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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524153EnglishN2013February18General SciencesBIOREMEDIATION OF TEXTILE DYE USING WHITE ROT FUNGI: A REVIEW
English0113G. Roseline JebapriyaEnglish J. Joel GnanadossEnglishIndustrial development worldwide has led to an increase in the amount of wastewater production leading to a considerable decrease in levels and quality of the natural water in the ecosystem. Textile dyes are an important class of pollutants in natural water ecosystem. Textile dyes are molecules designed to impart a permanent colour to textile fabrics. Effluent from textile dyeing units contain large amount of dyes and create an environmental problem, which increase toxicity and decrease the aesthetic value of rivers and lakes. A variety of physio-chemical methods are in use worldwide. However, there is an increasing concern as to their impact in effectively treating textile effluents as they introduce secondary pollutants during the ‘remediation’ process which are quite costly to run and maintain. Research on biological treatment has offered simple and cost effective ways of bioremediation textile effluents. This review summarizes the efficiency of white rot fungi and their enzymes for the treatment and removal of textile dye containing effluents. The advantages and disadvantages of the various methods are discussed and their efficacies are compared.
EnglishTextile dye, decolourization, biological methods, white rot fungi.INTRODUCTION
Increase in population and modernized civilization has led to flourishing of textile industries in India. Textile sector is a complicated industrial chain and high diversity in terms of raw materials, processes, productions and equipment. It is estimated that textile account for 14% of India’s industrial production and around 27% of its export earnings. India is the second largest producer of cotton yarn and silk and third largest producer of cotton and cellulose fiber. The report of the ministry of textiles says the total production of yarn during the year 2003-2004 was 3051 kt. There are about 10,000 garment manufacturers and 2100 bleaching and dyeing industries in India. Majority are concentrated at Tirupur and Karur in Tamil Nadu, Ludiyana in Punjab and Surat in Gujarat. Dyeing is a combined process of bleaching and colouring, which generates huge volumes of wastewaters which results in environmental degradation. More than 100,000 commercial dyes are available to textile industries worldwide with over 700,000 tons of commercial dyes a year being produced (45) .
Impact of textile dyes on the environment
The textile industry accounts for two-thirds of the total dyestuff market (65) and consume large volumes of water and chemicals for wet processing of textiles. The discharges of wastewater are the main cause of the harmful environmental impact of the textile industry. Robinson et al., (67) estimated about 10-15% of textile dyes are discharged into waterways as effluent and effluents discharged from such industries consist of high sodium, chloride, sulphate, hardness and carcinogenic dye ingredients. Effluents from textile industry are characterized by their high visible colour (3000- 4500 units), chemical oxygen demand (800-1600 mg/L), and alkaline pH range of 9-11. They also possess large amount of organic chemicals, low biodegradability and total solids in the range of 6000-7000 mg/L (42). The chemical used in the textile processing are varied in chemical composition, ranging from inorganic compounds to polymers and organic products and depend on the nature of the raw material and product (47) . Major pollution by textile wastewater comes from dyeing and wastewater is characterized by high suspended solids, chemical oxygen demand (COD), heat, colour, acidity and other soluble substances (82). The presence of dyes in aqueous ecosystem reduces sunlight penetration into deeper layers diminishing photosynthetic activity, declines the water quality, lowering the gas solubility which causes sensitive toxic effects on aquatic flora and fauna (51). Therefore, the release of harmful dyes in the environment can be an ecotoxic risk and can affect man through the food chain (78). Among different textile dyes used, azo dyes and nitrated polycyclic aromatic hydrocarbons are two groups of chemicals that are abundant in the environment. They cause rigorous contamination in river and ground water in the surrounding area of dyeing industries (65) . The impact of azo dyes in food industry and their degraded products on human health has caused concern over a number of years. Moreover azo dyes have been linked to human bladder cancer, splenic sarcomas, hepatocarcinomas and nuclear anomalies in experimental animals and chromosomal aberrations in mammalian cells. Some azo dyes induce liver nodules in experimental animals and there are a higher numbers of bladder cancers in dyeing industries workers. Benzidine based azo dyes are widely used in dye manufacturing, textile dyeing, colour paper printing and leather industries. Benzidine has long been recognized as a human urinary bladder carcinogen and tumorigenic in a variety of laboratory animals (23) . The chemicals used in dyeing industries are carcinogenic and mutagenic and the effluents even reduce the rate of seed germination and growth of crop plants (52). The decreased carbohydrate, protein and chlorophyll content of plants indicate the toxic nature of the dye industry effluents. Increased proline concentration was observed in plants exposed to textile dye effluent (2). Algal growth and fishes are not affected by dye concentrations below 1 mg/L. The most toxic dyes for algae and fishes are basic and acid dyes. The chemicals present in the textile industry effluents affect the normal life of animals. Toxic compounds from dye effluent get into aquatic organisms, pass through food chain and ultimately reach man and cause various physiological disorders like hypertension, sporadic fever, renal damage, cramps etc (62) .
Methods used in removal of dyes
Effluent discharge from textile and dyestuff industries into water bodies and wastewater treatment systems is currently causing significant health concerns to environmental regulatory agencies. Government legislation is increasingly becoming stricter especially in the developed countries, regarding the removal of dyes from industrial effluents. Removal of dyes can occur physically, chemically and biologically (Fig.1). Generally in physical method dyes removed by adsorption, in chemical method chromophore has been modified through chemical reaction, biological method occurs through sorption and enzymatic degradation. Physical method: Adsorption refers to a process where a substance or material is concentrated at a solid surface from its liquid of gaseous surrounding. There are two types of adsorption based on the type of attraction between the solid surface and the adsorbed molecules. If this attraction forces are due to chemical bonding, the process is called chemical adsorption (Chemisorption). Adsorption techniques have gained favor recently due to their efficiency in the removal of pollutants too stable for conventional methods (9). Membrane filtration technique has been widely used for drinking and wastewater treatment. The process of filtration consists of microfiltration, ultrafiltration, nanofiltration and reverse osmosis. Ultrafiltration, nanofiltration and reverse osmosis can be applied as main or post treatment processes for separation, purification and reuse of salts and large molecules including dyes from dyebath effluents and bulk textile processing wastewater (34). Ion exchange techniques are effective in decolourizing cationic and anionic dyes and have not been used in extensively for dye wastewater treatment due to the opinion that ion exchangers cannot accommodate a wide range of dyes (73). Alumina is a synthetic porous crystalline gel available in the form of granules whereas, silica gel is a porous and non crystalline granule of different size prepared by the coagulation of colloidal silicilic acid. Alumina and silica gel have been studied by various workers for the removal of dyes (27). The irradiation process to treat dye containing effluent in a dual tube bubbling reactor requires large volumes of dissolved oxygen for organic substances to be broken down effectively by radiation (40) . Chemical method: The electrochemical technique is very efficient to remove colour from dye wastewater (22). Electrochemical removal of dyes from wastewater is a relatively new process exhibiting efficient colour removal and degradation of recalcitrant pollutants (57). This process is very simple and is based on applying an electric current to wastewater by using sacrificial iron electrodes to produce ferrous hydroxide. These ferrous hydroxides remove soluble and insoluble acid dyes from the effluent. Ozonation is a technology initially used in 70’s and it was carried out by ozone generated from oxygen. Oxidation by ozone is capable of degrading chlorinated hydrocarbons, phenols, pesticides and aromatic hydrocarbons (83). Ozone rapidly decolourize water soluble dyes but with non soluble dyes react much slower. Moreover, textile processing wastewater usually contains other refractory constituents that will react with ozone (50). A solution of hydrogen peroxide and an iron catalyst, known as Fenton’s reagent, is a suitable chemical means of treating wastewaters that are either resistant to biological treatment or poisonous to live biomass. Chemical separation used the action of sorption or bonding to remove dissolved dyes from wastewater and has been shown to be effective in decolourization of both soluble and insoluble dyes (55). Fenton oxidation process can decolorize a wide range of dyes and in comparison to ozonation; the process is relatively cheap and results generally in a larger COD reduction (28). Photochemical or photocatalytic method degrades dye molecules to CO2 and H2O by UV treatment in the presence of H2O2. Degradation is caused by the production of high concentrations of hydroxyl radicals. UV light may be used to activate chemicals such as H2O2, and the rate of dye removal is influenced by the intensity of the UV radiation, pH, dye structure and the dye bath composition. UV light has been tested in combination with H2O2, TiO2, Fenton reagents, O3 and other solid catalysts for the decolourization of dye solution (24). Merits and demerits of physical and chemical methods are listed in Table 1. Biological method: Biological method is generally considered to be the most effective and less energy intensive to removing the bulk of pollutants from wastewater. Different microorganisms have been used for the treatment of various dye effluents. The most important advantage of this method is the low running costs. Biosorption, biodegradation and ligninolytic enzymes have been explored as methods of biological treatments for removal of dye containing effluents. Removal of dye by low cost adsorbents has been extensively reviewed (15; 17). Fungal and bacterial biomass which is a byproduct of fermentations can be used as a cheap source of biosorbent (19) . Knapp et al. (38) reports both bacterial and fungal cells are capability of partial or complete removal of industrial dyes by using adsorption process. However, with some fungi, adsorption is the only decolourization mechanism, but with white rot fungi both adsorption and degradation can occur simultaneously or sequentially. There are many reports on decolourization of dye wastewater by live or dead fungal biomass. However, only limited information is available on interactions between biomass and molecular structure of dyes (18). The major mechanism of removal of dye by dead cells is biosorption, which involves physicochemical interactions (adsorption, deposition, and ion exchange). Hu (26) demonstrated the ability of bacterial cells to adsorb reactive dyes. Zhou and Zimmerman (86) used actinomyces as an adsorbent for decolourization of effluents containing anthroquinone, phalocyanine and azo dyes. Yesilada et al., (84) investigated decolourization of textile dyes by using pellets of the white rot fungus Funalia trogii. The decolourization activity was significantly affected by dye concentration, amount of pellet, temperature, and agitation of the media. Removal of dye effluents by biosorption is still in the research stage. It was not practically approached for treating large volumes of dye effluents due to the disposal of the large volumes of biomass after biosorption Biodegradation of the dye are broadly demonstrated by pure and mixed cultures of bacteria and fungi under aerobic and anaerobic conditions. Aerobic biodegradation process influence by several environmental and nutritional factors such as pH, temperature, amount of oxygen and co-metabolic carbon sources. Bacteria and fungi are the two major groups of microorganisms that have been extensively studied in the treatment of dye wastewater. The enzymes secreted by aerobic bacteria can breakdown the organic compounds. Thus, the isolation of aerobic bacterial strains capable of degrading different dyes has been carried out for more than two decades (63) . Biodegradation of the dye by certain groups of fungi during dye removal has been extensively demonstrated. The degradation and mineralization of dyes is successful by certain white rot fungi (16). Ligninolytic enzymes secreted by white rot fungi bind non-specifically to the substrate and therefore can degrade a wide variety of recalcitrant compounds and even complex mixtures of pollutants including dyes (20). Various enzymes involved in dye decolourization are Laccase, Manganese Peroxidase (MnP), Manganese Independent Peroxidase (MIP), Lignin Peroxidase (LiP), Tyrosinase etc. Production of these enzymes and their activity in biodegradation of dyes is often judged from the appearance of the mycelial mat, which ultimately appears colourless (37). The potential advantages of using enzymes instead of fungal cultures are mainly associated to the following factors: shorter treatment period, operation of high and low concentrations of substrates, absence of delays associated with the lag phase of biomass, reduction in sludge volume and no difficulty of process control (1). However there are several practical limitations in the use of free enzymes such as the high cost associated with production, isolation and purification of enzymes and the short life times of enzymes. To overcome this limitations enzyme immobilization has shown to improve enzyme stability (46). In addition, enzyme immobilization allows enzyme reultilization and continuous operation in bioreactor which is very important for an industrial application of the enzyme. Some of the work done so far using fungi is listed in Table 2.
Dye decolourization by white rot fungi
White rot fungi have been studied for nearly three decades and new species are being shown to decolourize various textile dyes with their lignindegrading enzymes (13). Tien and Kirk (76) reported the first dye decolourization by white rot fungi Phanerochaete chrysosporium. Banat et al., (8) also reported that other white rot such as Hirschioporus larincinus, Inonotus hispidus, Phlebia tremellosa and Coriolus versicolor can be used to decolourise dye effluent. Several other white rot fungus were used for the decolourization of distinct synthetic textile dyes and its effluents (29). Wesenberg et al. (81) surveyed 29 white rot fungi capable of dye decolourization. Since then, several investigators have evaluated the decolourization of commercial dyes by new species (3; 41; 67). Dye decolourization capabilities vary with the fungal species or enzymes (54). Lignin-modifying enzymes play significant roles in dye metabolism by white rot fungus (45) . The ligninolytic enzymes (lignolytic or lignin modifying or lignin degrading enzymes) are extracellularly excreted by the white rot fungi initiating the oxidation of lignin in the extracellular environment of the fungal cell. The ligninolytic enzymes produced by white rot fungi have been categorized into two groups: peroxidases (MnP and LiP) and laccases. Depending on the species and the environmental conditions, white rot fungi produce one or more types of these ligninolytic enzymes. Ligninolytic enzymes are directly involved not only in the degradation of lignin in their natural lignocellulosic substrates but also in the degradation of various xenobiotic compounds (60) including dyes (74). The physiology and production of lignin modifying enzymes (LME) by white-rot fungi has shown great potential in degrading azo dyes and related effluents. Decolourization of dyes by using lignin modifying enzymes were studied extensively example using laccase from Trametes versicolor (81; 32) , Trametes hirsute, Trametes modesta, Sclerotium roysii (54) Laccaria fraterna, Pleurotus ostreatus (6) , Lentinus polychrous (33). LiP from Phanerochaete chrysosporium and MnP from Phanerochaete chrysosporium, Bjerkandera adusta, Pleurotus eryngii (25) .
Mechanism of dye decolourization by white rot fungi
The mechanism of dye decolouization by white rot fungi are mainly categorized into four types namely biosorption, biodegradation, bioreactor and immobilized lignin modified enzymes (Fig.2). Among these mechanisms biodegradation plays a major role in dye decolourization by white rot fungi because they can produce ligninolytic enzymes to mineralize the dyes. However, the relative contributions of laccase, MnP and LiP to the decolourization of dyes may be different for each fungus. Phanerochaete chrysosporium LiP played a major role in dye decolourization. Anthraquinone dye act as a laccase substrates but in the case of azo and indigoid dyes were not the substrates of laccase (80). Pathway of indigo dye degradation by laccase has been demonstrated by Campos et al. (11) and laccases used in their experiment was produced and purified from Trametes hirsuta and Sclerotium rolfsii. Kitwechkun and Khanongnuch (36) studied the decolourization of azo dye (Orange II) by immobilized white rot fungus Coriolus versicolor. Martin et al. (43) screened several fungi for degradation of syringol derivatives of azo dyes possessing either carboxylic or sulphonic group. Trametes versicolor showed the best biodegradation performance and its potential was confirmed by the degradation of differently substituted fungal bioaccessible dyes. Biodegradation assays using mixtures of these bioaccessible dyes were performed to evaluate the possibility of a fungal wastewater treatment for textile industries. Biosorption mechanisms play a major role in decolourization of dyes by fungi. Knapp et al., (37) reported that the extent of colour removal by adsorption was always limited and generally less than 50%. In the case of Coriolus versicolor adsorption accounted for only 5-10% of colour removal (18). However, the adsorption level depends on type of microorganisms and their environmental condition. In some fungi, biosorption is the only decolourization mechanism. With white rot fungi, adsorption does not appear to be the principle mechanism of decolourization. It is likely that adsorption can play apart in the overall process, since prior adsorption to fungal mycelium may serve to bring chromophores onto closer contact with the degradative enzymes, which are often largely associated with cell surface. The biosorbents were reused in three repeated adsorption/desorption cycles without a significant loss in the biosorption capacity. Numerous studies have appeared on various reactor designs for LME production including stirred tanks, packed beds, airlifts, bubble columns, rotating disks, etc., there is a dearth of analogous reports on the use of reactor systems employing white rot fungus for waste treatment. Towards the design of bioreactor systems for decolourization, Zhang et al. (85) used alginateimmobilized basidiomycetes, producer of LiP, MnP and Lac, in several reactor configurations. In addition, they used the three different reactor configuration (continuous packed-bed bioreactor, fed batch fluidized-bed bioreactor and continuous fluidized-bed bioreactor) to design and test for decolorization of an azo dye, Orange II using white rot fungus. It was found that the fed batch fluidized-bed bioreactor was particularly suitable for Orange II decolourization since it showed very high decolorization efficiency. Detailed studies on bioreactor performances are starting to emerge, seeking to extend the capacity of white rot fungus to decolourize dyes in continuous (56) or sequencing batch mode (10) over long periods of time without the need for supplementation of new mycelium and, though a challenge, under nonsterile conditions. Immobilised fungal cells have several advantages over dispersed cells such as simple reuse of the biomass, easier liquid–solid separation and minimal clogging in continuous-flow systems (85) . In addition, immobilised cultures tend to have a higher level of activity and are more resilient to environmental perturbations such as pH, or exposure to toxic chemical concentrations than suspension cultures (72). Schliephake and Lonergan (71) studied the decolourization of the synthetic dye Remazol Brilliant Blue R (RBBR) by the white rot fungus Pycnoporus cinnabarinus grown on nylon web cubes in a 200 L packed bed bioreactor. They found that the dye was rapidly decolourised due to the action of the laccases produced by the fungus. Kapdan et al. (30) studied the decolouration of the textile dye Everzol Turquoise Blue G by the white rot fungus Coriolus versicolor immobilised on discs in a rotating biological contactor (RBC). The white rot fungus Phanerochaete chrysosporium immobilised on cubes of polyurethane foam (PUF) decolourised the polymeric dye Poly R478 (69). Rodriguez Couto et al. (68) also studied the decolourization of the polymeric dye Poly R478 by cultures of Phanerochaete chrysosporium grown on grape seeds, wheat straw and wood shavings under solid-state conditions. The most important criteria for good immobilized enzyme activity are the mechanical properties (rigidity and durability), physical form (granules, sheets, inner tube walls, etc), and resistance to chemical and microbial attacks, material hydrophilicity, price, and availability (49). The stability of a decolourization process depends on the properties of the enzyme support. The investigation by Wang et al (79) on dye decolourization by laccase encapsulated by alginate-gelatin-PEG (polyethylene glycol) confirms that a support material must be chosen to maximize enzyme activity and its mechanical properties and will dictate the configuration of the reactor.
resulting in a huge threat of pollution. It is worthwhile noting that the removal of dyes can be done by various techniques. The removal of dyes described in this review has advantages and disadvantage. Conventional technology was not efficient against the removal of all types of dyes because their molecular structure and chemical properties is complex. Few current technologies such as coagulation, ozonation and activated carbon can efficiently remove only restricted group of dyes. Combination of physical, chemical and biological processes more efficient for textile dye removal but can be expansive. Last two decades vast number of research work has under gone on efficiency of white rot fungus on dye decolourization. Even though various methods to assess decolourization of dyes researchers has been paid more attention on using lignin degrading enzymatic system of white rot fungi for solving the serious environmental pollution problem. Although lignin modifying enzymes gives effective decolourization results this approach is not optimal. So, future studies should be conducted using advanced analytical techniques, to elucidate the catabolic processes involved in the degradation of distinct dye groups by the lignin modifying enzymes of white rot fungus. Advances in molecular techniques can help to create microbes with improved metabolic capabilities by cloning the gene coding for the decolourizing enzymes into suitable expression systems using strong promoters.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524153EnglishN2013February18General SciencesPOLYCHLORINATED DIBENZO P DIOXINS AND FURANS- A REVIEW
English1422D. J. Mukesh KumarEnglish D. DeepikaEnglish B. SrinithyaEnglish P. T. KalaichelvanEnglishPolychlorinated dibenzo p dioxins and furans are considered as the highly toxic pollutants among the organic pollutants emitted from various industries as byproducts. They are almost found in all the section of the global ecosystem. They can persistent in the environment and with stand for a long period of time and considered to be accumulated in the food web. This review paper describes about the different sources of emission of this organic compound from the environment. Various remediation methods for the reduction of PCDD/PCDF from the environment were also discussed in this paper.
EnglishPersistent organic pollutants, Dioxins, Toxic equivalent factor, SourcesINTRODUCTION
Persistent organic pollutants (POPs) are the most dangerous pollutants released by human activity into the environment. Persistent organic pollutants have been released as unwanted byproducts from industries for decades. In current days, these POPs reveals few unusual characteristics like Persistence iREMEDIATION/REDUCTION OF PCDD/PCDFn environment, Bio-accumulation, and can travel to a long distance. They also cause adverse health effects to both humans and animals since it is highly toxic and persistent in the environment (GEF, 2009) There are various types of persistent organic pollutants; they are short listed into 12 compounds which also include polychlorinated dibenzo-pdioxin and polychlorinated dibenzofurans (PCDD/PCDF). Some forms of carbon such as coal, charcoal, graphite, inactivated amorphous carbon can generate PCDD/PCDF. The generation of PCDD/PCDF from these carbon sources is due to the degeneration and deformation of graphite structures. (Physician Consensus Statement, March 1998) The polychlorinated dibenzo-p-dioxin (PCDD) has 75 derivatives and polychlorinated dibenzofurans (PCDF) have 135 derivatives which are commonly referred to ‘dioxins’ (Kutz et al., 1999). These 210 individual derivatives of PCDD and PCDF have been emitted from both thermal and industrial processes. Characteristics of Higher chlorinated PCDD/PCDF (Kutz et al., 1999).
Less soluble in water
Low volatile
Absorb strongly to surfaces
MODE OF TRANSFER TO ENVIRONMENT
Terrestrial food chain
Air→plants/soil→cattle→milk/meat→man PCDD/PCDFs are less lipophillic, poor water soluble and hence bind to the granular particles such as soil and sediments. They might also accumulate in adipose tissues of organisms. They are accumulated on plant surfaces through deposition (wet/dry) of chemicals which adhere to the particles present in the atmosphere and also by diffusive transport which transfers gaseous chemicals in the air to the plant surfaces. Some amounts of PCDD/PCDFs rested on soil, move back to the environment by resuspending less chlorinated congeners (Kutz et al., 1999).
