Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Warning: Cannot modify header information - headers already sent by (output started at /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php:195) in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 234
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241511EnglishN2013June18General SciencesBENZOPHENONE SENSITIZED ONE-POT PHOTOREDOX REACTION OF N-(Α-CYANO-Α-SUBSTITUTED PHENYL)-METHYLANILINES LEADING TO THE SYNTHESIS OF BENZOIMIDAZOLOQUINOLINES
English0109Manpreet KaurEnglish Baldev SinghEnglishN-(α-cyano-α-substituted phenyl)-methylanilines (I) on exposure to bright sunlight using soda glass photoreactor are transformed smoothly, with insertion of one methylene group from the solvent (methanol), into substituted benzoimidazoloquinolines (II) with improved yields under benzophenone sensitized conditions employing basic aqueous alcoholic medium in the presence of iodide salt. These compounds have been characterized through their, elemental analysis, IR, 1H NMR, 13C NMR and mass spectral studies.
EnglishAzomethines, N-(?-cyano-?-substituted phenyl)-methylanilines, benzophenoneINTRODUCTION
Upon exposure with ultraviolet radiations organic nitriles have provided a variety of new heterocyclic compounds depending on the reaction conditions employed[1,2,3] . Consequentely, with the idea to utilise the solar radiations for these photochemical reactions, these N-(α- cyano-α-substituted phenyl)- methylanilines (I) have been subjected to solar radiations, as these compounds (I) have been reported to undergo photodecomposition on exposure to sunlight. Earlier from these laboratories the synthesis of substituted benzoimidazoloquinolines[4] and a photoredox reaction of N-(α-cyano-α-substituted phenyl)- methylanilines under unsensitised condition and consuming longer time period with poor yields have been reported[5] .
EXPERIMENTAL
All the chemicals and solvents (Aldrich company U.S.A and B.D.H standard) used for this photoredox reaction were of high purity and were used without further purification. These reactions were monitored intermitantly by percolated alumina, silica gel 60 F 254 thin layer plates procured from Merck Company. All melting points were measured with an open capillary apparatus are uncorrected. All the compounds were characterized through their IR, 1H NMR, 13C NMR, mass spectral studies and elemental analysis. IR spectra were recorded on a Perkin Elmer RXIFT infrared spectrometer using KBr pellets. 1H NMR and 13C NMR spectra were recorded on a 400 MHz Bruker advance spectrometer using TMS as internal standard. Mass spectra was recorded on Thermo scientific LTQ-XLLCMS. Elemental analysis was carried out using Elementar Vario Micro cube CHN analyzer. General procedure for the synthesis of 3- hydroxy-9-methyl-2-oxo-1,2,2a,11-tetrahydrobenzo [3,4-a] imidazolo [3,4-a] quinoline (I) General procedure for the preparation of azomethines variously substituted azomethines were prepared by following identical procedure as described in literature[8] . Synthesis of 2-(3- methylbenzylideneamino) phenol is described as a representative case. 2-Hydroxybenzaldehyde 1.22 g (0.01 mol) were mixed with 1.07 g (0.01 mol) of m-toluidine in 10cc of ethyl alcohol. The reaction mixture after gentle warming provided the required azomethine. M.p. 79-810C. (II) General Procedure for the preparation of N-(α-cyano-α-substituted phenyl)- methylanilines To the aqueous methanolic solution of azomethine 2.11 g (0.01 mol) taken in conical flask, an equimolar quantity of sodium cyanide 1.06 g (0.01 mol) were added in good ventilated hood. The reaction mixture was kept for overnight period. Usual work up of reaction mixture provided the crystalline product which was recrystallized from petroleum ether. M.p. 98- 1000C. (III) General Procedure for the preparation of 2-oxo-1,2,2a,11-tetrahydro-benzo[3,4-a] imidazolo[3,4-a] quinoline An alcoholic solution of doubly recrystallized 3.2 g (0.01 mol) of N-(α-cyano-α-substituted phenyl)-methyl-3-toluidine in methanol (300 ml) was taken in a one litre capacity conical soda glass flask. To this mixture were added potassium hydroxide (2.0 g), potassium iodide (7.5 g) and few crystal of benzophenone. To ensure the expulsion of dissolved oxygen in the reaction mixture it was flushed with nitrogen gas for a period of half an hour to provide an inert atmosphere. Finally the flask stoppered tightly and exposed to sunlight for one week (40 hour approximately) turning the reaction mixture dark brown. After this period, excess of methanol was pulled off in vacuo. The mother liquor was extracted with solvent ether. The etheral layer was dried over anhydrous magnesium sulphate and on pulling off the ether in vacuo provided the crude product which on recrystallization from petroleum ether yielded cream coloured crystalline 3-hydroxy-9-methyl-2-oxo-1,2,2a,11- tetrahydro-benzo[3,4-a] imidazolo[3,4- a]quinoline in 78% yield m.pt 225-270C (Scheme 1). These benzoimidazoloquinolines have been characterized through elemental analysis, IR, 1H NMR, 13C NMR and high resolution mass spectral data[8] . General Procedure for the preparation of 2- oxo-1,2,2a,11-tetrahydro-benzo[3,4-a] imidazolo[3,4-a] quinoline All these benzoimidazoloquinolines (IIa to IIi) were prepared by following identical procedure (table 1 and table 2). 10-Methyl-2-oxo-1,2,2a,11-tetrahydrobenzo[3,4- a]imidazolo[3,4-a]quinoline (IIa) M.p.: 153- 550C; Yield 75%; IR (Potassium bromide): 3366- 3310 (-N-H), 1715 ( C N H O ), 1610-1585 (C=C) cm-1 ; 1H NMR (400 MHz, CDCl3) δ 2.3 (s, 3H, - CH3), 6.6 (m, 2H, -CH2), 5.3 (s, H, -CH), 7.0-8.1 (m, 7H, Ar), 1.5 (s, 1H, -NH); 13C NMR (400MHz, CDCl3) δ: 22.6, 116.3, 117.7, 118.7, 120.3, 121.5, 126.4, 127.7, 128.4, 131.5, 131.6, 132.5, 137.6, 141.7, 147.3, 156.4, 158.3; MS: Molecular ion peak m/z 250.22; Anal.Calcd for C16H14N2O: C, 76.77; H, 5.67; N, 11.23; Found: C, 76.27; H, 5.36; N, 11.10. 9-Methyl-2-oxo-1,2,2a,11-tetrahydro-benzo[3,4,- a]imidazolo[3,4-a]quinoline (IIb). M.p.: 232- 350C; Yield: 74%; IR (Potassium bromide): 3372-3329 (-N-H), 1711 ( C N H O ), 1603-1582 (C=C) cm-1 ; 1H NMR (400 MHz, CDCl3) δ 2.1 (s, 3H, -CH3), 6.8 (m, 2H, -CH2), 5.4 (s, H, -CH), 7.2-8.0 (m, 7H, Ar), 1.5 (s, 1H, -NH); 13C NMR (400MHz, CDCl3) δ: 23.5, 116.5,117.7, 118.5, 120.3, 120.8, 126.4, 127.8, 128.8, 131.3, 131.4, 132.4, 137.5, 141.8, 147.6, 155.4, 159.3; MS: Molecular ion peak m/z 250.43; Anal.Calcd for C16H14N2O: C, 76.78; H, 5.64; N, 11.19; Found: C, 76.23; H, 5.32; N, 11.03. 9-Chloro-2-oxo-1,2,2a,11-tetrahydro-benzo[3,4,- a]imidazolo[3,4-a]quinoline (IIc). M.p.: 128- 300C; Yield: 73%; IR (Potassium bromide): 3386-3317 (-N-H), 1720 ( C N H O ), 1610-1590
(C=C) cm-1 ; 1H NMR (400MHz, CDCl3) δ : 6.6 (m, 2H, -CH2), 5.5 (s, H, -CH), 6.8-7.9 (m, 7H, Ar), 1.3 (s, 1H, -NH); 13C NMR (400MHz, CDCl3) δ: 116.4, 117.3, 118.2 121.3, 121.4, 126.3, 127.4, 128.6, 131.5, 131.4, 132.2, 137.4, 140.8, 146.6, 156.4, 158.3; MS: Molecular ion peak m/z 270.87; Anal.Calcd for C15H11ClN2O: C, 66.55; H, 4.10; N, 10.35; Found: C, 66.03; H, 4.02; N, 10.11. 3-Hydroxy-10-methyl-1,2,2a,11-tetrahydrobenzo[3,4,-a]imidazolo[3,4-a]quinoline (IId). M.p.: 232-34oC; Yield: 76%; IR (Potassium bromide): 3373-3310 (-N-H), 1723 ( C N H O ), 1615-1566 (C=C) cm-1 ; 1H NMR (400 MHz, CDCl3) δ: 2.3 (s, 3H, -CH3), 6.7 (m, 2H, -CH2) , 5.1 (s, H, -CH), 7.2-8.0 (m, 6H, Ar), 8.2 (s, 1H, - OH), 1.2 (s, 1H, -NH); 13C NMR (400MHz, CDCl3) δ: 22.6, 116.3, 117.5, 119.2 120.3, 120.4, 126.6, 127.7, 128.4, 130.5, 130.2, 132.4, 137.2, 140.5, 146.4, 155.4, 159.3; MS: Molecular ion peak m/z 266.56; Anal. Calcd. for C16H14N2O2: C ,72.27; H, 5.28; N, 10.34; Found: C, 72.02; H, 5.09; N, 10.24. 3-Hydroxy-9-methyl-2-oxo-1,2,2a,11-tetrahydrobenzo[3,4.-a]imidazolo[3,4-a]quinoline(IIe). M.p.: 225-27oC; Yield: 78%; IR (Potassium bromide): 3376 (-N-H), 1725 ( C N H O ), 1615- 1566 (C=C) cm-1 ; 1H NMR (400 MHz, CDCl3) δ: 2.5 (s, 3H, -CH3), 6.9 (m, 2H, - CH2) , 5.3 (s, H, -CH), 7.1-8.2 (m, 6H, Ar), 8.3 (s, 1H, -OH), 0.6(s, 1H, -NH); 13C NMR (400MHz, CDCl3) δ: 21.4 ,112.7, 117.8, 118.6, 120.5, 120.7, 123.9, 127.5, 128.8, 131.2, 131.2, 132.7, 136.3, 140.7, 147.6, 155.7, 159.2; MS: Molecular ion peak m/z 266.23 and others prominent peak are at m/z 221.21, 206.25, 191.31, 163.31, 107.25, 77.25; Anal. Calcd. for C16H14N2O2: C ,72.16; H, 5.30; N, 10.50; Found: C, 72.07; H, 5.27; N, 10.32. 9-Chloro-3-hydroxy-2-oxo-1,2,2a,11-tetrahydrobenzo[3,4,-a]imidazolo[3,4-a]quinoline(IIf). M.p.: 200-02 0C; Yield: 72%; IR (Potassium bromide): 3373 (-N-H), 1725 ( C N H O ), 1590- 1575 (C=C) cm-1; 1H NMR (400 MHz, CDCl3) δ: 6.4 (m, 2H, -CH2), 5.6 (s, H, -CH-), 6.8-7.8 (m, 6H, Ar), 1.2 (s, 1H, -NH), 8.1 (s, 1H, OH); 13C NMR (400MHz, CDCl3) δ: 112.4, 117.4, 117.9, 121.2, 121.4, 123.5, 127.4, 128.3, 130.2, 130.6, 132.7, 136.3, 140.3, 147.4, 155.4, 158.2; MS: Molecular ion peak m/z 286; Anal.Calcd for C15H11ClN2O2: C, 62.84; H, 3.87; N, 9.77; Found: C, 62.14; H, 3.23; N,9.28. 5-Methoxy-10-methyl-2-oxo-1,2,2a,11- tetrahydro-benzo[3,4,-a]imidazolo[3,4- a]quinoline (IIg). M.p.: 137-390C; Yield: 71%; IR (Potassium bromide): 3365 (-N-H), 1725 ( C N H O ), 1600-1585 (C=C) cm-1 ; 1H NMR(400MHz, CDCl3) δ: 6.2 (m, 2H, -CH2), 5.6 (s, H, -CH), 6.8-7.9 (m, 6H, Ar), 1.2 (s, 1H, - NH), 2.7 (s, 3H, CH3), 3.4 (s, 3H, -OCH3); 13C NMR (400MHz, CDCl3) δ: 24.7, 114.4, 117.2, 117.5, 121.4, 121.6, 123.6, 127.3, 128.6, 130.4, 130.4, 132.3, 136.5, 140.6, 147.7, 154.6, 158.8; MS: Molecular ion peak m/z 280; Anal.Calcd for C17H16N2O2: C, 72.84; H, 5.75; N, 9.99; Found C, 72.15; H, 5.23; N, 9.16. 5-Methoxy-9-methyl-2-oxo-1,2,2a,11tetrahydrobenzo[3,4,-a]imidazolo[3,4-a]quinoline (IIh)., M.p.: 127-29 0C, Yield: 72%; IR (Potassium bromide): 3360 (-N-H), 1720 ( C N H O ), 1600- 1580 (C=C) cm-1 ; 1H NMR (400 MHz, CDCl3) δ: 6.3 (m, 2H, -CH2), 5.5 (s, 1H, -CH), 6.8-8.1 (m, 6H, Ar), 1.3 (s,1H, -NH), 2.5 (s, 3H, CH3), 3.2 (s, 3H, -OCH3); 13C NMR (400MHz, CDCl3) δ: 23.7, 112.4, 116.7, 117.4, 117.6, 120.4, 120.6, 126.6, 127.5, 128.4, 131.4, 131.3, 132.5, 136.7, 140.5, 147.5, 153.7, 158.4; MS: Molecular ion peak m/z 280; Anal.Calcd for C17H16N2O2: C, 72.84; H, 5.75; N, 9.99; Found: C, 72.12; H, 5.23; N, 9.14. 5-Methoxy-9-chloro-2-oxo-1,2,2a,11-tetrahydrobenzo[3,4,-a]imidazolo[3,4-a]quinoline(Ii).
M.p.: 122-25 0C; Yield: 73%; IR (Potassium bromide): 3360 (-N-H), 1720 ( C N H O ), 1610- 1585 (C=C) cm-1 ; 1H NMR (400MHz, CDCl3) δ: 6.3 (m, 2H, -CH2), 5.4 (s, H, -CH-), 6.8-7.9 (m, 6H, Ar), 1.3 (s, 1H, -NH), 3.2 (s, 1H, -OCH3); 13C NMR (400MHz, CDCl3) δ: 112.6, 117.7, 117.6, 117.5, 121.3, 121.5, 126.7, 127.4, 128.7, 130.5, 130.5, 132.5, 136.7, 140.7, 147.6, 153.7, 158.4; MS: Molecular ion peak m/z 300; Anal.Calcd for C16H13ClN2O2: C, 63.90; H, 4.36; N, 9.31; Found: C, 63.11; H, 4.04; N, 9.09.
