per 1000 live births by the year 2000 5. India faces considerable challenge in the vital registration and cause of death (COD) reporting. Overall, about one in two of all births and deaths are registered in India. More reliable medically certified cause of death is available in only about one in 30 of all death
Materials and Methods
The verbal autopsy technique, which involves questioning the family of a dead infant about the features of the child’s final illness provides a means of obtaining information on the cause of death.
We set up a verbal autopsy system in the study areas of 4 health centers where the deaths occurring at the village level are identified by the Anganwadi workers (Dept. of women and child development). They will inform the infant deaths to the Auxiliary nurse midwife (Dept of health and family welfare) who conducts the verbal autopsy and then the deaths will be discussed in detail during the monthly meetings along with the Medical officer and the research investigator. The study was a prospective, observational study, combining both the qualitative and quantitative methods undertaken to find out the causes of infant deaths and to study the feasibility of infant mortality audit at the PHC level.
Duration and Study Site: The study was undertaken in four PHC areas of Dhanora, Waradh, Dahegaon and Mardi of Yavatmal District in 2005. The populations catered to by these PHCs were 22,449, 21,259, 28,530 and 25,494 respectively.
Study subjects
The study incorporated all the infant deaths, which occurred in a one-year period from 2nd Jan 2004 to 1st Jan 2005. This data was compared with the corresponding district data which was available in 2005 and the gaps in reporting were identified site-wise.
Eligibility criteria for inclusion were those which:
1. Qualified to be classified as infant death according to WHO ICD – 10 classifications
2. Deaths must have occurred within these 4 PHC areas.
3. All the deaths occurred in any health facility or en route to a health facility.
4. The deaths must have occurred between the above mentioned period.
Still births and deaths of infant outside the study area were excluded from the study
In the initial phase, consent from appropriate authorities, development of verbal autopsy questionnaire and piloting was done. Training of Anganwadi workers (AWs) for case identification and reporting and Training of ANMs in the art of conducting verbal autopsy was done in next phase. Finally the investigation of the Infant deaths using verbal autopsy was done ensuring quality, checking the Operational feasibility and data was analysed for report writing.
Consent of appropriate authorities
Permission was obtained well in advance prior to the beginning of the study from the appropriate district authorities to train the ANMs at DTO (District Training Office) and to attend the monthly meetings at PHCs. Co-operation with the ICDS and District Health System was ensured. Individual informed consent was taken from the respondents prior to interview.
Development of verbal autopsy questionnaire
Suitable verbal autopsy questionnaire was developed for the Auxiliary Nurse Midwife and LHV (Lady Health Visitor) with the help of standard verbal autopsy by WHO (WHO 1996), the Verbal Autopsy Method and Criteria developed by SEARCH (Hill 1992), Gadchiroli, the Verbal Autopsy Questionnaire used in the SRS (Hill 1999) and the verbal autopsy from the Primary Health Care Management Advancement Programme (PHC MAP) published by Aga Khan Foundation
RESULTS
It was observed that from four health centers in the district, there was underreporting of 17 infant deaths during the year 2003-04. Among the 4 health centers it was found that the under reporting was more than 50% in Dhanora and Dahegaon. The reported IMR for these PHCs are 19 and 25 per 1000 live births respectively but it was found to be 39 and 59 per 1000 live births from the study there by leading to different IMR values from various sources as documented in Table 1.
Out of the total of 90 deaths, 59 (65.6%) were males while 31 (34.4%) were females.
More than three-fourths of the infant deaths 74, (82.2%) were not medically certified
As shown in Figure 1. Out of the total 90 deaths investigated, where age at death was recorded, 57 (63.3%) were early neonatal deaths (0-7 days), 12 (13.3%) were late neonatal deaths (8-28 days) and 21 (23.3%) deaths occurred in the post neonatal period as shown in Table 2
Among the total infant deaths investigated, in 66 (73.3%) cases delivery took place at home. In 23 (25.6%) cases, deliveries were institutional. In 1 (1.1%) case delivery took place during transport. Among the 90 infant deaths, 57 occurred in the early neonatal period and nearly half of the deaths i.e. 47% were contributed by both Prematurity and LBW followed by Asphyxia with 25%which shows the lack of skilled person during delivery as shown in Figure 2.
In contrast to the early neonatal period, in post neonatal period the majority of deaths were contributed mainly by the infectious causes especially acute respiratory infections with 35% followed by CNS infections (12%) as shown in Fig 3. LBW contributes to another 20% of the deaths that occurred in post natal period. It is seen that the deaths due to LBW and Prematurity contributed to 75% of all deaths in the study, whereas it was only around 49% as per the district data. Even though asphyxia contributed to 34%, of the cases, it was under reported as only 10% by management information system of health system.
Discussion
Infant mortality rate (IMR) is considered as one of the most sensitive indicators of health status and development of a community5. Each year, a total of 25 million infants are born in India and at the present neonatal mortality rate of 45 per 1000 live-births. 6 The objective of RCH – II Programme and the Tenth Plan is to decrease the prevailing IMR to 45/1000 by 2007 and 28/1000 live births by 20127.
The choice of Respondent is crucial for the accuracy of information. In the LSHTM workshop8, it was suggested that the interviewer should ask which members from the household were present at the time of death, were close to the deceased and are available for the interview. In the present study, out of the 90 infant deaths investigated, in the majority of deaths (66, 73.3%) the mother was the respondent while the father was the respondent in 18 (20.0%) deaths. The same is also supported by the findings of a previous study by Kalter et al, 1990 9 involving verbal autopsy. Though their methodology was quite different, Garrene and Fontaine, 1990 10 also found that mothers could provide accurate diagnostic information upto one year after the death of the child. In a review of 35 studies, which had used verbal autopsy for assigning causes of death, Chandramohan et al,1994 11 concluded that mothers are the principal respondents for childhood deaths.
In case of the 57 (63.3%) early neonatal deaths, 41 (72%) were males and 16 (28.1%) were females. Among 21 (23.3%) post neonatal deaths, 12 (57.1%) deaths were males while 9 (42.9%) were females. But when the total mortality rate is split into neonatal and post neonatal deaths, neonatal death rate is higher for males than for females while post neonatal death rate is higher for female infants than male infants12. The reverse findings in the study area could be attributed to the fact that gender bias is not yet as severe a problem as in the other parts of the country as depicted by the relatively better sex ratio of Maharashtra State (933 females per 1000 males)13.