Release to air
Release of PCDD/PCDFs into air is either by stationary or diffused sources. Stationary source: This particularly involves industrial activities such as production and manufacturing processes. Diffused or dispersed source- which mostly relates to products containing PCDD/PCDFs. Some of the processes which release PCDD/PCDFs into air are:
1. Combustion processes
2. Metal processing operations
3. Drying and baking operations
4. Thermal processes
Even though the development of many technologies have tried to decrease and control the levels of emission of PCDD/PCDFs into air, it is more important to prevent the shifting of emission from one media to another (Environment and Social Development Organization, 2005) Release to water Dumping of wastes, applying pesticides directly, discharge of waste water runoff from contaminated sites result in release of PCDD/PCDFs into water (Environment and Social Development Organization, 2005) Release to land Direct application of contaminated products and deposition of PCDD/PCDFs through environmental process are the ways of releasing PCDD/PCDFs into land (Environment and Social Development Organization, 2005)
MODE OF ACTION
PCDDs and PCDFs are collectively called as dioxins which enter into human cell by using Aryl hydrocarbon (Ah) receptor which is generally present in the cell. The two main remarkable things about aryl hydrocarbon receptor are:
1. Even after 30 years of research, scientists do not know why it is present in the cell. Ah receptor’s normal ligand and its function are yet unknown.
2. Every species above invertebrates has the Ah receptor.
TOXIC EQUIVALENT FACTOR (TEF)
Toxic equivalent factor (TEF) was developed to rank the toxicity level of individual Dioxins. Toxicity equivalent factor helps to represent increasing toxicities of complex PCDD/PCDF mixtures and are expressed as a single Toxic equivalent quantity value (Kutz et al., 1999). Polychlorinated Biphenyls toxicity equivalents are similar to 2, 3, 7, and 8,-TCDD and concentration of PCDD/PCDFs congeners are expressed through TEFs which helps us to know risk levels. It is used to evaluate human health risks posed by PCDD/PCDF mixtures by using TCDD (Tetra Chloro dibenzo p dioxin) as an index chemical (Risk Assessment Forum., 2010). To apply TEF method, dose-response function must be known since toxicity of index chemical gives scaling factor for each Dioxin like compounds (DLC) and this when multiplied with environmental exposure concentration gives individual PCDD and PCDF dose equal to index chemical dose. TEF values are determined by correlating the ratio of molar dose of Tetrachloro dibenzo-p-dioxin to produce 50% effect to that of chemical which is to be tested to produce 50% effect. The TEC (TCDD Equivalent Concentration) can be known by multiplying the TEF value of an individual dioxin to the concentration of that derivative in the tissue sample (Michael et al., 1996). Then the total TEC can be obtained by summing up all the TEC values of each congener. TEQ can be calculated by using the following equation (Otto Hutzinger et al., 2000) TEQ = ((PCDDi × TEFi) n ) + ((PCDFi × TEFi) n )
EXPOSURE AND HEALTH RISK ASSESSMENT
Exposure of PCDD/PCDFs into the environment affects the people severely. They were exposed to these compounds by inhaling them from air, eating plants and animals which are accumulated by high concentration of PCDD/PCDFs. These compounds alter the endocrine functions which end up infertility disorders, pregnancy problems. These are due to the strong resemblance/correspondence of the dioxin structure to the sex and steroid hormones. It also causes inflection in thyroid and testosterone levels in plasma, attenuating neurological effects and reduced glucose tolerance (WHO, 1996) Human carcinogenesis was predicted by study which was done based on human exposures by gathering an occupational group who differ in the order of magnitude of accumulation of PCDDs in tissues more than background levels (McGregor et al., 1998). A study explains the quantitative information about dose-response relationship. The dose-response relationship is considered to be important (McGregor et al., 1998). From the data collected in 1997, based on the results of single cohort studies done on small number of workers exposed to contaminated herbicides or on the basis of animal carcinogenicity, the results were not consistent and no assessment of PCDD/PCDFs were made (McGregor et al., 1998). In humans, dioxins carried to newborn can be determined by plasma concentrations where it stays in blood and onto the new born (Farland., 2003). As drug-receptor complex results in biological response similarly plasma concentrations can result in human exposure data whereas for animals Physiologically-Based Pharmacokinetic models are used to provide reasonable values (Farland., 2003). The exposure of PCDD/PCDF to humans occurs through intake of animal as a major source of food. Several countries have characterized Tolerable Daily Intake (TDI) of PCDD/PCDF depending on No Observed Adverse Effect Level (NOEAL) acquired from animal tissues (Kulkharni et al., 2007). A Tolerable Daily Intake for TCDD at 10pg/kg was established by WHO in 1990, based on TCDD induced liver cancer in rats. WHO highlighted that if the average intake over a long periods is not exceeded, then the TDI expresses a Tolerable Daily Intake for lifetime exposure and that irregular excursions above TDI would have no health effects. The range of TDI is the equal to the typical/average daily intake by all passages of emission to PCDD/PCDFs estimated as TEQs. WHO suggested that TDI is not applicable to breastfed newborns as the approach of TDI is in accordance with the dose absorbed throughout the lifespan (WHO, 1996). In addition to this, another consultation reported that even though for many concerns, humans might be less sensitive than animals, there are still some ambiguities remain regarding animal to human susceptivities. Moreover there are many dissimilarities occur in half lives for destruction of different TEQ compound mixtures. A combined uncertainty factor of 10 was proposed in order to account for all such ambiguities. By applying this uncertainty factor of 10, a TDI (Tolerable Daily Intake) range was developed (Otto Hutzinger et al., 2000).
PCDD/PCDFs SOURCES
Incineration sources
Incineration is the waste treatment process that involves the burning of the organic substances which are present in the waste materials. They are been treated at high temperature which transfers the waste in Ash or flue gas. The incinerator units are categorized into
? Municipal Waste Combustors (MWC),
Medical Waste Incinerators (MWI),
Hazardous Waste Incinerators (HWI),
Boilers and Industrial Furnaces (BIF),
Cement kilns (CK),
Biomass Combustors (BC).
i. Municipal waste incinerators
Municipal incineration is the most expensive technique. They involve skilled working and maintenance of the incineration, this technique is commonly being adopted by the developed companies The flue gases of Municipal solid waste incinerators are responsible for the emission of PCDD/PCDFs (Kim et al., 2001). The presence of dioxins and their precursors in municipal solid waste were observed to be around 50ng I-TEQ/kg (Abad et al., 2002). Some municipal waste incinerators include a. Mass Burn Refractory-Wall, b. Mass Burn Water Wall, c. Refused Derived Fuel, d. Modular Starved Air, e. Modular Excess Air f. Rotary Water Wall (Thomas et al., 1995)
ii. Hospital waste incinerators
Hospital wastes like used syringes, needles, test tubes, bandages, cell cultures, plastics, human anatomic remains, wastes contaminated with viruses, bacteria, fungi etc were not disposed in a proper way and hence the incineration (combustion) of high chlorinated wastes emit PCDD/PCDFs (Stanmore et al., 2000). Hospital waste incinerators are smaller and less organized than municipal waste incinerators and so they may be less functioned than municipal waste incinerators (Thomas et al., 1995)
iii. Sewage sludge incinerators
Sewage sludge incinerators are used mostly to burn dewatered sewage sludge which are also a main source of emitting PCDD/PCDFs (Fullana et al., 2004) Due to improper land filling and recycling, restriction to sea disposal has led to the usage of incinerators which emit PCDD/PCDFs into the environment (Kulkharni et al., 2007).
iv. Hazardous waste incinerators
The toxic compounds released from chemical processes are referred as hazardous wastes. These compounds can be carcinogenic, mutagenic, explosive, inflammable, oxidizing, corrosive and highly toxic based on their kinds. The incineration for such hazardous wastes is termed as hazardous waste incinerators. Such incineration process is also a source of emission of PCDD/PCDFs (Karademir et al., 2004). Food chain designing is used to figure out the emission of hazardous wastes to plants and animal tissues (Aykan Karademir., 2003)
Thermal and combustion processes
High temperature and combustion processes are considered to be the major source of emitting PCDD/PCDFs into the environment. Thermal processes are applicable to municipal, medical and chemical waste incineration. Iron, steel, nickel and magnesium are also produced in high temperature combustion processes. The main sources of PCDD/PCDFs to the atmosphere are flue gases released from thermal processes (Grzegorz Wielgosi?ski., 2010).
i. Thermal degradation of commercial products
Thermal processecing of commercial products are also responsible for the emission of PCDD/PCDFs. Combustion of PCBs produces polychlorinated dibenzo furans and burning of PVCs also lead to congeners of PCDD/PCDFs (Rajagopalan et al., 2004).
ii. Coal and wood burning
In non industrial processes, several studies have shown that the PCDD/PCDFs are present in the emission as well as in ash/soot from wood fires. While comparing coal fired utilities to wood burning, the emission of PCDD/PCDFs is very less, even though they are larger in size, and they also affect very large areas (Kulkharni et al., 2007).
iii. Cement kilns
Another major source of PCDD/PCDFs is cement kilns, which vary widely in their emission patterns and quantities. The variations may be because of many factors, which include kiln’s model, performing conditions, fuels and unrefined materials fed into it. Hazardous wastes like PCDD/PCDFs are produced during the combustion of varied mix of fuels including petroleum coke, coal, refinery distillation ends and other supporting fuels in kilns. Industrial sources i. Metal treatment and processing industries Copper smelting and electric arc furnaces in steel processing, which are also a high temperature processes emit PCDD/PCDFs (Rajagopalan et al., 2004). ii. Paper and pulp industries During pulp bleaching, the phenol present in the pulp reacts with chlorine and chlorinated compounds which results in emission of PCDD/PCDFs under high pressure and temperature conditions (Rajagopalan et al., 2004) iii. Photochemical processes In photochemical dechlorination, the higher chlorinated PCDD/PCDFs are converted to lower chlorinated congeners. For instance, hepta, hexa, penta, and tetra congeners are produced from the photochemical dechlorination of octa chlorinated dibenzo dioxins and octa chlorinated dibenzo furans (Rajagopalan et al., 2004) Reservoir sources The accumulation of PCDD/PCDFs in soils, sediments, organic matter, landfills sites and vegetation is mainly due to their persistent and hydrophobic nature (Kjeller Lo et al., 1995) PCDD/PCDF reservoirs where they are already present either as products or in the environment. They are not intentionally present but are from other sources. The main feature of reservoir sources is that they have the capability of releasing PCDD/PCDFs into the environment again. As a by-product they can be released into three mediaair, water, land as product and waste (Environment and Social Development Organization, 2005)
REMEDIATION/REDUCTION OF PCDD/PCDF
Remediation As PCDD/PCDFs are carcinogenic, understanding the pathway of their contamination is of more concern. Mostly the toxic PCDD/PCDFs are accumulated in soils and sediments which have their source from reservoirs. The estimated amount of soil polluted with PCDD/PCDFs was 500,000 tons, which needs remediation (Johnson., 2008). i. ex situ remediation technique Ex situ is the offsite convertion, in this the remediation technique are not directly located in the particular contaminated product. Ex situ thermal process is used to transport the contaminants from soil to vapor phase. It is achieved by three steps: Soil conditioning, thermal treatment, exhaust gas purification. In soil conditioning, the soil is broken into smaller granular particles and they are sieved in preparation for thermal treatment, which increases the heat supply to the soil and evaporation of pollutants occurs and finally the contaminants are transferred to the gas phase (Koning et al., 2000). The methods which come under ex situ remediation are: composting, Land farming, biopilling and bioreactor processing. This process degrades petroleum hydrocarbons (TPH), polycyclic aromatic hydrocarbons (PAH), benzene, toluene, ethylbenzene, xylenes (BTEX), phenol compounds, PCDD/PCDFs etc (Koning et al., 2000). ii. In situ remediation techniques This technique is applicable only for specific type of soils, which include high permeable and low organic content homogenous soils. It is suitable for removing pollutants that can be deprived in lower temperature. In this process a steam air is introduced into the soil at 60-100?C. The steam-air mixture must be controlled in this temperature range, since pollutants must not be transferred to ground water. After the injection of steam air mixture into the soil, the volatile and non volatile contaminants move from soil to vapor phase.
Treatment of fly ash
PCDD/PCDFs are formed generally during combustion of organic matter in the presence of chlorine, where flyash is the residue and results in major environmental pollution. (Nam et al., 2008) found that PCDD/PCDFs in flyash can be degraded by Sphingomonas wittichii strain RW1. From a study in 2005, it was identified that the 75.5% of PCDD and 83.8% of 2,3,7,8-TCDD were eliminated from flyash by degradation and adsorption on viable and non viable cell biomass (Nam et al., 2008) From a study of 2008, a biocatalyst was introduced to degrade PCDD/PCDFs, through a combination of mix of 4 bacterial and 5 fungal strains. 68.7% of PCDD and 66.8% of 2, 3, 7, 8- TCDD were degraded by the biocatalyst. It was confirmed that, an extracellular non specific enzyme named oxidases could degrade highly stable PCDDs and lignin in fly ash (Nam et al., 2008). Sorption / desorption of PCDD/PCDFs Cyclodextrin are sugar molecules which are bound together in a ring. They are produced from starch in the means of enzymatic conditions. These are widely used in chemical industries and environmental engineering. Cyclodextrin (CD) was used for degrading PCDD/PCDFs, which are present in soil and water. There are five classes of cyclodextrins commonly. They are, (1) α-cyclodextrin (ACD), (2) β-cyclodextrin (BCD), (3) hydroxypropyl-α-cyclodextrin (HPACD), (4) hydroxypropyl-β-cyclodextrin (HPBCD), and (5) hydroxypropyl-γ-cyclodextrin (HPGCD). Among these, the efficient CDs in removing the contaminants are hydroxypropyl-β-cyclodextrin (HPBCD), α-cyclodextrin (ACD), β-cyclodextrin (BCD) (Cathum et al., 2010). CDs are first made to trap (bound) to PCDD/PCDFs in soil and water. The initial concentration of unbound PCDD/PCDFs was monitored. After a certain period of days, CDs would remove PCDD/PCDFs present in soil and water. And the highest efficiency of removing all congeners of PCDD/PCDFs is 96%, which is achieved by hydroxypropyl-β-cyclodextrin (HPBCD). Following to that, α-cyclodextrin (ACD) has an efficiency of 45% and β- cyclodextrin (BCD) has an efficiency of 50% in removing PCDD/PCDFs. The CDs were selected based on the diameter of the molecular void and functional groups present in it (Cathum et al., 2010). Thermal desorption Many PCDD/PCDF contaminated sites are treated by thermal desorption method. It is a separation process, in which heat is used to separate hydrocarbons from contaminated soils. Equipment is designed for thermal desorption called thermal desorber. It supplies enough heat to the contaminant soil, due to which the constituents are evaporated and separated from the soil (Kulkharni et al., 2007).
Bio degradation
Anaerobic reductive dechlorination (ARD) and aerobic dioxygenation are the two methods which have been studied for microbial degradation of PCDD/PCDFs (Field, Chang., 2008). In anaerobic reductive dechlorination, the hydrogen molecules replace the chlorine molecules (Mohn., 2008). In biodegradation process the reduction of toxic compounds are done by means of micro organisms. The micro organisms reduce Persistent Organic Pollutants (POPs) especially dioxin and dioxin like compounds by oxidation and cleavage of aromatic rings in presence of oxygen (Chang., 2008). The genes involved in anaerobic dechlorination and aerobic angular dioxygenation called as dioxin detoxification genes (DDGs) are accountable for reducing toxicity of PCDD/PCDFs. Pseudomonas and Sphingomonas (RW1) are efficient strains for oxidizing PCDD/PCDFs (Chang ., 2008). Lower chlorinated congeners are reduced under aerobic conditions and higher chlorinated congeners are reduced under anaerobic conditions. Intermediate products are formed during aerobic and anaerobic processes are less equal or more toxic than the original pollutants (Kao et al., 2000).
Destruction of PCDD/PCDFs by Carbon Nanotubes
Carbon NanoTubes can be seen as smooth and flat graphite sheets that have been deformed, so that carbon atoms twist in a helical manner to form a tiny tube (Baughman et.al., 1999). They are of two types namely single walled carbon nanotubes (SWCNT) and multi walled carbon nanotubes (MWCNT). The characteristics of CNTs are high surface area, interstitial space with a cluster of nanotubes, electron mobility, electrical conductivity, (Dai et al., 2002) mechanical properties , (Saridara et al., 2005) like chemical and thermal stabilities. Thus Carbon NanoTubes are used to carry catalysts that help in destruction of dioxins (Lina Zhou et al., 2010). As dioxins have high melting and boiling point, the estimation of adsorption isotherms is difficult. A technique was developed, which depends on Temperature Programmed Desorption (TPD) to study adsorption isotherm of dioxins (Yang et al., 1999). From a study, it was identified that doped graphene and doped nanotubes are efficient in disruption of dioxins (Kang ., 2005). Vanadia – tungsta – titania catalysts are more effective than noble metal catalysts to reduce the concentration of dioxins below 0.1ng TEQ/Nm3 (Lina Zhou et al., 2010). The adsorption and absorption of carbon nanotubes only transfer the contaminants from gas phase to solid or liquid phase, but the catalysts alone cause the elimination of dioxin totally (Yoshikawa et al., 2004).
FUTURE ASPECTS AND CONCLUSION
As PCDD/PCDFs are highly toxic and more persistent, understanding about the source of contamination is essential. PCDD/PCDFs are emitted from various sources like industrial sources, reservoir sources, combustion sources and incineration sources. These POPs affect human health adversely; especially it causes infertility, endocrine disruption, modulation of sex and thyroid hormones. To summarize, biodegradation is most effective reduction method for converting toxic PCDD/PCDFs into non toxic and harmless compounds. In future, the destruction of gas phase PCDD/PCDFs contaminants by adsorption and catalytic destruction using Carbon Nano Tubes can be a promising method to reduce the PCDD/PCDF contamination.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524153EnglishN2013February18HealthcareSTUDY OF OBESITY AND ITS RISK FACTORS AMONG WOMEN OF REPRODUCTIVE AGE GROUP
English2328Shashidhar BasagoudarEnglish Chandrashekhar R.EnglishObjectives: 1. To find out the proportion of overweight or obesity among women of reproductive age group. 2. To find the association between various socio-demographic factors and overweight or obesity. Material and Methods: A cross-sectional study conducted among ever married women of reproductive age group who have attended the Urban health training centre during the study period of six month. Data was collected by direct interview through prestructured questionnaire and anthropometric measurement. Results: Among the 244 women studied 11.9% were having overweight, 9.9% were obese, 20.1% were underweight and only 58.2% of the women were having normal BMI. Overweight or obesity was significantly more among those women who were eating junk foods regularly, watch television while eating and those with mild to moderate physical activity. There was significant association between family history and overweight. There was no significant association between religion, type of family and type of diet with overweight. Overweight was more common in literates compared to illiterates and proportion of being overweight increases with higher socioeconomic status. Conclusion: Overweight or obesity is one of the major problems even in those areas with high prevalence of undernourishment. Physical inactivity and the dietary factors are the major risk factors for such high proportion of overweight or obesity.
Englishobesity, overweight, reproductive age, BMIINTRODUCTION
Obesity may be defined as an abnormal growth of the adipose tissue due to an enlargement of fat cell size or an increase in fat cell number. Obesity is expressed in term of body mass index (BMI).1 The latest WHO projections indicate that at least one in three of the world's adult population is overweight and almost one in ten is obese.2 According to National Family Health Survey-3 in India 14.8% (28.9% for urban and 8.6% for rural) of married women in the age group of 15-49 years were overweight or obese.3 Overweight or obesity can have a serious impact on health. Carrying extra fat leads to serious health effects such as cardiovascular diseases4,5, type 2 diabetes mellitus6 , musculoskeletal disorders like osteoarthritis, gall bladder disease and some cancers (endometrial, breast and colon). These conditions cause premature death and substantial disability.4 Because of difference in the proportion of fat content, in Asians, the health risks caused due to overweight or obesity occur at lower levels of BMI compared to other regions of the world. 7, 8 The earlier BMI cut off values were developed by western researchers based on studies in Caucasian populations, Therefore new classification with lower cut off values of BMI was developed to classify overweight and obesity among Asian people.9 India being one among the Asian countries the new classification is applicable to Indians and it is also obvious that Indians are more at risk of complications due to overweight or obesity. Raichur is one of the underdeveloped districts of Karnataka. Most of the studies previously done in this area have shown about the under nutrition but as it is the phase of transition everywhere, it was essential to have data regarding overweight and obesity in this area also. Hence a study was conducted with the objective of assessing the proportion of women having overweight or obesity among women of reproductive age group and also to know the factors influencing the occurrence of overweight or obesity.
MATERIAL AND METHODS
A cross sectional study was carried out at the Urban Health Training Centre (UHTC), Amtalab, Raichur, which is part of the department of Community medicine, Raichur Institute of medical sciences. Study was conducted among the ever married women in the reproductive age group (15- 45 years) who have attended the UHTC during the study period of 6 months (January 2012 to June 2012). Women who were pregnant during study and those women who did not give consent for the study were excluded from the study. Oral consent for participation in the study was obtained from all the participants after informing about the study and its purpose. Data was collected about sociodemographic profile and some risk factors for obesity through prestructured questionnaire by interview method. Anthropometric measurement like weight and height are also recorded. BMI classification for Asians was utilized for assessing the overweight or obesity. Data was analyzed using SPSS 16 software. Data is expressed as proportion or percentage, association between various factors and obesity was assessed using chisquare test and p value of Englishhttp://ijcrr.com/abstract.php?article_id=1300http://ijcrr.com/article_html.php?did=13001. Park K. Textbook of preventive and social medicine. 21 st ed. Jabalpur: Banarsidas Bhanot; 2011. P. 366-70.
2. World Health Organization. Fact sheet on obesity available on http://www.who.int/features/qa/49/en/index.h tml cited on 29/11/2012
3. National Family Health Survey-3, India, 2005-2006 available on http://www.rchiips.org/NFHS/pdf/India.pdf cited on 29/11/2012
4. World Health Organization. ObesityPreventing and managing the global epidemic. WHO technical report series 894. Geneva: WHO;1999:456.