RESULTS AND DISCUSSION
Present study describes the synthesis of variously substituted N-(α-cyano-α-substituted phenyl)- methylanilines which have been obtained by the hydrocyanic acid addition on substituted open chain azomethines and subsequently their photoredox reaction under sensitized conditions. To the methanolic solution of these N-(α-cyanoα-substituted phenyl)- methylanilines were added an aqueous solution of potassium hydroxide, potassium iodide and benzophenone and this reaction mixture was exposed to direct sunlight in soda glass reactor. Under the sensitized conditions, these N-(α- cyano-α-substituted phenyl)-methylanilines smoothly transformed to provide a new fused heterocyclic ring system (II) in lesser time as required under unsensitized conditions[6] (Scheme 1). These compounds have been characterized as substituted 2-oxo-1,2,2a,11-tetrahydrobenzo[3,4- a]imidazolo[3,4-a] quinoline derivatives through their elemental analysis, IR, proton magnetic resonance, 13C NMR and high resolution mass spectra. In infrared spectrum of 3-Hydroxy-9- methyl-2-oxo-1,2,2a,11-tetrahydrobenzo[3,4- a]imidazolo[3,4-a]quinoline shows medium intensity absorption bands in the region 3376- 3315 cm-1 which has been assigned to the secondary amide function (-N-H-stretching). The lower position of these bands indicates the presence of either inter or intramolecular hydrogen bonding in these products. Strong infrared absorption band at 1725 cm-1 has been assigned to the cyclic amido carbonyl function ( ). Absorption bands in the region 1654-1566 cm-1 has been assigned to the aromatic carbon-carbon double bond stretching vibrations. Weak intensity absorption bands in the region 1410-1400 cm-1 correspond to carbon-nitrogen single bond vibrations. The various infrared absorption bands indicate that transformation of nitrile function present in α-cyanoamines has occurred as absorption band corresponding to the nitrile function is missing.
In the high resolution (400 MHz) proton magnetic resonance spectrum of 3-Hydroxy-9- methyl-2-oxo-1,2,2a,11-tetrahydro-benzo[3,4-a] imidazolo [3,4-a] quinoline shows multiplet at δ 8.2-7.1 (equivalent to six protons) which has been assigned to aromatic protons, another multiplet at δ 6.9 (equivalent to two proton) which has been assigned to the methylenic protons (-CH2-), a broad singlet at δ 5.3 (equivalent to one proton) has been assigned to the methynic proton (-CH-), a singlet at δ 2.5 (equivalent to three protons) has been assigned to one methyl group and a broad absorption signal at δ 0.6 (equivalent to one proton) has been assigned an amido proton (-NH), on deuterium exchange the signal for this (- N-H-) proton disappears confirming the presence of one active proton on the amine function. In their 13C NMR spectra, compound 3-Hydroxy9-methyl-2-oxo-1,2,2a,11-tetrahydro-benzo[3,4- a]imidazolo [3,4-a]quinoline displays signal at δ 159.2 has been assigned to carbonyl carbon while another signal at δ 155.7 has been assigned to phenolic carbon. The aniline carbon displays its signal at δ 147.6 and the tolylic carbon displays its signal at δ 140.7. The other signals at δ 132.7, 120.7, 120.5, 128.8, 131.2, 131.2, 127.5, 136.3 corresponds to C-10, C-8, C-7, C-6b, C-5, C-4, C-6, C-2b. The signal at δ 119.5 has been assigned to carbon atom of benzylic group while a signal at δ 118.6 assigned to carbon atom of methylene group. The signal at δ 21.4 assigned to carbon atom of methyl group. In high resolution mass spectra of 3-Hydroxy-9- methyl-2-oxo-1,2,2a,11-tetrahydro-benzo [3,4-a] imidazolo[3,4-a]quinoline, the molecular ion peak appears at m/z 266. The base peak appears at m/z 193 due to the loss of a neutral molecule aziridinones molecule and phenolic group OH. The molecular ion peak loses hydrogen cyanide H-N-C=O to give a peak at m / z 221. The other ion peak appears at m / z 206 with the loss of methyl (-CH3) group. With the loss of O+ ion, the prominent ion peak appears at m / z 191. Then the loss of (-HCN) gives the daughter ion peak at m / z 166. Others ion peaks at m / z 106, 78 appear on fission of the fragment ions. Under these reaction conditions, benzophenone seems to transfer its energy to α-cyanoamine to form diradical specie on which hydroxide free radical generated in situ by iodide salt, to form hydroxyamino radical which is subsequently attacked by hydroxymethyl radical[7], during photoirradiation the hydroxymethylamino intermediate gets dehydrated to form imidazoline intermediate, bringing the two aromatic C-phenyl and N-phenyl rings in close proximity which on oxidation with loss of H-atom get connected to form fused cyclic imidazolo ring system (Scheme 2)
CONCLUSION
Moreover the originality of the work lies in using simple reagents which are easily available at convenience. The synthesis of improved yields of substituted benzoimidazoloquinolines with sensitized benzophenone which act as a catalyst in synthesis.
ACKNOWLEDGEMENT
The author wish to thank SAIF (PU) and NIPER (Mohali) for spectral studies.
Englishhttp://ijcrr.com/abstract.php?article_id=1314http://ijcrr.com/article_html.php?did=13141. Kaneko, C.; Yokee, I.; Ishikawa, M. Tetrahedron . 1967, 5233.
2. Chow, Y. L.; Haque. Canad. J. Chem. 1968, 46, 290.
3. Omura, K.; Matsura, T. J.C.S Chem. Commun. 1966, 1615.
4. Singal, K. K.; Singh, B. Synthetic communication. 1985, 829.
5. Singal, K. K .; Singh, B. Chemica Acta Turcica. 1998, 26, 1.
6. Ohno, M.; Shibahara, S.; Kondo, S.; Maeda, K.; Umezawa. J. Amer. Chem. Soc. 1974, 96, 4326.
7. Pfoertner, K. H. Helv. Chim Acta. 1975, 58, 865. 8. Layer, R. W. Chem Rev. 1963, 63, 489.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241511EnglishN2013June18General SciencesANTIFUNGAL ANTIBIOTIC OF STREPTOMYCES SP. SS12: PRODUCTION AND CHARACTERIZATION
English1029Shipra SinghEnglish Anita RawatEnglish Deepak Chand SharmaEnglishStreptomyces sp. (strain SS12) was isolated from terrestrial soil of western U.P., India and found to exhibit antimicrobial activity against various pathogenic bacteria and fungi. Optimization of physical and chemical parameters for antibiotic production in submerged fermentation resulted in 1.75 fold increase in production level in terms of inhibition zone diameter. The bioactive compound was found thermo stable (121?C for 15min.), pH stable (from 4-9) and soluble in water and ethyl acetate. The antifungal antibiotic was found to have comparable activity with nystatin and could completely inhibit the spore germination and degradation of mycelia in test fungus (Aspergillus sp.). On supplementing 0.5% of the crude culture filtrate containing bioactive compound resulted in 76% inhibition of growth in submerged culture in compare to control.
EnglishAntifungal antibiotic, Actinomycetes, Optimization, Streptomyces sp. SS12, Bioactive.INTRODUCTION
Inappropriate and over prescription of antibiotics has resulted in the development of resistant microbial pathogens (WHO, 2012). The incidences of infections by opportunistic fungi are increasing at alarming rate, especially in patients with feeble immune systems. Many antifungal compounds exist but safe and effective antifungal drugs have not yet been developed because of the high degree of similarity between fungi and mammalian cells (Xu et. al., 2013). Therefore, amphotericin B, which was developed many years ago, is widely used for the treatment of deep-seated mycoses despite its serious side effects (Gallis et al., 1990). Azole group antifungal agents, miconazole, keto- conazole, fluconazole, and itraconazole are also being used clinically; but these medicines have nephrotoxicity and hepatotoxicity and cause vomiting and impotence (Fukai et al., 2003). This has consequently resulted in a strong demand for potent drugs that have least side effects and the search for the new antifungal metabolites remains as a challenging task. Actinomycetes are group of gram positive bacteria and the most prolific microorganisms for the production of antibiotics which are responsible for approximately two-thirds of the world’s naturally occurring antibiotics by the 1980s (Berdy, 1989). The antagonistic activity of actinomycetes to fungal pathogens is usually related to the production of antifungal compounds (Getha and Vikineswary, 2002; Ouhdouch et al., 2001) and extracellular hydrolytic enzymes (Mukherjee and Sen, 2006; Prapagdee, 2008; Valois et al., 1996). The exploration of new habitats plays an important role in search of new microbes possessing potentials to produce novel metabolites and is required urgently to counter the threats posed by the fast emerging phenomenon of antibiotic resistance (Shiburaj 2003). The present investigation was planned to optimize the production and characterization of antifungal compound produced by novel Streptomyces sp. SS12 (Singh et al., 2012).
MATERIAL AND METHODS
The Strain The bacterial strain was isolated from a pretreated soil sample collected from the terrestrial soil of western U.P., India, maintained on nutrient agar slants at 4?C, and also stored as glycerol stocks at −20?C. The strain was identified as Streptomyces sp. SS12 based on 16S rDNA sequence analysis (GenBank accession number AY426610) and BIOLOG biochemical profiling (Singh et al., 2012). Optimization of culture parameters for the production of antifungal antibiotic from Streptomyces sp. SS12 in SmF Selection of suitable antibiotic production medium The submerged fermentation was carried out in ten different culture media (M1- M10) to select preeminent production medium (Table 1). The activity of cell free fermented broth (permeate of 0.22? syringe filter) was evaluated after 48h by well diffusion method. Further various physiochemical parameters were optimized for the production of antimicrobial antibiotic in selected medium. Optimization of incubation period Fermentation broth was incubated for different time intervals (12, 24, 48, 72, 96, 120 and 144h) to find the optimal incubation period for antibiotic production. Optimization of various chemical parameters To find out the best suited carbon source the medium was supplemented with 1% (w/v) of different carbon sources such as monosaccharides (glucose, fructose), disaccharides (lactose, maltose), polysaccharide (starch), and alcohol (glycerol) followed by incubation at 28?C for 48h. The concentration of selected carbon source was optimized by supplementing the basal medium with various levels of glycerol (0.5, 1.0, 2.0, 3.0 and 4.0% v/v). The bacterial strain was grown in a set of basal media (with optimized level of glycerol) prepared by substituting beef extract with nitrogen equivalent of ammonium chloride, yeast extract, soybean meal, peptone and casein and incubated at 28?C for 72h in orbital shaker. The concentration of selected nitrogen source was optimized by growing the strain at various levels of nitrogen (2.0, 4.0, 6, 8.0 and 10.0 g/l) in basal medium.
Effect of various physical parameters on the production of antifungal antibiotic.
To study the effect of pH on the production of antifungal antibiotic, the bacterial strain was cultivated in the medium of varied pH (0.1M citrate buffer for pH 5.0; 0.1M phosphate buffer for pH 6.0 to 8.0; 0.1M glycine-NaOH buffer for pH 9.0). The effect of temperature was assessed by incubating the inoculated flasks at different temperatures (30, 35, 37, 40, 45 and 50?C). Rate of agitation was optimized by incubating the flasks at the rpm of 100-300 (100, 200, 250 and 300). Extraction of antimicrobial metabolites Organic solvents including ethyl acetate, petroleum ether, chloroform, benzene and xylene were used to determine the ideal solvent for extraction of the antibiotic from the culture supernatant (Busti et al., 2006). The cell free broth was mixed vigorously with the solvent and centrifuged at 5000 rpm for 10min to separate the phase antimicrobial compound. The solvent was evaporated to dry in water bath at 80?C and the residues obtained were used for assay. Characterization of partially purified antimicrobial compound Thermo stability of the antibiotic Thermo stability of the antifungal antibiotic was determined by exposing 1ml of suitably diluted, filter sterilized crude sample to 60, 80 and 100?C for 1, 2, 4, 6 and 8h. An untreated antibiotic sample (same dilution) was used as the control. These pre incubated antibiotic samples were used to determine their residual activity against the test organisms.
Effect of autoclaving on activity 1ml of suitably diluted crude antibiotic sample was taken in 2 sets of micro centrifuge tubes. Each set was autoclaved at 121?C, 15psi for 15min and 115?C, 10psi for 20min. Untreated antibiotic sample was treated as the control. pH stability of the antibiotic The pH stability of the partially purified antibiotic was studied by preparing antibiotic dilutions (5x) in buffers of pH 4.0, 7.0 and 9.0 and incubating them for 1, 2, 4, 6, 8 and 24h. These pre incubated antibiotic samples were used for determining the residual activity against the test organisms. Determination of fungi static or fungicidal nature of antibiotic To know the fungicidal or fungistatic nature of antibiotic, fungal spores and mycelia (Aspergillus sp.) were suspended in 500µL of potato dextrose broth (PDB) containing 10µL of undiluted partially purified culture filtrate of Actinomycetes strain SS12 and incubated for 12h at 30?C. PDB without antibiotic was served as control.
Effect of different concentrations of antibiotic on spore germination
A series of test tubes containing 1ml fungal spore suspension (9x105 spores/ml) were supplemented with different concentrations of the culture filtrate (ranging from 0.5% to 5.0%). These were incubated at room temperature for 30min and 60min. After this pretreatment with antibiotic, 10μL sample of each spore suspension was placed on nutrient agar plates and incubated at 30?C and a plug was cut out and observed under microscope at various time intervals (1, 2, 3, 4, 5 and 6h). Untreated fungal spore suspension was used as the control and 100% spore germination time was noted. A comparative study of spore germination time and germ tube morphology, in control and test set-up, was conducted microscopically. Comparison of antibiotic with commercially available antifungal compounds The activity of antibiotic produced by Streptomyces sp. SS12 and commercially available preparations of antifungal antibiotics (Nystatin) was tested and compared by disc diffusion method. For agar disc diffusion assay, commercially available discs of Nystatin (100 units/disc), were used.
RESULTS AND DISSCUSSION
Optimization of medium component for antibiotic production Selection of suitable antibiotic production medium
Among the media tested for antimicrobial production M9 gave highest production level, which was reflected from a larger zone (25mm) while production was not detected in M1 and M4 (0mm) (Fig. 1). This may be due to the fact that M9 medium contains certain components that favors good bacterial growth and antibiotic production. The contribution of certain media components towards increasing antibiotic production, in submerged batch culture, has been reported for natamycin production by Streptomyces natalensis (Farid, 2000). Similarly Oskay (2011) showed that the activity of actinomycete isolates could be increased or decreased remarkably under different cultural conditions.
Effect of incubation period on antibiotic production
The antifungal activity of the culture filtrates of Streptomyces sp. SS12, was detectable after 12h of incubation and it enhanced with time. The antifungal activity was substantially high after 72h of incubation, and thereafter, no further increase was recorded (Fig. 2).
Optimization of various chemical parameters for antibiotic production
In order to design the effective medium, the roles of different carbon and nitrogen sources were evaluated for their impact on bioactive metabolite production. Glycerol was found to be the most appropriate carbon source (Fig. 3 & 4). The results were in accordance with Streptomyces sp. (Hague et al., 1995), where antibiotic production attains optima with glycerol. As glycerol was found best suited carbon source for bioactive metabolite production by the strain, different levels of glycerol (1~5%) were taken to determine the optimal concentration for bioactive metabolite production. 2% of glycerol supplemented in the medium promoted the highest antibiotic production. A fall in antibiotic production was observed at still higher concentrations of glycerol. These results are in line with those obtained by Mustafa Oskay, (2009). Hassan et al. (2001) found similar results with Streptomyces violatus in batch cultures. Nitrogen sources such as peptone, yeast extract and (NH4)2HPO4 have been reported to play important role in antifungal antibiotic production by Bacillus sp. (Fiddaman and Rossal, 1994). Media containing nitrogen sources such as ammonium chloride, yeast extract, peptone, soybean meal and casein were tested for antibiotic production (Fig. 5). Highest zone of inhibition was observed when medium was supplemented with peptone. Growth in the medium supplemented with 1% of peptone was highest after 72h of incubation and it decreased constantly with further increase in peptone concentration (Fig. 6). Effect of various physical parameters on the production of antifungal antibiotic Antibiotic production was increased with increase in pH of the buffered medium from 5.0 to 7.0, reaching a peak at 7.0. Further increase in pH beyond 7.0 causes a decline in antibiotic production (Fig. 8). The antibiotic production increased with increase in temperature, reaching a peak at 30?C. With further rise in temperature, antibiotic production decreased, and at 45?C antibiotic activity could not be detected (Fig. 7). The strain grew well at moderate temperatures and the growth was very sparse at 50?C. It has been noticed that the initial pH of the medium has a great influence on antibiotic production by actinomycetes (Tarasova et al., 1977). Maximum growth and antibiotic production were achieved at 200rpm. The growth was poor at low rpm (Fig. 9) and very less antibiotic production was observed in static conditions.