Out of the 90 deaths investigated, more than half of the infant deaths (69, 76.7%) occurred at home. This is consistent with the findings of previous studies in rural areas which have demonstrated the unwillingness of parents to move ill infants from home because of traditional beliefs and practical difficulties (14-16) due to which most of the neonatal deaths occur at home.
Out of the 90 deaths investigated, more than three-fourths of the infant deaths (74, 82.2%) were not medically certified. This is consistent with the reported low levels of medical certification in the country.(17)The low levels of medical certification along with the low registration of childhood deaths in Maharashtra (28.2% in age group 0 – 4 years) and other states in India (18) results in the total lack of good quality data on infant deaths.
The encouraging aspect of the study was the identification of Low Birth Weight (LBW) and Neonatal Sepsis as important causes of neonatal and infant deaths. LBW was identified as a cause of death in 47.77% of infant deaths and 52.17% of neonatal deaths. This is in concordance with the high incidence of low birth weight reported in developing countries like India (26% of all live births).(22)
Neonatal sepsis was identified as a cause of death in 26.08% of neonatal deaths. This was consistent with the findings from various studies in India, which have shown that Neonatal sepsis is responsible for 20-27.5% of neonatal deaths.(23-25)The algorithm used in the present study was adopted from the verbal autopsy questionnaire used at SEARCH, Gadchiroli (26)
In the light of the above, it is clear that verbal autopsy conducted by ANMs can serve as a viable alternative to improve the infant mortality data. A study in Chandigarh (19) trained field assistants (PHC worker equivalent) with high school education to investigate infant deaths using verbal autopsy technique. In the study by Kalter et al. 1990,(20)mothers were interviewed by professional interviewers who were Filipino women with undergraduate college degrees. For studies involved in verbal autopsies of adult deaths, workers with higher levels of education were used. Chandramohan et al. 1998(21) utilized interviewers with at least 12 years of formal education. In the present study, the ANMs conducted the verbal autopsy and also assigned the causes of death, which were later reviewed by the PHC Medical Officer.
RECOMMENDATIONS
Health Infrastructure and Medicines: To provide necessary equipment at the health centers like the essential medicines, equipment, vaccines, resuscitation kits, delivery kits etc to promote safe deliveries and prevent the asphyxial deaths.
Human resources: Most of the sub centers and primary health centers are over burdened with work and they are understaffed. Good perinatal care will be achieved only if these centers are staffed optimally.
Capacity building: Capacity building of staff members at the primary and secondary referral levels by providing skills and knowledge regarding the risk concept and appropriate technologies to promote methodology of IMNCI.
Community Participation: To organize village referral teams with the involvement of community members, to establish community funds to pay for emergency referrals and transport that could be made available in an emergency.
Leadership and Strengthening of Referral Services: Regular supervisory visits of the referral level staff members will support the TBAs, ANMs and mothers in caring for the newborns.
Intersectoral Collaboration: Collaboration between sectors like Health, Women and Child Development is essential for complete reporting of infant deaths.
Health Education: Provide health education to families, monitor the neonates for high risk or sicknesses and improve the health seeking behaviour, and increase utilization of health facilities
CONCLUSIONS
It was seen that the verbal autopsy can be used not only to give information for the health planners to prioritize health services based on the mortality pattern of an area but also the health workers can get a feedback of the information that they have collected. So VA can be used for collecting information for action at the local level.
The results suggest that there should be a shift in child survival programmes to give greater emphasis to maternal and neonatal health, in particular to safe delivery and cord care. In conclusion, the use of the verbal autopsy tool by health workers to find out the cause of death is feasible. It can also provide information for local action by health authorities to reduce the infant mortality rate, according to area-specific causes of death.
ACKNOWLEDGEMENTS
The Researcher is grateful to the Chief Executive Officer of Yavatmal district, PHC staff of Dhanora, Waradh, Dahegaon and Mardi centers in particular the ANMs for taking part in the study so graciously and thanks all the participants in this study. 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.
Conflict of interest: The Authors declare that there is no conflict of interest
Source of Funding: This research study was supported by Department of Community Medicine, Mahatma Gandhi Institute of Medical Sciences.
Ethical clearance: The study got ethical clearance from the College Ethical Board and all the participants were included only after their consent to participate in this research as mentioned in methodology section.
Englishhttp://ijcrr.com/abstract.php?article_id=1213http://ijcrr.com/article_html.php?did=1213
Bang A.T, Bang R.A and the SEARCH team, Diagnosis of causes of childhood deaths in developing countries by verbal autopsy: suggested criteria. Bulletin of WHO 70(4) : 499-507 (1992)
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Jha. P: Reliable Mortality Data : A powerful tool for public health; The National Medical Journal of India Vol 14; No.3 (2001)
Annual Report – Survey of Causes of Death (Rural). New Delhi: Vital Statistics Division, Office of the Registrar General of India, Ministry of Home Affairs, 1992.
LSHTM. Verbal Autopsy Workshop; verbal autopsy tools for adult deaths. Workshop report. London: London School of Hygiene and Tropical Medicine, 1993.
Kalter HD, Gray RH, Black RE,et al. Validation of postmortem interviews to ascertain selected causes of deaths in children. International Journal of Epidemiology 1990: 19:380-386.
Garenne M, Fontaine O. Assessing probable causes of death using standardized questionnaire: A study in rural Senegal. In: Palloni A,ed. Measurement and Analysis of Mortality. Oxford: Clarendon press, 1990.
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RGI. Sex Ratio of Maharastra, Census of India accessed on line at www.censusindia.net. New Delhi, 2001
Bang AT, Bang RA, Morankar VP,et al. Pneumonia in neonate: can it be managed in the community? Arch Dis Child 1993; 68: 550-56.
Sutrisna B, Reingold A, Kresno S, et al. Care-seeking for fatal illness in young children in Indramayu, West Java, Indonesia. Lancet 1993; 342: 887-89.
Bhandari N, Bahl R, Bhatnagar V, Bahn MK. Treating sick young infants in urban slum setting. Lancet 1996; 347:1174-75.
Kumar S. Status of Medical Certification of Cause of Death in India In: Counting the Dead in India in the 21st Century, Proceedings of the Second International Workshop on certification of Causes of Death, Goa, India, 9-12 February, 2000. Vol. Series B. Tata Institute of Fundamental Research, Mumbai.