5. Gupta R, Gupta VP. Obesity is a major determinant of coronary risk factors in India: Jaipur heart watch studies. Indian Heart J 2008;60:26-33.
6. Colditz GA, Willett WC, Stampfer MJ, et al. Weight as a risk factor for clinical diabetes in women. Am J Epidemiol 1990;132:501-13.
7. Jafar TH, Chaturvedi N, Pappas G. Prevalence of overweight and obesity and their association with hypertension and diabetes mellitus in an Indo- Asian population. CMAJ 2006;175:1071-7.
8. Prasad DS, Kabir Z, Dash AK, Das BC. Abdominal obesity, an independent cardiovascular risk factor in Indian subcontinent: A clinic epidemiological evidence summary. J Cardiovasc Dis Res 2011; 2:199-205.
9. World Health Organization (WHO), International Association for the Study of Obesity (IASO), and International Obesity Task Force (IOTF). The Asia-Pacific Perspective: Redefining Obesity and Its Treatment. Geneva: World Health Organization. 2000:378-420.
10. Kumar N, Gupta N, Kishore J. Kuppuswamy’s socioeconomical scale: updating income ranges for the year 2012. Indian journal of public health 2012 Jan; 56(1):103-104.
11. Anuradha R, Ravivarman G, Jain T. The Prevalence of Overweight and Obesity among Women in an Urban Slum of Chennai.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524153EnglishN2013February18HealthcareRELATIONSHIP OF ULTRASONOGRAPHIC ENDOMETRIAL THICKNESS AND MORPHOLOGY TO BODY MASS INDEX IN POSTMENOPAUSAL WOMEN
English2936Shalaan R.M.English Deghidi A.N.English Hegazy A.I.EnglishBackground: Menopause is that point in time where permanent cessation of menstruation occurs following the loss of ovarian activities. Ultrasonography is simple, non-invasive technique, highly acceptable to the patient. It offered detailed delineations of the uterus and its myometrium, endometrium and vessels. So, several uterine disorders can be evaluated by ultrasound.. BMI is an inexpensive and simple method of classifynging for weight categories that may lead to heath troubles
Objective: To investigate the relationship between ultrasonographic endometrial thickness and morphology to body mass index in postmenopausal women. Materials and Methods: Three hundred postmenopausal women (mean age, 59.95+3.73 years; range 55-65) were studied. Age, years since menopause and BMI characteristics were recorded. The relationship between ultrasonographic endometrial thickness and and morphology to baseline characteristics was evaluated in each woman. Results: BMI was positively correlated with endometrial thickness (r= 0.841), but age and years since menopause were negatively correlated (r= -0.224) (r= -2.84). Conclusion: There is positive relationship between BMI and endometrial thickness in asymptomatic postmenopausal females.
EnglishBody mass index; endometrial thickness; transvaginal ultrasonographic.INTRODUCTION
Menopause is a date for those women who still have a uterus, it is defined as the day after a woman’s last period ever finishes. This span of time is also referred to as “change of life” or “climacteric”. The average age of menopause is 51 years, and the normal age range for last period ever is somewhere between 45 to 55. 1 A woman who still has uterus can be declared to be in post menopause once she has gone 12 full months with no flow at all, not even any spotting. The reason for this delay in declaring a woman post menopausal is because periods become very erratic at this time of life, and therefore a reasonably long stretch of time is necessary to be sure that the cycling has actually ceased. At menopause, the ovaries produce less of the hormone estrogen. Less progesterone is produced as well. Although periods tend to be less regular around menopause, irregular bleeding can be a sign of problems. 2 Transvaginal ultrasound is routinely performed as part of a pelvic examination in postmenopausal woman . 3 The normal value of endometrial thickness in asymptomatic postmenopausal women is ≤ 5mm. Five millimeters has been “cut off point” for excluding endometrial pathology after menopause and more than 5mm need endometrial pathology to exclude disease. 4 Body mass index “BMI” is a number calculated from a person’s weight and height. BMI is an inexpensive and easy to perform method of screening for weight categories that may lead to heath problems. 5 Formula = weight (kg) / (height (m))2 . 6 BMI of 18.5- 24.9kg / m2 is normal weight . BMI under 18. 5 kg / m2 indicate under weight. BMI of 25-29.9 kg / m2 indicate overweight. BMI over 30 kg / m2 indicate obesity . BMI over 40 kg / m2 indicate morbid obesity Obesity increases endogenous free estrogen level including peripheral conversion of adrenal steroids by fat cells and decreased levels of sex hormones binding globulin.7 It has been shown that women who are 20 – 50 pounds overweight have threefold and women more than 50 pounds have tenfold increased risk of endometrial cancer.8 Several studies (Andolf et al., 1993)7 and (Douchi, et al., 1998)8 have reported relationship between obesity and endometrial thickness, also as risk factor in development of endometrial cancer that stimulate us to do this study. The aim of the work is to find if there is any relationship between ultrasonographic endometrial thickness and morphology to body mass index in postmenopausal women.
METHODS
Three hundred Postmenopausal women were included in this study. They attended outpatient clinics of Internal medicine at Zifta General Hospital and Benha University Hospital. Patients were at least one year post menopause. Participations in the study were voluntary and based on the women who want to fill and sign informed consent.They informed that all collected data and information will be strictly confidential and will not be accessed by any other party without prior permission from the participant. The participants had the right to withdraw from the study at any given time without giving any explanation. All cases were subjected to the following: Complete History Taking, General examination including weight, height BMI is calculated as follows: BMI = weight (kg) / height (m2). Vaginal sonography was done to all patients by Ultrasonography apparatus(TOSHIBA (Japan) with transvaginal probe 7.53 MHZ). The transducer tip was covered with ultrasound coupling gel and introduced into a protective sheet; a small amount of gel was applied the uterus was also systematically scanned for other incidental pathology .The endometrial thickness is measured from the proximal and distal interfaces between highly reflective and surrounding poorly reflective layers and measured in longitudinal axis of the uterus. Endometrial texture is examined to notice the presence of asymmetry. Irregularity or local thickening of the endometrium denoting the presence of a symmetrical endometrial hyperplasia or endometrial carcinoma Endocervical canal was examined to exclude cervical pathological lesions .The ovaries were then examined to diagnose the presence or absence of associated ovarian lesions. Atrophic endometrium appeared as a thin echogenic line. The endometrium normally measures 5mm or less in anteroposterior diameter in postmenopausal women. Cases with endometrial thickness more than 5mm were subjected to curettage by Novak curette.9-11 Curette are introduced and sampling was done. The endometrial specimen was immediately preserved in 10% formalin and sent for histopathalogical examination
Statistical Analysis:
The data were collected in file for each patient and then coded and fed to the computer on statistical package for social sciences (SPSS) version 11.0 for statistical analysis. Mean, Standard deviation and prevalence were calculated. Chi square test was done to compare between categorical variables. Paired student’s ttest was done to compare between nonparametric variables.
RESULTS
This study has been conducted on 300 asymptomatic menopausal women. The age of onset of menopause ranging from 55-65 years with a mean of 59.95 years and S.D +3.73 years and the years of age since menopause ranging from 5 -15 years with a mean of 9.95 years and S.D of ± 3.73.The thickness of the endometrium ranges from 3-8 with a mean of 5.85 mm and S.D + 0.640 .The body mass index ranges from 21.2 – 46.7Kg/m2 with a mean of 28.74 Kg/m2 and S.D + 6 .
To find a significance ,we used Chi square test. Chi square = 0.841, p < 0.001. There was highly significant positive correlation between Endometrial thickness and Body Mass Index.
Chi square = -0.224 . p < 0.05. There was a significantly negative correlation was found between Endometrial thickness and Age.
There was highly significant negative correlation was found between Endometrial thickness and Years since menopause.
12 cases in this study had endometrial thickness more than 5mm to whom endometrial sampling was performed with the following results, 10 cases had atrophic Endometrium, one case showed Endometrial Polyp(Endometrial thickness =7.3, BMI =45) and only one case revealed a picture of Chronic endometritis (Endometrial thickness =6.8, BMI =39.7). Histopathological examination for 12 cases with endometrial thickness more than 5 mm revealed that 10 cases (83.3%) showed atrophic endometrium , one case (8.3%) showed chronic endometritis and one case (8.3%) showed endometrial polyp .
DISCUSSION The endometrial thickness was measured by the use of vaginal ultrasound, endometrial thickness below 5 mm endometrial thickness was used as a cut off value which is the chosen cut off value for our standard upper limit of normal endometrium (Neele et al.,2002). Significant disagreement persists with regard to the relationship between BMI and sonographic endometrial thickness in postmenopausal women.12 In the present study, it was found that BMI was significantly correlated with endometrial thickness in asymptomatic postmenopausal women. On stepwise multiple regression analysis, BMI was still correlated with endometrial thickness, irrespective of age and years since menopause. This study agrees in part with the report by Andolf et al.,7who demonstrated that endometrial thickness correlated with BMI. However, they omitted both age and years since menopause from their analysis. The observation disagrees with the report by Van den Bosch et al. 13 which indicated that no significant association could be found between endometrial thickness and weight or BMI, after adjusting for age. They concluded that age is a significant confounder regression analysis. The findings also disagree with those of Tsuda et al., 12 who reported that BMI showed no correlation with endometrial thickness in Japanese women with normal endometrium, while years since menopause was related to endometrial thickness. However,Van den Bosch et al.,13 excluded years since menopause, and Tsuda et al.,12 excluded age from the analysis. Although age and years since menopause are related variables, it remains unclear whether these two variables have similar effects on endometrial thickness. We consider it is necessary to include both of these variables in the analysis. We found negative correlation of age or years since menopause with endometrial thickness.Tsuda et al.12 seported that years since menopause was a significant variable associated with endometrial thickness. They documented that for women less than 5 years since menopause, mean endometrial thickness was significantly greater than that for those more than 5 years from menopause. However, in their study, endometrial thickness did not differ with years since menopause in women more than 5 years on from menopause. There is a report that some but not all postmenopausal ovaries secrete estrogens and androgens. 14 The major source of estrogens in postmenopausal women is peripheral aromatization in adipose tissue. The endometrium is a target organ for estrogens. It appears that sonographic endometrial thickness mainly reflects serum E2 levels. 14The findings of this study agrees with Dandolu et al., 15 who reported that body weight and body mass index were higher in women with a thick endometrium independent on age and parity. For every 1-point increase in BMI, there was a 7.56 g increase in uterine weight. Berker al.,16 demonstrated that there was no statistically significant difference in respect of BMI. When endometrial histopathology was assessed according to endometrial thickness by ultrasonography, in nine of the 75 cases endometrium were greater than 5mm.No statistically significant association was found between BMI and endometrial thickness Increased prevalence of high BMI is another risk factor for endometrial cancer due to differing hormone levels. 17 Significant association was found between BMI and endometrial thickness in the present study.
CONCLUSION
There is a positive relationship between ultrasonographic endometrial thickness and morphology to body mass index in postmenopausal women.
Englishhttp://ijcrr.com/abstract.php?article_id=1301http://ijcrr.com/article_html.php?did=13011. Freeman EW.; Sammel MD. ; Lin. Symptoms associated with menopausal transition and reproductive hormones in midlife. Am .J. Obstet. Gynecol .2007 ; pp.30 – 40
2. Timmermans A.;Opmeer BC. ; Ersema, SV. And et al. Patient`s references in the evaluation of postmenopausal bleeding. An. Intern. J.Obestet. Gynecol .2007; 114 (9):1146 – 1149.
3. Warming l. ; Ravn,P.;Skouby,S. and et al. Measument precision and normal range of endometrial thickness in a postmenopausal by transvaginal ultrasound .Ultrasound in Obestet. Gynecol .2002 ;20(5): 492 –49
4. Neele,SJM. ; Marchien Van baal,W.; Van Der Mooren, P. and et al. Ultrasound assessment of endometrium in healthy , asymptomatic early postmenopausal women . Ultrasound in obestet. Gynecol.2002;16 (3) :254- 259 .
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7. Andolf E. ; Dahlander ,K. and Aspenberg, P.Ultrasonic thickness of the endometrium correlated to body weight in asymptomatic postmenopausal women.Obstet. Gynecol.1993; 82(6):936-40.
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9. Katanozaka M, Yoshinaga M, Douchi T, Nagata Y.Ultrasonographic endometrial thickness for detecting endometrial cancer in postmenopausal women. Med J Kagoshima Univ 1988;50:29–33.
10. Karlsson B, Granberg S, Wikland M, et al. Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding—A Nordic multicenter study. Am J Obstet Gynecol 1995;172:1488–94.
11. Granberg S, Wikland M, Karlsson B, Norström A, Fridberg LG. Endometrial thickness as measured by endovaginal ultrasonography for identifying endometrial abnormalities.Am J Obstet Gynecol 1991;164:47–52.
12. Tsuda H. ;Kawabata,M. ;Kawabata,K. and et al. Improvement of diagnostic accuracy of transvaginal ultrasound for identification of endometrial malignancies by using cut off level of endometrial thickness based on length of time since menopause. Gynecol. Oncol. 1997;64(1):35-7.
13. Van den Bosch T. ;Vandendael,A. ;Van Schoubroeck,D. and et al. Age, weight, body mass index and endometrial thickness in postmenopausal women. Acta Obstet. Gynecol. Scand.1996; 75(2):181-2
14. Longcope C.; Hunter,R. and Franz C. Steroid secretion by the postmenopausal ovary. Am. J.Obstet. Gynecol. 1998; 138(5):564-8.
15. Dandolu V.; Singh, R.; Lidicker,J. and et al. BMI and uterine size: is there any relationship ? Int. J. Gynecol. Pathol., 2010; 27(6): 568-71.
16. Berker B.; Erkmen, M. and Sevim,D. Relationship between body mass index and endometrial thickness in postmenopausal women. Clin. Obstet. Gynecol2005.;11 (3): 34-44.
17. Parazzini F.; La Vecchia,C. ;Bocciolone,L. and et al.The epidemiology of endometrial cancer. Gynecol. Oncol1992. ;41(1):1-16
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524153EnglishN2013February18HealthcareSTUDY OF SUDDEN NATURAL DEATHS IN MEDICO-LEGAL AUTOPSIES WITH SPECIAL REFERENCE TO CARDIAC CAUSES
English3742Sandesh H. ChaudhariEnglish Anand MugadlimathEnglish Mandar SaneEnglish K.U. ZineEnglish D.I. IngaleEnglish Rekha HiremathEnglishThis prospective cross-sectional study was carried out at Government Medical College, Aurangabad (M.S.) during a period of one year. Most of the sudden deaths were in 41-50 years of age group. Males predominate the females among all sudden deaths with male to female ratio 4.3:1. Cardiovascular causes were the principle cause followed by the respiratory causes among all sudden deaths. Deaths due to coronary artery disease and myocardial infarction amount to almost half of the cases of sudden natural deaths (40.25%). Confirmation of cause of death by histopathological examination was emphasized.
Englishsudden death, natural death, autopsy.INTRODUCTION
The term sudden death refers to the sudden and unexpected deaths; the external examination fails to elicit cause of death. The majority of these are natural deaths. But very often, natural deaths form the basis of medico-legal investigations, if they have occurred suddenly and unexpectedly in apparently healthy persons and under the suspicious conditions. In such cases, it is usually not possible to certify the cause of death only on external examination of body. In all such cases, an autopsy is imperative to obviate the possibility of unnatural death. After the completion of autopsy the outcome may quite often reveal some natural disease, the presence of which may pose issues like association of the disease with trauma, work, crime, emotion, excitement, etc may suggest suspicion of foul play and its relative contribution towards death. The study of sudden death helps in establishing the precise causes of death and enable in assisting the legal authorities in detection of crime, improve the mortality statistical data and pacify the bereaved and aggrieved relatives where the medical negligence was the sufficient ground for legal proceedings
MATERIAL AND METHODS
The material for the present study consists of the cases who died suddenly and/or unexpectedly and had been subjected to medico legal autopsy .The criteria for selection of cases was as per definition- “Sudden death is a death which is not known to have been caused by any trauma, poisoning or violent asphyxia and where death occurs all of a sudden or within 24 hours of the onset of the terminal symptoms”.
History about the cases was obtained retrospectively from the police record and meticulous autopsy was carried out in every case and the whole organ or pieces of organ showing gross pathologic changes were retained for histopathological examination and also for chemical analysis (CA). On the basis of histopathological report, final opinion as to cause of death was dispensed.
RESULTS AND OBSERVATIONS
Age wise distribution showed maximum number of cases belonged to 41-50 years age group with male predominance. Amongst these 159 cases, 129 cases (81%) were male and 30 (19%) were female. The male to female ratio was 4.3:1. [Table no.1] Among the causes of sudden death, 71 cases (44.6%) were due to cardiovascular causes (CVS), remaining were due to respiratory causes (25.7%), gastrointestinal causes (11.3%), 6.2% were due to central nervous system (CNS) causes, 5 cases each (3.1%) due to genitourinary (GUT) and miscellaneous causes and 9 (5.6%) showed multiple system involvement. [Table no. 2] Maximum cases of sudden death due to cardiac causes (44.6%) were seen in 41-50 years of age group; coronary artery disease (CAD) (71.83%) was the leading cause with male dominance .On histopathological examination, out of 13 cases of myocardial infarction, 4 cases (30.8%) showed microscopic changes suggestive of recent myocardial infarction and in 9 cases (69.2%), old healed scar of myocardial infarction was seen. It was observed that out of 71 cases of heart disease, biventricular hypertrophy was present in 15 cases (21%), solitary left ventricular hypertrophy in 32 cases (45%) and solitary right ventricular hypertrophy in 3 cases (4%). It was observed that in cardiovascular system, the minimum survival time was least (15 minutes), the mean survival time was also least 4.58 hours. Out of 41deaths(25.7%) due to respiratory diseases, pulmonary Koch’s [18 deaths (43.90%)] account for major cause of sudden death followed by pneumonia [12 cases (29.26%)], COPD [3 cases (7.31%)], pulmonary embolism [2 cases (4.87%)], solitary lung abscess [1 case (2.43%)] and deaths due to combined TB, Pneumonia, Pyothorax and lung abscess include rest of the diseases [5 cases (12.19%)]. In GIT, out of 18 cases, maximum number of cases of sudden death was due to liver pathology [7 cases (38.88%)]. In CNS, maximum numbers of sudden deaths were due to intracranial haemorrhage (60%) with male predominance.In GUT, out of 5 cases, 2 males (40%) died of pyonephrosis and each case of eclampsia, placental separation and pyonephrosis were responsible for female death. Miscellaneous causes of sudden death include septicemia, anemia, cerebral malaria and diabetic nephropathy, total 5 cases (3.14%) [Table no 3].
DISCUSSION
The definition of a sudden death varies according to authority and convention. In this medico legal study of sudden death, the duration of death process ranged from 1 to 20 hours, but it was difficult to determine how long the fatal symptoms had been present, as death often occurs before the victim reaches hospital, the situation in which no data on the symptoms are available for want of eye witnesses. In the present study, incidence of sudden death was 9% amongst the medico legal autopsies conducted during the study period. The finding of incidence of sudden death in the present study is somewhat consistent with the study of Sarkoija T. et al (5%) 1 and Siboni A. et al (4.06%) 2 . The present study do not match with that of Nordrum I. et al (27.8%) 3 , Meina Singh et al (2.66%) 4 , Azmak A.D. (28.98%) 5 , and Ambade V.N. (15.48%) 6. Age distribution for the present study showed most of the cases (30.81%) belonged to 41 to 50 years age group with male predominance (Table no.1). This finding matches with the studies of Meina Sing A. et al (34.5%) 4 and Ambade V N. (20%) 6 . In the present study, out of 159 total sudden deaths, 129 (81%) were male and 30 cases (19%) were female with male to female ratio 4.3:1(Table no1). This finding is consistent with the study of Azmak A D (males 83.4%, females 16.6%)5 Sarkoija T. et al (males 82%, females 18%)1 ,Nordrum I. et al (males 79.67%, females 20.32%)3 , Thomas A.C. et al (males 73.9%, females 26%)7 and Ambade V. N. (males 79.27%, females 20.73%)6 . Although there are numerous causes of sudden death, cardiovascular causes [71 cases (44.6%)] were the principle cause among sudden death in the present study. (Table no 3). Dr Narayan Reddy10 and Apurva Nandy11 stated that, most of the sudden deaths were due to cardiovascular causes, about 45 -50%. Similar findings were seen in the study of Kuller L. et al (49.5%)12 , Siboni A. et al (46.2%)2 , Di Maio V.J.M. et al (60.9%)13, Sarkojia T. et al (61%)1 , Luke J.L. et al (38%)14, Nordrum I. et al (69.15%)3 , Azmak A D (55%)5 . Coronary artery disease was not only the principle cause among cardiovascular causes, [54 cases (76.05%)] but also important cause among all sudden deaths amounting to 33.96%, with male preponderance, which is consistent with previous studies1, 2,3,4,6,7,12,13,14. This is because underlying heart disease is nearly always found in victims of sudden cardiac death. Typically in adults it takes the form of atherosclerosis or scarring from a prior heart attack. Therefore, risk factors for sudden cardiac death include similar risk factors for atherosclerosis, such as smoking, high blood pressure (B.P.), indiscriminate use of alcohol, sedentary life style, and stress and strain in life and lack of regular medical check up. In young victims, a thickened heart muscle from any cause, typically high B.P., or valvular heart disease is important predisposing factor for sudden cardiac death. Adrenaline released during intense physical or athletic activity often acts as a trigger for sudden cardiac death when less often, inborn blood vessel abnormalities of coronary arteries and aorta, may be present in young sudden death victims In the present study, out of 159 cases of sudden death, 41 cases (25.78%) were due to respiratory causes. The important were pulmonary tuberculosis 18 (43.90%) and pneumonia 12 cases (29.26%) (Table no. 3). The findings of deaths due to respiratory diseases are comparatively higher as compared to all above studies2, 3, 4, 7,9,12,13.. Most important causes of gastrointestinal diseases in our studies were gastroenteritis, cirrhosis of liver and peritonitis. The incidence of deaths due to liver pathology, 5 cases (27.7%) in our study nearly matches with the study of Kuller L. et al13 (27.7%) It is observed that in cardiovascular system, the minimum survival time was least (15 minutes); the mean survival time was also least 4.58 hours. This means that, when the lesion is in cardiovascular system the death sets in rapidly as compared to other systems. Study demonstrates the importance of histopathology in autopsy diagnosis of sudden deaths. Samples were taken for histopathological examination from the site showing gross pathological changes of heart, lung tissue, inflamed peritoneum, meninges, and brain tissue. Microscopic changes confirmed the gross diagnosis.