Characterization of the partially purified antibiotic
Thermo stability of the antifungal antibiotic
The antifungal compound produced by SS12 was found stable up to 24h at 80?C. However, a marginal decrease in the antifungal activity was observed after 24h (Table 2).
Effect of autoclaving on antifungal activity of antibiotic
A combined temperature and pressure treatment by autoclaving did not affect the stability and activity of the antifungal antibiotic (Table 3).
pH stability of the antifungal activity
The antibiotic was stable at pH 4.0, 7.0 and 9.0 for upto 24h (Table 4). The pH alterations did not affect the antifungal activity of the antibiotic against Aspergillus sp.
Mode of action of antibiotic
On microscopic observation complete inhibition of spore germination was observed (Fig. 11). Morphological alteration in mycelia was observed in compare to control under the light microscope (Fig 12). Effect of different concentrations of antibiotic on biomass production Concentrations of crude antibiotic as low as 0.5% caused 70% growth inhibition as compared to the control. An increase in concentration of antibiotic upto 5% concentration did not show substantial increase in fungal growth inhibition (Table 5).
Effectiveness of antifungal antibiotic produced by Actinomycetes SS12 vis-a-vis some commercially available antifungal agents
The antifungal activity of the antibiotic was compared with Nystatin using agar disc diffusion technique. The antifungal activity was studied against Aspergillus sp. nystatin disc (100units/disc) showed comparable inhibition zone to that of partially purified antifungal antibiotic (Table 6 and Fig. 13).
CONCLUSION
Optimization of process parameters resulted in 1.6 fold enhancement of antifungal antibiotic production. The bioactive compound showed stability and activity at broad range of temperature and pH. Microscopic observation of treated mycelia (Aspergillus sp.) showed significant distortion of mycelia while spore was not able to germinate in presence of antibiotic. As the compound showed comparable activity with commercially available antifungal (nystatin), hence, could be potential candidate for commercialization after established non-toxic nature.
ACKNOWLEDGEMENTS
Authors acknowledge the great help received from the scholars whose articles cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Authors are grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=1315http://ijcrr.com/article_html.php?did=13151. WHO 2012: Department of Communicable Disease Surveillance and Response: WHO Global Strategy for Containment of Antimicrobial Resistance. WHO/CDS/DRS/2001 1.2 [http://www.who.int/csr/resources/publicati ons/drugresist/en /EGlobal_Strat.pdf].
2. Xu SX, Shen JL, Tang XF, Feng B. Newer antifungal agents for fungal infection prevention during hematopoietic cell transplantation: a meta-analysis. Transplantation Proceedings 2013; 45(1): 407-414.
3. Berdy J. The discovery of new bioactive microbial metabolites: screening and identification. In: Bushell ME, Grafe U (eds) Bioactive metabolites from microorganisms, Elsevier Science Publications, Amsterdam. 1989. pp. 3-25.
4. Busti, E., P. Monciardini, L. Cavaletti, R. Bamonte, A. Lazzarini, M. Sosio, and S. Donadio. Antibiotic-producing ability by representatives of a newly discovered lineage of actinomycetes. Microbiol. 2006, 152:675-683.
5. Farid, M.A., el-Enshasy, H.A., el-Diwany, A.I. and el-Sayed el-S.A. Optimisation of the cultivation medium for natamycin production by Streptomyces natalensis J. Basic Microbiol, 2000. 40(3): 157-166.
6. Fiddaman, P.J. and Rossall, S. Effect of substrate on production of antifungal volatiles by Bacillus subtilis J. Appl. Bacteriol. , 1994. 76(4): 395-405.
7. Fukai T, Yonekawa M, Hou AJ, Nomura T, Sun HD, Uno J. Antifungal agents from the roots of Cudrania cochinchinensis against Candida, Crytococcus and Aspergillus species. J. Nat. Prod., 2003. 66: 1118-1120.
8. Gallis HA, Drew RH, Pickard WW. Amphotericin B: 30 years of clinic experience. Rev. Infect. Dis., 1990. 12: 308- 329.
9. Getha K, Vikineswary S. Antagonistic effects of Streptomyces violaceusniger strain G10 on Fusarium oxysporum f. sp. cubense race 4: Indirect evidence for the role of antibiosis in the antagonistic process. J. Ind. Microbiol., 2002. Biotechnol., 28: 303-10.
10. Hague, S.F., S.K. Sen and S.C. Pal. Nutrient optimization for production of broad spectrum antibiotic by streptomyces antibioticus SR 15. 4. Acta- Microbial. Immunol. Hune. 1995. 42 (2): 155-162.
11. Hassan MA, El-Naggar MY, Said WY. Physiological factors affecting the production of an antimicrobial substance by Streptomyces violatus in batch cultures. Egypt. J. Biol. 2001. 3: 1-10.
12. Mukherjee G, Sen SK. Purification, Characterization, and antifungal activity of chitinase from Streptomyces venezuelae P10. Curr Microbiol. 2006. 53: 265-9.
13. Mustafa Oskay. Antifungal and antibacterial compounds from Streptomyces strains. African Journal of Biotechnology, 2009. Vol. 8 (13), pp. 3007-3017. 14. Oskay M. Effects of some environmental conditions on biomass and antimicrobial metabolite production by Streptomyces sp., KGG32. Int J Agric Biol., 2011. 13:317-24.
15. Ouhdouch Y, Barakate M, Finance C. Actinomycetes of Moroccan habitats: Isolation and screening for antifungal activities. Eur. J. Soil Biol., 2001. 37: 69-74.
16. Prapagdee B, Kuekulvong C, Mongkolsuk S. Antifungal Potential of Extracellular Metabolites Produced by Streptomyces hygroscopicus against Phytopathogenic Fungi. Int. J. Biol. Sci., 2008. 4: 330-337.
17. Shiburaj, S. Screening, isolation and characterization of an antibiotic producing Actinomycete Streptomyces setonii 19NRA1 (Ph.D thesis), 2003. University of Kerala.
18. Singh S, Rawat A, and Sharma DC. 2012. Antifungal antibiotic production by Streptomyces sp. isolated from soil. International Journal of Current Research and Review, 4 (24), 07 -16.
19. Tarasova, S.S., V.V. Biryukov and V.G. Makarevich. Double-substrate equations of kinetics of Actinomyces aureofaciens growth and tetracycline biosynthesis. Antibiotiki. 1977. 22(44): 291-297.
20. Valois D, Fayad K, Barasubiye T, Garon M, Dery C, Brzezinski R, Beaulieu C. Glucanolytic actinomycetes antagonistic to Phytophthora fragariae var. rubi, the causal agent of raspberry root rot. Appl. Environ. Microbiol. 1996. 62: 1630-5.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241511EnglishN2013June18General SciencesSIDEROPHORE PRODUCTION FROM AZOTOBACTER SP. AND ITS APPLICATION AS BIOCONTROL AGENT
English3042I. MuthuselvanEnglish R. BalagurunathanEnglishScreening and isolation of siderophore producing bacterial strains were carried out from soil samples collected from plant rhizosphere region. The isolate showed positive for siderophore on Chrome azurol sulfonate agar medium was selected for further studies. The organism was subjected to various biochemical tests and 16S rRNA analysis, which lead to its identification as Azotobacter sp. The Azotobacter sp. holds optimal growth temperature and pH at 30ºC and 8.5 respectively. It was also optimized for carbon and nitrogen with optimal growth in Malic acid and peptone respectively. The presence of magnesium and zinc with iron concentration of 4m concentration also favored the siderophore production. Siderophore production was carried out using optimized media and the harvested siderophore was partially purified by ion exchange chromatography. The antagonist activity of the siderophore producing Azotobacter sp. and partially purified siderophore were tested against fungal pathogens such as Fusariurm sp., Alternaria sp., Phytophthora sp., Rhizoctonia sp., Colletotrichum sp. and Curvularia sp. This result showed that the Azotobacter sp. under study is a good producer of siderophore, which can be beneficial for its antagonistic activity towards fungal pathogens.
EnglishChrome azurol sulfonate agar medium, 16S rRNA analysis, Amberlite IR120, Antagonism.INTRODUCTION
Iron is essential for the growth of almost of the microorganisms. Although iron is abundant in nature, it is not readily available to microorganisms because of its extreme insolubility in aerobic water and soil environments (Neilands, 1972). To sequester iron from the environment, microorganisms excrete high-affinity ferric chelating compounds, termed as siderophores, which solubilize and transport the metal (Neilands, 1974). Nitrogenase and other proteins involved in nitrogen fixation require a high complement of iron (Brill, 1980). Therefore, it is likely that nitrogen fixing organisms evolved efficient ironacquisition mechanisms. Iron-deficient nitrogenfixing cultures of Azotobacter spp. produce 2,3- dihydroxybenzoic acid (DHB), 2-N,6-N-di-(2,3- dihydroxybenzoyl)-L-lysine (DHBL), and a yellow-green fluorescent peptide (YGFP) (Carbin and Bulen, 1969). Although,VB the chemical nature of these molecules and their physiological response to iron make them strong candidates for siderophores (Neilands, 1977). The alternative strategies for disease management include the use of bacteria that show beneficial effects on plants and these bacteria are known as Plant Growth Promoting Rhizobacteria (PGPR). The positive effects of PGPR are normally divided into two categories: growth promotion and biological control (Kleopper, 1997). Also, certain root colonizing bacteria can protect plants from soil-borne pathogens when used as inoculants (Slininger et al., 1996). Azotobacter strain was one of the most active PGPR and dominant bacteria in the rhizosphere and had been intensively used as nitrogen fixers and bio-control agents. Bio-control by using antagonistic microorganisms is a potential alternative to chemical compounds for crop protection against phytopathogens (ElKatatany et al., 2003). The mechanisms through which Azotobacter spp. control plant diseases involve competition for niches and nutrients antibiosis, predation, and induction of plant defense responses. In past years, Azotobacter sp. had drawn a worldwide attention because of production of secondary metabolites such as siderophore, antibiotics, enzymes and phytohormones and involving in nitrogen fixation. It has been observed that the antagonistic activity also conferred through the action of siderophores produced from Azotobacter spp. called Azotobactin. The Azotobactin possesses three different types of coordinating moieties, a hydroxamate, an R-hydroxy acid, and a catechol, making it a representative of several classes of siderophores simultaneously. The known interference of pyoverdine-mediated uptake of FeIII provides indirect evidence that azotobactin shows antibacterial effect against root colonizing bacterial and fungal pathogens (Schalk, 2008). Azotobactin is thus a good model compound to test whether the results obtained on the uptake of iron and can be extended as bio-control agent for the plant. The azotobactin seems to be released only under severe Fe limitation (Duhme et al., 1998). Therefore azotobactin is sometimes considered the “true” siderophore of this bacterium (Page et al., 1991). These had been implicated in reduction of plant pathogenic fungi and harmful rhizobacteria (Gupta et al., 2001). Azotobacter sp. by itself has utility as an extremely economical and eco-friendly biopesticide (Rachin and Ahmed, 2005). This work interested with the molecular identification through 16S rDNA sequencing of Azotobacter sp. isolated from soil, production of siderophore, process optimization (pH, cell mass, iron, sugars, organic acids, nitrogen sources, and metals), partial purification of siderophore and application study of siderophore, antagonistic activity towards plant fungal pathogens.
MATERIAL AND METHODS
Isolation of Azotobacter sp. The rhizosphere soil samples from various plant roots were collected from different locations of cultivable lands around Chennai. The enrichment of the culture was made by inoculating one gram of sail sample into sterile Ashby’s mannitol broth (G/L: Mannitol – 20, K2HPO4 – 0.2, MgSO4 - 0.2, NaCl - 0.2, K2SO4, CaCO3 - 15, pH-7.4) and incubated at room temperature for three days for the formation of pellicle. The pellicle was collected aseptically and inoculated into same fresh broth incubated further in the same condition. This method was repeated thrice for the enrichment. After enrichment, the pellicle was streaked into sterile Ashby’s mannitol agar medium and incubated at 28°C for more than 48 hours. Screening for Siderophore production In order to screen the production of siderophore, the isolates were grown in Chrome azurol sulfonate agar medium. The inoculated agar plates were incubated at 37°C for 24 hours. The observation was made for the change of medium color from blue to reddish yellow to determine the siderophore production. The isolate which showed high intensity of color change was considered for further study.
Identification of the bacterial isolate
The selected bacterial isolate was subjected to identification by conventional methods such as Gram’s staining to check the Morphology and Gram’s reaction. The motility was checked using Hanging drop method. The further identification was done using routine biochemical tests based on the key provided by the Bergey’s manual of Systematic bacteriology. The molecular identification of the positive isolate was carried out through 16S ribosomal coding gene sequencing. DNA extraction was carried out by alkaline lysis and phenol chloroform extraction method. The PCR amplification of 16S ribosomal RNA coding sequence using universal primers and the reaction conditions as follows: 94°C (1 min) for denaturation, 51°C (30 sec) for annealing and 72°C (1 min) for extension. The amplified products were purified and cycle sequenced using Big Dye terminator cycle sequencing kit. The sequence was determined using ABI PRISM sequence analyzer. The obtained sequences were subjected to BLAST (Basic Local Alignment Research tool) analysis with online tool with the preexisting sequence available in NCBI/Genbank to confirm the sequences. The obtained 16S ribosomal RNA sequences of strain was aligned with various Azotobacter spp. obtained from GenBank, NCBI using Clustal-X Ver.2.0 aligning tool. The phylogenetic analysis was carried out using MEGA (Molecular Evolutionary Genetic Analysis) Ver.4.0 (Nei and Kumar, 2000). Siderophore production The culture inoculum was prepared using Luria Bertani broth contains 1% Peptone, 1% Sodium chloride and 3% Yeast extract. The isolate was inoculated into sterile LB broth and incubated at 37°C for overnight and 150 rpm agitation. The Siderophore production was carried out using Fedeficient mannitol medium containing g L-1 : K2HPO4, 6.0; KH2PO4, 3.0; MgSO4 0.2; NH4SO4, 1.0 and succinic acid, 4.016; pH-7.0 was inoculated with 1% of overnight inoculums and incubated at 30°C for 24-30 hours with constant shaking at 120 rpm. The culture broth was centrifuged at 10,000 rpm for 10 min and the cell free supernatant was subjected to siderophore assay. Partial purification Partial purification of siderophore was carried out by ion exchange chromatography using amberlite IR120 (Mayer et al., 1998). After the production of siderophore, the bacterial cells were harvested by centrifugation at 10000 rpm for 5 min and the supernatant was collected. The supernatant was considered as crude siderophore extract and pH was adjusted to pH 6.0. The crude extract was passed through an ion exchange chromatographic column containing Amberlite IR120 (Na+). The siderophore was later eluted with methanol (60%). The obtained partially purified siderophore was proceeded with further studies.