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Kalter HD, Gray RH, Black RE,et al. Validation of postmortem interviews to ascertain selected causes of deaths in children. International Journal of Epidemiology 1990: 19:380-386.
Chandramohan D, Maude G, Rodrignes L and Hayes R (1994) Verbal Autopsies for adult deaths: Issues in their development and validation. International Journal of Epidemiology (23); 213-222.
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Bang AT, Bang RA, Baitule SB, Reddy MH,et al. Effect of Home Based Neonatal Care and Management of Sepsis on Neonatal Mortality. Lancet 1999;354:1955-56
Kaushik SL, Parmar VR, Grover N, Kaushik R. NMR: Relationship to Birth weight and gestational age. Indian J Pediatr 1998; 65: 429-433.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241515EnglishN2013August17HealthcareEFFECT OF CARDIAC REHABILITATION VS HOME EXERCISES AFTER CORONARY ARTERY BYPASS GRAFTING (CABG) ON HEMODYNAMICS
English95101Pratibha ManhasEnglish Tushar J. PalekarEnglishBackground: Exercise training has been shown to modify the sympathovagal control of heart rate toward an increase in parasympathetic tone. At the same time, the improved vagal activity is associated with reduced death risk from cardiac events (Wu S-K, Lin Y-W et al). Although a cardiac rehabilitation exercise program is standard therapy for patients after a cardiac event and especially for those who have received Coronary artery bypass grafting (CABG), the relationship between a cardiac rehabilitation exercise programme and acute hemodynamics and comparison with home based exercise programme has not been clearly demonstrated. Objectives: To find the effect of cardiac rehabilitation and home exercises on blood pressure, Heart rate, Respiratory Rate and Rating of perceived exertion (RPE) and compare the effects of cardiac rehabilitation and home exercises. Method: Thirty consecutive eligible patients undergone Coronary artery bypass grafting (CABG) referred by cardiovascular surgeons had participated in this study. After completion of baseline exercise stress test at discharge or within first week after discharge were randomly assigned to group A (Hospital based Cardiac rehabilitation) and group B (Home based cardiac rehabilitation) for 6 weeks. Materials: Perceived exertion scale, Stop watch, Blood Pressure apparatus, Pulse oxymeter Result: There were significant improvements in hemodynamics (p=0.000) both with hospital based cardiac rehabilitation and home based exercises but there were no significant differences between hospital cardiac rehabilitation and home based exercises. Conclusion: This study had concluded that both hospital based cardiac rehabilitation and home based exercises are effective in improving acute hemodynamics.
EnglishCABG, Cardiac Rehabilitation, Home ExercisesINTRODUCTION
Cardiac Rehabilitation programmes are associated with significantly improving exercise tolerance and functional capacity, increasing psychosocial well being, alleviating activity related symptoms, reducing disability and decreasing cardiovascular morbidity and mortality. This is achieved through exercise, patient education and advice, relaxation, drug therapy, and specific help for patient’s psychological sequelae.1 There is good evidence that both exercise and comprehensive cardiac rehabilitation programmes are effective, reducing all-cause mortality by 27% following myocardial infarction.2 The National Service Framework for Coronary Heart Disease in England and Wales seeks to expand the uptake and coverage of cardiac rehabilitation to patients following a heart attack, coronary artery bypass graft or coronary angioplasty, and also patients with heart failure and angina.3 The concept of cardiac rehabilitation and secondary prevention has been defined as the effort toward cardiovascular risk factor reduction designed to lessen the chance of a subsequent cardiac event and to slow and perhaps stop the progression of the cardiovascular disease process.4 Uptake of hospital-based cardiac rehabilitation programmes is poor, particularly among women, the elderly and people from minority ethnic groups. Home-based cardiac rehabilitation programmes were first reported in the early 1980s and might be more acceptable and convenient for some patients, thus increasing uptake. This review explores whether there is any evidence that homebased cardiac rehabilitation programmes are superior to usual care in improving cardiac risk factors and mortality and whether benefits occur to patients’ post-myocardial infarction (MI) and after vascularisation procedure. In addition they have explored whether the outcomes from home-based cardiac rehabilitation are similar to centre (or hospital) based programmes.5 Phase II cardiac rehabilitation programs are associated with significantly improving exercise tolerance and functional capacity, increasing psychosocial well being, alleviating activity related symptoms, reducing disability, and decreasing cardiovascular morbidity and mortality.6 Exercise based cardiac rehabilitation is associated with significant improvements in autonomic markers of neural regulation of sinoartrial node such as increase in R-R interval of electrocardiogram (ECG), in its variance, and in overall spontaneous baroreflex.7 Relatively few studies have evaluated the effectiveness of cardiac rehabilitation following revascularisation and there is still insufficient evidence about the effects of cardiac rehabilitation on survival. Cardiac rehabilitation programmes have reported some benefits in aerobic capacity a reduction of smoking and lower blood pressure8-9 ; lower anxiety scores 10and improvement in lipoprotein patterns.11 Cardiac rehabilitation has been hypothesized to favourably impact acute hemodynamics by modulating autonomic function. Nishime11 et al. Showed that cardiac rehabilitation only had the tendency toward improved heart rate recovery, where as Tiukinhoy12 et al. Reported a significant enhancement for the rehabilitation group with a similar heart rate recovery in their control group. Although Kligfield13 and associates investigated the effect of age and gender on acute hemodynamics in cardiac patients, the measurement of heart rate recovery was evaluated after submaximal effort rather than after peak exercise. Moreover despite the documented benefits of formal cardiac rehabilitation exercise programs, the cost, lack of time, and accessibility contribute to relatively low participation rates.14 Some studies have demonstrated positive effects for cardiac patients enrolled in home based exercise programs such as in quality of life, modulation of risk factors and peak oxygen consumption.15 The purpose of this study was to investigate whether the cardiac rehabilitation and home based exercise programme had a positive effect on acute hemodynamics and to compare the difference between cardiac rehabilitation and home based exercise programme.