CONCLUSIONS
Incidence of sudden death among the total medico legal autopsies performed is 9%. Most of the sudden deaths are in the age group of 41-50 years (30.81%) with marked preponderance of males. Cardiovascular disease accounts for the maximum number of sudden deaths, in which Coronary artery disease is not only the main cause of cardiovascular deaths, but also among all sudden deaths.
Almost half of the sudden deaths show a strong correlation with chronic habits like smoking, tobacco chewing and alcoholism. The death sets in very rapidly in cardiovascular disease, as mean survival time is 4.58 hours. The most common causes of sudden deaths are coronary artery disease, tuberculosis, pneumonia and intracranial hemorrhage. Histopathological study helps in confirmation of the cause of death in sudden deaths.
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors, editors and 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=1302http://ijcrr.com/article_html.php?did=13021 Sarkioja T, Hirvonen J. Causes of sudden unexpected deaths in young and middle aged persons. Forensic Sci Int 1984; 24:247-61.
2 Siboni A, Simonsen J. Sudden unexpected natural death in young persons. Forensic Sci Int 1986; 31:159-66.
3 Nordrum I, Eide TJ, Jorgensen L. Unexplained and explained natural deaths among persons above one year of age in a series of medico-legal autopsies. . Forensic Sci Int 1998; 93:89-98.
4 Meina Singh A, Subadani Devi S, Nabachandra H, Fimate L. Sudden death in Manipur – A preliminary study. J Forensic Med Toxicol 2002; 19(2): 26-28.
5 Azmak A.D. Sudden natural deaths in Edirne, Turkey from 1984 to 2005. Med Sci Law 2007; 47(2): 147-55. PMID: 17520960.
6 Ambade V. N. Study of natural deaths in Nagpur Region. J Medicolegal Association of Maharashtra. 2002; 14(2): 11-14.
7 Thomas A.C, Knapman PA, Krikler DM, Davis MJ. Community study of the causes of “Natural” sudden death. Br Med J 1988; 297(3): 1453-56. 999
8 Clark JC. Sudden death in chronic alcoholic. Forensic Sci Int 1988; 36; 105-111
9 De la Grandmaison, Durigon M. Sudden adult death: A Medicolegal series of 77 cases between 1995 and 2000. Med Sci Law 2003; 43(1): 89.
10 Reddy Narayan KS. The Essentials of Forensic Medicine and Toxicology. Medical Book Co. Hyderabad 27th edi.2008:133-134.
11 Nandy Apurba. Principles of Forensic Medicine,2nd edi.New Central Book Agency (P) Ltd., Calcutta 2007 :136-37.
12 Kuller L, Lilienfeld A, Fisher R. Sudden and unexpected deaths in young adults. JAMA 1966;198(3): 248-52.
13 Di Maio Vincent JM, Di Maio Dominick JM. Natural death as viewed by the medical examiner. A Review of 1000 consecutive autopsies of individuals dying of natural disease. J Forensic Sci 1991; 36(1): 17-24.
14 Luke JL, Helpern M. Sudden unexpected death from natural causes in young adults. Arch Pathol 1968;85:10-16.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524153EnglishN2013February18HealthcareCOMPARISON OF SEROPOSITIVITY OF HIV, HBV, HCV AND SYPHILIS AND MALARIA IN REPLACEMENT AND VOLUNTARY BLOOD DONORS IN WESTERN INDIA
English4346Chetna JainEnglish N.C. MograEnglish Jhaman MehtaEnglish Rishi DiwanEnglish Gaurav DalelaEnglishObjective: This study was conducted to evaluate the seroprevalence of HIV, HBV, HCV, and Syphilis and Malaria among blood donors. The data generated will help the clinicians for judicious use of blood as well as awareness regarding the Transfusion transmitted infections. Research Design Methods: A total of 46,224 blood donors were screened during a period from April 2008 to October 2012, at blood bank, S.R.G. Hospital and Medical College Jhalawar - District, Rajasthan State. Results: Among these 22905 (49.55%) were voluntary donors and 25219 (54.58%) were replacement donors .Seropositivity for Human Immunodeficiency Virus (HIV) was 0.034%, Hepatitis B Virus (HBV) was 1.57%, Hepatitis C Virus (HCV) was 0.04%, Rapid plasma Reagin method (RPR) for syphilis was 0.019% and Malaria was 0.017% respectively. Conclusions: Infections are slightly more common among replacement donors compared to voluntary donors. There was a gradual decrease of Transfusion Transmitted Infections (TTIs) in blood donors over the years by reason of following of stringent blood donor selection criteria.
EnglishTransfusion Transmitted Infections (TTI), Seroprevalence, Human Immunodeficiency Virus (HIV), Hepatitis C Virus (HCV), Hepatitis B Virus (HBV).INTRODUCTION
Blood transfusion is the biggest treatment modality to save lives of thalassemic children, DIC and Post Partum Hemorrhage women, surgeries, accidents etc. There is a 1% chance of Transfusion Transmitted Infections (TTIs) with each unit of transfusion. TTIs can exist as asymptomatic diseases in the host1 .So all donors must be screened for high risk behavior related diseases2 . Unsafe blood transfusion pays high cost to society. Morbidity and mortality resulting from transfusion of infected blood have far – reaching consequences, not only for recipients themselves, but also for their families, communities and society3 . The diseases transmitted by blood are HIV, Hepatitis B and C, Syphilis, Malaria and infrequently Cytomegalovirus, Epstein Bar Virus, Parvo virus B19, Brucellosis etc. Prevention of TTIs presents one of the greatest challenges of transfusion medicine4 . As per guidelines of the ministry of health and family welfare (Government of India) under the Drug and cosmetic Act 1945, all blood donors are be to screened against five major infections HIV 1 and 2, HBsAg, HCV, syphilis and Malaria. Even with strict donor screening and testing practices, safe blood free from TTIs remain an intricate goal. Although technological developments have led to improve the more sensitive methods to detect markers of TTIs, the problems of false – negative results because of ‘window period’, asymptomatic carriers, high genetic variability in viral strains and technical mistakes stay behind 6 . Hepatitis B is one of the most common diseases transmitted by blood and infected two million people worldwide including an estimated 400 million chronically infected cases. Individuals with chronic infection have a high risk of developing liver cirrhosis and hepatocellular carcinoma7 . The present study was undertaken to assess prevalence and trends of TTIs among voluntary and replacement blood donors in this part of the country as prevalence varies in different geographic areas of the country.
MATERIAL AND METHOD
Present study was carried out in blood bank of S.R.G. Hospital and Jhalawar medical college, Jhalawar, Rajasthan. 46224 donors were analyzed for prevalence of TTIs from April 2008 to October 2012. These were 22905(49.55%) voluntary donors and 25219(54.58%) were replacement donors. This study included replacement donors and replacement donors. The replacement donors defined as who donated for their patients and were close relatives, family members or friends of the recipient. We arranged Different outdoor camps to obtain the voluntary donations. At voluntary places care was taken to remove professional and paid donors by taking Proper history and clinical examination. A detailed pre – donation questionnaire was included in donor registration foresee. Information regarding history of surgery, hospitalization, blood transfusion, occupation, high – risk behavior and tattoo marks etc. were collected. All samples were screened for HIV (Elisa and Rapid test) 8 , Hepatitis B surface antigen (Elisa, Hepalisa – J. Mitra and co. and Rapid test) 9 , Hepatitis C virus (Elisa Microlisa – J. Mitra and co. and Rapid Test) 10, RPR-Rapid plasma Reagin method11 and Malaria- by Thick smear examination. Tests were performed according to the manufacturer’s instructions of commercially available kit in blood bank in department of Pathology, Jhalawar Medical College and S.R.G. Hospital. The donated blood was discarded whenever the pilot donor sample was found positive for any TTIs.
RESULTS
46224 blood donors were screened in last four years. The numbers of donations have increased from 8209 in 2008 to 12396 in 2011 (Table-1). Table no. – 2 is showing the result of seropositive samples for HIV, HBV, HCV, VDRL and Malaria. Seropositivity was observed more in replacement donors than in voluntary donors. The year wise comparative study and present study also have shown in table 1 and 2 of seropositivity by replacement and voluntary donors.
DISCUSSION
TTIs continue to be a threat to safe transfusion practices. With every one unit of blood, there is a 1% possibility of transfusion – associated risk including TTIs12. Professional donors and donors with high risk behavior such as drug addict, homosexuals and prostitutes constitute the major risk segment. In our study, voluntary donations were about 49.55% of the total. In Northern India, the voluntary donor rate vary from 9.1% to 52.33%.13 and the National AIDS Control Organization (NACO) suggests that in 2007, voluntary donations in India were about 55%. We encountered a steady rise in voluntary donors from 6.53% in 2008 to about 72.29% in 2011, a trend noted in other studies too14. Although there are many studies on the prevalence of TTIs in blood donors, data regarding comparison between seropositivity of Voluntary and Replacement blood donation is sparse. The HIV Seroprevalence in Indian scenario has been reported between 0.2% to 1%15.The seropositivity of HIV has increased from 0.012% to 0.08% in last four years and more in replacement donors. Majority of donors were truck – drivers (high risk behavior group), one was schoolteacher and a donor was student. More people migrating from rural to urban area may be a cause of increase numbers in HIV Seropositivity. Studies done by Chandra et al16 (2001-2006) at Lucknow, U.P. shows HIV positivity of 0.01% which is similar to our studies. It is also clear from national data that higher incidence of HIV was found in Maharashtra, Chennai and south India. The prevalence of HIV in our study has not increased possibly because of increase in the percentage of voluntary donations which has increased from 6.53% to 72.29% in recent past. Different studies from India have shown Hepatitis B seropositivity rate from 2% to 8% in different geographical areas. HBV is a major source of transfusion transmitted hepatitis and is associated with career rate, chronic liver diseases and hepatocellular carcinoma even. In present study there is a dramatic difference in seropositivity among voluntary and replacement donors. In replacement donors HBV is around 3.0%; while in voluntary donors it is less of around 0.68%. The prevalence was similar to study done by Chaudhary et al17 Lucknow. Jhalawar district is dived into 6 blocks. Among these families of Khanpur block show high Prevalence of HBV cases ; the reason may be the reuse of needles by quacks and compounder’s malpractices, social practices of tattoos, as this district is socioeconomically deprived and literacy rate is also low here. Prevalence of HCV is comparatively less (0.01% to 0.06%) in our study compared to other studies though it was comparatively higher among replacement donors (0.26%). In one case in 2011 we found a donor co-infected by HBV and HCV. Transfusion transmitted syphilis is not a main peril of modern blood transfusion therapy, transfusion transmitted syphilis rarely have been recognized. The screening of syphilis commonly done by the rapid plasma regain test; it is not the syphilis transmission that is worrisome being a sexually transmitted disease it is presents point towards donor’s Indulgence in “high risk” behavior and higher risk of exposure to infections like HIV and hepatitis (Ness, 1991). The risk of TTI of HBV, HCV and HIV could be curtailed by foreword of few more sensitive and specific tests for screening of donor’s sample. Preface of nucleic acid amplification testing (NAT) for HCV, HIV, anti hepatitis B core antigen (HBcAg) and IgM for hepatitis B infection is recommended to identify the infections during window period.
CONCLUSION
To conclude, with the implementation of firm selection norm of donor as per the guide lines laid down for the blood banks in the gazette notification by the Government of India and use of sensitive and specific laboratory screening tests, it is achievable to decrease the occurrence of seropositivity of transfusion transmitted infections and improve the blood product safety.
Englishhttp://ijcrr.com/abstract.php?article_id=1303http://ijcrr.com/article_html.php?did=13031. Widman FK (ed) (1985) Technical manual American Association of blood Banks, Arlington, PP 325-344.
2. Jasmin Jasani, Vaidehi Patel, Kaushik Bhuva, Anand Vachhavi. Seroprevalence of transfusion transmissible infections among blood donors in a tertiary care hospital. International Journal of Biological and Medical Research. 2012; 3(1) : 1423-1425, www.biomedscidirect.com.
3. World Health Organization (WHO). Blood safety strategy for African region. Brazzaville, World Health Organization, Regional office for Africa, Brazzaville 2007 : 1-25.
4. Srikrishna A, Sitalaxmi S, Prema Damodar S (1999) How safe are our donors? Indian J. Pathol Microbiol 42: 411-416.
5. Government of India. Drugs and Cosmetics rules, 1945 (Amended in 2009) awailable http://www.cdsco.nic.in/html/drugandcosmetics Act.pdf
6. Gagandeep Kaur, Sabita Basu, Ravneet Kaur; Patterns of infections among blood donors in a tertiary care centre : A retrospective study. TheNational Medical Journal of India Vol 23, No. 3, 2010.
7. Karki’s, Ghimire P, Tiwari BR, 2008. Trends in hepatitis B and hepatitis C seroprevalence among Nepalese blood donors. Indian Journal of Infectious Diseases, 61 : 324-326
8. Dawson G.J., er al. The Journal of the Infectious Diseases, (1988) 157 (1); 149 “Reliable Detection of Individuals Seropositive for the Human Immunodeficiency Virus (HIV) by competitive Immunoassays using Escherichia coli-Expressed HIV structural Protenis.”
9. A.Boniolo M. Dovis, R. Matteja The use of an enzyme linked immunosorbent for screening hybridoma antibodies against Hepatitis B Surface antigen. J. Immunol Meth, 49:1 (1982)
10. Sarin, S.K. and Hess. G. (1998). Transfusion associated Hepatitis, CBS Publishers, New Delhi.
11. Caumes E., Janier M. Syphilis, editions techniques. Encyclo. Med Chir (Paris France) Maladies infectiouses. 8-039-A-10(1994)
12. Garg S, Mathur D.R., Garg D.K., Comparison of seropositivity of HIV, HBV, HCV and syphilis in replacement and voluntary blood donors in Western India. Indian J Pathol microbial 2001, 44-409-12.
13. National AIDS Control Organization (NACO) website 2012 http://www.nacoonline.org/upload/Final%20pu blications/Blood%20safety/voluntary%20blood %20donation.pdf
14. Nanda A, Tyagi S, Basu S, Marwah N. Prevalence of transfusion transmitted infections among voluntary and replacement donors. Indian J hemat Blood Transf 2001; 19: 104-5.
15. Sharma RR, Cheema R, Vajapayee M, Raou, Kumar S, Marwaha N, et al. prevalence of markers of transfusion transmissible diseases in voluntary and replacement blood donors. Nat Med J India 2004 ; 17 : 19-21.
16. Chandra T, Kumar A, Gupta A. Prevalence of transfusion transmitted infections in blood donors: An Indian experience. Transfusion 2009; 49(10):2214-20.
17. Chaudhary N, Phadke S (2001) Transfusion transmitted disease. India J Paediatr 68; 951- 958
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524153EnglishN2013February18HealthcareENERGY BALANCE, PSYCHOSOCIAL PROBLEMS AND BIOCHEMICAL PROFILE OF OBESE CHILDREN
English5461Kalpana C.A.English Lakshmi U.K.EnglishChildhood obesity is reaching epidemic proportions in both developed and developing countries. Reduced physical activity and increased energy intake both have major contribution to the establishment of childhood obesity. Psychological and social problems, increased plasma insulin, elevated blood lipid, lipoproteins and blood pressure are the various factors known to be associated with childhood obesity. Hence, the study was conducted to determine the energy balance, psychosocial problems and biochemical profile of selected obese children. Time utilization pattern of obese boys and girls (n=64) was studied to assess their physical activity and energy expenditure levels. The energy balance was calculated by finding the difference in the energy intake and energy expenditure of the children. Psychosocial and behavioural adjustment problems faced by obese children at school and home were studied for both the boys and girls. Biochemical parameters namely blood glucose, haemoglobin and lipid profile which included total cholesterol, serum triglycerides, HDL, LDL and VLDL cholesterol were determined using standard procedures. Both boys and girls exhibited a positive energy balance which was higher in obese boys than in obese girls. The mean total cholesterol level of obese boys (158.3 mg/dl) was within the normal range but in the case of obese girls the level (178.7 mg/dl) was found to be slightly higher than the normal. Overweight and obese children are likely to develop lifestyle diseases like diabetes mellitus and cardiovascular diseases at a younger age which are largely preventable. Strategies aimed at reducing caloric intake and increasing caloric expenditure through regular exercise are necessary to meet the challenges.
EnglishChildhood obesity, energy balance, psychosocial problems, biochemical profileINTRODUCTION
Obesity is reaching epidemic proportions in both developed and developing countries and is affecting not only adults but also children and adolescents [1].Once considered a problem of affluence, obesity is fast growing in many developing countries also. As a result of rapid socioeconomic advancements in recent decades, the population is undergoing significant changes in lifestyle, dietary and meal patterns, such as increased consumption of fats and oils, decreased intake of complex carbohydrates, eating out and skipping meals. Both physical activity and energy intake have a major contribution to the establishment of childhood obesity [2]. Sleep duration may be related to a child’s exposure to obesity related factors in the environment [3]. Physical health risk of obesity may not manifest themselves for years but the psychological and social problems are experienced every day. Obese children often suffer from teasing by their peers. Some are harassed or discriminated by their own family. [4]. Obesity is a key factor for many chronic and non communicable diseases. Increased plasma insulin levels, elevated blood lipid and lipoprotein levels, and elevated blood pressure are the various factors known to be associated with childhood obesity leading to adult morbidity and mortality. [5]. Childhood obesity prevention involves maintaining energy balance at a healthy weight, while protecting overall health, growth and development and nutritional status. Interventions that combine a dietary component, physical exercise and/or behavioural therapy are effective in treating childhood obesity. Hence, the study was conducted to determine the energy balance, psychosocial problems and biochemical profile of selected obese children.
MATERIALS AND METHODS
Childhood obesity is associated with a number of problems and co-morbidities; hence the following parameters were studied on 32 obese boys and 32 obese girls.
1. Assessment of Physical Activity Pattern Time utilization pattern of both obese boys and girls (n=64) was studied to assess their physical activity and energy expenditure levels. An equal number of normal boys and girls (n=64) were also assessed for their time utilization pattern for comparison with the obese children. For studying the time utilization pattern, each child was asked to prepare an activity time log for a week stating the time spent on each activity from the time one gets up in the morning to the time one goes to bed. The activities were then classified into sedentary, moderate and heavy based on the type of activity. The time spent for each type of activity was calculated for the whole day along with the time spent for sleep for determining the difference in activity pattern and sleep hours of obese children.
2. Determination of Energy Balance Energy balance is the state in which an individual’s energy expenditure equals his or her metabolizable energy intake. Negative energy balance occurs when expenditure is greater than intake and positive energy balance occurs when intake is greater than expenditure. Hence, an in depth study on energy balance was carried out on the 64 obese children. Basal Metabolic Rate (BMR) and physical activity are the two major factors which determine the energy expenditure of an individual. The energy expenditure of the obese children was assessed using the time utilization pattern. The average workload per day was computed with the number of hours spent for each activity in school and at home along with hours spent for sleep. Energy expenditure for sedentary, moderate, heavy activities and sleep was determined using the formula [6]
The basal energy requirement is regularly estimated as the energy need per kg of body weight which is assumed as one calorie for every hour per kilogram of body weight. Thus the basal energy expenditure for 24 hours for children is calculated as 1 X 24 X body weight. Energy that is saved during sleep is calculated as 0.1 X body weight X hours of sleep. This is reduced from the total basal energy expenditure for 24 hours to get the basal energy expenditure of the individual. Total Energy Expenditure (TEE) was calculated from the Basal Metabolic Rate (BMR) and the type of physical activities of the children. The actual food intake was determined from 24 hour recall method. From the average daily food intake, the energy intake was computed using the nutritive value of Indian foods and compared with the recommended dietary allowances [7]. The energy balance was thus calculated by finding the difference in the energy intake and energy expenditure of the children.
3. Psychosocial and Behavioural Adjustment Problems
Obesity is a stigmatized condition. Obese children are exposed to the consequences of public disapproval for their fatness. This stigma is seen in schools, homes and in the society. Hence, the psychosocial and behavioural adjustment problems faced by obese children at school and home were studied for both the boys and girls. Based on the scale developed by Parikh and Das [8], a Psychosocial and Behavioural Adjustment Scale (PSBA Scale) was constructed by the investigator after identifying 60 relevant statements through review of literature and in consultation with psychology experts and categorizing into six groups with equal number of positive and negative statements. Self perception of physical attributes, behaviour in the family, emotional and behavioural problems, social and academic problems and problems with values and adjustment were the aspects included in the development of this scale. The children were asked to respond to each statement in terms of their own agreement and disagreement on a five point continuum. The scores given for positive statements were as follows:
The order was reversed for the negative statements. The total score was the summation of numerical weight assigned to each response. This 5 point scale was given scores of 1,2,3,4 and 5 with 5 being the maximum score indicating least problems and 1 being the lowest score indicating most problems.