Siderophore assay
Siderophore assay was carried out based on the CAS shuttle assay of Payne (1994). The culture extract (0.5 ml) was mixed with CAS reagent and 0.5ml of chrome azurol S reagent. The color obtained was measured using the spectrophotometer at 630 nm after 20 minutes of incubation. The blank was prepared using uninoculated broth medium by carrying same procedure. The siderophore content in the aliquot was calculated by using following formula:
Optimization of Physico-Chemical parameters for Siderophore Production
Siderophore production as a function of time
The siderophore production was carried out by submerged shake flask fermentation in using mannitol medium at 35°C, 100 rpm agitation. Culture was aseptically with drowned periodically at every 6 hours intervals up to 48 hours. The growth rate of the culture was estimated by spectrophotometrically at 360nm and siderophore content of the cells free culture filtrate at different intervals was estimated.
Effect of pH
The mannitol medium was prepared with different pH values ranging from of 4 to 10 in separate flasks. Each flask was seeded with 3% overnight inoculum of Azotobacter sp. and incubated at 35°C for 30 hours under shaking at 120 rpm. After incubation the growth and siderophore production was measured at 410 and 630 nm respectively.
Effect of sugars and organic acids The sterile mannitol basal medium was prepared without carbohydrate source and aliquoted into different conical flasks. Each flask were amended with different carbon sources like glucose, sucrose, dextrose and lactose, different organic acid like oxalic acid, malic acid and lactic acid, at the concentration of 0.1%. The flasks were inoculated with 3% of overnight inoculum and incubated at 30°C for 36 hours under shaking at 100 rpm. After incubation the growth and siderophore production was estimated. Effect of nitrogen sources The sterile basal nitrogen source free mannitol medium was prepared and amended with different concentrations of organic nitrogen sources like peptone and yeast extract, inorganic nitrogen source such as urea, ammonium nitrate and ammonium chloride added at the concentration range of 0.1%. The medium inoculated with 3% of Azotobacter sp. overnight inoculum and incubated at 35°C for 30 hours under shaking at 120 rpm. After incubation the siderophore production was estimated.
Effect of iron concentration
The mannitol medium was prepared with different iron concentration (FeCl3.6H20) in the range of 1- 100 μm. The medium inoculated with Azotobacter sp. and incubated at 30°C for 36 hours under shaking at 100 rpm. After incubation the growth and siderophore production was estimated. Effect of metal ions The sterile mannitol medium was prepared in several flasks and amended with 100μM /L concentration of different metal ions like Na2+, K+, Ca2+,Cu2+, Mg2+, Mn2+, and Zn2+. The flasks were inoculated and incubated at 35°C for 36 hours under shaking at 100 rpm. After incubation, siderophore production was estimated.
Antagonistic activity of Azotobacter sp. Dual culture technique
The antagonistic properties of Azotobacter sp. were tested against plant fungal pathogens such as Fusariurm sp., Alternaria sp., Phytophthora sp., Rhizoctonia sp., Colletotrichum sp. and Curvularia sp. by dual culture technique (Rabindran and Vidhyasekaran, 1996). Azotobacter sp. was streaked on Potato Dextrose Agar (Potato infusion-4 g L-l ; Dextrose-10g L-l ; Agar-18g L-l ) at one side of petri dish, approximately 1 cm away from the edge. Five mm of fungal mycelial agar disc of actively growing 8- 15 day-old-culture from PDA was taken and placed at the opposite side of petri dishes perpendicular to the bacterial streak. Petri dishes were then incubated at room temperature for 4 days. Petri dishes inoculated with fungal discs alone were served as control. The experiment was done in triplicates. Observations on width of inhibition zone and mycelial growth of test pathogens were recorded and percent inhibition of pathogen growth was calculated. Where, I=Inhibition of Mycelial growth, C=Growth of plant pathogen in the control plate (cm) and T=Growth of pathogen in dual cultures (cm).
Bio control assay of partial purified siderophore
Sterile potato Dextrose Agar was prepared and solidified in petri dishes. The well size 6mm diameter was made aseptically in the agar plate. Forty µl of partially purified siderophore was added to the well and allowed to diffuse radially for 1 hour at low temperature. The inoculum size of 6x103 spores of plant pathogenic fungi was swabbed over the surface of the PDA plates and incubated at room temperature for 48 hours. After incubation, the zone of inhibition of the mycelia growth was measured.
RESULTS AND DISCUSSION
There were 26 bacterial isolates that produced siderophore were isolated and siderophore production was confirmed by the color change from blue to reddish yellow (Milagres et al., 1999). In order to obtain nitrogen fixer among the siderophore producers, The isolates were short listed by inoculating the isolates using Derx’s medium. Among the short listed isolates which showed double benefit organisms that producing siderophore and nitrogen fixing capcity, potent siderophore producer was used used for futher study. The siderophore production is quiet common phenomenon exhibited by various organisms like Pseudomonas spp., Bacillus spp.,, Clinical isolates like E. coli, Klebsiella etc. (Syed and Vidhale, 2011) for the acquisition of iron complex from the soil. The production of antagonisms against fungal pathogen through siderophore production by nitrogen fixing organisms giving dual benefit for the plants (Frank et al., 1983).
Identification of Bacteria
The potent isolate was Gram negative short oval shape rod in nature and motile. The biochemical test showed that the isolate could be considered as Azotobactersp. (Table 1). For the confirmation of identification, molecular identification was carried out 16S ribosomal coding gene identification. The amplified gene product showed 1 Kb in size in agarose gel electrophoresis whereas showed 995 nucleotide base pair in size after sequencing. The Blast result revealed that obtained nucleotide base pairs showed 100% identify with Azotobacter chroococcum (Accession AB742373) 16S ribosomal genes sequence (Table 2). Furthermore, the sequence was aligned and phylogenetic tree was constructed using related sequences. The sequence paired with Azotobacter chroococcum of Indian isolate with bootstrap value of 99% (Fig. 1). So the isolate was confirmed as Azotobacter chroococcum and designated as IMS. Widely, the biochemical test of identification is found to be preliminary identification in which the genus will be identified and species can be identified certain extent. Whereas the molecular identifications through 16S ribosomal RNA coding sequence analysis is widely accepted method among the modern techniques for prokaryotes. The prokaryotic 16rRNA sequence consisted of maximum of 1.6 kb in size and unique sequence distributed among the prokaryotes facilitates to identify the species. The complete sequence of 16S rRNA comprises of approximately 1.5 kb has been so far reported (Gimmestad et al., 2006).
Growth rate and siderophore prodution
The organism did not exhibit any traces of siderophore synthesis during beginning hours of incubation whereas the bud in the vegetative growth was observed. The strain started siderophore production after 10 hours of inoculation (Fig. 2). The maximum of siderophore production was observed (65% of siderophore units) at 30 hours of incubation and started decreasing beyond 42 hours of incubation. The highest production of siderophores occurred in Nitrogen fixing Azotobacter sp. at a period of 18 hours coinciding with the stationary growth phase (Frank et al., 1983).
Production optimization
Of the different level of pH tested, production of siderophore by Azotobacter sp. was optimum at pH 7.0 with the yield of 62. In the pH values below and above the neutral the production was also somewhat significant (Table.3). The most of the previous reports of Azotobacter sp. have been stated that the siderophore has been produced in large quantity at neutral pH (Frank et al., 1983). The other nitrogen fixing bacteria Rhizobium strains isolated from root nodules of Sesbania sesban (L.) Merr. produced siderophore in culture after 4 h of incubation and at neutral pH (Sridevi and Malaliah, 2007) Since the production of siderophore depended largely on the pH of the medium. It was very important to maintain the pH of the fermentation broth between 7.0-7.5, which is the optimum for siderophore production in Azotobacter sp. The pH of the medium increased from 7 to 8.5 during the growth period in accordance with the siderophore concentration which suggest that alkalinity is important to avoid siderophore destruction - The mannitol medium with different organic acids oxalic acid, malic acid and lactic acid, at the concentration of 4.0 g L-1 showed considerable amount of siderophore production by Azotobacter sp. in which the quantity was high in malic acid with the yield of 71% (Fig. 3). The presence of sugars such as sucrose increased the growth of the organism but not siderophore production. Similar results were obtained in Azotobacter sp. (Anne et al., 2000) and in Pseudomonas fluorescens, Pseudomonas putida and Alcaligens faecalis (Sayyed et al., 2005). In contrast Nocardia levis MK-VL_113 utilized sucrose and tryptone as good carbon and nitrogen sources for the elaboration of bioactive metabolites (Kavitha and Vijayalakshmi, 2009). Mannitol and sucrose at the concentration 2% stimulated growth and siderophore production in Rhizobium strains (Sridevi and Malaliah, 2007). Nitrogen sources such as peptone, yeast extract, urea, ammonium nitrate and ammonium chloride was added to the mannitol medium at the concentration of 1 g L-1. Among these, the organic nitrogen peptone and urea enhanced the siderophore of Azotobacter sp. with the yield of maximum 70% respectively. In other nitrogen sources siderophore production was almost same as control (Fig. 4). Some of the amino acids as nitrogen sources tested stimulated the siderophorogenesis in Azotobacter sp. (Anne et al., 2000). Arginine and praline stimulated growth and siderophore production in Rhizobium strains (Sridevi and Malaliah, 2007). The Nocardia levis MK-VL113 utilized tryptone as a good nitrogen source for the elaboration of bioactive metabolites. The presence of urea metabolism is known to increase the pH due to hydrolysis of urea into ammonium ion intracellularly (Sama et al., 2009).
Effect of iron concentration
The iron concentration is an essential parameter which determines the production of siderophore. The mannitol medium was prepared with different iron concentration (FeCl3.6H20) in the range of 1- 100 µm. The presence of low concentration (1- 3µM) of iron enhanced the siderophore production of Azotobacter sp. up to 82%.The iron concentration between 5µM to 30 µM decreased the production and beyond this level the production was inhibited though growth occurred (Fig. 5). Increase in growth with increase in iron concentration reflects the iron requirement for the growth of the organism for cellular process (Syyed, et al., 2005). Siderophores are ironspecific compounds which are secreted under low iron stress and found that production of siderophore in the medium employed was inversely proportional to the iron concentration in the medium (Budzikkiewicz, 1993). The addition of limited iron in the media can increase the growth of the culture, which can lead to an increased production of siderophore in Rhizobium strains (Sridevi and Malaliah, 2007). The increase of Fe (III) concentration had a negative effect in siderophore production, especially above 10 µM (Villigas et al., 2002).
Metal ions
Inorder to find out the effect of other minerals towards siderophore, the production was carried out in mannitol medium amended with different mineral ions. The metal ions Mg2+ and Zn2+in the medium enhanced the siderophore production. The other metal ions tested inhibitory effect on siderophore production (Fig.6). The siderophore and cofactors produced by Azotobacter sp. is an iron chelating substance with the ability to bind to different metal ions was increased, Molybdenum and Cadmium (Neilands, 1974). Whereas, synthesis of metabolites azotichelin and aminochelin was inhibited by Mn2+ and Zn2+ in Azotobacter vinelandii (Page, 1995). Lead increased the siderophore production in Pseudomonas fluorescens, Pseudomonas putida while Mn2+, Hg2+ and Co2+ decreased the production (Sayyed et al., 2005).
Antagonistic activity
Azotobacter sp. was evaluated for its ability to control plant root fungal pathogens such as Fusariurm sp., Alternaria sp., Phytophthora sp., Rhizoctonia sp., Colletotrichum sp. and Curvularia sp. by dual culture technique and assay of cell free supernatant. It was found that the Azotobacter sp. Lp1 inhibited all the tested pathogens in both the methods of evaluation. The percentage of inhibition was increased from 40% to 50.5% in partially purified siderophore (Fig. 7). This proved the ability of siderophore as biocontrol agent in our study. Azotobacter sp. was found to effectively inhibited 20-40% of the tested fungi in dual culture technique and 25-50% in purified siderophore assay (Table.4). Azotobacter sp. produces azotobactin type siderophore under iron starving conditions with high stability and affinity for iron that restricts growth of microorganism with low iron competition ability such as phytopathogenic fungi (Kloepper, 1977). Purified siderophore of A. calcoaceticus at 500 µg/mL concentrations inhibited the growth of phyto-pathogens up to 30.00%, suggested that both siderophore rich supernatant as well as pure siderophore has the inhibitory potential against phyto-pathogenic fungi (Prashanth et al., 2009). The isolates of Azotobacter spp. were found to effectively inhibit the mycelia growth of both fungal pathogen in dual cultures with rhizospheric bacteria and soil borne pathogens (Sapna et al., 2012). Siderophore mediated antagonism was observed against common phytopathogens viz., A. flavus, A. niger, C. capsicum and F. oxysporum by A. calcoaceticus isolated from wheat rhizosphere (Sapna et al., 2012). CONCLUSION The production of microbial metabolites and their applications in various fields were gaining attention. Siderophores facilitates the bacteria to take up iron under iron-limited environment. In the present study, siderophore producing bacteria was isolated and the production conditions were optimized for their better production. A further study in this field can bring about their applications in various fields.
Englishhttp://ijcrr.com/abstract.php?article_id=1316http://ijcrr.com/article_html.php?did=13161. Gimmestad M, Magnus Steigedal, Helga Ertesvåg, Soledad Moreno, Bjørn Erik Christensen, Guadalupe Espín, and Svein Valla. Identification and Characterization of an Azotobacter vinelandii Type I Secretion System Responsible for Export of the AlgEType Mannuronan C-5-Epimerases.J Bacteriol 2006; 188(15): 5551-5560.
2. Neilands JB. Evolution of biological iron binding centers. Struct Bonding 1972; 11: 145-170.
3. Neilands JB. Iron and its role in microbial physiology. In: Neilands JB, editor. Microbial iron metabolism: a comprehensive treatise. New York: Academic Press; 1974. P. 3-34.
4. Brill WJ. Biochemical genetics of nitrogen fixation. Microbiol Rev 1980; 44: 449-467.
5. Corbin JL and WA Bulen WA. The isolation and identification of 2,3-dihydroxybenzoic acid and 2-N,6-Ndi (2,3-dihydroxybenzoyl)- L-lysine formed by iron-deficient Azotobacter vinelandii. Biochem 1969; 8: 757-762.
6. Neilands JB. Siderophores: biochemical ecology and mechanisms of iron transport in enterobacteria. In: Raymond KN, editor. Advances in chemistry, no.162, bioinorganic chemistry II. Washington DC: American Chemical Society; 1977. P. 3-32.
7. Kloepper JW. Current status and future trends in bio-control research and development in the U.S. In: International Symposium on Clean Agriculture, Sapporo, OECD: 49-52
8. Slininger PJ, Van Cauwenberge JE, Bothast RJ, Weller DM, Thomashow LS,Cook RJ. Effect of growth culture physiological state, metabolites and formulation on the viability, phytotoxicity and efficacy of the take-all biocontrol agent Pseudomonas fluorescens 2-79 stored encapsulated on wheat seeds. Appl Microbiol Biotechnol 1996; 45: 391-398
9. El-Katatany M, Hetta A, Sliaban G, ElKomy H. Improvement of cell wall degrading enzymes production by alginate encapsulated Trichoderma spp. Food Technol Biotechnol 2003; 41: 219-225.
10. Gupta C, Dubey R, Kang S, Maheshwari D. Antibiosis-mediatednecrotrophic effect of Pseudomonas GRC2 against two fungal plant pathogens.Curr Sci 2001; 81: 91-94.
11. Rachid D, Ahmed B. Effect of iron and growth inhibitors on siderophores production by Pseudomonas fluorescens. Afr J Biotechnol 2005; 4: 697-702.
12. Schalk IJ. Metal trafficking via siderophores in Gram-negative bacteria: specificities and characteristics of the pyoverdine pathway. J Inorg Biochem 2008; 102: 1159-1169.