METHODS
Thirty consecutive eligible patients undergone Coronary artery bypass grafting (CABG) referred by cardiovascular surgeons had participated in this study. All of them had undergone phase I cardiac rehabilitation programme such as early mobilization and walking under supervision after surgery. Patients with previous Coronary artery bypass grafting (CABG) surgery, neurological impairments, severe musculoskeletal diseases, complication during hospitalization, uncontrolled dysrhythmias and who cannot complete stress test at discharge were excluded from the study. After completion of baseline exercise stress test at discharge or within first week after discharge were randomly assigned to one of the following groups for 6 weeks. Group A – Cardiac rehabilitation exercise programme.
Patients in this group had received a 30 – 40 min. of aerobic exercise training session (riding a stationary bicycle or jogging on a treadmill) with the intensity corresponding to 60 – 85 % of the peak heart rate achieved by perceived exertion scale 11 to 13. There was at least 10 min. of stretching exercises for warm up and 10 min of cool down. Heart rate (HR), Blood Pressure (BP), Respiratory Rate (RR) and exercise intensity was monitored by senior cardiopulmonary physical therapist during the exercise session and a total of 18 exercise sessions will be given to the patients. Group B – Home based exercise Patients in this group had received a home based exercise programme with an intensity corresponding to 60 – 85 % of the Peak Heart Rate (PHR) obtained by the rating of perceived exertion scale from 11 to 13. Patient was advised to exercise 3 times per week and exercise session will include a 10 min. warm up, 30 – 40 min. of aerobic training (brisk walking or jogging) and 10 min. cool down. Subjects were asked to document exercise record book
Statistical Analysis
The statistical tests used for the analysis of the result:
1) Paired t-test
2) Unpaired t-test Level of significance was decided to 95%CI.
RESULTS AND DISCUSSION
The results of this study showed significant changes in acute hemodynamics (p=0.00) with cardiac rehabilitation at hospital set up and home based exercises. Mean differences were Systolic Blood Pressure (SBP)(3.86±2.2), Diastolic Blood Pressure(DBP) (5.33±3.45), Heart Rate (HR) (5.33±3.45), Respiratory Rate (RR) (3.46±1.55), Rate of Perceived Exertion(RPE) (3.06±0.88) in group who had received hospital based rehabilitation and group who had received home based exercises were Systolic Blood Pressure (SBP) (3.46±1.59), Diastolic Blood Pressure(DBP) (3.46±1.59), Heart Rate(HR) (3.53±1.35), Respiratory Rate (RR) (2.53±0.91), Rate of Perceived Exertion( RPE )(2.26±0.96). Intergroup comparison did not show significant changes but clinically hospital based cardiac rehabilitation found to be more effective. The improvements in acute hemodynamics at follow up were consistent with previously published studies. The parasympathetic tone predominates at rest and acute hemodynamics increases during exercises in response to the combination of sympathetic activation and parasympathetic withdrawal and the inverse occurring during recovery after the exercise. The autonomic dysfunction is known to have adverse effects on subsequent clinical outcome in patients with coronary artery disease. One possible explanation for the discrepancies may be that the patients with coronary artery disease are subject to the activation from sympathetic activity after cardiac event.16 Weber17 et al also reported a higher heart rate after Coronary Artery Bypass Grafting (CABG) surgery and a high incidence of supraventricular arrhythmias during the hospital stay. Moreover the subjects in Kavanagh’s 18study were tested 14 week after the cardiac event or surgical procedure and Tiukinhoy’s 13subjects were evaluated after 6 and 9 months for the cardiac rehabilitation and control groups, respectively. This improvement in hemodynamics in both the groups may reflect that long term endurance training increases the parasympathetic activity and decreases the sympathetic activity directed to the human heart. Pardo19 et al indicated that exercise conditioning over a12-week period improved heart rate variability, reduced the resting heart rate in cardiac patients, lowered the risk of sudden cardiac death through increased vagal tone. Studies had also found that sympathetic system increases activity during the first 3 weeks after the onset of a cardiac event, where as the parasympathetic nervous system has been considered to improve gradually during the 3 months period.6,9 The reduction in acute hemodynamics in this study may imply that the balanced sympathetic and parasympathetic tone occurred gradually after CABG. For the comparison between groups at the follow up tests, there were no significant results. The improvements in both the groups were supported by the finding that endurance training has positive effect on the activation of parasympathetic tone.16 Although there was no statistical significance that existed between hospital based cardiac rehabilitation and home based rehabilitation. Home based rehabilitation had similar magnitudes in all test parameters after the intervention when compared with hospital based rehabilitation. Several studies have indicated a tendency toward improvement in peak aerobic capacity, quality of life, and risk factor reduction in home based rehabilitation programmes 14,15 . Smith20 et al. recently reported that the low risk patients whose cardiac rehabilitation was initiated in the home environment may be more likely to sustain positive physical and psychosocial changes over time because of the higher physical habitual activity of home subjects. Autonomic dysfunction is known to adversely affect clinical outcome in patients with cardiovascular disease. However improvement in autonomic regulation on heart rate recovery after cardiac rehabilitation may be an additional benefit of an exercise training program. Exercise is one of the main components of lifestyle change and it may an effect on modifying autonomic imbalance. Therefore, a more structured nature of exercise counselling and a more frequent interaction between staff and patients may be needed to encourage home based exercise subjects to engage in regular physical activity to achieve greater improvement 16 .
CONCLUSION
This study had concluded that both hospital based rehabilitation and home based exercises are effective in improving acute hemodynamics.
ACKNOWLEDGEMENT
Author would like to thank Dr. D. Y. Patil Vidyapeeth, Pune, for funding this research. Authors also acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=1214http://ijcrr.com/article_html.php?did=12141. Thompson D, Bowman G, Kitson A, de Bono D, Hopkins A: Cardiac rehabilitation services in England and Wales: a national survey. Int J Cardiol 1997, 59:299-304.
2. Campbell N, Grimshaw J, Rawles J and Ritchie L: Cardiac rehabilitation in Scotland: is current provision satisfactory? J Public Health Med 1996, 18:478-480.
3. Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med 2004;116(10):682– 692.