4. Biochemical profile
Biochemical parameters namely blood glucose, haemoglobin and lipid profile which included total cholesterol, serum triglycerides, HDL, LDL and VLDL cholesterol were determined in the laboratory for the selected children (n=64) using the following standardized methods.
a. Blood Haemoglobin
An accurate volume of blood (0.02ml) was drawn from a finger prick using a haemoglobin pipette and delivered on to a (1x1 cm) strip of Whatman No.1 filter paper. The filter paper with the blood sample was dropped into Drabkin’s solution in a test tube and allowed to stand for 30 minutes. The solution was then centrifuged and the supernatant was read in a photo electric colorimeter. The mean haemoglobin levels were then compared with reference values.
b. Blood Glucose
A finger prick was done for the selected overweight and obese children to collect their blood sample and blood glucose was estimated using a Glucometer.
c. Blood lipid profile
With the help of a laboratory technician, 5ml of blood was drawn from the vein of obese children and blood lipid profile comprising of Total cholesterol, Triglycerides, Low density Lipoprotein, High density Lipoprotein and Very Low Density Lipoprotein was estimated using standard procedures.
d. Blood Pressure
Obesity and overweight may predispose children to increased blood pressure. Elevated blood pressure in children is an early risk factor for cardiovascular disease and is positively associated with BMI [10]. Hence, blood pressure was measured for the selected obese children (n=64) with the help of an experienced medical officer.
RESULTS AND DISCUSSION
1. Mean hours spent on physical activities by Obese and Normal children
The mean hours spent in various physical activities during the day by obese boys and girls in comparison with normal children are presented in Table I.
The duration of sleep hours per day for obese boys was 8.1 and for normal boys were 7.1 with no significant difference. The hours spent per day on sedentary activities among obese boys was found to be higher by 13.3 hours compared to only 8.3 hours spent by normal boys which was found to be statistically significant (pEnglishhttp://ijcrr.com/abstract.php?article_id=1305http://ijcrr.com/article_html.php?did=13051. Flynn, D; Colecchia, A; Sacco, T; Bondi, M; Roda, E. and Marchesini, G. (2006), “Hepatic steatosis in obese patients clinical aspects and prognostic significance”, Obesity Review, Vol. 5, Pp. 27-42.
2. Stubbs, C.O. and Lee, A.J. (2004), “The Obesity Epidemic: Both Energy Intake and Physical Activity Contribute”, MJA, Vol.181, No.9, Pp. 489 - 491.
3. Speiser, P.W. Rudolf, M.C. and Anhalt, H. (2005), Childhood Obesity. J.Clin. Endocrinol Metab, 90: Pp.1871-1877.
4. Cornette, R. (2008). “The Emotional Impact of Obesity on Children”. Worldviews Evid Based Nurs 5 (3): 136–41.
5. Lau, D.C.W., Douketis, J.D., Morrison, K.M., Hramiak, I.M. and Sharma, A.M. (2007), “Canadian Clinical Practice Guidelines on the Management and Prevention of Obesity in Adults and Children (Summary)”, CMAJ, Vol.176, No.8, Pp. S1 - S13.
6. Swaminathan, M. Principles of Nutrition and Dietetics. Second Edition, Bapco Publishing, Bangalore, 2005. p.528.
7. Indian Council of Medical Research (ICMR). (2006), “Dietary Guidelines for Indians, Indian Council of Medical Research”, Hyderabad, Pp. 72 - 74.
8. Parik and Das, (1988), Secondary Handbook of Psychological and Social Instruments. Personality, Concept Publishing CO, New Delhi, Pp.70-75
9. Brion, M.A., Ness, A.R., Smith,G.D. and Leary, S.D. (2007), “Association Between Body Composition and Blood Pressure in a Contemporary Cohort of 9 Year Old Children”, J.Hum.Hyperten, Vol.21, Pp. 283 - 290.
10. Li, Y., Zhai,F., Yang, X., Schouten,E.G., Hu,X., He,Y., Luan,D. and Ma,G. (2007), “Determinants of Childhood Overweight and Obesity in China”, Brit.J.Nutr, Vol.97, Pp. 210 - 215.
11. Jennifer, L.B. and James, M. (2008) Neighborhoods and Obesity, Nutrition, Vol.66 (1), Pp.2-20.
12. National Institute of Nutrition (1990), “Techniques of Iron Status Measurement” Manual of Collection, Processing and Estimation of Samples for Iron and Iodine Status Measurements. National Institute of Nutrition, Hyderabad, India.
13. World Health Organisation (2003), Joint WHO/FAO Expert Consultation on Diet, Nutrition and the Prevention of Chronic Diseases. WHO Technical Report Series 916, Geneva, Switzerland.
14. National Cholesterol Education Programme (NCEP), 2005, Expert Panel on Blood Cholesterol in Children and Adolescents, Amer. Heart. Ass., 112, 3184-3209.
15. Ramzan, M., Ali, I. and Salam, A. (2009), Iron Deficiency Anemia in School Children of Dera Ismail Khan, Pakistan, Pakistan Journal of Nutrition, Volume: 8 Issue: 3, Page No.: 259-263
16. Manuraj, K. Sundaram, R. Paul, A. Deepa, S. Krishna Kumar R. (2007) Obesity in Indian children: Time trends and relationshipwith hypertension, The National Medical Journal of India vol. 20, No. 6.
17. Finucane, F. M., Pittock, S., Fallon, M., Hatunic, M., Ong, K. Burns, N. Costigan, C., Murphy. N. and Nolan J. J. (2008,) Elevated blood pressure in overweight and obese Irish children, Irish Journal of Medical Science, Volume 177, Number 4 , Pp.379-381
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524153EnglishN2013February18HealthcareCOMPARATIVE SHEAR BOND STRENGTH EVALUATION OF THREE TOOTH COLORED RESTORATIVE MATERIALS USED IN PRIMARY TEETH - AN IN VITRO STUDY
English6268K. Vimala GeethaEnglish Eapen ThomasEnglish Phani BabuEnglishThe goal of research and development is to develop an ideal restorative material. The ideal restorative material would be identical to natural tooth structure, in strength adherence and appearance. Hence the aim of the study was to evaluate the shear bond strength (SBS) of three recently evolved tooth colored restorative materials used in primary teeth dentine and verify, after SBS testing, the failure mode of the adhesive interface. Sixty extracted deciduous human molars with one of the proximal and occlusal surfaces free of caries were selected and randomly assigned into three groups according to the restorative material used. Teeth were sectioned parallel to occlusal surface to expose the mid coronal dentin of the non carious surface and the restorative materials were packed into a plastic straw (3 mm x 2 mm) covering the centre of flattened occlusal surface. SBS tests were performed and the obtained values were statistically analyzed using ANOVA and Turkey tests (pEnglishDeciduous teeth, shear bond strength, Vitremer, Ketac N 100, Ormocer.INTRODUCTION
Dental amalgam has been the restorative material of choice for many decades.1However, the increasing awareness about the safety of dental amalgam have helped the dental profession to focus on the need to develop alternative restorative materials like glass ionomer cements and resin composites. 2 Resin modified glass ionomers were developed as hybrids of conventional glass ionomer cements and visible light activated composite resins to overcome the disadvantages. They are more esthetic and less water sensitive than conventional glass ionomers, but are also harder to use and less esthetic than composite resins. Several studies indicated that resin modified glass ionomers have higher dentin bond strengths than conventional glass ionomer restorative materials. 3,4,5 One of the resin modified glass ionomer cements that is most commonly used as posterior restorative material is “Vitremer”. KetacTMN100 is the first paste/paste, lightCured resin modified glass ionomer material developed with nanotechnology. Because it adds benefits not usually associated with glass ionomers, it has resulted in a whole new category of glass ionomer restorative: the nano-ionomer.
The technology of Ketac N100 restorative represents a blend of fluoroaluminosilicate (FAS) technology and nanotechnology. In an attempt to overcome some of the limitations and concerns associated with the traditional composites, a new packable restorative material was introduced called ormocer, which is an acronym for organically modified ceramic technology. Ormocer material contains inorganic–organic copolymers in addition to the inorganicsilanated filler particles. Ormocer was formulated in an attempt to overcome the problems created by the polymerization shrinkage of conventional composites because the coefficient of thermal expansion is very similar to natural tooth structure.6 One of the simplest means to evaluate restorative materials is by testing the bond strength to dentin and/or enamel. This is done either by applying a tensile or shear stress to a bonded specimen and measuring the load per unit area at the time of rupture of the bond.7 There has been much work published examining the shear bond strengths of various restorative materials, but little work has been done on the materials vitremer, N100 - the nanoionomer and Admira as they are newly developed restorative materials. Till date very little literature is available regarding the shear bond strength performance of these materials in deciduous teeth. Keeping this in mind, the present study was conducted to compare the shear bond strength of tooth colored restorative materials in deciduous teeth.
RESEARCH METHODOLOGY
The present study was planned and conducted in the Department of Pedodontics and Preventive Dentistry, Sri Ramachandra Dental College and Hospital, Chennai.
Sample selection
Sixty extracted deciduous human molars with one of the proximal and occlusal surfaces free of caries were selected and stored in physiologic saline at room temperature until use. The teeth were randomly divided into three groups of twenty teeth each and mounted in a self cure resin, leaving only the crown exposed. Different colours were added to self cure acrylic to differentiate between the groups.
Specimen preparation
Teeth were sectioned parallel to the occlusal surface to expose mid-coronal dentin of the noncarious surface using a low speed diamond disk with water coolant. Plastic straws measuring (3mm X 2mm) were cut and placed on the dentin surface to be used for bonding and restoration subsequently. The restorative materials were packed into a plastic straw covering the centre of flattenedocclusal enamel and dentin surfaces.
Restorative procedure
All the restorative procedures were done according to the manufacturers instructions. Group I - Ketac ™ N100Nano-Ionomer self etch Primer is applied for 20 seconds within the plastic straw with the help of an applicator tip, air dried and light cured for 20 seconds. Then, the Ketac ™ N100 Nano-Ionomer restorative material is packed in to the plastic straw in increments and light cured for 40 seconds. Group II - Vitremer (3M ESPE)-Vitremer self etch primer was applied for 20 seconds within the plastic straw with the help of a applicator tip, air dried and light cured for 20 seconds. Then, the Vitremer (3M ESPE) restorative material is packed inside the plastic straw in increments and light cured for 40 seconds. Finally, the gloss is applied to the restorative material inside the plastic straw and light cured for 20 seconds. Group III - Ormocer (Admira - Vocco)- Total Etch, etching gel from Ivoclar, Vivadent was applied for 15 seconds within the plastic straw, rinsed with water and air-dried. Ormocer based bonding agent was applied for 20 seconds in the etched area, air dried and cured or 20 seconds. Then the Admira restorative material is packed inside the plastic cylinder and light cured for 40 seconds.
Shear bond strength test
Each restorative combination was subjected to shear bond strength analysis using INSTRON universal testing machine, Lloyd Instrumentsmodel type: LR100K in CIPET (Central Institute of Plastic Engineering Technology) Guindy, Chennai. The shear bond strength was assessed by applying force through the chisel with the test speed of 2mm/minute between the restorative material and tooth material junction. The stress failure was calculated and recorded as the shear bond strength in kg f/cm2 using Dapmatand Control software. The values for bond strength were calculated as Mega Pascal (Mpa) and the results were evaluated statistically using Student's independent t-test. One way ANOVA was used to calculate the p-value. Multiple Range test by Turkey-HSD procedure was employed to identify the significant groups at 5% level.
Evaluation of the failure mode after SBS test
The mode of fracture in each specimen was observed under Stereomicroscope (zoom Stereomicroscope - SMZ-U model) in Government Veterinary College, Madhavaram, and Chennai using the following criteria:
1. Adhesive fracture - Fracture between tooth and restorative material.
2. Cohesive fracture – Fracture within the restorative material.
RESULTS
Mean and standard deviation (SD) values of SBS test of all three restorative materials are presented in table 1. Table 2 shows the intra-group comparative evaluation of mode of bond failures in all three restorative materials.
Statistical analysis
Mean and standard deviation were estimated from the sample for each study group. Mean values were compared between different study groups by using student’s independent t-test or one-way ANOVA followed by Turkey-HSD procedure. Proportions were estimated and compared by using Pearson’s chi-square test or Fisher’s Exact test (2-tailed) appropriately. In the present study, pEnglishhttp://ijcrr.com/abstract.php?article_id=1306http://ijcrr.com/article_html.php?did=13061. Hubel S, Mejare I. Conventional versus Resin Modified Glass Ionomer cement for class II restorations in primary molars. A 3 year clinical study. Int J Paediatr Dent 2003;13(1):2-8.
2. K.M.Y. Hse, S. K. Leung, S.H.Y. Wei. Resin Ionomer materials for children: A review. Australian Dental Journal 1999;44 (1):1-11.
3. Mc Carthy MF, Hondrum SO, Mechanical and bond strength properties of light-cured and chemically cured glass ionomer cements. Am J OrthodDentofacialOrthop 1994 Feb;105(2):135-141.
4. Almuammar MF, Schulman A, Salama FS. Shear bond strength of six restorative materials. J ClinPediatr Dent. 2001; 25 (3):221-225.
5. SfondriniMF, Cacciafesta, Pistorio A, Sfondrini G. Effects of conventional and high- intensity light curing on enamel shear bond strength of composite resin and resin modified glass ionomer. Am J OrthodDentofacialOrthop 2001;119(1):30-35.
6. Ajlouni R, Bishara SE, Soliman MM et al. The use of Ormocer as an alternative material for bonding orthodontic brackets. Angle Orthod. 2005 Jan;75(1):106-8.
7. Camile S. Farah, Vergil G Orton, Stephen M. Collard. Shear bond strength of chemical and light cured glass ionomercements bonded to resin composities. Australian Dental Journal 1998; 43(2):81-86.
8. Sumikawa DA, Marshall GW, Gee L, Marshall SJ. Microstructure of primary tooth dentin. Pediatric Dentistry 1999; 21(7):439- 444.
9. Hosoya Y, Kawashita Y, Yoshida M, Suefuji C, Marshall GW Jr. Fluoridated light - activated bonding resin adhesion to enamel and dentin: primary vs. permanent. Pediatric Dentistry 2000;22(2): 101-106.
10. Hosoya Y, Nishiguchi M, Kashiwabara Y, Horiuchi A, Goto G. Comparison of two adhesives to primary vs. permanent bovine dentin. J ClinPediatr Dent 1997;22(1):69-76.
11. Emily Placido et al. Evaluation of shear bond strength of two resin-modified glass ionomer cements. Virginia Commonwealth University;2003.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524153EnglishN2013February18HealthcareHEALTH INFRASTRUCTURE FACILITIES IN KARWAR DISTRICT OF KARNATAKA
English6975Rama B. GoudaEnglish Guruprasad GaneshkarEnglishHealth infrastructure is one of the basic infrastructural facilities which are helpful in the easy execution of economic activities, these are to be called as the heart of basic amenities. The objective of the present is to know the Government health services provided and developed in different talukas of Karwar District in Karnataka State. And it has been put forth and explained how the health facilities are developed and distributed among the people of this district which comprises eleven talukas. The present study is based on secondary data collected from published and unpublished sources of Government and non-government institutions. From the study analysis it is found that there is wide disparities in the provision of health infrastructure in different talukas of Karwar district. Hence with this attempt and study findings some remedial measures or suggestions are discussed.
EnglishHealth, Infrastructure, PHC’s, Development, ServiceINTRODUCTION
“Health infrastructure is nothing but the availability of necessary health amenities, like, hospital buildings, beds, transport facilities, etc., and health equipments like, medicines, x-ray, laboratory services etc. in the health sector in a economy”. Basic amenities are the infrastructural facilities, the provisions of which are very vital for economic development. The scarcity of these reduces the economic development. The comfortable and proper living of people is made possible through the provision of these facilities. Without provision of these no society or nation would develop. The economic development of different sectors will be depending upon the availability and accessibility of these infrastructural facilities. Hence health infrastructure is an essential factor for the Human Resource or Manpower Development of a country.
Review of Literature
Dutt P. R. (1965), Karne Manisha (2007), revealed the importance of Health Centres and there infrastructure facilities as the institution for the promotion of the health and welfare of the people. This seeks to achieve its purpose of welfare and relief as may be related to the general public health work .Impressive health outcomes and a thought to be attributable to the priority assigned by the government to health care, as evidenced by clinics, immunization campaigns, vector control and a commitment to minimzing inequality in access to health care. Lavees Bhandari and Siddartha Dutta (2007), Manisha Tiwari ( 2004 ) examined that the last couple of decades have witnessed tremendous level of development in the field of medical sciences. And mentioned that health care system covers all those services which protect and promote health of the community. Thus there are many studies which concluded with revealing the importance and need for health infrastructures in the economics development of the country. The main objective of the study is to reveal how the health services have been provided and developed in different Talukas of Karwar District in Karnataka State. It further attempts to understand and explain how the health and health facilities like hospitals, beds and drugs stores are developed and distributed among the people of Karwar District which comprises eleven Talukas.
DATA SOURCES AND METHODOLOGY
The study is based on secondary data collected from official documents and other published and unpublished materials like Government reports, District at a Glance, Research articles and books etc. The information contained in sources has been analyzed and used for the same. As for the development of a state or region, three types of infrastructural facilities and all-round development are complimenting with each other keeping this purpose in view, review of secondary literature has been done in relation to health infrastructure like establishment of Government Hospitals, Primary Health Centres, Beds and Drug stores etc in Karwar district.
RESULTS AND DISCUSSION
The following discussion shows the structure and composition of health infrastructure in different talukas of Karwar district. Different aspects of health infrastructure like number of Government hospitals, availability of Beds, PHC’s, Drugs Shop etc. in the study area are discussed with the help of data’s presented in the table. Problems in the provision of health infrastructure are discussed in the last part of this discussion.
1. Government Hospitals
The Government Hospitals play vital important role in protecting the health of the people in Uttar Kannada (Karwar) district. An analysis has been made to know the extent of health infrastructure facilities particulars offered in each taluka during different years. The study found that there are only 13 Government hospitals in different talukas of Karwar district and this has been not increased since 1998-99 to 2009-10, where in only 7.69 percent (1) Government hospital is there in Ankola, Bhatkal, Honnavar, Karwar, Kumata, Mundagod, Siddapur, Sirsi, and Yallapur respectively. But in Haliyal and Supa(Joida) there are 15.38 percent (2) Government hospitals since 1998-99 to 2009-10.There is not significant change in study area. (Uttar Kannada, District Statistical Glance, 1998-99 to 2009-10).
2. Beds in Government Hospitals in Karwar District
The provision of beds to the patients in the hospitals is very important in treating the same in the hospitals. The provision of bed is very prominent in the hospital service. Table - 1 indicates about the provision of beds to the number patients in the hospitals of each taluka from the year 1998-99 to 2009-10. Thus comprising all the eleven taluka hospitals the total number of beds provided was 618 in the year 1998-99, out of which, Ankola had 1.30 percent (80), Bhatkal 7.28 percent (45), Haliyal 11.33 percent (70), Honnavar 3.40 percent (21), Karwar 48.54 percent (300), Kumata 5.02 percent (31), Mundagod 0.97 percent (6), Siddapur 4.85 percent (30), Sirsi 9.22 percent (57) and Supa 3.24 (20) and Yallapur 4.85 percent (30) beds had been provided. Karwar Taluka had provided the highest number of beds and Mundagod had provided the least number of beds in the hospitals. During the year 2009-10, all the eleven Talukas of the district increased the number of beds 920 to 970. Ankola, Honnavar, Kumata and Supa talukas provided 5.15 percent (50) beds and Bhatkal, and Sirsi talukas was provided 10.31 percent (100) beds, Haliyal taluka had provided 8.25 percent (80) beds, Karwar had provided the highest number of beds i.e., 41.24 percent (400) and remaining talukas i.e., Mundagod, Siddapur and Yallapur had provided least number of beds i.e., 3.09 percent (30) only. It implies that the provision of beds in the hospitals of all the talukas was not the same. The number of beds did increase in the subsequent years except in Siddapur and Yallapur Taluka.
3. Primary Health Centres (PHCs)
As the mother’s health is important in caring the health of child in the rural areas, the primary health centres are looking after the health of ruralties. The primary health centres are providing better health infrastructure facilities in the rural areas. As is shown in the Table - 2 that in the rural areas of Uttara Kannada (Karwar) district there were 36 Primary Heath Centres during the year 1990-91, in the year 1995-96 there were 55 PHCs and which increased to 58 in the year 2000-01. During the year 2005-06 the total numbers of PHCs were 59 and in 2009-10 this number of PHCs has been increased to 83. In the same way, during the year 2009-10 Ankola and Bhatkal, had few number of PHCs i.e., 6.02 percent (5) separately. Haliyal and Supa had 8.43 percent (7) separately. Honnavar and Yallapur talukas had provided 10.84 percent (9) of PHCs. Karwar had provided the highest number of PHCs i.e., 15.66 percent (13), Kumata, Mundagod and Siddapur talukas had provided 8.23 percent (6) Sirsi taluka had provided 12.05 percent (10) Primary Health Centres. The above study reveals that the number of PHCs had been increased slowly in Uttara Kannada district and rural areas. But still there is need of increasing such Health Centres to some extent. This analysis shows that there is a significant disparity in the provision of PHC’s and other Government hospital facilities in Rural and Urban areas. Where in these facilities are better in urban talukas compared to rural talukas.
4. Beds in Primary Health Centres (PHCs)
Even the provision of beds has been made in the primary health centres of Karwar district. Most of the primary health centres are providing the bed facilities for proper treatment of pregnant and other patients. As per study the Table – 3 reviews the provision of total number of beds in Primary Health Centres of Uttara Kannada district was 230 during the year 1990-91, whereas during the year 2000-01 and 2009-10 the provision of beds could increase to 390 and 366, respectively. Taluka-wise distribution of beds in Primary Health Centres during the year 1990-91 shows that Ankola, Karwar, Mundagod and Siddapur had 7.83 percent (18) separately. Haliyal and Supa taluka accounts 5.22 percent (12), Honnavar had 13.04 percent (30) beds PHCs, Kumata taluka PHCs possessed the highest number of beds that is 14.78 percent (34) and Sirsi and Yallapur PHCs had 10.43 percent (24) beds each. In the same way, during the year 2009-10 Ankola and Bhatkal PHCs possessed 6.56 percent (24) beds each. Haliyal and Sirsi talukas had 11.47 percent (42), Honnavar PHCs possessed the highest number of beds i.e., 13.11 percent (48), Karwar had 9.83 percent (36) beds, Kumata, Mundagod, Siddapur, Supa and Yallapur PHCs had 8.20 percent (30) beds each talukas PHCs. In the above Table of information we come to know that in each subsequent year that is from 1990-91 to 2009-10 the number of beds in PHCs could increase constantly. During the year 1990-91 Haliyal and Supa talukas had least beds in PHCs and Kumta taluka had highest numbers of beds in PHCs. In the same way during the year 2009-10 Ankola and Bhatkal had very least number of beds in PHCs and Honnavar taluka had highest number of beds in PHCs.