13. Duhme AK, Hider RC, Naldrett MJ, Pau RN. The stability of the molybdenum-azotochelin complex and its effect on siderophore production in Azotobacter vinelandii. J Biol Inorg Chem 1998; 3: 520-526.
14. Page WJ, Collinson SK, Demange P, Dell A, Abdallah MA. Azotobacter vinelandii strains of disparate origin produce azotobactin siderophores with identical structures. Biometals 1991; 4: 217-222.
15. Nei M and Kumar S. 2000. Molecular Evolution and Phylogenetics. Oxford University Press, New York.
16. Meyer JM, Stintzi A, Coulanges V, Shivaji S, Voss JA, Taraz K, Budzikiewicz H. Siderotyping of the fluorescent pseudomonads: Pseudomonas fluorescens and Pseudomonas putida strains from Antartica. Microbiol 1998; 144: 3119-3126.
17. Payne SM. Detection, isolation and chacterization of siderophores. MethodsEnzymol 1994; 235: 329.
18. Rabindran R and Vidhyasekaran P. Development of a formulation of Pseudomonas fluorescens PfALR2 for management of rice sheath blight. Crop Protection 1996; 15: 715-721.
19. Milagres AMF, Machuca, A, Nepoleo. Ddetection of siderophore producing fungi and bacteria by modified CAS agar assay. Microbial methods 1999; 37: 1-6
20. Syed Sajeed Ali and Vidhale NN. Evaluation of siderophore produced by different clinical isolate Pseudomonas aeruginosa. Inter J Microbiol Res 2011; 3(3): 131-135. 21. Frank AF, Jack TS, Thomas Emery. Siderophores Produced by Continuous Culture vinelandii OP in Iron-Limited Nitrogen-Fixing Azotobacter. Appl Environ Microbiol 1983; 46(6): 1297-1300.
22. Sridevi M and Mallaiah KV. Production of catechol-type of siderophores by Rhizobium strains from Sesbania sesban (L.) Merr. Asian J Biol Sci 2007; 3(1): 187-194.
23. Anne ET, Manisha Mehrotra, Derek Ottem, William JP. Dual regulation of catecholate siderophore biosynthesis in Azotobacter vinelandii by iron and oxidative stress. Microbiol 2000; 146: 1617-1626.
24. Sayyed RZ, Badgujar MD, Sonawane HM, Mhaske MM, Chinchokar SB. Production of Microbial iron chelators (siderophores) by fluorescent Pseudomonads. Ind J Biotechnol 2005; 4: 484-490.
25. Kavitha and Vijayalakshmi M. Cultural parameters affecting the production of bioactive metabolites by Nocardia levis MKVL 113. JAppl Sci Res 2009; 5(12): 2138- 2147.
26. Sarma MVRK, Krishna Saharan, Lalit Kumar, Ashwani Gautam, Avhijeet Kapoor, Nishant. Siderophoregenic Acinetobacter L; calcoaceticus isolated from wheat rhizosphere with strong PGPR activity. Malay J Microbiol 2009; 5(1): 6-12.
27. Budzikkiewicz H. Secondary metabolites from fluorescent Pseudomonas. FEMS Microbiology Reviews 1993;104: 209-228.
28. Villegas M,, Pilar Villa ED, Alina Frías. Evaluation of the siderophores production by Pseudomonas aeruginosa PSS. Rev Latinoam Microbiol 2002; 44(3-4): 112-117.
29. Prashant SD, Rane Makarand R, Chaudhari Bhushan L, Chincholkar Sudhir B. Siderophoregenic Acinetobacter L; isolated from wheat rhizosphere with strong PGPR activity. Malay J Microbiol 2009; 5(1): 6-12
30. Sapna Chauhana, Kunal Wadhwab, Manjula Vasudevaa & Neeru Narulab. Potential of Azotobacter spp. as biocontrol agents against Rhizoctonia solani and Fusarium oxysporum in cotton (Gossypium hirsutum), guar (Cyamopsis tetragonoloba) and tomato (Lycopersicum esculentum). Arch Agro Soil Sci 2012; 58(12): 1365-1385.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241511EnglishN2013June18HealthcareA DESCRIPTIVE STUDY OF ATTENTION DEFICIT HYPERACTIVITY DISORDER IN SABIA CITY, SAUDI ARABIA
English4348Raed A. H. Abu TalebEnglish Aesha FarheenEnglishIntroduction: Among childhood mental disorders, attention deficit hyperactivity disorder is a common yet under diagnosed condition. Few studies have addressed this problem in Saudi Arabia. Objectives: To assess proportion of attention deficit hyperactivity disorder (ADHD) positive students among primary school children in Sabia City, Jizan and study their personal characteristics. Subjects and Methods: Four primary schools in Sabia City were randomly selected. A total of 200 pupils (100 boys and 100 girls) were included in this study. Data collection tools included the personal characteristics questionnaire and the Arabic version of the ADHD Rating Scale. Results: A total of 13.5% of students were positive regarding ADHD, with higher percentage of positive results among male than female students (15% vs. 12%, respectively). Younger students had higher percentage of positive results than older students. Highest percentage of positive results were observed among students who were first born (20.7%) followed by those who were last born (14.8%). Students whose fathers were illiterate had the highest proportion of positive results (31.3%), while students whose mothers were illiterate had significantly highest proportion of positive results (40.8%, p10 members had the highest proportion of positive results. Conclusions: ADHD is common among primary school children in Sabia City. Symptoms of ADHD are more among boys than girls. There is higher proportion of ADHD symptoms among school children whose mothers are illiterate.
Englishattention deficit hyperactivity disorder, school children, Saudi ArabiaINTRODUCTION
Behavioural and learning disorders among children present major challenges to parents and teachers. Studies show that attention deficit hyperactivity disorder (ADHD) is the most common mental disorder in childhood. It is also among the most prevalent chronic health conditions affecting school-aged children (1) . Diagnosis of ADHD depends on the core symptoms that include inattention, hyperactivity and impulsivity. These symptoms should exist before 7 years of age and persist for at least 6 months to a degree that is maladaptive and inconsistent with developmental level. In addition, these symptoms should exist in two or more settings (e.g.at school and at home) (2). A review of global prevalence in school-aged community samples indicates rates varying from 4% to 12% (3). In Saudi Arabia, ADHD manifests in about 4 -12 % of children aged 6 to 12 years (4) . Under-diagnosis and under-treatment of this condition leads to problems in adult life. Studies show that due to lack of awareness about ADHD and associated problems these children are often rejected from class or exposed to punishment by teachers and parents(5). Early recognition, assessment and management of this condition can redirect the educational and psychosocial development of most children with ADHD.
Studies show that with adequate and timely management, a high percentage (90%) of patients with ADHD show good recovery (6, 7) . This study was conducted in Sabia city of Saudi Arabia to find the proportion of primary school children with ADHD and their sociodemographic characteristics.
MATERIAL AND METHODS
200 students (100 boys and 100 girls) from 4 primary schools in Sabia City, Jizan, were randomly selected to study the prevalence of ADHD using the Arabic version of the ADHD rating scale (8). This scale contains 14 items, covering the three components of ADHD, i.e., inattention (items: 3, 6, 7, 12 and 13), hyperactivity (items: 1, 2, 9 and 10) and impulsivity (items: 4, 5, 8, 11 and 14).Each item is a 4-point scale (0-3) arranged in the following format: not at all, just a little, pretty much, very much. Scoring was done with the overall cut-off point for boys as 23.5 and 22.5 for girls (9). Information was obtained from two settings (school and home). Data on sociodemographic variables, and possible risk factors was collected using interview questionnaire which was administered to the parents of the study subjects. All pupils who proved to have high scores (henceforth referred to as screen positive) were referred to Jizan Psychiatric Hospital to receive the necessary specialized management. The Statistical Package of Social Sciences (SPSS), version 16.0 was used for computerized data entry and analysis. Descriptive statistics were performed (frequency and percentage). To test the significance of differences between ADHD screen positive and normal children, ? 2 was applied. A significant statistical level was considered when the p-value ? 0.05.
RESULTS
Table1 shows that 17% of students were aged 6 years, 25.5% aged 7 years, 36% of students were aged 8 years, while 21.5% of students were aged 9 years or more. Three students (1.5%), had no brothers or sisters among siblings, and most (42.5%) were in the middle birth order. The educational status of students’ fathers showed that 8% were illiterate, while 47.5% were university graduates. On the other hand, educational status of mothers showed that 24.5% were illiterate, while 31.5% were university graduates. The family size of 37% students was 3-5 members, 49% had 6-10 members, while 14% had more than 10 members (Fig 1.) Fig 1 shows the proportion of students with positive results on ADHD screening. Out of total 200 students, 27 (13.5%) showed positive result on ADHD screening (Table 2). Studying the distribution of screen positive children it is seen that higher percentage of positive results were found among male than female students (15% vs. 12%) respectively. Percentage of positive results decreased with increasing age. Highest percentage of positive results were observed among students who were first born (20.7%) followed by those who were last born (14.8%). According to father’s educational status, students whose fathers were illiterate had the highest proportion of positive results (31.3%). Students whose family size was >10 members had the highest proportion of positive results (25%). None of the above differences were significant. Students whose mothers were illiterate had the highest proportion of positive results (40.8%). Differences in screening results according to mothers’ educational status were statistically significant (pEnglishhttp://ijcrr.com/abstract.php?article_id=1317http://ijcrr.com/article_html.php?did=13171. Manos MJ, Tom-Revzon C, Bukstein OG, Crismon ML.Changes and challenges: managing ADHD in a fast-paced world. J Manag Care Pharm. 2007; 13(9 Suppl B):S2-S13.
2. Booklet: Attention deficit hyperactivity disorder. Accessed online on 10 April 2013, from http://www.nimh.nih.gov/health/publications /attention-deficit-hyperactivity disorder/adhd_booklet.pdf
3. Kieling C, Kieling RR, Rohde LA, Frick PJ, Moffitt T, Nigg JT, Tannock R, Castellanos FX.The age at onset of attention deficit hyperactivity disorder. Am J Psychiatry. 2010;167(1):14-6.
4. Al-Hamed JH, Taha AZ, Sabra AA, Bella H. Attention Deficit Hyperactivity Disorder (ADHD) among Male Primary School Children in Dammam, Saudi Arabia: Prevalence and Associated Factors. J Egypt Public Health Assoc. 2008; 83(3-4):165-82.
5. Alqahtani MM. The comorbidity of ADHD in the general population of Saudi Arabian school age children. J Atten Disord. 2010;14(1):25-30.
6. Al-Ghamdy YS, Qureshi NA. Attention deficit hyperactivity disorder. Epidemiologic pathophysiologic , diagnostic and treatment perspectives. Saudi Med J. 2001; 22(8) : 666-73.
7. Smoot LC, Boothby LA, Gillett RC.Clinical assessment and treatment of ADHD in children. Int J Clin Pract. 2007;61(10):1730- 8.
8. DuPaul GJ. The ADHD Rating Scale: normative data, reliability, and validity. In: Russell A Barkley. Unpublished manuscript, University of Massachusetts Medical Center, Worcester. New York: The Guilford Press; 1990. Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment.
9. Wender PH. Attention-Deficit Hyperactivity Disorder in Adults. New York, NY: Oxford University Press; 1995.
10. Scahill L, Schwab-Stone M. Epidemiology of ADHD in school-age children. Child Adolesc Psychiatr Clin N Am 2000; 9: 541- 55.
11. Pastor PN, Reuben CA. Attention deficit disorder and learning disability: United States, 1997–98. Vital Health Stat. 2002; 10 (206):1–12.
12. Doyle R. The history of adult attentiondefidt/hyperactivity disorder. Psychiatr Clin North Am 2004; 27: 203-14.
13. Polanczyk G,de Lima MS,Horta BL, Biederman J, Rohde LA:The worldwide prevalence of ADHD:a systematic review and metaregression analysis.Am J Psychiatry 2007,164(6):942-948.
14. Bener A, Qahtani RA, Abdelaal I. The Prevalence of ADHD among Primary School Children in an Arabian Society. J Atten Disord 2006; 10(1):77-82.
15. Faraone SV, Biederman J, Spencer TJ, Aleardi M: Comparing the efficacy of medications for ADHD using meta-analysis. MedGenMed 2006, 8(4):4.
16. Newton-Howes G. What happens when children with attention deficit/hyperactivity disorder grow up? J R Soc Med 2004;97:531–535
17. Berger I, Felsenthal-Berger N. J Child Neurol. 2009; 24(6):692-6. Attention-deficit hyperactivity disorder (ADHD) and birth order. 18. Barkley RA. Attention deficit hyperactivity disorder: a handbook for diagnosis and treatment. New York: Guilford, 1998.
19. Marks G. Family size, family type and student achievement: cross-national differences and the role of socioeconomic and school factors. Journal of Comparative Family Studies, 2006; 37(1): 1-24.
20. Kashala E, Tylleskar T, Elgen I, Kayembe KT, Sommerfelt K. Attention deficit and hyperactivity disorder among school children in Kinshasa, Democratic Republic of Congo. African Health Sciences 2005; 5(3):172-181.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241511EnglishN2013June18HealthcareRISK FACTORS ASSOCIATED WITH LOW BIRTH WEIGHT IN NEWBORNS: A TERTIARY CARE HOSPITAL BASED STUDY
English4955Archana PaliwalEnglish Veerbhan SinghEnglish Indu MohanEnglish Ram Chandra ChoudharyEnglish Bhupendra Nath SharmaEnglishObjective: To estimate the incidence of low birth weight in new born babies in a tertiary care hospital.To determine the maternal factors which could affect the weight of new born baby. Research Design and Methods: Cross sectional study includes all institutional deliveries comprising mothers and their new born babies. Information regarding mother was obtained by personal interview and ANC record data during six months. Results: 796 mothers were studied, a significant association was found between low birth weight and age of mother at the time of admission, parity, literacy level of mothers, birth spacing, ANC check-up, consumption of iron / folic acid, occupation and type of work of mothers, mother having any medical illness like anemia, pregnancy induced hypertension and any previous or present bad obstetric complications. Conclusions: The finding of the present study clearly reveals that low birth weight can be tackled by providing adequate antenatal care to pregnant women in time. To bring more and more women to hospital for deliveries and provide them adequate ANC, this will prove a long way to reduce birth of low birth weight babies.
Englishlow birth weight, maternal risk factor, literacy, institutional deliveryINTRODUCTION
“There is no indicator in human biology which tells us so much about the past events and the future trajectory of life, as the weight of infant at birth.” -V. Ramalingaswami [ 1] Birth weight is a reliable index of intrauterine growth and is one of the major factor that determines child survival and his physical and mental developments. [2] The alarmingly high neonatal-perinatal loss in India is attributed to several factors, but the leading cause is low birth weight (LBW) babies which accounts for over one third of all neonates.[3] In underdeveloped and developing countries the problem of low birth weight babies is alarming. WHO estimates that globally about 25 millions low birth weight (LBW) babies are born each year comparising 14% of all live birth, nearly 93% of them are in developing countries, where the incidence varies widely.[4] In India 30- 35% babies are LBW and more than half of these LBW new born are full term babies.[5] Low birth weight is part of the complex interaction of such factors as prenatal growth retardation, prematurity, complications of labour and delivery, congenital malformation and adverse prenatal and postnatal social and psychosocial influences. These factors cannot be separated easily to show separate impacts.[6] Low birth weight is a global community health indicator it is imperative that periodic monitoring be under taken to evaluate the impact of preventive health sevices.[7] Low socioeconomic status, maternal undernutrition, anemia and illness, inadequate prenatal care, obstetric complications and maternal history of premature LBW infants have all been reported to influence the occurrence of LBW. These factors operate to various extents in different environment and cultures.[8] Various maternal factors affect the fetus, directly or indirectly and leads to low birth weight. Many of these factors have been well studied, for example age of the mother, parity, spacing, socioeconomic status, diseases complicating pregnancy like toxemia, antepartum hemorrhage, mode of delivery, hydroamnios, oligohydroamnios, blood group incompatibility, premature rupture of membrane, acute and chronic medical disorders like anemia, hyperemesis, chronic urinary tract infection, tuberculosis, diabetes, illegitimacy,smoking during pregnancy or other drug intoxication or alcohol ingestion. With this background, it was realized to conduct a study on birth weight and associated factors for children born at our institute.