4. Benzer W. Oldridge NB: Current concepts in cardiac rehabilitation medical considerations and outcomes evaluations. J Clin Basic Cardiol 2001;4:211-19
5. Katte Jolly, Rod S. et al: Home based cardiac rehabilitation compared with centre based rehabilitation and usual care: A systematic review and metanalysis. International Journal of Cardiology111(2006);343-351
6. Lucini D, Richard VM, Costantino G, Lavie C, Porta A, Pagani M: Effects of cardiac rehabilitation and exercise training on autonomic regulation in patients with coronary artery disease. Am Heart J 2002;143:977-83
7. Thornton EW, Fabri BM, Fox MA, Jackson M: Predicting blood pressure reactivity and heart rate variability from mood state following coronary artery bypass surgery. Int J Psychophysiol 2003; 47:43-55
8. Hedback B, Perk J, Engvall J, Areskog N: Cardiac rehabilitation after coronary artery bypass grafting: effects on exercise performance and risk factors. Arch Phys Med Rehabil 1990,71:1069-1073.
9. Ben-Ari E, Kellerman J, Fisman E, Pines A, Peled B and Drory Y: Benefits of long-term physical training in patients after coronary artery bypass grafting – a 58 month follow-up and comparison with a maintained group. J Cardiopulm Rehabil 1986,6:165-170.
10. Engblom E, Korpilahti K, Hamalainen H, Ronnemaa T and Puukka P: Quality of Life and Return to Work 5 Years After Coronary Artery Bypass Surgery long term results of cardiac rehabilitation. J Cardiopulm Rehabil 1997, 17:29-36.
11. Nishime EO, Cole CR, Wallace GS,et al: Heart rate recovery improved in a cohort of adults after cardiac rehabilitation. J Am Coll Cardiol 2002;39:164
12. Tiukinhoy S, Beohar N, Hsie M: Improvement in heart rate recovery after cardiac rehabilitation. J Cardiopulm Rehabil 2003;23:84-87
13. Kligfield P, McCormick A, Chai A,Jacobson A,Feuerstadt P, Hao SC: Effect of age and gender on heart rate recovery after submaximal exercise during cardiac rehabilitation in patients with angina pectoris, recent acute myocardial infarction or coronary bypass surgery. Am J Cardiol 2003;92:600- 603
14. Lind L,Andren B: Heart rate recovery after exercise is related to the insulin resistance syndrome and heart rate variability in elder men. Am Heart J 2002;144:666-72
15. Gordon NF, English CD, Contractor AS, et al: Effectiveness of three models for comprehensive cardiovascular disease risk reduction. Am J Cardiol 2002;89:1263-68
16. Wu S-K, Lin Y-W, Chen C-L, Tsai SW:Cardiac Rehabilitation vs Home Exercise after coronary artery bypass graft surgery: A comparison of heart rate recovery. Am J Phys Med Rehabil 2006;85:711-717.
17. Weber UK, Pfisterer M et al: Low dose sotalol to prevent supraventricular arrhythimas after CABG surgery and its effect on hospital stay. J Am Coll cardiol 1996;27:309-10.
18. Kavanagh T , Mertens DJ et al : Peak oxygen intake and cardiac mortality in women reffered for cardiac rehabilitation. J Am Coll Cardiol 2003;42:2139-43.
19. Pardo Y, Merz CN et al: Exercise conditioning and heart rate variability: evidence of a threshold effect. Clin Cardiol 2000; 23: 615- 20.
20. Smith KM, Arthur HM et al: Differences in sustainability of exercise and health related quality of life outcomes following home or hospital based cardiac rehabilitation. Eur J Cardiovasc Prev Rehabil 2004:11:313-19.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241515EnglishN2013August17TechnologyTHERMOSOLUTAL INSTABILITY OF AN INCOMPRESSIBLE, VISCOUS FLUID CONFINED IN A POROUS MEDIUM IN THE PRESENCE OF MAGNETIC FIELD
English102110Arti BansalEnglishThe paper critically examines, within the framework of linear analysis, thermosolutal instability of an incompressible, viscous fluid confined in a porous medium in the presence of magnetic field, analytically and numerically both. The analytical discussion provides the sufficient conditions of stability and instability and the characterization of modes. By actually calculating the root of eigenvalue equation (of degree 4) neutral stability curves are drawn. The numerical results show the effect of various physical parameters on the critical wave number ac. It is concluded that RD-1 , S and R4 have stabilizing character and Richardson number J has destabilizing character. The non-dimensional parameter R2 shows a dual character, which depends upon thermal diffusivity ?
EnglishThermosolutal instability, porous medium, magnetic fieldINTRODUCTION
The problems on thermal instability (Bénard convection) in a fluid layer under varying assumptions of hydrodynamics and hydromagnetic have been discussed in detail by Chandrasekhar[1] in his celebrated monograph. The problem of thermosolutal instability in fluids through a porous medium is of importance in geophysics, soil sciences, ground-water hydrology and astrophysics. The development of geothermal power resources holds increased general interest in the study of the properties of convection in a porous medium.The instability of fluid flows in a porous medium under varying assumptions has been well summarized by Scheidegger [2] and Yih [3]. While investigating the flows or flow instabilities through porous media, the liquid flow has been assumed to be governed by Darcy’s Law [4] by most of the research workers, which neglects the inertial forces on the flow. Beavers et al. [5] demonstrated experimentally the existence of shear within the porous medium near surface, where the porous medium is exposed to a freely flowing fluid, thus forming a zone of shearinduced flow field. Darcy’s equation however, cannot predict the existence of such a boundary zone, since no macroscopic shear term is included in this equation (Joseph and Tao [6]). To be mathematically compatible with the Navier-Stokes equations and physically consistent with the experimentally observed boundary shear zone mentioned above, Brinkman [7] proposed the introduction of the term 1 k μ V in addition to μ 2 V in the equations of fluid motion. The thermosolutal convection in a porous medium was studied by Nield and Bejan [8]. Instability of compressible or incompressible flow has been studied extensively by a number of research workers in past few decades. In almost all such investigations, the Boussines’q approximation is used to simplify the equations of motion. Goel et.al. [9] examined the shear flow instability of an incompressible viscoelastic second order fluid in a porous medium in which the modified Darcy’s law is replaced by the celebrated Brinkman model so that both the inertia and viscous terms are included in their usual forms. The behaviour of conducting fluid is very much different in the absence and in the presence of a magnetic field. The interesting properties associated with a magnetic field, have attracted a number of research workers to work in this direction. Bansal and Agrawal [10] have studied the thermal instability of a compressible shear flow in the presence of a weak applied magnetic field. The problem for compressible shear layer in the presence of a weak applied magnetic field through porous medium has been studied by Bansal et.al. [11]. In the present paper, an attempt has been made to examine the thermosolutal instability of an incompressible, viscous fluid in the presence of magnetic field and confined in a porous medium following Brinkman model. The Boussinesq approximation is used throughout the paper. It states that variations of density in the equations of motion can safely be ignored everywhere except its association with the external force. The approximation is well justified in the case of incompressible fluids.