5. Drug Shops
Drug shops are the stores where medicine and chemicals are preserved and sold, all types of medicines and surgical instruments are supplied and provided to the hospitals and patients. Thus, the drug shops are as important as hospitals in preserving the health of public.
The Table -4 reveals that the total district had 101 drug shops during the year 1993-94, out of which 5.94 percent (6) were found in Ankola. Further the number of drug shops were found in Honnavar, Karwar, Kumata, Yallapur, Mundagod and Siddapur constitute 10.89 percent (11), 11.88 percent (12), 6.93 percent (7), 3.9 percent (4), 21.79 percent (22) and 0.99 percent (1). Thus, Sirsi had the highest number of drug shops and Supa had the least number of drug shops. In this way, from the years1993-94 to 2009-10, the number of drug stores could increase from 101 to 338. Out of which Ankola taluka had 5.62 percent (19), Bhatkal taluka had 7.10 percent (24), Haliyal and Honnavar talukas had 12.13 percent (41), Karwar had 13.91 percent (47), Kumata had 11.24 percent (38), Mundagod and Siddapur had 4.73 percent (16), Sirsi taluka had the highest number of drug shops i.e., 24.26 percent (82) and Supa had very least number of drug shops i.e., 0.89 percent (3) and Yallapur had 3.25 percent (11) respectively Thus, from the above information in the table we can observe that the number of drug shops increased from the year to year. The Sirsi had more number of drug shops and Supa belonged to the least number of drug shops in Karwar District.
Problems in the Provision of Health Infrastructure Facilities
In the study area there are so many reasons for the poor growth of health infrastructure facilities in the Karwar district of Karnataka State. Those are., 1) Lack of financial resources. Means the public expenditure on health in Karnataka was less than 1 percent of GDP indicating inadequacies in the public provision of critical health services; 2) Shortage of building facilities for health centres; 3) Lack of physical infrastructure like., supplies, diagnostic facilities, laboratory equipments, etc. and these are extremely helpless condition which a very sad reflection on the functioning of health centers and a general deterioration of physical infrastructure facilities; 4) Lack of human resource (manpower); 5) Scarcity of road and transport facilities; 6) Inbalanced growth of plane and hilly zones as well as Urban and Rural areas; 7) Lack of health education to the people; 8) Doctors and other staff are not showing interest to serve in rural area like., SCs and PHCs; 9) Not proper establishment of health policies and programmes.
Suggestion to improve to health infrastructure facilities
On the basis of the findings of the present study there are so many solutions to resolve problems in connection to provision of health infrastructures and some suggestions to the improvement of health infrastructure facilities in the study area like:
1) Proper allocation of the financial resources and increase the public expenditure on health care.
2) Equal distribution and creating the new health infrastructure amenities.
3) Government should take the support of NGOs and Private Institution for the development of health infrastructure.
4) Construction of buildings in the Ideal Location to help these beneficiaries and staff.
5) Full fill the shortage staff in a health centers among all type of health care.
6) Maintain the balanced growth of plane and hilly zones as well as Urban and Rural areas.
7) Make the strict rules to continuously absent and rude behaved staff.
8) Make the new policy and establishment to helpful to all people in a state. etc.
CONCLUSION
It is concluded that, in the present study area different types of health infrastructure facilities are available like, health hospitals, primary health centres and beds, drug shops etc. During the past years the vast spread and development of health infrastructure facilities and several health policies and programmes are implemented at both National and State level. But the facilities were not distributed equally among all talukas in study area. There is disparity in the provisions of health facilities in different talukas of Karwar district. And even in case of rural and urban composition in relation to health infrastructure there is differentiation, where as health infrastructure are well developed in Urban taluka places compared to rural areas of Karwar district. Hence, Government should give priority to bring about equality in distribution of health infrastructure facilities in different talukas of karwar district and also it must concentrate to increase health infrastructure facilities in rural areas of it to view the good health status of population.
ACKNOWLEDGEMENT
We are thankful to all the authors who have made significant contributions to the Health studies of which we have made references in the present study. And we are also grateful to IJCRR editorial board members, team of reviewers who have helped us to bring quality to this paper.
Englishhttp://ijcrr.com/abstract.php?article_id=1307http://ijcrr.com/article_html.php?did=13071. Dutt P. R., “Rural Health Services in India: Primary Health Centres”, Centra Health Education Bureau, New Delhi, 1965.
2. Madan G.R., “Indian Rural Problems”, Radha Publications, New Delhi, 2002.
3. Kasturi Sen., “Restructuring Health Services: Changing Contexts and Comparative Perspectives”, Zed Books, London, 2003.
4. Krishnareddy M.M., “Health and Family Welfare, Public Policy and People’s Participation in India”, Kanishka Publishers and Distributers, New Delhi, (2000).
5. Om Prakash Sharma., “Rural Health and Medical Care in India: A Sociological Study”, Manak Publication Pvt. Ltd., 2000.
6. Dinesha P. T. Jayasheela and V.Basil Hans., “Health Infrastructure in India Present Challenges and Future Prospects. ed., by- Dr. Talwar Sabanna., Serials Publications, New Delhi (India), 2010.
7. Government of India’s report on “Eleventh Five Year Plan- 2007-2012” publications Planning commission of India, Oxford University Press, 2007.
8. Lavees Bhandari and Siddartha Dutta., “Health Infrastructure in Rural India,” India Infrastructure Report - 2007
9. Karne Manisha, “Public Health care in IndiaIssues and Problems,” Health Action December. pp. 8-11. 2007.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524153EnglishN2013February18HealthcareHISTOPATHOLOGICAL STUDY OF MENINGIOMA IN CIVIL HOSPITAL, AHMEDABAD
English7682Smita ShahEnglish R. N. GonsaiEnglish Rinku MakwanaEnglishObjective: This study was done to determine the clinical and histological pattern of intracranial meningioma, to determine the sociodemographic characteristic and clinical presentation and correlate this to the clinical patterns of intracranial meningioma, to find out the anatomical location of meningioma and to document the WHO histological grade of meningioma.
Materials and Methods: We have studied 51 cases of meningioma. Meningioma was diagnosed primarily by contrast enhanced CT Scan and Magnetic Resonence Imaging (MRI) of brain. This was confirmed by histopathological examination. Histopatholgical results were examined according to age and sex distribution, anatomical location of tumor, histological type and WHO grading of tumor. Correlation of clinical features and radiological findings were made with histpathological results.
Results and conclusion: Most of the sufferer was female 34 (67%). The commonest age group was 40-59 years. The commonest site of tumor was convexity of brain 26 (60%). The commonest histopathological type was meningotheliomatous meningioma 20 (39%). The 92% of the meningioma was WHO GRADE I tumor.
Englishmeningioma, WHO grading of meningioma, prognosis of meningiomaINTRODUCTION
The tumor originating from the meninges was termed as meningioma by Cushing in 1922 . Meningiomas originate from the arachanoidal cap cell, a meningothelial cell in the arachnoidal membrane. They generally arise were arachnoidal villi are many . The arachnoid cap cells are most prevalent near collections of arachnoid villi at the dural venous sinuses and their large tributaries. Meningiomas may arise anywhere the cap cells are located Meningiomas are account for 15% of all intracranial tumors. They commonly occur in the fourth to sixth decades of life, with a mean age of 45 years at diagnosis. Females have meningiomas more often than males; ratio is 2:1 for intracranial and 4:1 for spinal meningiomas . The etiology of meningioma is unknown. Cases exist in which the tumor has arisen under a fracture, from an area of scared dura, or around a retained foreign body. Low and high dose radiation has been implicated in meningioma formation especially during childhood. Neurofibromatosis 1 and 2 genetic diseases inherited in autosomal dominant fashion may be associated with meningioma . 90% of meningiomas are located intracranialy and of these 90% are supratentorial. According to site meningiomas are located at parasaggital, convexity, sphenoid ridge, suprasellar, posterior fossa, olfactory groove, middle fossa, tentorial, peritorcular, lateral ventricle, foramen magnum , spinal, orbit or optic nerve sheath, few located at ectopic site . At spinal level meningioma clearly favors the thoracic region. Cervical being uncommon and lumber is rare. Also recognized are epidural, calvarial and intrapetrous as well as variant located entirely outside the craniospinal confines . Although most meningiomas are benign, they have a surprisingly broad spectrum of clinical characteristics, and histologically distinct subsets are associated with high risk of recurrence, even after seemingly complete resection. In rare instances, meningiomas are malignant. The WHO classification aims to better predict the divergent clinical characteristics of meningiomas with a histological grading system based on statistically significant clinicopathological correlations. Meningiomas are classified as benign, atypical, or malignant. Benign meningiomas are not encapsulated; they grow invaginating, but demarcated, from the brain. They grow with finger like projections, and penetrate surrounding mesenchymal tissue, including bone. They may produce both an osteoblastic and a lytic reaction . Meningiomas show positive immunostain with vimentin, desmoplakin, and epithelial membrane antigen. They have a grade 1 biological behaviour. Meningiomas grow in 3 primary histologic patterns: (1) meningothelial, (2) fibroblastic, or (3) transitional, a combination of meningothelial and fibrous. Meningothelial meningiomas consist of lobules of cells with oval pale nuclei, with chromatin marginated around the nucleus. The cell has an ill defined cellular membrane, and nuclear and cytoplasmic invaginations often produce pseudoinclusions . Fibroblastic meningiomas have parallel interlacing bundles of spindle shaped cells with abundant collagen and reticulin between cells. Transitional meningiomas have a mixed pattern of both meningothelial and fibroblastic features. They more often contain whorls or psammoma bodies. Benign meningiomas of WHO grade I can invade the dura, dural sinuses, skull, and even extracranial compartments, such as orbit, soft tissue, and skin. Although these types of invasion make it more d fficult to resect the tumour, they are not considered as atypical or malignant. By contrast, brain invasion is associated with recurrence and mortality rates similar to atypical meningiomas in general, even if the tumour seems completely benign otherwise . WHO grade II meningiomas include atypical, chordoid, and clear cell meningiomas . Both grade II and III WHO classifications of meningiomas require brain invasion as a criterion 10 . WHO grade II meningiomas make up 5% to 7% of all meningiomas 11 . Some pathologists feel that a meningioma should be called “malignant” only when there is frank brain invasion, although brain invasion has been documented in benign, atypical, and anaplastic meningiomas and felt to be an additional criteria for malignant classificatio . Atypical meningiomas are diagnosed based on increased mitotic index of equal to or greater than 4 mitoses per 10 high power fields or 3 or more of the following features: increased cellularity, small cells with high nuclear to cytoplasmic ratio, prominent nucleoli, uninterrupted patternless or sheet like growth, and foci of "spontaneous" or "geographic necrosis" 10 . Clear cell and chordoid variants of meningioma are associated with higher recurrence rates even without the above criteria 12,13 . Thus, these meningiomas are graded as WHO grade II by definition. Clear cell meningiomas make up only 0.2% of all meningiomas. This type usually behaves aggressively and can metastasize to the CSF. Clear cell meningiomas often occur in patients of younger age and occur more often in the spinal and cerebellar pontine region. Recurrence rate of clear cell meningiomas is 46% to 80% 14 Clear cell meningioma is composed of sheets of polygonal cells with clear, glycogen rich cytoplasm positive for periodic acid Schiff, and ense perivascular and interstitial collagenisation. Chordoid meningiomas are histologically similar to chordoma, with cords of small epithelioid tumour cells that contain eosinophilic or vacuolated (i.e., resembling physaliferous cells) cytoplasm embedded in a basophilic, mucin rich common in the spinal cord and posterior fossa, whereas chordoid meningiomas are typically supratentorial. WHO grade III meningiomas make up 1.0% to 2.8% of all meningiomas. These include anaplastic, rhabdoid, and papillary types . Malignant meningiomas have further increase in mitoses and cellularity with conspicuous necrosis 15 . Anaplastic or malignant meningiomas by definition must have equal to or greater than 20 mitoses per 10 high power field 10 . Atypical and malignant meningiomas have a much higher recurrence rate after resection than do benign meningiomas. Recurrence rates were 6.9% for benign meningiomas, 34.6% for atypical meningiomas, and 72.7% for malignant meningiomas . Papillary and rhabdoid meningiomas are rare variants and have an aggressive clinical course and higher rates of recurrence, metastases, and mortality 10 Papillary meningiomas generally occur in the pediatric population. Their cell processes terminate in papilla on blood vessels, with tapering of their processes to form pseudorosettes. Rhabdoid meningioma is a new pathologic variant of malignant meningioma with peritumoral edema, bone involvement, and significant cystic components on Magnetic Resonence Imaging (MRI) study of brain 16 The prognosis for meningiomas following gross total resection depends on the histology. In a single series of 1799 meningioma specimens from 1582 patients followed for an estimated average of 13 years, 93.1% of benign meningiomas, 65.4% of atypical meningiomas, and 27.3% of malignant meningiomas were cured by surgery . Recent research has investigated possible prognostic factors in atypical and malignant meningiomas specifically. In an analysis of 76 atypical meningiomas and 10 malignant meningiomas, high mitotic count, brain invasion, and parasagittal falcine location were significantly associated with decreased recurrence free survival 17 . Also, Ki 67 index greater than 4% was also associated with decreased time to recurrence. These appear to be important pathologic indicators of aggressiveness of these tumor types. A recent study found that anatomic location of tumor also to have prognostic significance 18 . They reviewed 378 patients with meningioma, looking for causes for high grade pathology. They found that nonskull base meningiomas, prior surgery, and male sex all increased risk of grade II or III pathology, which extrapolates to poorer prognosis and increased likelihood of recurrence.
MATERIAL AND METHOD
This was descriptive study. This study was carried out at the histopathology laboratory, Department of Pathology, B. J. medical college Ahmedabad, from January 2010 to August 2011. We have studied 51 cases. Histological subtype and WHO grading for all meningiomas were carried out. The parameters like patient’s age, gender, location of tumor, microscopic appearance of tumor were studied.
RESULTS
The present study was conducted at pathology department of B. J. Medical College and Civil Hospital Ahmedabad, Gujarat, India. A total of 51 cases diagnosed as meningioma by histopathological examination were studied. Detailed clinical history and radiological findings were assessed in all 51 cases. In our study meningiomas were most common in the age group of 40 59 years (59%), followed by in the age group of 20 39 years (21%). Meningiomas were least common in the age group of Englishhttp://ijcrr.com/abstract.php?article_id=1308http://ijcrr.com/article_html.php?did=13081. Cushing H. The meningiomas (dural endotheliomas): their source, and favoured seats of origin. Brain 1922;45:282 316.
2. Kleihues P, Burger PC, Scheithauer BW. Histological typing of tumours of the central nervous system. 2nd ed. World Health Organization. Berlin: Springer Verlag, 1993:30.
3. Das A. Tang WY. Smith Dr. meningiomas in Singapore, demographic and biological characteristics. J Neurooncol 2000.47, 153 60.
4. Al Mefty O, Kersh JE, Routh A, Smith RR. The long term side effects of radiation for benign brain tumors in adult. J Neurosurg 1990; 73; 502 512.
5. Christensen HC, Kosteljanetz M, Johanses C. Incidence of gliomas and meningiomas in Denmark. 1943 to 1997. Neurosurgery 2003, 52: 1327 34.
6. Lang FF, Macdonald OK, Fuller GN, DeMonte F. Primary extradural meningiomas. A report on nine cases and review of the literature from the era of computerized tomography scanning. J Neurosurg 2000,93:940 950.
7. Kleihues P, Cavenee WK, International Agency for research on cancer, Pathology and genetics of tumors of nervous systems, Lyons: IARC Press 2000
8. Perry A, Scheithauer BW, Staff ord SL, Lohse CM, Wollan PC. “Malignancy” in meningiomas: a clinicopathologic study of 116 patients, with grading implications. Cancer 1999; 85: 2046–56.
9. Bollag RJ, Vender JR, Sharma S. Anaplastic meningioma: Progression from atypical and chordoid morphotype with morphologic spectral variation at recurrence. Neuropathology 2010;30(3):279 87.
10. Campbell BA, Jhamb A, Maguire JA, Toyota B, Ma R. Meningiomas in 2009: controversies and future challenges. Am J Clin Oncol 2009;32(1):73 5.
11. McGovern SL, Aldape KD, Munsell MF, Mahajan A, Demonte F, Woo SY. A comparison of World Health Organization tumor grades at recurrence in patients with non skull base and skull base meningiomas. J Neurosurg 2010;112(5):925 33.
12. Zorludemir S, Scheithauer BW, Hirose T, Van Houten C, Miller G, Meyer FB. Clear cell meningioma. A clinicopathologic study of a potentially aggressive variant of meningioma. Am J Surg Pathol 1995; 19: 493–505.
13. Couce ME, Aker FV, Scheithauer BW. Chordoid meningioma: a clinicopathologic study of 42 cases. Am J Surg Pathol 2000; 24: 899–905.
14. Tong tong W, Li Juan B, Zhi L, Yang L, Bo Ning L, Quan H. Clear cell meningioma with anaplastic features: case report and review of literature. Pathol Res Pract 2010;206(5):349 54.
15. Maier H, Ofner D, Hittmair A, Kitz K, Budka H. Classic, atypical, and anaplastic meningioma: three histopathological subtypes of clinical relevance. J Neurosurg 1992;77:616 23.
16. Kim EY, Weon YC, Kim ST, et al. Rhabdoid meningioma: clinical features and MR imaging findings in 15 patients. AJNR 2007;28(8):1462 5
. 17. Vranic A, Popovic M, Cor A, Prestor B, Pizem J. Mitotic count, brain invasion, and location are independent predictors of recurrence free survival in primary atypical and malignant meningiomas: a study of 86 patients. Neurosurgery 2010;67(4):1124 32.
18. Kane AJ, Sughrue ME, Rutkowski MJ, et al. Anatomic location is a risk factor for atypical and malignant meningiomas. Cancer 2011;117(6):1272 8.
19. Haradhan Deb Nath, MD mainuddin, MD kmal Uddin, Ehsam mahmood et al, surgical outcome of supratentorial meningioma. A study of 25 cases. JCMCTA 2009;41 44.
20. Alkyildiz EU, Oz B, Comunoglu N, Aki H et al. The relationship between histomorphological characteristics and ki67 proliferation index in meningioma Bratisl Lek listy 2010;111(9) 505 509.
21. Joseph. Wanjeri et al. Histology and clinical pattern of meningiomas at the Kenyatta National Hospital Nairobi, Kenya. A thesis submitted for the award of the degree of master of medicine in neurosurgery, University of Nairobi, 2011.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524153EnglishN2013February18HealthcareHISTOPATHOLOGICAL SPECTRUM OF SINONASAL MASSES -A STUDY OF 162 CASES.
English8391Seema K. ModhEnglish K. N. DelwadiaEnglish R. N. GonsaiEnglishIntroduction:
Lesions of the sinonasal region are commonly encountered in clinical practice and important from clinical and pathological perspectives as they have a varieties of histological patterns.
Aims and Objectives:
1) To study the incidence of benign and malignant lesions of sinonasal region.
(2) To study distribution of various lesions for sex differences and symptomatology.
(3) To compare the findings of the study with other studies. Methods: Present study included 162 polypoidal lesions of the nasal cavity. The study period constituted from December 2011 to October 2012. All the tissues were fixed in 10% buffered formalin, processed, stained with H and E and studied for various histopathological patterns. Periodic acid Schiff’s and reticulin stains were used wherever necessary. Results: Among 162 cases, 110 cases (67.11%) were nonneoplastic and 52 cases (32.09%) were neoplastic. Among the non-inflammatory lesion, nasal polyp (83.64%) was the commonest lesion followed by fungal infection. Benign tumours (69.23%) were more frequent than malignant tumours (30.77%). Among benign neoplastic lesions, angiofibroma (41.67%) was commonest and hemangioma (19.4%) was the next common lesion. All lesions were common in second and third decades, with male predominance. Malignant lesions were comparatively less to that of benign lesions. Squamous cell carcinoma was most common malignant lesion. Conclusion: Categorizing the sinonasal lesions according to histopathological features into various types, helps us to know the clinical presentation, treatment, clinical outcome and prognosis of the disease, so all polypoidal lesions need histological examination.
EnglishNonneoplastic, Neoplastic, Benign, Malignant.INTRODUCTION
Sinonasal lesions are common lesion encountered in clinical practice and important from clinical and pathological perspectives as they give rise to a varieties of histological patterns and grades of malignancies. The presence of mass in the nose is a seemingly simple problem; however, it raises numerous questions about differential diagnosis. Although neoplasms of the nose and paranasal sinuses are not common, they are of interest because of their various types. It has been found, the nose and paranasal sinuses account for less than 1% of all malignant tumors in general, not more than 3% of the head and neck region malignancies. It may be due to the most often occurring simple nasal polyps or polypoidal lesions due to various other pathological entities ranging from infective granulomatous disease to polypoid neoplasm including the malignant ones. The nose and nasal sinuses are exposed to various infections, chemically irritating, antigenically stimulating, mechanically, traumatic and undoubtedly many other influences. Consequences of these multifaceted deleterious exposures include the formation of tumor like and truely neoplastic conditions [1]. Clinically sometimes, it becomes quite impossible to distinguish between inflammatory conditions presenting as simple polyps, polypoidal lesions due to specific disease and polypoid neoplasm (benign and malignant). Therefore it becomes important that all polyps and polypoidal lesions should be submitted for histopathological examination. Nasal polyps are defined as prolapsed lining of the nasal sinuses. They are essentially rounded projections of edematous membrane [2]. They are often bilateral and multiple which lead to visible broadening of nose [3]. The commonest site of origin is in the ethmoidal labyrinths, particularly from the mucosa of middle turbinate [4]. Nasal polyps most often occur in middle aged males. M:F ratio is 3:1 [3]. The symptoms of tumors of nose and paranasal sinuses often masquerade as chronic inflammatory condition. Even though these malignant neoplasms have extremely low incidence, they have a long clinical history with frequent local recurrence and they cause relatively great amount of morbidity. In nasal cavity, tumors of various type have a tendency to become polypoid. Thus an epithelial papilloma of the nasal cavity often resembles a nasal polyp. Some lesions are specific to certain location, for e.g., epithelial papilloma of turbinate, juvenile angiofibroma of nasopharynx. Thus the study was undertaken to study the histopathology and classify the lesions of nasal cavity and to study the relative distribution of various lesions for age and sex.