MATERIAL AND METHOD
It is a cross sectional study, which was carried out at M. G. Hospital, Sitapura, Jaipur. This institute provides tertiary health care and specialized medical care to population of South Jaipur zone (semi-urban).Study was conducted in the department of Obs and Gyane at Mahatma Gandhi Medical College and Hospital (MGMC and H), Sitapura, Jaipur during Six Months. Study population was all institutional deliveries comprising mothers and their new born babies. Information regarding mother obtained by personal interview and ANC record data. MGMCandH is a tertiary level institute attached with medical college.
METHOD
Before starting the study, the permission of the hospital ethical committee was taken and informed verbal consent was obtained from all the patients included in the study. All pregnant ladies, attending Mahatma Gandhi Hospital for delivery during study period were examined and interviewed within 24 hours after child birth. Neonates were followed up in hospital, till their stay. In case of discharge from hospital, contact was made telephonically or by home visits whichever was feasible. Pre-structured and pretested protocol was used for collection of information. Regarding mother, information was collected regarding identification, religion, occupation, socio-economic status, literacy status and type of work, type of family, residential environment, life-style and past and present obstetric record, medical history, details of present delivery, complications if any during delivery. Regarding new-born, information regarding birth weight in 1st hour, sex, APGAR scoring, general condition, anthropometric measurements. APGAR score: An APGAR score access how well a newborn is doing at 1 and 5 minutes after birth. The five factors were evaluated.Here are the APGAR factors:
A = appearance: The skin color should be pinkish.
P = pulse: The pulse should be 140–160 beats per minute.
G = grimace: After stimulation, the newborn should pull away or maybe give a good cry.
A = activity: The arms and legs should be flexed and resist extension.
R = respiration: There should be a good, loud cry (from the baby, not you).
RESULTS
The alarmingly high neonatal-perinatal loss in India is attributed to several factors, but the leading cause is low birth weight (LBW) babies.
The study was conducted on 796 mothers who delivered in Mahatma Gandhi Hospital, Sitapura, Jaipur within last six months (Jan12 to Jun-12). The information was collected and analyzed, according to our aims and objectives. Out of 796 babies delivered in the hospital 221 (27.72%) were low birth weight and rest 575 (72.24%) were of normal birth weight. In our study the sex ratio was 904/1000. At the time of admission almost 50% mothers belonged to 20-25 years age group with a mean age of 24.75 years. 26.26% mothers were illiterate while 27.51% mothers were educated up to primary and less than 7.29% mothers were graduate and above. 56.78% mothers were house wives, remaining were engaged in agriculture, manual labour, semi professional jobs of other gainful employment. 70.23% mothers were from joint family.66.71% mothers had a family size of 4-9 members. Average number of members in the families of mother was 5.82. 48.12% mothers got married before the age of 18 years with a mean age of marriage 17.8 years. 44.72% mothers had their first delivery up to age of 21 years mean age at time of first delivery 19.60 years. In our study 44.22% of the mothers were primi para 36.06% were second para.Only 17.08% multipara mothers had birth spacing of ≥ 36 months. 51.13% of mothers are anemic according to WHO criteria. 5.03% mothers had the history pregnancy induced hypertension and 24.75% mothers had one of the obstetric complication during their pregnancy. 61.81% mothers performed moderate physical activity during their pregnancy period. Occurrence of low birth weight is slightly higher in female babies (30.16%) than in male babies (25.60%).Occurrence of low birth weight babies was higher in younger age group mothers comparatively. As the mother’s literacy level improved proportion of normal birth weight babies increased. The proportion of low birth weight babies was highest in primi mothers and it is decreased as the parity increased. A significantly higher proportion of normal birth weight babies 81.70% was observed among those who received proper ANC compared to ones who did not, and this association was found statistically highly significant. A significantly higher proportion of normal birth weight babies (80.98%) was observed among those who took iron folic acid during their pregnancy period compared with ones who did not taken and this association was also fount statistically significant. In our present study 480 mothers were second gravida and more. Among them 48 (10%) had previous bad obstetric history. There was significant relation between previous obstetric history and low birth weight babies. It was observed that there was high incidence of obstetric complications in the mothers during present pregnancy who gave birth to LBW babies. Main problem encountered anemia (37.84%), PIH (45%), pre term labour (75.95%).
DISCUSSION
In the present study 796 deliveries and the new born who were delivered in Mahatma Gandhi Hospital, Sitapura, Jaipur within last six months (Jan-2012 to Jun-2012) were taken with the aim and objective of to identify the magnitude of low birth weight babies and to determine the association of maternal and socio-economical factors on the birth weight of babies. In the present study incidence of low birth weight (Englishhttp://ijcrr.com/abstract.php?article_id=1318http://ijcrr.com/article_html.php?did=13181. V. Ramalingaswami; Meharban Singh, “The challenges of low birth weight babies” Care of the new born 6th edition, Sagar Publications, New Delhi 2004 P 219
2. Ramankutty P. Tikreeti RA, Rasaa study on birth weight of Iraqi (Paediatr 1983;29:5-10.
3. Guha’s Neonatology principles and practice IIIrd edition, Jaypee brothers medical publishers (P) Ltd. 2005, P-27
4. Park K’s text book of preventive and social medicine. 21st Edition, Banarasidas Bhanot publishers, Jabalpur 2011, P 494
5. WHO Bridging the gaps, The World Health Report, 1995, Report of the Director General.
6. Overpeck MD, Moss AJ, Hoffman HJ, Hendershot GE. A comparison of the childhood health status of normal birth weight and low birth weight infants. Pub] Hlth Rep 1989;104:58-70
7. H.S. Joshi, Sh Subba, SB Dabral, S Dwivedi, D. Kumar and S Singh ; Risk Factors Associated with Low Birth Weight in Newborns; Indian Journal of Community Medicine Vol. 30, No. 4, OctoberDecember, 2005; 142-143
8. Shiva Rafati MD Hajieh Borman MD Mohammad-Bagher Akhavirad MD, Nader Fallah MSc- 2005
9. Kumar M. Paul, V. K. Deorari A et al Neonatal outcomes at a sub-district hospital in North India. Journal of Tropical Pediatric 2002;48(1)43-6
10. World Health Statistics Quarterly 1984 and State of World Children UNICEF 2006
11. J.S. Deshmukh, D. D. Motghare, S. P. Zodpay and S. K. Wadhva Low Birth Weight and Associated Maternal Factors in urban area, Indian journal of Pediatrics Jan1998 vol-35; 33-35
12. Kaushik Sl, Parmar VR, Grover N et alNeonatal mortality rate; relationship to birth weight and gestational age. Ind J Ped. 1998; 65(3);429-33
13. Uttekar BP, Barge S, Khan W, Deshpande Y, Uttekar V, Sharma J et al. Assessment of ASHA and JSY in Rajasthan. 2007, Apr
14. Gogoi G, Ahmed FU. Effect of Maternal Nutritional Status on the Birth Weight Among Women of Tea Tribe in Dibrugarh District. Indian Journal of Community Medicine, 2007 Apr;32(2):120-122.
15. Abner H, Levkeff, Milton Westphal M, Clinton Miller III Yvome Michal. Maternal risk factors in infants with very low birth weight. Obstet Gynecol 60:612, 91982)
16. Fernando Arias, Paul Tomich. Etiology and outcome of low birth weight and preterm infants. Obstet gynecol 60: 277, 1982
17. Kiran A, Garg B S. A study of factors affecting LBW. Indian Journal of community Medicine 2006
18. Barker DJP. Mothers, babies and health in later life. Edinburgh: Churchill Livingstone; 1998.
19. Joshi SM and Pai NP. Effect of maternal bio-social determinants on the birth weight in a slum area in Mumbai. Ind J. of Com Med. 2000 Jul-Sep;25(3):121-124
20. Singh A, Arora AK. The Changing Profile of Pregnant Women and Quality of Antenatal Care in Rural North India. Indian Journal of Community Medicine, 2007 Apr;32(2):136.
21. NFHS-III (National Family Health SurveyIII), International Institute for Population Sciences, Mumbai, India, 2005-06, pg.191- 222.
22. Mavalankar DV, Gray RH, Trivedi CR. Risk Factors for Preterm and Term Low Birth Weight in Ahmadabad, India. International Journal of Epidemiology, Apr. 1992; 21:263-272
23. Launer LJ, Villar J, Kestler E, de O nis M. The effect of maternal work on fetal growth and duration of pregnancy: a prospective study. British Journal of Obstetrics and Gynaecology 1990; 97 : 62-70.
24. Samanta, Kallol. Study of maternal and parinatal morbidity and mortality in hypertensive disorders complicating pregnancy. Journal of Obstetrics and Gynecology, 2006 Sep. Rajiv Gandhi University of Health Sciences
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241511EnglishN2013June18HealthcareA STUDY OF BLOOD CULTURE ISOLATES AND THEIR ANTIMICROBIAL SUSCEPTIBILITY PATTERN IN A TERTIARY CARE HOSPITAL OF JAIPUR, RAJASTHAN
English5663Ashina singleEnglish Sweta GuptaEnglish Dinesh JainEnglish Pushpa DurlabhjiEnglishBackground: Blood culture is a gold standard for accurate detection of etiological agents of infectious diseases and can assist in choice of appropriate antimicrobial therapy. So, the present study was undertaken to identify the blood culture isolates and to study the antimicrobial susceptibility pattern of blood culture isolates. Methods: Of 500 blood specimens processed from various wards and intensive care units of Mahatma Gandhi Medical College and hospitals, Jaipur, bacteria were identified and isolated. Antibiogram was performed on all positive samples. Results: 19.6% blood culture positive cases out of which 62.2% Gram positive bacteria and 37.8% Gram negative bacteria . Among Gram positive organisms, Staph aureus was found to be the predominant isolate (47.54%) followed by Coagulase negative staphylococci (CONS) (24.5%) ,Streptococcus species (19.6%) and Enterococcus species (8.19%).Methicillin resistance was found in 34.4% strains of Staph aureus.Among Gram negative organisms, most common isolates were Salmonella typhi and Acinetobacter species(32%) followed by Escherichia coli (13.5%), Klebsiella species (8%),Pseudomonas species (8%) and Citrobacter species (5%).1.02% of Candida albicans was also isolated.Conclusion: The present study showed that most of the blood culture isolates, whether Gram positive or Gram negative were multidrug resistant. The rise in antibiotic resistance in blood culture isolates emphasizes the importance of rational and judicious use of antibiotics according to the antibiotic resistance pattern of that institution.
EnglishBlood Culture, Antimicrobial Susceptibility, Gram Positive Cocci, Gram Negative Bacilli.INTRODUCTION
Blood born infections are the leading cause of morbidity and mortality throughout the world and one of most common origin healthcare related infections. [1] Microbes present in bloodstream whether constantly or irregularly can worsen the condition of each major organ of the body. Around 200,000 cases of bacteraemia and fungemia were found annually in USA with mortality rates varying from 20-50%.[2] The incidence of bloodstream infections in patients has been reported to correlate with the increasing use of central venous catheters, other predisposing factors including prolonged intensive care unit (ICU) stay, poor hand washing practices of medical staff. [3] The bacterial detection in a patient’s blood has enormous diagnostic and prognostic meaning for clinicians for taking decision of management. Blood cultures report give a crucial information for the assessment of different diseases like pyrexia of unknown origin, systemic and localised infection including meningitis, untreated bacterial pneumonia , septic arthritis, infective endocarditis, unexplained leucocytosis or leucopenia, sepsis etc. [4]
A wide range of bacteria has been described in febrile patients including gram negative bacteria such as E.coli , Psedomonas aeruginosa, Klebsiella species,and Gram positive such as Coagulase negative staphylococci (CONS), Staph aureus, streptococcus and enterococcus species. [5] Recognition of antibiotic sensitivity pattern in regular period is compulsory for the clinicians to be alert of the emerging microbes that create a risk to the society, to give safe and effective empirical antibiotics, approve balanced clinical practices. [6] Now so many, isolated bacteria are resistant to potential antibiotics and their linked disorders require early and aggressive management with effective antimicrobial agents. Logical and proper use of these agents requires knowledge of common pathogens and drug resistance patterns. [7] Inadequate information is available about frequency of isolation and resistance to antimicrobial agents in Jaipur Rajasthan. So,the present study has been carried out in the department of microbiology in MGMC& H, representing rural and urban population of Jaipur.
MATERIAL AND METHODS
This study was carried out in the department of Microbiology, Mahatma Gandhi Medical College Hospital, Jaipur (Rajasthan). The test group selected was the population of patients with suspicion of bacteremia / septicaemia / PUO (pyrexia unknown origin) of various OPDs, IPDs, ICUs in the hospital regardless of their age, sex, occupation, religion and ethnicity.
1. Sample Collection:
The samples were collected in the hospital by technician / nursing staff under the appropriate aseptic precautions. 10 to 20 ml of blood was drawn by venipuncture in case of adults and 1 to 5 ml of blood in infants and small children.
2. Sample Culture:
The sample collected was inoculated into two culture bottles each containing 50 ml of brain heart infusion broth. After 48 hrs of incubation at 37º C subculture was made onto McConkey agar and blood agar. The subculture was repeated on seventh day until the final result is negative. The isolates obtained were further identified as per the standard laboratory technique based on CLSI guidelines. [8]
3. Organism isolation and identification
Isolates were identified by gram staining and conventional biochemical tests i.e. Oxidase test, Catalase Test, Indole Test, Methyl-Red (MR) Test ,Vogues-Proskauer (VP) Test, O-F test, Citrate Test, Urease Test, Triple-Sugar-Iron (TSI) Test, Decarboxylase test, Slide Coagulase Test,Tube Coagulase Test.[9]
4. Susceptibility testing
Antibiogram was performed on Muller–Hinton (MH) agar plates with commercially available discs (Hi-media, Mumbai) by Modified Kirby Bauer disc diffusion method and were interpreted as per CLSI (Formerly NCCLS) recommendations. [8] The routine antimicrobial susceptibility tests were put for following antibiotics: For Gram Positive Cocci: Amoxycillin, Linezolid, Cotrimoxazole, Doxycycline, Vancomycin, Ciprofloxacin, Imipenem, Amikacin, Gentamicin, Augmentin, Chloramphenicol, Cefuroxime. For Gram Negative Bacilli: Doxycycline, Augmentin, Ciprofloxacin, Ceftriaxone, Cefuroxime, Co trimoxazole, Chloramphenicol, Amikacin, Ticarcillin, Imipenem, Piperacillin, tazobactum, Amoxycillin, Colistin, Polymyxin B, Tigecycline.