FORMULATION OF THE PROBLEM
Here we consider an infinite, horizontal, incompressible, viscous fluid saturating an isotropic porous medium and which is subjected to uniform magnetic field in the horizontal direction. Uniform temperature and concentration gradients are maintained along z-axis. Equations expressing the conservation of momentum, mass, magnetic field, temperature, solute mass concentration and equation of
NUMERICAL RESULTS AND DISCUSSION
Eq.(10) is a fourth degree equation in ? with real coefficients, which depends upon RD -1 , S, J, J’, R2, R3, R4, l and a. Our aim has been to examine the effect of various parameters such as RD -1 , R2, R4, magnetic force number S and the Richardson number J on the stability of the system. This has been achieved by actually calculating the roots of the equation (3.2) correct upto three decimal places. The calculation of critical wave numbers has lead to the neutral stability curves. Fig.2. shows the critical wave number ac for different value of RD -1 (curve-I). When RD -1 =0, for a < 1.321 unstable modes are non-oscillatory i.e., the eigenvalue equation has all real roots with at least one positive root. For 1.321 < a < 2.153 unstable modes are oscillatory and system becomes stable for a ≥ 2.153 . As RD -1 increases, ac decreases so that the range of stable wave numbers increases. It is concluded that RD -1 has a stabilizing character and a large value of RD -1 is required to stabilize the system for all wave numbers. Curve-II separates the unstable modes into unstable oscillatory and unstable nonoscillatory modes. As RD -1 increases, the range of both the unstable oscillatory and the unstable nonoscillatory modes decreases. Fig.3. shows the stabilizing character of magnetic field (curve-I). Short wave length perturbations are more stable. The unstable modes are divided into oscillatory and non-oscillatory modes. The large wave length perturbations are unstable and nonoscillatory and the modes which are intermediatory between stable and unstable nonoscillatory modes are unstable and oscillatory, i.e., a > ac are stable, ac* < a < ac are unstable and oscillatory and a < ac* are unstable and nonoscillatory. It is important to observe that whereas the unstable modes are non-oscillatory in the absence of magnetic field, some oscillatory unstable modes are introduced in its presence . Fig.4. shows the destabilizing character of J. As J increases, ac increases which decreases the range of stable wave numbers. As is clear from this figure, the range of both the non-oscillatory unstable and the oscillatory unstable modes increases with J. Fig.5. shows the dual character of the nondimensional parameter R2, which in fact, depends upon the thermal diffusivity ?. As R2 increases from 0 to 0.3, the range of stable wave increases. As R2 increases from 0.3 to 3.5 approximately, the range of unstable wave numbers decreases rapidly, however, this decrease in the range of unstable wave numbers is slow as R2 further increases beyond 3.5. The neutral stability curve also shows that the critical wave number for maximum instability is given by ac = 2.081 and it occurs for R2 = 0.3. Similar character is exhibited for R3. Stabilizing character of fluid viscosity is exhibited in Fig.6. As R4 increases, the range of stable wave numbers increases sharply upto R4 = 4 (approx.) and then increases slowly as R4 further increases.
CONCLUSION
The analytical discussion provides the sufficient conditions of stability and instability and the characterization of modes. Theorem 2 states that non-oscillatory modes are stable if ? ? 0 and 0 ' ? ? . This situation is known as potentially stable arrangement. The numerical results show the effect of various physical parameters on the critical wave number ac . On the basis of numerical discussion & neutral stability curves obtained in paper, it is concluded that medium porosity parameter RD -1 , magnetic force number S and fluid viscosity have stabilizing character and Richardson number J has destabilizing character. The non-dimensional parameter R2, which depends upon thermal diffusivity ?, shows a dual character,
ACKNOWLEDGEMENT
The author is grateful to Professor S.C. Agrawal, Retd. H.O.D., Department of Mathematics, C.C.S. University, Meerut, for providing valuable support.
Englishhttp://ijcrr.com/abstract.php?article_id=1215http://ijcrr.com/article_html.php?did=12151. Chandrasekhar S., Hydrodynamic and Hydromagnetic Stability. – Oxford, UK: Clarendon Press, 1961.
2. Scheidegger A. E. Growth of instabilities on displacement fronts in porous media. Phys Fluids 1960; 3 94.
3. Yih C. S. Flow of a non-homogeneous fluid in a porous medium. J. Fluid Mech. 1961; 10 133.
4. H. Darcy Les fontaines publiques de la ville de Dijon Paris : Victor Dalmont (1856).
5. Beavers G.S., Sparrow E.M. and Magnuson R.A. , Experiments on coupled parallel flows in a channels and a bounding porous medium. – J. Basic Engng. Trans. 1970, ASME, vol.D92, pp.843-845.
6. Joseph D.D. and Tao L.N., The effect of permeability on the slow motion of a porous sphere in a viscous liquid, 1964.
7. Brinkman H. C. A calculation of the viscous force exerted by a flowing fluid on a dense swarm of particles 1947; Appl. Sci. Res., A1 27.
8. Nield D. A. and Bejan A. Convection in porous medium 1992; Springer.
9. Goel A. K., Agrawal S. C. and Jaimala shear flow instability of an incompressible viscoelastic second order fluid in a porous medium. Indian J. pure appl. Math. 1997 28(4) 563.
10. Bansal N. and Agrawal S. C. thermal instability of a compressible shear flow in the presence of a weak applied magnetic field. Proc. Nat. Acad. Sci. India 1999 ;69(A) III .