MATERIAL AND METHODS
This study comprised of 162 consecutive cases, the specimen of which were received in the histopathology section of the Dept. of Pathology of our institution with the clinical diagnoses of ‘Nasal polyp’ from January 2012 to October 2012. The age and sex of the patients were recorded. The consent of all the patients included in the study was taken. The tissues were routinely processed for histopathological sections and were stained by HandE stain. Special stains by Reticulin and PAS methods were undertaken wherever applicable. The cases were classified into Nonneoplastic and Neoplastic lesions. The Neoplastic lesions were further classified according to WHO classification on histopathological examination. (Shanmugaratnam 1978)[5].
RESULTS AND OBSERVATIONS
Histopathological examination revealed that out of 162 cases clinically diagnosed as nasal polyp, there were 110 cases (67.11%) with different types of nonneoplastic lesions and 52 cases (32.09%) of neoplastic ones. Among the 52 neoplastic lesions, there were 36 cases (69.23%) of benign tumors and remaining 16 cases (30.77%) were malignant in nature. Inflammatory polyp was the commonest lesion observed in this region. It constituted 83.64% (92 cases) of all nonneoplastic cases. The other nonneoplastic lesions in the decreasing order of frequency were fungal infection (7 cases, 6.36%), mucormycosis (4 cases, 3.64%), rhinosporodiosis (2 cases, 1.82%), rhinoscleroma (2 cases, 1.82%), non-specific inflammation (2 cases,1.82%) and one case (0.91%) of wegner’s granulomatosis was seen. Inflammatory polyp was the most common lesion involving this region. The age range of patients was 10 to 80 years, but peak was seen in 2nd to 4th decade of life. These polyps were typically bilateral in 62% cases. The patients presented with symptoms of nasal stuffiness and obstruction and mass protruding from the nostril. Other symptoms were total and partial loss of smell, headache due to sinusitis, sneezing, and mucoid or watery discharge. On examination, the mass was glistening grape-like, insensitive to probing and did not bleed on touch. Microscopically, the polyps were composed of loose mucoid stroma and mucus glands, covered by respiratory epithelium. The stroma was infiltrated by lymphocytes, plasma cells, neutrophils and eosinophils. Allergic nasal polyps show abundant eosinophis in the stroma as well as the other inflammatory cells. Fungal infections were more common in 3rd and 4 th decade. They presented with foul smelling nasal discharge, which on microscopy, showed inflammation ranging from negligible to large number of neutrophils and histiocytes within granulation tissue. Most common fungal infection was Aspergillosis. Mucormycosis was more common in 5th decade with male preponderance. Microscopically, there was formation of non-invasive mycetomas/ fungus balls. Rhinosporodiosis was present in 5th and 6th decade. The diagnosis was made by the identification of many globular cysts reaching up to 200 nm in diameter. Each of these cysts represented a thick-walled sporangium containing numerous spores. Rhinoscleroma was present in 5th decade with male predominance. Microscopically, the predominant cells were foamy macrophages (Mikulicz cells) and plasma cells. Other nonneoplastic lesions include non-specific inflammation which were observed in 65 years old male and 45 years old male patients and wegner’s granulomatosis which was present in 17 years old male which on examination, showed a leukocytoclastic vasculitis with geographic necrosis surrounded by palisaded histiocytes, lymphocyte-poor granulomatous reaction, and epithelial ulceration.
Neoplastic lesions
Among the 52 cases of neoplastic lesions, there were 36 benign cases (69.23%) and 16 malignant ones (30.77%). Angiofibroma and hemangioma were the most common lesions observed in the benign group. There were 15 cases (41.67%) of angiofibroma .It was more common in the 2nd decade and there was marked male preponderance in this type of neoplasm. Microscopically, it was composed of an intricate mixture of blood vessels and fibrous stroma. Next common benign neoplasm was hemangioma with 7 cases (19.4%).It was more common in 3rd to 5th decade with male to female ratio of 1:1.33. There were 4 cases (11.1%) each of squamous papilloma and inverted papilloma, which commonly presented with mass, nasal obstruction, or epistaxis. Microscopically, papillomas were composed of proliferating columnar and/or squamous epithelial cells, with an admixture of mucin-containing cells and numerous microcysts, but inverted papilloma has invaginations of the surface epithelium into the underlying stroma. Other neoplastic lesions include 3 cases (8.33%) of fibrous dysplasia, one case (2.78%) each of cement-ossifying fibroma, neurilemmoma and plasmacytoma. The distribution of cases has been shown in table no -1. The distribution of the malignant neoplastic lesions has been depicted in table no -2. Squamous cell carcinoma was the commonest malignant lesion observed, which was most common in 6th and 7th decade. There was histological evidence of squamous differentiation, in the form of extracellular keratin or intracellular keratin and/or intercellular bridges. The tumour cells were arranged in nests, masses, or as small groups of cells or individual cells. One case of transitional cell carcinoma was present in 40 years old male and one case of adenocarcinoma was present in 50 years old male. Microscopically in adenocarcinoma, a well differentiated seromucinous composition and tubulopapillary architecture was seen. Next common was the hemangiopericytoma with 2 cases (12.5%) both in males. Microscopically, the lesions appeared vascular and highly cellular, oval tumor cells arranged themselves around blood vessels but they had little atypia, necrosis, or mitotic activity.
Other malignant neoplastic lesions include acinic cell carcinoma with 2 cases (12.5%) both in females and one case (6.25%) each of chondrosarcoma, rhabdomyosarcoma and teratocarcinosarcoma which were present in 42 years old male, 28 years old male and 30 years old female respectively.
DISCUSSION
Polypoidal masses in the nasal cavity form a complex group of lesions with a wide spectrum of histopathological features. While there are many nonneoplastic lesions including mainly the allergic and inflammatory one, there are also good number of neoplastic tumefaction in the nose and nasal sinuses. These lesions are often quite impossible to distinguish clinically and are labelled as nasal polyp[6]. Histopathological examination of such polypoidal masses show a spectrum of lesions ranging from nonneoplastic ones to neoplastic tumors including benign and malignant neoplasms. The true nasal polyps are the tumor like nonneoplastic polypoidal masses arising from nasal cavity and sinuses. Two types are encountered- one is associated with nasal allergy and another with numerous inflammatory or granulomatous polyp. In our study, we have observed 110 cases (82.06%) of nasal polyps. The incidence of nasal polyps was slightly higher in this study (82.06%) compared to the observations by Tondon et al (64%) and Anjali et al (62.85%) [7]. The age range of the patients was from 10 to 80 years. Most commonly patients are in 2nd to 3rd decade which is comparable with Ghosh and Bhattacharya (1966) [8] and Zafar et al (2008[9]). There is male preponderance with male to female ratio of 1.53:1 which was same as that observed by Zafar et al and Dasgupta et al [6,7]. Although adolescence or early childhood is stated to be the commonest age of occurrence, there are reports of this disease occurring in all age groups (Maloney and Collins 1977, Fechner 1990)[10,11]. Nasal polyps were bilateral in 60% cases in our study, while according to Batsakis bilateralism was the rule [12]. In our study, 7 cases (6.36%) of fungal infection were found in the age group of 20-60 years with male predominance which is comparable with Ghosh and Bhattacharya [8]. In our study, 4 cases (3.64%) of mucormycosis were found with peak in the 5th decade with male predominance. This findings were similarly observed by Dafale et al [13]. The incidence of Rhinoscleroma in our study (1.82%) was same as that observed by Zafar et al [9], but lower than that observed by Tondon et al (9% of all inflammatory lesions). In the study by Tondon et al [7], younger peak age of presentation was noted (20-29 years) compared to our observation where the peak age was in 5th decade, however, the sex ratio was almost the same (1:25). Rhinosporodiosis consisted of 1.82% of all the neoplastic lesions which was similar to that observed by Bjerregaard et al (1992) [14] in which incidence was 3.3%. This chronic granulomatous disease caused by rhinosporodiosis seeberi, often present as polypoidal mass that develop on nasal mucosa. This lesion is common in the endemic zones of India including West Bengal (Sammaddar and Sen 1990)[15]. Wegener's granulomatosis (WG) is a multisystemic disease characterized by a necrotizing granulomatous vasculitis affecting predominantly the lower and upper respiratory tract, lung and kidneys [16]. The prevalence of the disease is about 3 persons per 100,000 people, equally in both sexes. We found one such case in 17 years old male. In our study, out of 110 nonneoplastic lesions, 2 cases were of nonspecific inflammation. This was probably because of wrong site or inadequate biopsy. Angiofibroma were the most common benign tumor in our study. Juvenile angiofibroma are the characteristic lesions with blood filled spaces separated by excessive fibrous tissue occurring chiefly in the adolescent males [16]. Angiofibroma in our study constituted 41.67% of cases and occurred mainly in the young people, mainly the cases of juvenile angiofibroma, occurring in the pubertal age group and predominantely in males. Hemangioma were second most common benign neoplasm observed in the present study and constituted 19.4% of cases as observed by Bjerregaard et al(1992)[14] and more common in 3rd to 5th decade as documented by Sayed and Al-Serhani et al[17]. These neoplasms presented as bleeding nasal polyp. This was observed in the young as well as elderly people. Willis (1962) has regarded this neoplasm as hamartoma or malformation rather than true neoplasm, but occurrence of such lesions in elderly people with a history of less than 6 months duration is against the theory of hamartomatous origin. Papillomas in the nose and nasal sinuses are stated to be commonly occurring benign epithelial neoplasm. This group includes squamous papilloma and inverted papillomas. Such lesions were more common in adult males (Oberman 1964) [18]. We have also observed 8 such cases (22.22%) and they were three folds more common in the males. Similar observations were made Tondon et al (1971) [7]. Maximum number of cases occurred in 4th and 5th decade comparable to study by Panchal et al (2005)[19]. According to Tsai et al[20], fibrous dysplasia in nasal cavity is rare. However, we found 3 cases (8.33%).Microscopic features were similar to fibrous dysplasia at other sites and consistent with Ruggieri et al and Tsai et al showing narrow, curved misshaped discontinuous woven bone trabeculae having a characteristic fishhook configuration, interspersed with fibrous tissue of variable cellularity. The woven bone trabeculae were not surrounded by osteoclasts. According to Jayachandran and Meenakshi [21], cement-ossifying fibroma is a rare benign, nonodontogenic tumor like lesions, a subdivision of fibro-osseous lesions. The age of occurrence is between 20 to 40 years with male to female ratio of 1:2. In our study, one case (2.78%) was seen in maxilla of a 35 year old female. The most striking feature if this lesion on microscopy was the presence of large, sharply defined, irregularly shaped, calcified spherules set in a densely fibrotic stroma. Neurilemmoma arising in the nasal cavity are rare. We encountered one case (2.78%) of neurilemmoma, in a female aged 13 years. A different study found neurilemmoma in less than 4% of cases [22]. Histology revealed uniform spindle cells arranged in loose stroma (Antoni B.) Nuclei were arranged in a palisaded pattern (Verocay body). Similar observations were made by another study. Extramedullary plasmacytomas are uncommon tumors, with a worldwide annual incidence of 3 per 100,000 population. They account for 1% of all tumors of the head and neck and 4% of all nonepithelial tumors of the nasal tract [16]. We encountered one such case in 30 years old female. The malignant polypoid tumors of nose and nasal sinuses constitute an important and varied group. Often to, these lesions simulate the simple nasal polyps or chronic inflammatory disease and thus delay in the diagnosis. Malignant tumors in this location are not common in our country (Jussawalla et al 1984, Chaturvedi et al 1986)[23],however carcinomas are, by far, the commonest malignant lesion. In our series, we have observed 38 carcinomas (92.75%) out of 41 malignant lesions The commonest carcinoma of the nose and sinuses is the squamous cell carcinoma. Squamous cell carcinoma constituted 43.75% of cases in our study. Comparable findings were observed by Panchal et al(2005) [19]and Bjerregaard et al(1992[14]).SCC was more common in 6th to 7th decade with male to female ratio of 1.67:1 as documented by Ghosh and Bhattacharya[8].
Transitional cell carcinoma and adenocarcinomas also occur but are less frequent (Frazel and Lewis 1963). Adenocarcinoma constituted 6.2% of all cases and was present in 50 years old male.Similar findings were observed in study by Panchal et al(2005)[14]. Transitional cell carcinoma constituted 6.2% of cases with presentation in 40 years old male. Tumors of minor salivary gland origin occur in nose as well as nasal sinuses, large majority of such tumors are malignant. Acinic cell carcinoma however was rare and found only in 2 cases. Only 3 cases were belonged to the sarcoma group in our study, consisting of one case each of chondrosarcoma, rhabdomyosarcoma and teratocarcinosarcoma. Such malignancy of connective tissue origin are rare but can present as primary neoplasm of nose and paranasal sinuses.( Birt 1930, Manon and Soule 1965)[24]. Rhabdomyosarcoma involves the head and neck region in 40 to 45% of cases. The sinonasal tract is involved in about 10% of cases affecting the head and neck. We encountered a case of rhabdomyosarcoma in 28 years old male. Teratocarcinosarcomas in the nose, sinuses, or nasopharynx have various elements resembling immature neuroepithelial tissue, including (a) well-formed glands lined with atypical epithelium, (b) nonspecific myxoid tissue, (c) rhabdomyosarcomatous differentiation, (d) benign and malignant cartilage, and (e) cellular areas [16]. We encountered one such case in 30 years old female. Hemangiopericytoma is a rare angiogenic tumor accounting for only 5% of total cases. We observed two such cases one in 52 years old male and 29 years old male.
CONCLUSION
To conclude, classifying the sinonasal lesions according to histopathological features into various types, helps us to know the clinical presentation, treatment, clinical outcome and prognosis of the disease. Although most of nasal polyps sent for histopathology are inflammatory, secondary to infection or allergy, various benign and malignant lesions of nose may present as polypoidal masses, so all polyps need histopathological examination.
ACKNOWLEDGEMENT
We would like to express our gratitude to Department of Pathology and Department of ENT surgery, B.J. Medical College, Ahmedabad. We also acknowledge the great help received from the scholars whose articles cited and included in references of this manuscript. We are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. We are grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript.
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11. Frankel SK, Cosgrove GP, Fischer A, Meehan RT, Brown KK. Update in the Diagnosis and Management of Pulmonary Vasculitis. Chest. 2006; 129:452-465.
12. Batsakis JG. The pathology of head and neck tumors: Nasal cavity and paranasal sinuses. Head Neck Surg 980;2 :410-9.
13. S.R. Dafale, V.V. Yenni, H.B. Bannur. Histopathological study of polypoidal lesions of nasal cavity- a cross sectional study. Al, Ameen J Med Sci 2012; 5(4) : 403-406.
14. Bjerregaard B, Okoth- Olende,et al. Tumors of nose and maxillary sinus-10 years survey. J Layngol Otol 1992; 106:337.
15. Samaddar, R.R. nd Sen,M.K.(1990): Rhinosporodiosis in Bankura. Indian Journal of Pathology and Microbiology, 33:129.
16. Rosai and Ackerman’s Surgical pathology, Elsevier 9th edition, 2004
17. Sayed YE, Al-Serhani A. Lobular capillary hemangioma (pyogenic granuloma) of nose. J Laryngol Otol 1997;117 : 941.
18. Oberman, H.A. (1964): Papilloma of nose and paranasal sinuses. American Journal of Clinical Pathology, 42:245.
19. Panchal L, Vaideeswar p,et al. Sinonasal epithelial tumors: A pathological study of 69 cases. J Postgrad Med 2005;1(1):30-34.
20. TsaI TL, ho CY, Guo YC, et al. Fibrous ysplasia of the ethmoid sinus. J Chin Med Assoc 2003; 66:192.
21. Jayachandran S, Meenakshi R. Cementoossifying fibroma. Indian J Dent Res 2004;;15 :35-9.
22. Hasegawa SL, Mentzel T, Fletcher CDM. Schwannomas of the sinonasal tract and nasopharynx. Mod Pathol. 1997; 10: 777- 784.
23. Jussawalla, D.J., Sath, P.V., Yeole, B.D. and Natekar.M.V. (1984) : Cancer incidence in Aurangabad City. Indian Journal of Cancer.21-25. 24. Birt, B.D. (1930): Reticulum cell sarcoma of the nose and paranasal sinuses. Journal of Laryngology and otology 84: 615.
Inflammatory polyp : Proliferation of tubular glands lined by ciliated, respiratory-type epithelium and goblet cells, without nuclear atypia. The stroma is edematous with inflammatory cells and eosinophils
Mucormycosis. Hyphae are broad, often distorted and frequently appear twisted. Branching is rightangled (arrow) and septae are absent (PAS stain).
Non-keratinizing Squamous cell carcinomashowing many broad, interconnecting bands of neoplastic epithelium without keratinization characterizes this lesion and pleomorphic cells with loss of polarity and marked mitotic activity are present (HandE section)
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524153EnglishN2013February18HealthcareINCIDENCE OF CANDIDIASIS AND TRICHOMONIASIS IN LEUCORRHOEA PATIENTS
English9296Supriya PandaEnglish P.NagamanasaEnglish Sandhya Sri PandaEnglish T.V. RamaniEnglishObjective: Aim of the present study was to know the incidence of candidiasis and trichomoniasis in women of childbearing age complaining leucorrhoea.
Methods: Vaginal swabs collected from each patient were processed immediately for hanging drop, wet mount and 10% KOH mount preparations; and gram stain. Culture was done on Sabouraud’s Dextrose Agar. Candida isolates were identified by germ tube test, chlamydospore formation, sugars fermentation and assimilation tests.
Results: Out of 50 cases included in this study, 17 cases (34%) were negative for both Candida and T. vaginalis. T.vaginalis was present in 3 cases (6%) and Candida in 26 cases (52%). Mixed infection by both was present in 4 cases (8%). C.albicans was the commonest candida species (83%) causing leucorrhoea. Leucorrhoea was more common in 31-35 years old and who came from rural areas. Low back pain and pain in the lower abdomen was the most common associated clinical feature.
Conclusion: Present study reveals that candidiasis and trichomniasis are the most common cause of leucorrhoea.
Englishleucorrhoea, Candida, T. vaginalisINTRODUCTION
Leucorrhoea is the most common complaint among sexually active women of childbearing age in primary health care (1). Physiological leucorrhoea does not need medical intervention. However leucorrhoea with profuse quantity, foul smell, with changes in its colour or with blood seek immediate medical assistance. It is a symptom associated with many illnesses and having varied aetiology. It is difficult to treat because the signs and symptoms are not specific for any single underlying cause (2). Infection of vaginal mucosa by Trichomonas vaginalis and Candida is the most common cause of leucorrhoea .These are treatable as well as preventable causes as both these infections are transmitted sexually. Although 25 % of both the infections are asymptomatic (3, 4), chronic inflammation would be an anticipated progression to dysplasia if it remains unresolved (5, 6). There is an association between T.vaginalis and the risk of cervical neoplasia (7). Chronic trichomoniasis can cause complications like pelvic inflammatory disease and infertility.
AIM
The present study was undertaken to know the incidence of candidiasis and trichomoniasis in married, non-pregnant, nondiabetic women of childbearing age presenting with leucorrhoea in north coastal Andhra Pradesh.
MATERIAL AND METHODS
A prospective study of 62 consecutive married, non-pregnant women attending Out Patient Department (OPD) of Gynaecology in MIMS general hospital from June to August 2010 with complaint of leucorrhoea was done. Written consent was taken from them. All of them gave the history of their sexual partner as their spouse.
Exclusion Criteria: age less than 16 years and more than 45 years, diabetes mellitus, sole cervical erosion, cervical growth, endometrial and myometrial growth, unmarried and pregnant women.
Specimen Collection: Cusco’s speculum was introduced without lubricant. Vaginal discharge was collected in the posterior blade and was taken by 3 cotton swabs. These were transported and processed immediately.
Processing: One swab collected in normal saline was used to prepare Hanging drop preparation immediately in the Gynaecology OPD. With the second swab direct wet mount, 10 % KOH mount and Gram stained smear were prepared. Sabouraud’s Dextrose Agar medium with gentamycin was inoculated with the third swab and incubated at 37 degree centigrade for 48 hrs. T.vaginalis was identified by its motility in hanging drop and wet mount preparations; in gram stained smear as gram negative, variable shape, with eccentric lenticular nucleus and foamy cytoplasm, slightly larger than a leucocyte(8). Candida isolates were subjected for species identification as Candida albicans by germ tube test, chlamydospore formation in cornmeal agar medium and growth at 42 degree C. Other Candida species were identified by sugars fermentation and sugars assimilation tests (9).
RESULTS
Out of 62 cases presented with leucorrhoea, 12 cases were excluded (sole cervical erosion=6, Cervical polyp=1, fibroid uterus=5) and 50 cases were included in the study.
Clinical profiles included
Age- 19 –45 years, Weight- 40 – 57 Kgs , Rural background- 48 cases ( 96%), Urban background- 2 cases ( 4 %), Low back pain with low abdominal pain- 37 cases ( 74 % ), Pruritus vulvae- 30 cases (60 %), Foul smell discharge- 19 cases (38%), Burning micturation-14 cases ( 28%), Pallor- 7 cases (14%), Per speculum examination- curdy discharge with white flakes- 28 cases, strawberry mucosa- 3 cases Out of 50 patients, 17 cases (34 %) were negative for both Candida and T.vaginalis. Only T.vaginalis was present in 3 cases (6%) and only Candida in 26 cases (52%). Mixed infection by both was seen in 4 cases ( 8% ).Out of 30 cases of candidiasis, 23 cases (77%)were detected by gram stain, 28 cases(93%) by wet mount preparation and 30 cases by culture(100%).All seven cases of trichomoniasis were detected by both wet mount preparation and gram stain. Candida albicans was the commonest species isolated accounting for 83 % of the isolates (25 out of 30).