RESULTS
Total 500 samples were taken in this study. The present study showed that there were 19.6% (98/500) blood culture positive cases. Incidence of growth positive cases was found to be more among male patients 64 (65.3%) than in female patients 34 (34.6%).This observation shows that percentage of culture positive cases was found more (27.5%) in chidren and elderly than (23.4%) in infants and adults. Out of total culture positive cases, maximum no were from Intensive care units (53%) followed by indoor patient department (37.7%) and outdoor patient department ( 9%). Out of blood culture positive cases 62.2% were Gram positive bacteria and 37.8% were Gram negative bacteria .Among Gram positive organisms, Staph aureus was found to be the predominant isolate (47.54%) followed by Coagulase negative staphylococci CONS (24.5%) ,Streptococcus species (19.6%) and Enterococcus species (8.19%).Methicillin resistance was found in 34.4% strains of Staph aureus. Among Gram negative organisms, most common isolates were Salmonella typhi and Acinetobacter species(32%) followed by Escherichia coli (13.5%), Klebsiella species (8%),Pseudomonas species (8%) and Citrobacter species (5%).1.02% of Candida albicans was also isolated.
Prabhu et al , Gram positive cocci (64%) and Gram negative bacilli (36%). Bichitrananda S et al ,Gram positive cocci (73%) and Gram negative bacilli (26.8%).[17,13,14] However, in some other studies, rate of isolation of was different as reported by Mehta M et al (80.96%) were Gram negative bacteria and (18%) were Gram positive bacteria , Anubmani et al (46%) Gram positive and (56%) Gram negative bacteria, Atul Garg et al Gram positive bacteria (32.5%) and Gram negative ( 67.5%).[18,19,11] In the present study, among Gram positive organisms, most commonly isolated bacteria was Staph aureus followed by Coagulase negative staphylococci CONS, Streptococcus and Enterococcus. This observation is in concordance with other studies conducted by Arora U et al , their study showed that Staph aureus was the predominant organism followed by CONS. [12]Similar findings reported by K Prabhu et al, Vanitha Rani et al, Karki et al, Mehta M et al. [13,16,17,18] Among Staph aureus, Methicillin resistance was found to be 34.4%. In other studies, percentage of MRSA was 29% as reported by K Prabhu et al, 30% by Anbumani et al, 15% by Barati et al. [13,19,20] Our study showed that out of Gram negative bacteria ,most common were Acinetobacter (32%) and Salmonella typhi (32%) , followed by Escherichia coli (13.5%), Klebsiella species(8%) and Pseudomonas species (8%).This is in concordance with study conducted by Bichitrananda et al in 2011. [14] In our study 1.02% of Candida albicans was isolated. In other study conducted by Vanitha Rani et al, % of Candida spp isolation is 4%.[16] In some other studies conducted by Mehta M et al , most common Gram negative bacteria was Pseudomonas species. [18] E.coli is most common in study conducted by Karki et al. [17] Klebsiella species and Pseudomonas species were most common in study conducted by Anbumani et al. [19] The reason for this difference can be immunocompromised patients, ICU settings in hospitals. In the present study, among the antibiotics used for susceptibility testing for Gram positive isolates, Vancomycin showed the highest activity (100%) against Staph aureus, CONS, Streptococcus species and Enterococcus species. This correlates with other studies conducted by Sharma M et al, Atul Garg et al, Mehta M et al and Anbumani et al.[6,11,18,19] Our study showed that among Gram positive isolates, Staph aureus was found to be most sensitive to Vancomycin (100%) followed by Amikacin (93.33%), Doxycycline (89.65%), Linezolid (89.65%) , Amoxycillin sulbactum (65.51%) and Chloramphenicol (65.51%).This is in concordance with other studies conducted by Atul Garg et al, Karki et al, Mehta M et al. [11,17,18] In our study, it was found that Staph aureus was least sensitive to amoxicillin (6.89%) and cotrimoxazole (13.79%), this observation is in concordance with other studies conducted by Atul Garg et al , Arora U et al, Karki et al. [11,12,17] In the current study among the antibiotics used for suscepitibility testing for Gram negative isolates, ceftriaxone sulbactum was most effective (90%) followed by piperacillin tazobactum (70%) and amikacin (70%) against enterobacteriaceae. The present observation has been well documented by Atul Garg et al, Arora U et al and Roy et al. [11,12,21] Our study showed that in case of non fermenters (Acinetobacter species and Pseudomonas species) , most effective antibiotics were found to be imipenem (86.66%) followed by amikacin( 73.33%).This observation is in accordance with other studies conducted by Atul Garg et al, K Prabhu et al, Mehta M et al. [11,13,18] The present study showed that in case of Salmonella typhi, most effective antibiotics were found to be ceftriaxone (100%) followed by chloramphenicol (100%) and ciprofloxacin
DISCUSSION
Bloodstream infections range from transient bacteremia to septic shock. Blood culture is a gold standard for accurate detection of etiological agents of infectious diseases and can assist in choice of appropriate antimicrobial therapy. Moreover, early identification of bloodstream infections could avoid spreading of microbes into major organs such as brain, heart or kidneys. Early commencement of a sensitive antibiotic is decisive in management of patients with bloodstream infections. The initiation of such therapy is based on knowledge of the likely pathogens and their usual antimicrobial susceptibility pattern. In our study, percentage of blood culture positive cases was found to be 19.6% which correlates with the studies done by different scientists in various cities of India such as D S Murthy et al (2003 Hyderabad) (18.7%), Atul Garg et al (2004 Varanasi) ( 20.5%) , Arora U et al (2006 Amritsar) (20.02%).[10,11,12] Some other studies showed higher parsentage then our study such as Sharma M et al 2008 Rohtak (24.4%), K Prabhu et al 2010 Mangalore (44%),Bichitrananda S et al 2012 Bhuvneshwar (26.3%).[6,13,14] The isolation rate of blood culture positive cases in our study is 19.6% which is lower than other studies. One important reason for the lower isolation rate in present study could be because most of the patients have already received antibiotics before they come to the tertiary care hospital and other reason is that in most of the cases self medication is very common as the medicines are available at the counter. In the present study, percentage of blood culture positive cases among children and elderly was higher ( 27.5%) than that among adults ( 23.4%) which was in concordance with other study done by Sharma M et al in 2008. [6] In our study, there is male preponderance that is 65.3% were males and 34.6% were females which was also observed in another studies conducted at Nigeria by Meremikwu et al (55.1%) males and (44.9%) females , Vanitha Rani et al (60.2%) males and (39.7%) females ,Karki et al (63.3%) males and (36.7%) females. [15,16,17] The reason for this difference is because of gender bias. Females are hesitant enough to highlight their health related issues and they are given lesser importance. Our study reported that the percentage of isolation of blood culture positive cases is higher in ICU Intensive care units (53%) followed by indoor patient department (38%) and outdoor patient department (9%).This is in concordance with studies conducted by Arora U et al in 2006,Bichitrananda S et al in 2011. [12,14] Our study showed that the rate of isolation of Gram positive bacteria is higher (62.2%) than Gram negative bacteria( 37.8%).This observation is in accordance with other studies conducted by Karki et al in Nepal , Gram positive bacteria (66.2%) and gram negative bacteria ( 33.8%) . K (83.33%). This observation has been reported by Atul Garg et al, Vanitha Rani et al. [11,16]
CONCLUSION
So it is concluded that bloodstream infections are an important cause of morbidity and mortality and among the most common healthcare associated infections. The present study showed that most of the blood culture isolates, whether Gram positive or Gram negative were multidrug resistant. The rise in antibiotic resistance in blood culture isolates emphasizes the importance of rational and judicious use of antibiotics according to the antibiotic resistance pattern of that institution. Our study seems helpful in providing useful guidelines for choosing an effective antibiotic in cases of septicemia . It is also important for clinicians to be updated with current data concerning the efficacy of commonly prescribed agents and the selection of antimicrobials to be used for empiric therapy . Specific antibiotic utilization strategies like antibiotic restriction , combination therapy may help to decrease or prevent the emergence of resistance . Antibiotic usage according to the standard antimicrobial susceptibility testing may reduce the incidence of bloodstream infections.
Englishhttp://ijcrr.com/abstract.php?article_id=1319http://ijcrr.com/article_html.php?did=13191. Diekma DJ, Beekman SE, Chapin KC. Epidemiology and outcome of nosocomial and community on set blood stream infection. J Clin Microbiol 2003;41:3655-60.
2. Karlowsky JA, Jones ME, Draghi DC, Thornsberry C, Sahm DF, Volturo GA. Prevalence and antimicrobial susceptibilities of bacteria isolated from blood cultures of hospitalized patients in the United States in 2002. Annals of clinical microbiology and antimicrobials 2004;3:7.
3. Lorente C, Castillo YD,and Rello J.Prevention of infection in the intensive care unit: current advances and opportunities for the future. Current Opinion in Critical Care 2002, 8:461–464
4. Yagupsky P, Nolte FS. Quantitative aspects of septicaemia. Clin Microbiol Rev 1990;3:269-79.
5. Wisplinghoff H,Bischoff T, Tallent SM,Seifert H,Wenzel R P and Edmond M B. Nosocomial Bloodstream Infections in US Hospitals: Analysis of 24,179 Cases from a Prospective Nationwide Surveillance Study. Clinical Infectious Diseases 2004; 39:309– 17
6. Sharma M, God N, Chaudhary U, Aggarwal R, Arora DR. Bacteraemia in children. Indian J Pediatr 2002; 69: 1029 – 32
7. Graham C. Bacteremia and antibiotic resistance of its pathogens reported in England and wales between 1990 and 1998: Trend analysis. Br Med J 2000; 320: 213 – 216.
8. Clinical and Laboratory Standard Institute. Performance standards for antimicrobial disk susceptibility tests. NCCLS documents M 100 – SIS, 940 West Valley Road. Wayne, PA, USA, 2005; 19087.
9. Forbes BA. Bailey Scott’s diagnostic microbiology, 10th ed. St. Louis, Missouri, Mosby. 1998: 283–304.
10. Murty D S, Gyaneshwari M. Blood cultures in paediatric patients: A study of clinical impact. Indian J Med Microbiol 2007;25:220-4
11. Garg A., Anupurba S., Garg, J. and Sen, M. R. (2007). Bacteriological profile and antimicrobial resistance of blood culture isolates from a University hospital. Journal of the Indian Academy of Clinical Medicine 8(2), 139-143.
12. Arora U Devi P. Bacterial profile of blood stream infections and antibiotic resistance pattern of isolates. J K Sci 2007; 9:186-190.
13. Kavitha Prabhu, Sevitha Bhat, Sunil Rao Bacteriologic profile and antibiogram of blood culture isolates in a pediatric care unit Journal of laboratory Physicians Year : 2010, Volume : 2, Issue : 2, Page : 85-88.
14. Bichitrananda Swain and Sarita otta Bloodstream infections in a teaching hospital,Annals of Biological Research,2012,3(4):192 1928.
15. Meremikwu MM, Nwachukwu C E, Asuquo A E, Okebe J U and Utsalo S J. Bacterial isolates from blood cultures of children with suspected septicaemia in Calabar, Nigeria. BMC Infectious Diseases 2005, 5:110
16. Vanitha rani n, kannan gopal, venkata narendra m, vishwakanth d, v r d nagesh, yogitha m, venkata sunil m, thennarasu palani a retrospective study on blood stream infections and antibiotic susceptibility patterns in a tertiary care teaching hospital International Journal of Pharmacy and Pharmaceutical Sciences ISSN- 0975-1491 Vol 4, Issue 1, 2012.
17. Karki S, Rai GK, Manandhar R. Bacteriological analysis and antibiotic sensitivity pattern of blood culture isolates in Kanti Children hospital. J Nepal Paediatric Soc 2010; 30(2):94-97.
18. Mehta MP. Dutta, V Gupta. Antimicrobial susceptibility pattern of blood isolates from a teaching hospital in North India. Jpn J Infect Dis 2005;58:174-176.
19. Anbumani N, Kalyani J, Mallika M. Original research distribution and antimicrobial susceptibility of bacteria isolated from blood cultures of hospitalized patients in a tertiary care hospital. Indian Journal for the practicing doctor 2008;5(2):2008-05 - 2008- 06
20. Barati M, Taher M T, Abasi R, Zadeh M M, Barati M, Shamshiri A R. Bacteriological profile and antimicrobial resistance of blood culture isolates. Iranian Journal of Clinical Infectious Diseases 2009;1(4):87-95.
21. Roy I, Jain A, Kumar M, Agarwal SK. Bacteriology of neonatal septicaemia in a tertiary care hospital of Northern India. Indian J Med Microbiol 2002;20 :156-9.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241511EnglishN2013June18HealthcareMOTOR PROFICIENCY IN HEARING IMPAIRED AND HEALTHY CHILDREN: A COMPARISON
English6470Atiya A. ShaikhEnglish Aparna SadhaleEnglishObjective: To score and compare gross motor and fine motor skills in hearing impaired and healthy children and to find co-relation between age and motor proficiency scores in both groups. Material and Method: 180 healthy children and 180 hearing impaired children were scored and compared with each other using short form battery test of Bruininks Osterestky Test of motor Proficiency. Results: There was a significant difference in scores of both groups in running speed, agility, balance, bilateral co-ordination activities, upper limb speed and dexterity and a positive correlation of scores with age in both groups. Conclusion: Hearing impaired children lack significantly in running speed, agility, balance, bilateral co-ordination activities, upper limb speed and dexterity as compared to healthy children, but both groups follow same trend of maturation
EnglishMotor proficiency, children, healthy, hearing impairedINTRODUCTION
There are about 360 million people suffering from ‘Disabling Hearing Impairment’ all over the world. Another 32 million affected by hearing loss are children under age of 15. Hearing loss is the 7th most common cause of ‘Years lived with disability’ (YLD) globally. It contributes to a loss of over 36 million years of healthy & productive years of life, imposing a heavy social and economic burden on individuals, families, communities and countries. In India there are 63 million people who suffer from profound hearing loss. Of this, large percentage is of children between 0-14 years. There are 3 million hearing impaired children in India with almost 25,000 hearing impaired babies born every year 1 . Children with hearing impairment often experience delayed development of speech language and cognitive skills. This may result in slow learning and difficulty in progressing in school, thus difficulty to obtain, perform and keep employment. Both children and adult may suffer from social stigmatization and isolation as a result of hearing impairment. This also makes it more difficult for the individual to escape poverty by slowing progress in school and workplace. The cost of special education and lost employment due to hearing impairment can also impose a substantial economic burden on countries. Few investigators like Mykelbust2 , Wiegersma P H 3 , Crowe T K4 and Gonclave V M5 etc have tried to unmask such problems in other countries; none of such efforts have been documented in India. India being a developing country with limited resources it becomes all the more important for us to know the exact impairments in hearing impaired children so that correct management in those areas can be done. For above purpose a suitable proficiency assessment scale was required. When literature was searched, Bruininks Osterestky Test of Motor Proficiency was found to be the most suitable test according to the objectives. It has reliability of 0.84-0.87 and validity of 0.4-0.9 .It has been widely used in assessment of motor proficiency in children by previous researchers and has proved its sensitivity in various conditions7,8. Thus an attempt was made to compare motor proficiency in hearing impaired and healthy children with the help of short form battery of Bruininks Osterestky Test of Motor Proficiency. Keeping in mind the vast number of hearing impaired children in our society, above information will help to tackle the need of the hour of working towards their optimal performance in academics, sports, occupational skills and thus social participation.
MATERIALS AND METHODS RESEARCH DESIGN:
Cross sectional Inclusion Criteria: Healthy children and hearing impaired children of both genders between age group of 4. 6 yrs to 14.6yrs Exclusion Criteria Children with Mental retardation, known behavioral, cognitive, sensory, musculoskeletal or neuromuscular disorders Setting of the study Special schools, public schools in Pune Sample Size: 180 children with hearing deficit, 180 healthy children Sample Selection: Convenience Materials Used Balance beam, Ball, Blocks, Boxes, Measuring tape, Score sheet, Chairs, Clipboard, Stopwatch, Table, Target, Bruininks Ostrestky Test of motor Proficiency.