11. Bansal A., Bansal N. and Agrawal S. C. Thermal instability of compressible shear layer in a porous medium in the presence of a weak applied magnetic field. Ganita 2004; vol.55, no.2,187-197.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241515EnglishN2013August17TechnologyEFFECT OF RICE HUSK FILLER ON MECHANICAL PROPERTIES OF POLYETHYLENE MATRIX COMPOSITE
English111118Atuanya C.U. English Olaitan S.A. English AzeezEnglish T.O. English Akagu C.C. English Onukwuli O.D.English Menkiti M. C.EnglishIn the present work, the effect of rice husk filler loading (10%, 20%, 25%, 30%, and 35%) on the mechanical properties of recycled low density polyethylene (RPE) and mixed with 20 percent weight fraction of virgin polyethylene (MPE) composites was aimed to be investigated. The waste polyethylene was blended with virgin polyethylene and the composites of RPE and MPE were moulded with the addition of rice husk filler using injection moulding machine at a pressure 150MPa and temperature 160oC. The composites were cut into specified dimensions and mechanical properties were conducted on them. Tensile strength increased up to 10 percent weight fraction of rice husk filler in the composites and later decreased above 10 percent filler loading. Tensile modulus, flexural strength and modulus, and Brinell hardness increases with increased filler loading, but impact strength decreases with increased in filler loading. The rice husk filler loading had significant effect (p < 0.05) on the mechanical properties of MPE composite compared with RPE composite which indicated that rice husk filler may be used for reinforcement of Polyethylene.
EnglishRise husk filler, Polyethylene, Mechanical propertiesINTRODUCTION
The material strength of the polymers required the reinforcement of the polymer matrices for purpose of improving the mechanical strength and performance of the polymer materials. Many researchers have worked on the use of natural fibers and fillers (jute, stalk, baggase, groundnut shell, palm kernel, banana and coconut, wood etc.) to strengthen the properties of the polymer in many applications (Sui et al, 2008; Hardinnawirda and SitiRabiatull, 2012; Behzad, 2011; Raju et al, 2012; Chantara et al, 2010; Luyt, 2009). Natural fillers due to its compositions (cellulose, pectin, hemicelluloses and lignin) contributed greatly to the structural performance of polymer composites (Raju et al, 2012; Kim et al, 2004; Yang et al, 2004). Currently, natural fibers form an alternative for glass fiber, the most widely applied fiber in the composite technology. The advantage of the natural fibers over synthetic fibers like aramid, carbon or glass fiber are not only due to its low densities, non abrasive, non-toxic, high filling levels possible resulting in high stiffness, specific properties, biodegradable, inexpensive, good thermal and acoustic properties, good calorific value, enhanced energy recovery and reduces biomass in the environment (Raju et al, 2012; Kim et al, 2004; Yang et al, 2005; Gacitua et al, 2005 ) but also due to the fact that natural filler prevents thermal expansion of composites. Rice husk is among natural materials that have been used in polymer composites (Imoisili et al, 2012) and contains 35% cellulose, hemicellulose 25%, lignin 20% and ash 17% (94% silica) by weight (Panthapulakkal, 2005). Researchers have shown that rice husk filler used in thermoplastics and thermosets composite improves mechanical and structural performance of the composites but studies on its benefit are limited to density, tensile strength and thermogravimetric analysis (Kim et al, 2004; Yang et al, 2004; Yao et al, 2008) without considering the waste polyethylene. This study was to investigate the effects of rice husk loading on the mechanical properties of recycled low density polyethylene (LDPE) matrix blended with virgin LDPE so as to reduce biomass of rice husk fiber and to conserve polyethylene waste in the environment.
METHODOLOGY
Both virgin and recycled polyethylene was used in the study. The waste polyethylene (PE) was obtained from the industrial waste of IBETO Group of Companies and crushed using the fabricated crushing machine at National Engineering Design and Development institute (NEDDI) both in Nnewi, Anambra State, Nigeria. The virgin PE was obtained from chemicals line in Ugah market, Onitsha, Anambra state, Nigeria. The rice husk used was a by-product of a local rice mill in Otolo Nnewi and Kpoko Bros., Atani Road, Onitsha, Nigeria. Composite Preparation The rice husk used was sun-dried and then ovendried at 1100C for 2 days to a moisture content of almost 3.0wt% and finally, sieved to 18-mesh size. The composites were prepared in mixingratio of virgin polyethylene, recycled polyethylene and rice husk as shown in the Table 1. Composite Processing The rice husk filler and polyethylene were manually mixed and then fed into an injection moulding machine of the reciprocating screw type to produce the composite samples. The operating pressure and temperature of the injection moulding machine was 150MPa and 1600C respectively. Process time for each sample is 30 – 60 seconds averagely. The following mechanical tests were carried out to assess the influences of the rice husk on the mechanical performance of polyethylene after conditioning to 65% Relative Humidity and temperature of 25oC. Samples of the rice husk filler - polyethylene composites were cut into specified dimensions and tested at room temperature in accordance with ASTM 638-90 standards.
Tensile Testing
Tensile properties were carried out on the specimens using a KAOH TIEH Instron Testing Machine, in accordance with ASTM 638-90, at a cross-head speed of 200rev/min. The dimensions of each sample were 150mm (length) x 30mm (width) x 5mm (thickness) and held by the gripping heads, the samples were pulled till failure and the respective loads and extensions noted. The values thus gathered were used to calculate the strain, tensile strengths, and modulus of the samples A to L using the equation (1) and (2) as reported by Raju et al (2012).
Flexural Testing Flexural properties were carried out by 3-point bending tests on composite samples with dimensions 60mm (span) x 20mm (width) x 5mm (thickness) using a WP 300.4 bending device in accordance with ASTM 790 – 90. Equation 3 and 4 was used to obtain the flexural strengths and modulus respectively of the samples.
Impact Testing
The unnotched impact properties were conducted on all specimens in accordance with ASTM D 256-90. Prepared samples were subjected to fracture by a pendulum – Type Impact Testing Machine and the unnotched toughness values of the composites obtained by reading off the energy expended to rupture each sample.
Hardness Testing
Brinell Hardness Test was conducted on samples using a manually-operated Universal Testing Machine. A hardened steel ball with a diameter of 10mm was used in performing the test. The indentations on the specimens were measured (diameter-wise) and appropriate mathematical methods used for conversion to obtain the Brinell Hardness Values. The equation for the Brinell Hardness Number (HBN) is written as:
???????
Where P is the applied Load measured in kg, D is diameter of steel ball (10mm) and d is the diameter of indentation (mm). Statistical Analysis The statistical analysis was conducted using SPSS Version 17.0 with bivariate correlations. The Pearson’s correlation coefficient test was used for the test of significance with two tail of p-value less than 0.05 was considered statistically significant between RPE and MPE composites.