Follow up:
Out of 50 patients, 24 patients were treated for candidiasis, 3 patients were treated for trichomoniasis and 4 patients for both. Partners were treated by the same regimen directly or indirectly through the clients. All of them were asked for a follow up after 7 days. Repeat test was done in 26 patients after 7-15 days. All of them were negative for both Candida and T.vaginalis.
DISCUSSION
In the present study highest incidence of leucorrhoea was seen in the age group of 31-35 years (34%) followed by 21-25years old (26%). N.Jindal et al from Amritsar has reported a consistent increase in the incidence of leucorrhoea from second to fourth decade of life. This could be because of sexual activity, which is at its peak during this age (10). Most of the women with leucorrhoea presented to Gynaecology OPD with low back pain and pain in the lower abdomen (74%) in our study. Pruritus vulvae was the second common clinical presentation (60%) followed by foul smelling discharge (38%) and burning micturation (28%) in the present study. In a study from Mumbai by Dr.Sampda Rajurkar,Seth G.S.Med. College and KEM hospital, most common symptom associated with leucorrhoea was Low back pain (71.4%) followed by foul smelling discharge (40.3%) and itching (35.3%) (11).Where as a study from Southern Iran had reported commonest clinical manifestation in leucorrhoea patients to be itching (57%) followed by local irritation (30%) and dysparaunea (24%) (12).Out of 50 samples tested, 17(34%) cases were negative for both Candida and T.vaginalis. Twenty six samples (52%) were positive for Candidiasis and 3 cases (6%) were positive for Trichomoniasis. Mixed infection by Candida and T.vaginalis was seen in 4 cases (8%) in our study. In a study from India by Poria VC et al., Candida accounted for 29.33% (by culture) and T.vaginalis accounted for 20%(by wet mount preparation) of leucorrhoea(13).Studies from abroad also revealed similar incidence of Candidiasis in leucorrhoea patient. Abauleth R.et al from France had reported incidence of Candidiasis and trichomoniasis as 29.4% and 6.9% respectively (14). In a study of leucorrhoea in Tibetan community by Dai Q et al, the incidence of candidiasis and trichomoniasis was found to be 6.5% and 2.5% respectively (15). Low rate of incidence in their study is due to their decision to include both symptomatic and asymptomatic women. All the seven cases of Trichomoniasis were reported from women with rural background in our study, but Tanuja Chakraborty et al from Surat has reported higher incidence of Trichomoniasis in urban women than rural women (16).We could not detect any case of Trichomoniasis in urban women. This may be due to inclusion of few numbers of (only 6 number) cases from urban background in our study. T.vaginalis is the cause of acute vaginitis in 5-50% of cases, depending on the population studied (17). Out of 50 women with leucorrhoea, 49 of them gave the history of first occurrence where as only one had recurrent infection in the present study. This is in accordance with the finding that recurrent vulvovaginitis is rare and occurs only in less than 5% of the population (18). In our study, C.albicans was the commonest species isolated (83%), followed by C.tropicalis(7%)and C.guielliermondi(3.3%),C.krusei(3.3%),C.parap silosis(3.3%).Poria VC et al reported an isolation rate of C.albicans to be 56.8%. In their study, C.tropicalis is the most common non-albicans species accounting for 20.4% of the isolates (13).Whereas N.Jindal et.al reported C.glabarata as the most common non-albicans species (11%) in their study and C.albicans accounted for (74.4%) of the isolates (10). According to Linda French et al C.albicans accounts for 80-90% of patients with vulvovaginal candidiasis; and among the non-albicans species, C.glabrata is the most common species reported (18). In the present study, mixed infection by both Candida and T.vaginalis was seen in 4 cases. Mixed infection is possible as both share a common route of transmission (sexually transmitted) and several pathogens may coexist (2). Although wet mount preparation is having a sensitivity ranging from 40-75%(18), in our study wet mount preparation was having a sensitivity of 93% and Gram stain was having a sensitivity of 77% for detection of Candida infection.
CONCLUSION
• Leucorrhoea was commonly seen in women who came from rural areas.
• Prevalence of candidiasis (60%) was found to be much higher than trichomoniasis (14%).
• C.albicans contributed for 83% of candidiasis.
• Leucorrhoea was commonly seen in 31-35 years old.
• Low back pain and pain in the lower abdomen was the most common associated clinical features.
ACKNOWLEDGEMENT
We 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. 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=1310http://ijcrr.com/article_html.php?did=13101. National Centre for Health Statistics. National Ambulatory Medicine Care Survey. Available at www.cdc.com/nchs/about/major/ahcd/ahcd1 .htm
2. Schaaf VM, Perez-Stable EJ, Borchardt K. The limited value of symptoms and signs in the diagnosis of vaginal infections. Arch Intern Med.1990;150:1929-1933
3. D.C.Dutta. Text Book of Gynaecology.5th Edition, 2009. NCBA Publication.
4. Howkins and Bourne Shaw’s Text Book of Gynaecology.15th Edition.2011.Elsevier Publication.
5. Balkwill F and Mantovani A. Inflammation and cancer: back to Virchow? Lancet 2001; 357: 539-546.
6. Lisa M Coussens and Zena Werb. Inflammation and cancer. Nature 2002; 420: 860-867.
7. Zuo- Feng Zhang and Colin B Begg. Is Trichomonas vaginalis a cause of cervical neoplasia? Results from a combined analysis of 24 studies. International Journal of Epidemiology 1994; 23(4):682-690.
8. G.Ewart Cree. Brit J Vener Dis.1968;44:226
9. Jagdish Chander. Text Book of Mycology.3r edition. January 2009, Mehta Publisher.
10. N.Jindal, P.Gill, A.Aggrawal. An epidemiological study of volvovaginal candidisis in women of childbearing age.Indian J Med Microbbiology.2007; 25: 75-176.
11. Dr.Sampda Rajurkar. Seth G S Medical College and KEM Hospital, Mumbai.2010. Available at www.authorstream.com/RSS/category/Educ ation
12. Ghotbi Sh, Beheshti M, Amirizade S. Causes of leucorrhoea in Fasa, Southern Iran. Shiraz E-Medical Journal. Vol 8, No.2. April 2007.
13. Poria VC, Joshi BK, Agrawal HH, Mohile NA. Study of Candida and Trichomonas vaginalis in Leucorrhoea. J Indian Med Assoc.1989 Aug; 87(8):184-185.
14. Abauleth R, Boni S, Kouassi-Mbengue A, Konan J, Deza S. Causation and treatment of infectious leucorrhoea at the Cocody University Hospital. Sante 2006 Jul-Sep; 16(3):191-195.
15. Dai Q, Hu L, Jiang Y et al. An epidemiological survey of bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis in the Tibetan area of Sichuan Province, China. Eur J Obstet Gynecol Reprod Biol. 2010 Jun; 150(2):207- 209.
16. Tanuja Chakraborty, SA Mulla, JK Kosambiya, Vikas K Desai. Prevalence of Trichomonas vaginalis infection in and around Surat. Indian J Pathology and Microbiology 2005; 48(4):542-545.
17. Linda O, Eckert MD. Acute vulvovaginitis. The New England J of Medicine.2006; 355: 1244-1252.
18. Linda French, Jennifer Horton, Michelle Matousek. Abnormal vaginal discharge: Using office diagnostic testing more effectively.The Journal of Family Practice. Oct 2004. Vol 53, No 10:805-814.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524153EnglishN2013February18HealthcareEVALUATION OF SIZE AND VOLUME OF MAXILLARY SINUS TO DETERMINE GENDER BY 3D COMPUTERIZED TOMOGRAPHY SCAN METHOD USING DRY SKULLS OF SOUTH INDIAN ORIGIN
English97100Vidya C.S.English N.M. ShamasundarEnglish Manjunatha B.English Keshav RaichurkarEnglishIn the field of forensic medicine, normally the available materials after sufficiently long period of death will be utilized to determine various body characteristics such as age sex etc for identification of individual.Identification of corpses is a difficult forensic procedure and it is mandated by laws and social rules. Comparison of ante mortem and post mortem medical records, such as dental documents, plays an important role in the identification of corpses. Gender has long been determined from the skull, the pelvis and the long bones with an epiphysis and metaphysic in unknown skeletonsaccording to krogmann. The methods such as 3D CT scan have been utilized to determine the gender. Objective: The aim of the present study is to evaluate size and volume of maxillary sinus to determine gender by 3D CT Scan method. This work is of National importance in identifying the sex of a person in the forensic medicine and also for criminal investigations. Method: The skulls of known sex were obtained from recently buried bodies. Initially skulls were scanned by 3D Multiaxial CT scan and dimensions and volume of maxillary sinuses were observed by using dedicated software. Results: The preliminary analysis of data discriminative by CT method has been tabulated. The volume of the maxillary sinuses of both sides was significantly greater in males compared to female skulls. The p value of left width and right sided volume of maxillary sinuses 0.015 and 0.021 respectively were considered statistically significant. Computerized tomography measurements of maxillary sinuses may be useful to support gender determination in forensic medicine.
EnglishINTRODUCTION
Forensic pathologists may be asked to identify the ethnic group and gender of a cranium of unknown origin. [1] Forensic personal identification is a fundamental topic of forensic sciences and technologies to identify live subjects, recently deceased bodies and human remains often at a crime scene by using several appropriate techniques. It has been reported that computerized tomography is a suitable imaging method in the identification of unknown human remains and presents a lot of advantages as compared with conventional radiographs. [2] The volumes of maxillary sinuses are of interest to surgeons operating endoscopically as variation in maxillary sinus volume. Other surgical disciplines, such as dentistry, maxillafacial surgery may benefit from this information.[3] This research was extended to predict the gender from an unknown cranium which will be applicable in the fields of forensic anthropology. The aim of the present study is toevaluate size and volume of maxillary sinus to determine gender by 3D CT Scan method.
MATERIAL AND METHOD
The skulls of known sex were procured from the department of anatomy for the study. A sample size for the complete project was 80 skulls and at present 30 skulls were studied. Macerated skulls were taken, cleaned thoroughly and subjected for 3D axial multislider, Siemens sensation cardiac 16 slice CT scan at Vikram hospital Mysore. Images were obtained with slice collimation of 1mm thickness. Axial and coronal images with slice thickness of 4mm were obtained for measurements of height, AP length and width of maxillary sinuses of both sides by using dedicated software (images 1,2). Volume of maxillary air sinuses of both sides were automatically estimated using syngovolume Siemens, by area length method using freehand interactive drawing of area in each axial sections.( image 3). Statistical Analysis Statistical analysis was performed with Systat 13 package. Mean and SD to assess the level of the parameters in males and females were determined. Independent sample t – test. Differences with a p value, p < 0.05 were considered significant.
Englishhttp://ijcrr.com/abstract.php?article_id=1311http://ijcrr.com/article_html.php?did=1311Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524153EnglishN2013February18HealthcareMEIER-GORLIN SYNDROME- A VERY RARE CONGENITAL MALFORMATION
English101103Vidyadevi KendreEnglish Shital BhattadEnglishThe Meier-Gorlin syndrome or ear, patella, short stature syndrome (MIM 224690) is a rare autosomal recessive disorder. It is characterized by severe intrauterine and postnatal growth retardation, microcephaly, bilateral microtia, and aplasia or hypoplasia of the patella. Despite the presence of microcephaly, intellect is usually normal (1). This case study discusses a case on Meier-Gorlin Syndrom.
EnglishINTRODUCTION
The Meier-Gorlin syndrome is a rare autosomal recessive disorder.it was first described by Meier and Rothschild (2) and the second case reported by Gorlin et al.1975 (3) so named after the two. While almost all cases have primordial dwarfism with substantial prenatal and postnatal growth retardation, not all cases have microcephaly, and microtia and absent/hypoplastic patella.(4)
CASE REPORT
A newborn born by nonconsanguineous marriage to phenotypically normal parents, He was born normally at 37-week gestation and weighed 2.1 kg, small for his gestational age, antenatal history was not significant. On examination, He had microtia and microcephaly with his head circumference of 30 cm and length being 46 cm at birth, metopic sutural prominence and hyper extensibility of joints with typical nose, which is more prominent and narrow, with a convex in profile view. On day 4 th of life he had systolic murmur but no signs of congestive cardiac failure. No cyanosis and spo2 was maintained and other systems were within normal limits. Routine blood investigations were normal. 2 D ECHO showed, small VSD.
DISCUSSION
The Meier-Gorlin syndrome is a rare autosomal recessive disorder.it was first described by Meier and Rothschild and the second case reported by Gorlin et al.1975 so named after the two. Cohen et al. (1991) (5)used the designation ear, patella, short stature syndrome (EPS) for a condition they observed in 2 sisters who had bilateral microtia, absent patella short stature, poor weight gain, and characteristic facial features. Other skeletal anomalies included complete habitual dislocation of the elbow, slender ribs and long bones, abnormal modeling of the glenoid fossas with hooked clavicles, and clinodactyly. Bone age was significantly delayed and there was flattening of the epiphyses. Hurst et al. (1988) (6)found 2 males with similar characteristics. Few studies have documented variable results of endocrine work-up, including growth hormone assays. Loeys et al. [1999](7) reported two brothers with MGS, delayed bone age, one of whom was subjected to glucagon stimulation test with subnormal GH and borderline Somatomedin C.Bongers et al. (2001) (8) reported 6 female and 2 male patients from 7 families with Meier-Gorlin syndrome and reviewed the literature on this condition. Most of their patients had bilateral small ears, patellar aplasia/hypoplasia, and short stature, except for monozygotic twins who had normal patella on physical examination. Radiographic studies of the patellae were recommended in patients with this condition to understand the patellar abnormality better. Guernsey et al 2011(9) had done genetic work up of 45 idividuals with MGS and found mutations in five genes from the pre-replication complex (ORC1, ORC4, ORC6, CDT1, and CDC6), crucial in cell-cycle progression and growth. In our case, physical characteristics like microotia, typical nose, microcephaly and IUGR are present. Which is reported in many cases(10). But we got VSD in addition to typical features.
Englishhttp://ijcrr.com/abstract.php?article_id=1312http://ijcrr.com/article_html.php?did=1312REFERENCES
1. Bicknell, L. S., Bongers, E. M. H. F., Leitch, A., Brown, S., Schoots, J., Harley, M. E., Aftimos, S., Al-Aama, J. Y., Bober, M., Brown, P. A. J., Van Bokhoven, H., Dean, J., and 15 others. Mutations in the pre-replication complex cause Meier-Gorlin syndrome. Nature Genet. 43: 356-359, 2011.
2. Meier, Z., Rothschild, M. Ein Fall von Arthrogryposis multiplex congenita kombiniert mit Dysostosis mandibulofacialis (Franceschetti-Syndrom). Helv. Paediat. Acta 14: 213-216, 1959.
3. Gorlin, R. J., Cervenka, J., Moller, K., Horrobin, M., Witkop, C. J., Jr. Malformation syndromes: a selected miscellany. Birth Defects Orig. Art. Ser. 11: 39-50, 1975.
4. Shalev, S. A., Hall, J. G. Another adult with Meier-Gorlin syndrome - insights into the natural history. Clin. Dysmorph. 12: 167- 169, 2003.
5. Cohen, B., Temple, I. K., Symons, J. C., Hall, C. M., Shaw, D. G., Bhamra, M., Jackson, A. M., Pembrey, M. E. Microtia and short stature: a new syndrome. J. Med. Genet. 28: 786-790, 1991.
6. Hurst, J. A., Winter, R. M., Baraitser, M. Distinctive syndrome of short stature, craniosynostosis, skeletal changes and malformed ears. Am. J. Med. Genet. 29: 107-115, 1988.
7. Loeys, B. L., Lemmerling, M. M., Van Mol, C. E., Leroy, J. G. The Meier-Gorlin syndrome, or ear-patella-short stature syndrome, in sibs. Am. J. Med. Genet. 84: 61-67, 1999.
8. Bongers, E. M. H. F., van Kampen, A., van Bokhoven, H., Knoers, N. V. A. M. Human syndromes with congenital patellar anomalies and the underlying gene defects. Clin. Genet. 68: 302-319, 2005.
9. Guernsey, D. L., Matsuoka, M., Jiang, H., Evans, S., Macgillivray, C., Nightingale, M., Perry, S., Ferguson, M., LeBlanc, M., Paquette, J., Patry, L., Rideout, A. L., and 11 others. Mutations in origin recognition complex gene ORC4 cause Meier-Gorlin syndrome. Nature Genet. 43: 360-364, 2011.
10. Terhal PA, Ausems MG, Van Bever Y, Ten Kate LP, Dijkstra PF, Kuijpers GMC. 2000. Breast hypoplasia and disproportionate short stature in the Ear-Patella-Short Stature Syndrome: Expansion of the phenotype? J Med Genet 37:719–721.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524153EnglishN2013February18HealthcarePYOGENIC LIVER ABSCESS - CLINICAL, RADIOLOGICAL AND BACTERIOLOGICAL CHARECTERISTIC AND MANAGEMENT STRATEGIES
English104107C.P. Ganesh BabuEnglish R. KalaivaniEnglishPyogenic liver abscess is one of the most common clinical condition seen in private set up. 100 patients with pyogenic liver abscess were managed at department of general surgery, MAPIMS between may 2006 to October 2009. The investigations conducted were abdominal ultrasound, chest x ray, complete blood count, liver function tests and hem agglutination tests. Depending on the size of the abscess the patients were managed by parental antibiotics and percutaneous needle aspiration or surgery. Results : pyogenic liver abscess common in males and seen in right lobe. 20% were multiple. percutaneous needle aspiration with parental antibiotics is the most successful therapy.
Englishpyogenic liver abscess, needle aspiration.INTRODUCTION
Pyogenic liver abscess is a condition with significant morbidity and mortality. The most common presenting clinical symptoms are upper abdominal pain, tenderness, hepatomegaly, high grade fever, nausea, and vomiting. These features are variable depending on the size of the abscess, general health of the patients, associated diseases and complications. In majority of cases, underlying cause could not be identified. It may be because of bacterial or parasitic invasion of liver . Majority of abscess are solitary and sub- diaphragmatic and noted in the right lobe of liver. For the last two decade , the advances in the imaging field coupled with ultrasound guided percutaneous needle aspiration and drainage brought dramatic changes in the pattern of treatment of liver abscess.. The aim of our study was to determine the clinical, radiological and bacteriological characteristic of the condition.
MATERIALS AND METHODS
100 patients with pyogenic liver abscess were managed in the department of surgery in MAPIMS from may 2006 to October 2009. All the patients were sent to radiology department for the confirmation of diagnosis on ultrasound, chest x ray was also performed. Ultrasound guided percutaneous needle aspiration and drainage was performed in the radiology department. Other investigations include complete blood count, liver function tests, heamagglutination tests.(Table 3). Abscess smaller than 5cm were managed by parental antibiotics therapy while larger than 5cm were planned to be managed by ultrasound guided percutaneous aspiration.
RESULTS
In our institution 85 out of 100 (85%) were males and 15 out of 100 (15%) were females, male: female ratio is 6:1. The patient’s age was ranging from 20 – 80 years. Mean age 50 years.5 Majority of patients (75%) with pyogenic liver abscess presented with upper abdominal pain , high grade fever was noted in 62%, hepatomegaly plus tenderness (20%) patients, jaundice in 12%, loss of appetite in 12%, nausea and vomiting was complaint in 5% of patients. (Table 2) 8 . Eighty five patients were diagnosed accurately on ultrasound with characteristic of lesion which plays central role for quick diagnosis. Intravenous antibiotic therapy ( cephalosporin combination with metronidazole and aminoglycosides) started to all patients. 52 patients improved completely by this regime. These patients were having a single abscess less than 5cms size. 28 patients having single abscess larger than 5cm were managed with antibiotic regime and percutaneous needle aspiration.4 . 20 patients having very large abscesses (10cm) were planned to be managed by antibiotic with catheter drainage. 15 patients got improved by this mode of management. Two patients planned for open surgery. 3 patients died, one due to septicemia, 2 because of organ failure. Blood cultures of 100 patients confirmed the presence of Escherichia coli in 36% while microbiological report of abscess aspirates of 63 patients confirm Escherichia coli.(Table 4). Other laboratory tests confirmed as Hb 11000 in 75 cases, bilirubin > 3mg in 15 cases, alkaline phosphatase > 150iu/L in 50 cases (Table 3).
DISCUSSION
In our study the most significant clinical feature of pyogenic liver abscess was upper abdominal pain with high grade fever, hepatomegaly and jaundice as reported by others. Patients with pyogenic liver abscess need rapid diagnosis. Advances in the imaging modalities like ultrasound and CT scan made a quick and early diagnosis possible. Abdominal ultrasound is diagnostic and always play a central role in diagnosis. Because of ultrasound the mortality of liver abscess has reduced from 30% to 10 to 20%. These improvement are due to improved imaging and effective antimicrobial therapy. In our study the diagnostic rate of ultrasound is 85%. Percutaneous aspiration in combination with systemic antibiotics should be considered as first line treatment. 28 patients with >5cm size abscess were managed by aspiration and antibiotics. Twenty patients with >10cms were managed by catheter. Failure of catheter drainage in our study is 5%... open surgery was planned. These patients were inaccessible to radiological intervention as they were multiple and large. 2 patients planned for surgery and 3 died because of sepsis. Literatures suggest that diabetic patients have increased risk. In our study 12 patients were diabetic and they were not responding well to antibiotic and stay longer. Escherichia coli was the most common pathogen isolated from aspirates/ blood of our patients. However, klebsiella, streptococcus, and enterococcus are also blamed.10). The underlying causes cannot not be made out. Literatures suggest most are cryptogenic. Only 12% of cases in our study were noted with complaint of acute/ chronic features of cholangitis .9) .
CONCLUSION
Patients with pyogenic liver abscess tend to be at high risk of morbidity especially elderly and diabetic. An early and accurate diagnosis coupled with aspiration/ drainage results in dramatic changes in prognosis. A high index of suspicion , rapid diagnosis and early administration of antibiotics with radiological interventions is an effective management strategy.
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