RESULTS
Effect of rice husk filler loading on tensile property of polyethylene composites
Tensile strength and modulus of the PE composite as a function of the weight fraction of the rice husk filler for both recycled polyethylene (RPE) and recycled polyethylene with 20 % virgin polyethylene (MPE) are illustrated in the Figure 1 and 2 respectively. Effect of rice husk filler loading on the flexural property of the polyethylene composites The flexural strength increases steadily from 38 MPa to 67.7 MPa and 56.6 MPa for RPE and MPE respectively with increased rice husk filler loading as illustrated in the Figure 3 as well as flexural modulus as shown in the Figure 4. Effect of rice husk filler loading on the impact strength of the polyethylene composites Figure 5 depicts that the impact strength of the polyethylene composites decreases steeply from 600J/m to 100J/m for RPE and 583J/m to 40J/m for MPE with increased weight fraction of the rice husk filler in the composite as shown in the Figure 5. Effect of rice husk filler loading on the brinell hardness of the polyethylene composites The magnitude of Brinell hardness of the rice husk filler polyethylene composites increases from 2.3N/mm2 to 13.15N/mm2 and 12.44N/mm2 for RPE and MPE respectively with increased weight fraction of rice husk filler loading as shown in Figure 6.
DISCUSSION
It can be deduced that the tensile strength of the composite increases with increased rice husk filler loading in both RPE and MPE as illustrated in Figure 1 and 2. The tensile strength of RPE and MPE composite with 10 percent of weight fraction of the rice husk filler loading increases from 30.33 MPa to 38.4 MPa and 31.58 MPa which amounted to 4.1 and 26.6 percent respectively. It was observed also that the tensile strength decreased to 18.37 MPa and 11.88 MPa for RPE and MPE respectively with increased rice husk loading up to 35 percent filler loading as illustrated in Figure 1. The increased tensile strength attributed to an effective creation of an interfacial adhesion bond between filler (hydrophilic) and PE (hydrophobic), which resulted to morphological changes as reported by many researchers (Luyt, 2009; Yao et al, 2008; Yang et al, 2004; Ratnam et al, 2010). The observation is contrary to the case of unsaturated polyester resin as reported by Hardinnawirda and SitiRabiatull (2012). This is an indication that rice husk filler has a better interfacial adhesion with polyethylene matrix compared with unsaturated polyester resin. It was also obtained that there is significant effect of 0.007 (p < 0.05) with a correlation coefficient of 0.932 between MPE and RPE composite which indicated that the incorporation of 20 percent of virgin PE was significant in the composite applications. The tensile strength of the composites decreases after ten (10%) percent of filler loading was due to the inability of the filler to support stresses transferred from the polyethylene matrix. The tensile modulus also increases with increased weight fraction of the rice husk filler loading as illustrated in the Figure 2 and similar to the report of many researchers (Yang et al, 2004; Imoisili et al, 2012; Raju et al, 2012). The flexural strength increases steadily from 38 MPa to 67.7 MPa and 56.6 MPa with 78.2 and 48.95 percent for RPE and MPE respectively with increased rice husk filler loading as illustrated in the Figure 3 as well as flexural modulus as shown in the Figure 4. This indicated that the increased filler loading, increases the stiffness of the rice husk filler/polyethylene composite. This is a common phenomenon and similar to the report of many researchers (Zaini et al, 1996; Yang et al, 2004; Imoisili et al, 2012). The 20 percent addition virgin PE on the flexural strength of the composite was significant with 0.035 (p < 0.05) and correlation coefficient of 0.844. Though, there is no significant effect on the flexural modulus between RPE and MPE since significant level 0.556 (p > 0.05) which indicated that 20 percent of weight fraction of the virgin PE in the composite was insignificant on flexural modulus. The result of unnotched Izod impact test depicts that the impact value decreases steeply with increased weight fraction of the rice husk filler in the composite as shown in the Figure 5. The addition of up to 35 weight fraction of rice husk weight filler loading causes the reduction in impact strength of the RPE and MPE to 40J/m which is 93.1% and 100 J/m which is 83.3% respectively. This observation could be attributed to the poor wetting of the rice husk filler by the PE blends, which lead to poor interfacial adhesion between the fiber and polymer matrix resulting in weak interfacial regions. Poor interfacial adhesion between hydrophobic matrix and hydrophilic nature filler usually results in decrease toughness as reported by Raju et al (2012). Thus, the decline in impact strength with increased rice husk filler loading is attributed to the poor interfacial adhesion between the hydrophobic polyethylene matrix and hydrophilic (rice husk filler). In addition, the incorporation of the filler resulted to reduction in polymer chain mobility, thereby lowering the ability of the system to absorb energy during fracture propagation. The significant effect of 0.001(p < 0.05) with correlation coefficient of 0.994 was obtained between RPE and MPE composites which attributed to 20 percent of virgin polyethylene. It is apparent from Figure 6 that the increase of 5 to 35 weight fractions of rice husk filler increases the hardness of both RPE and MPE composite from 2.3 to 12.44 and 13.15 N/mm2 which is equivalent to 440.9 percent and 471.7 percent for RPE and MPE respectively with Pearson correlation coefficient of 0.944 and significantly 0.009 (p < 0.05) with correlation coefficient of 0.923. This trend of results is expected because as more filler is incorporated into the polymer matrix, the elasticity of the polymer chain reduced resulting in more rigid composites.
CONCLUSION
Based on the result obtained, there is significant effect on mechanical properties of rice husk filled RPE and MPE composites with exception of flexural properties. The upward trend exhibited in tensile strength with the 10 percent rice husk filler for both RPE and MPE coupled with the enhancement in tensile modulus, flexural strength and modulus, and hardness indicated that rice husk filler may be used for the reinforcement of RPE and MPE up to 10 percent filler. However, a reduction in tensile strength at above 10 percent rice husk filler loading and the gradual drop in impact strength with increased rice husk filler loading may be due to poor interfacial bonding and agglomeration of rice husk filler. Also, Rice husk filler showed superior tensile strength properties in MPE composites due to addition of 20 percent weight fraction of virgin polyethylene compared with the low tensile strength recorded in the rice husk filler – RPE composite. Therefore, rice husk not only helpful for reinforcement of waste polyethylene but reduces biomass level of rice husk and polyethylene waste in the environment.
ACKNOWLEDGEMENT
The authors thank IBETO Group of Companies, National Engineering Design and Development institute (NEDDI) and Nnamdi Azikiwe University, Awka, Nigeria for both materials and financial support.
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