PROCEDURE
Ethical committee clearance from college authorities and consents from the school authorities and parents were obtained. Children were divided in 2 groups as hearing impaired and healthy. They were assessed for their motor proficiency using subtests from Bruinink’s Osterestky Test of Motor Proficiency. Scores for each test were noted.
OBSERVATION AND RESULTS
The hearing impaired group consisted of 95 male and 85 female subjects with mean age being 9.4 years .The healthy children group had 94 male and 86 females with mean age being 9.5 years (Table-1). When gross motor function scores of both groups were compared,using unpaired t test,there was a significant difference in scores for jumping up and clapping hands,walking forward heel to toe on balance beam,standing on preferred leg on balance beam,running speed and agility(p< 0.0001).The scores of catching a tossed ball with both hands and throwing ball at target with preferred hand in both groups did not have a significant difference (Table -2). On comparison of fine motor skill scores of both groups with unpaired t test, it was onserved that,there was a significant difference in scores of making dots in circle,sorting shape cards(p,0.0001).The scores of drawing a line through straight path ,copying a circle ,copying overlapping pencils did not show significant difference in both groups(Table-3) Analysis of trend of maturation was done by corelating age of children with total motor proficiency scores using spearman’s co-relation values .It showed a positive co-relation with r values being 0.904 and 0.906 for hearing impaired children group and healthy children group (graph-1).
DISCUSSION
A significant difference was found in scores of both groups for the test of running speed and agility. The test examined dynamic balance, balance in linear and angular acceleration. Affected predictive function of semicircular duct, faulty push pull mechanism and VOR can be the cause of affected dynamic balance9 and hence reduction of scores in hearing impaired children. For the test-standing on preferred leg on balance beam, hearing impaired children scored significantly low than healthy children. This can be attributed to the fact that the hearing impaired children receive abnormal input from a structurally abnormal vestibular system10,11,12,13 . The vestibular system serves to maintain a static position of the head in relation to the gravity for the purpose of maintaining balance and gaze stabilization14,15. Abnormal input from the vestibular system and lack of auditory perception leading to degeneration of infragranular layer of auditory cortex16 resulting in impaired motor output .The central auditory pathways can influence the cerebellum through the connections from the inferior colliculus and also can influence the motor neurons in spinal cord through the tectospinal tract17thus controlling postural control. Due to all these reasons, the balance in standing on preferred leg is affected in hearing impaired children. Walking heel to toe on balance beam is a relatively complex task which puts more demands on vestibular system which is already compromised in hearing impaired children9 ,so with reference to the mechanisms explained before13,14,15,16,17, scores are significantly reduced for this item in them. Normally the output relays from the inferior colliculus influence motor neurons of the spinal cord. Also the outputs from the inferior colliculus influence tectonuclear fibers which are responsible for controlling eye and head movements. The superior colliculus also sends signals to cerebellum17. Integration of all these leads to a co-ordinated reciprocal movement. Since the inputs to central auditory pathway are absent in hearing impaired children, there is degeneration of neurons in cochlear nuclei, superior and inferior colliculi,reduction in number of synapses along with degenerative changes in motor auditory cortex10,11,12,13. Hence leading to inappropriate processing so, when the child had to do a co-ordinated reciprocal movement like tapping feet alternately while making circle with fingers and jump up and clap hands, hearing impaired children scored significantly low as compared to healthy children. All these findings support the hypothesis that, hearing impaired children lack significantly in gross motor skill2, 3, 5,6,18 . Further two tests were used to assess upper limb coordination where the child had to catch a tossed ball with both the hands and throw a ball at a target with preferred hand. According to the literatures, the task was difficult to perform for hearing impaired children as the activities involve special and temporal co-ordination19, which is affected in hearing impaired children9 . Throwing a ball was done using preferred hand and the accuracy of throwing was judged which was equally good in hearing impaired children. Hearing impaired children used their visual and somatosensory system to judge the shift of centre of mass and maintain balance19. This is the most commonly played game in schools, hearing impaired children are trained to catch and throw the ball. It has been studied that when a function is lost, compensation and plasticity of the CNS may play some role in improvement motor performance. In cases of congenital sensoryneural hearing impairment, the other systems like visual system may try to compensate for the function of auditory and vestibular system. .With advancing age, there is increased experience which may be responsible for improved performance 20, 21 , hence hearing impaired children could perform equal with healthy children due to learning of compensatory mechanisms while practicing the game .Similar findings supported by few of other previous studies3, 4, 18 . Children were asked to draw a line through a straight path, copy a circle and copy overlapping pencils with preferred hand to assess visuomotor coordination. The children performed same in quality but took more time to finish the task. As the test does not consider the time required to finish the task, both the groups scored same on the point scale. Increase in duration to perform the task can be explained by Fitt’s law. According to it, movement time increases linearly with difficulty index due to visual constraints. More time is needed to upgrade the strategy22 . To test upper limb speed and dexterity children were asked to do sorting shape cards and making dots in circle with preferred hand. Both were time limited tests. Hearing impaired children showed significantly low scores in both tests as compared to healthy children. Visuomotor area 6A and parieto-occipital area 5 make the part of distributed network of retinal eye and hand related signals. These signals are all combined to form eye hand co-ordination. All these signals and information are processed in parieto occipital cortex. They also send signals to cerebellum leading to a controlled movement. Due to lack of signals from central auditory pathways, the neurons in parieto-occipital area are degenerated10, 11, 12 thus leading to compromised processing, hence the skills are slow in hearing impaired children. Previous studies have shown that hearing impaired children lack in gross motor skills9,10this study supports this fact and proves that ,all three systems (somatosensory, visual and vestibular) are needed to maintain good postural control15 The myelination of vestibulospinal, reticulospinal pathways, corticospinal, corticoreticulospinal pathways, ascending reticular activating system is complete by 8-10years in children23, 24. Synaptogenesis and requirement of appropriate motor unit results in a coordinated performance with advancing age22.Similar trend has been observed by other investigators15 . All this information can be used in screening of hearing impaired children for flaws in motor proficiency. They can be trained to use other compensatory strategies using the same information. Post training performance can again be judged using same scale. Job prescriptions and training can be started in schools depending on their capabilities. This would help them to gain maximum confidence and to come in main stream. The study was done in same geographic area and local schools with convenience sampling method, but the children of same age were selected to minimize error. Since Bruinninks Osterestky test of motor proficiency was used as outcome measure, we selected children of 4.6 years to 14.6 years. For minimizing further error, children were selected according to 3 groups as 4.6 yrs to 7.11 yrs, 8yrs to 10.11 yrs and 11 yrs to 14.6 yrs and 30 children in each group were selected. In future, detailed study can be done using a larger sample size for specific age groups from different schools. Children with different degrees and causes of hearing impairment, multiple impairments or trained vs. untrained children can also be studied for their motor proficiency in detail using this scale.
CONCLUSION
From the above study we conclude that, hearing impaired children lack significantly in running speed, agility, balance, bilateral co-ordination activities, upper limb speed and dexterity as compared to healthy children, but they follow same trend of maturation as that of healthy children.
ACKNOWLEDGEMENT
We would like to thank students, parents and principals of all schools visited. Dr. Shilpa Parab (PT), Principal, Chaitanya Medical Foundation’s College of Physiotherapy, Pune for their support and encouragement. We acknowledge the great help received from scholars whose articles cited and included in references of this manuscript. We are grateful to authors, editors and publishers of all those articles, journals and books from where the literature of this article has been reviewed and discussed. We are also grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript.
Permissions to reproduce published material:
Project published in book format by Lambert Academic Publishing. According to company policy author has a right to publish the material in article format.
Englishhttp://ijcrr.com/abstract.php?article_id=1320http://ijcrr.com/article_html.php?did=13201. World Health Organization, health statistics and health information ,data and statistics:2013
2. Mykelbust H: Auditory disorders in children: A manual for differential diagnosis. Deafness and motor functioning. Grune and Stratto .New York, 1954. Pg 180-201.
3. Wiegresma O H, Vander Velde A: Motor development of deaf children. Journal of child psychology psychiatry 1983. Jan (24) ;( 1):103-11.
4. Crowe T k, Horak F B: Motor proficiency associated with vestibular deficits in children with hearing impairments. Physical therapy 1988 0ct; 68(10) 1493-9.
5. Goncalves V M, Piovesana A M, De Moura Riero M V: Evaluation of static equilibrium in a population of hearing impaired children. Arg. Neuropsychiatry 1993 Sept; 51(3):346- 51.
6. Gayle G W, Pohlman R L: Comparative study of dynamic, static and rotary balance of deaf and hearing children.perceptual motors skills 1990 june; 70(3) 883-8.
7. Bruininks R H (1978),Bruininks osterestky test of motor proficiency,Examiners manual(Revised edition)
8. BOTMP Technical information:AGS Publishing 2004
9. Gyton A C, Hall J E, Textbook of medical physiology.Function of cerebral cortex in hearing, 10th edition. Noida. Harcourt,Asia PTE Limited, 2001 pg 608-11
10. Moore D R: postnatal development of mammalian central auditory system and the neural consequences of auditory deprivation –Acta Otolaryngology suppl 1985: 421:19- 30.
11. Perier O, Alegria J, Buyse M, D’ Alimonte G, Gilson D: Consequences of auditory deprivation in animals and humans. –Acta Otolaryngology suppl 1984; 411:60-70.
12. Red E E, Cahill H B, Pongstaporn T, Ryugo D K: The effect of congenital deafness on auditory nerve synapses: Type I and Type II, miltipolar cells in anteroventral cochlear nucleus of cats –Journal of Assoc. Reaserch otolaryngology 2002 Dec; 3(4):403-17.
13. Deafness induced changes in auditory pathways Audi –Neurology:2001;6:305-318.
14. Shummway Cook A, Horak F, Black FO: Critical examination of vestibular function in motor impaired learning disabled children international journal of pediatric otorhinolaryngology, 1987 Nov 14(1):21-30.
15. Kaga K:Vestibular ‘compensation in infant and children with congenital and acquired vestibular loss in both ears’, International journal of pediatric otorhinology 2007 vol49(3):215-224
16. Rine R M,Cornwell G, Gank, Locascico C, O’ Hare T: Evidence of progressive delay of motor development in children with sensorineural hearing loss and concurrent vestibular dysfunction –Perceptual motor skills, 2000 June;90(3-2)1101-12.
17. Singh I B, Text book of human neuroanatomy, Cranial nerve nuclei and Brainstem: Internal structures . 7th edition.New delhi.Jaypee Brothers Publishers;2006 pg:105-122 and pg:124-143
18. Cynthia and Potter, Lyn Newman Silverman: Characteristics of vestibular function and static balance skills in deaf children – physical therapy. Vol 64 No.7, July 1984.
19. Gayle G W, Pohlman R L: Comparative study of dynamic, static and rotary balance of deaf and hearing children.perceptual motors skills 1990 june; 70(3) 883-8.
20. Siegel J C, Marchetti M, Tecklin J S: age related balance changes in hearing impaired children –Physical therapy 1991 March;71(3):183-81.
21. Surez H,Angeli S,surez A,Rosels B:Balance,sensory organization in children with profound hearing loss and cochlear implants,International journal of pediatric otorhinology 2007 Apr71(4):629-31
22. Shumway –Cook A, Wollacot MH : Motor control:Theory and practical application.Motor control Posture and balance, Development of postural control , Reach Grasp and manipulation .Motor Control,4th edition,city, Lippoincort, Williams & Wilkins , pg:119-139,143- 65,462
23. Lance J W, Mcleoid J G: A physiological approach to clinical neurology. supraspinal control of motor neurons .3rd edition.Great Britain.William Clowes(Beccles);1981 pg:108-111
24. Umphred D A , Byl N,Lazearo R T,Roller M. Neurological rehabilation, normal sequential, behavioural & physiological change through developmental arc pg.4th edition.china,Mosby Inc2001 page no:58-73
Hearing Impaired children lack significantly in skills like jumping up and clapping hands,walking forward heel to toe on balance beam,standing on preferred leg on balance beam,running speed and agility as compared to healthy children.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241511EnglishN2013June18HealthcareIN VITRO ASSESSMENT OF THE ANTIMICROBIAL EFFECT OF ETHIOPIAN MULTI-FLORA HONEY ON METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS
English7179Alem GetanehEnglish Yeshambel BelyhunEnglish Feleke MogesEnglish Belay AnagawEnglish Bikes DestawEnglish Chandrashekhar UnakalEnglish Andargachew MuluEnglishBackground: Methicillin-resistant Staphylococcus aureus (MRSA) is one of the most significant human pathogens that cause both nosocomial and community-acquired infections worldwide which are associated with high morbidity and mortality rates with rapid development of resistance. Honey is one of the oldest traditional medicines considered to be important in the treatment of several human ailments including infections not responding to standard antiseptic and antibiotic therapy. Assessing the antimicrobial effect of honey on antibiotic resistant bacteria has a paramount importance. Objective: To assess in vitro antimicrobial effect of Ethiopian multi-flora honey against MRSA. Methods: The antimicrobial effect of Ethiopian multi-flora honey against MRSA was investigated by a tube dilution method for determination of minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC). A MRSA isolate was inoculated on nutrient broth medium containing various concentrations of honey solutions and incubated aerobically at 36-37oC. After overnight incubation the tubes were read macroscopically to confer the growth by comparing with that of the control tubes and were sub cultured on agar plate to determine the lowest concentration of the test honey that prevent any visible growth represents the MIC. The MBC could also be determined at the lowest concentration of honey that can kill 99.9% of the bacteria. Result: The mean MICs and MBCs were 11.25 % (v/v) and 16.25 % (v/v) for the “Tazma mar” from low land , 9.38 and 14.38 % (v/v) “Tazma mar” from high land , 23.12 and 28.12 % (v/v) red honey from low land, 33.12 and 38.12 % (v/v) red honey from high land, and 17.5 and 22.5% (v/v) white honey from high land areas respectively against MRSA. Conclusion: Honey has both a bacteriostatic and bactericidal activity. However, the “Tazma mar” honey antibacterial potency on both the test (MRSA) and control bacterial isolates was highly effective than other honey types.
EnglishMRSA, Multi-flora Honey, MIC, MBC.INTRODUCTION
The development of resistance to multiple antibiotics and increased disease transmission by bacteria in hospitals/communities has been recognized as the major challenges as the bacterial population that expresses the resistance phenotypes1,2 . MRSA is any strain of Staphylococcus aureus that has developed resistance to beta-lactam antibiotics3 , thus limiting the treatment options to very few agents such as vancomycin and teicoplanin4 . It is one of the most significant human pathogens that cause both nosocomial and community-acquired infections worldwide which are associated with high morbidity and mortality rates with rapid development of resistance.4, 5, 6 In health-care settings, MRSA is a frequent cause of surgical wound infections, urinary tract infections, bloodstream infections (sepsis), and pneumonia7 . Antibiotic use is generally considered the main risk factor for antibiotic resistance. One of the possibilities to reduce the use of antimicrobial agents is the use of non-antibiotic compounds such as honey for the treatment of infections8 . The use of traditional medicine to treat infection has been practiced since the origin of mankind and honey produced by Apis mellifera or Apis mellipodae is one of the oldest traditional medicines considered to be important in the treatment of several human ailments9 , as well as the micro flora isolated from Ethiopian honey demonstrated bacteriocin production potentially active against Staphylococcus aureus10 . Honey is an ancient remedy for the treatment of infected burns and wounds6, 11 which has recently been rediscovered’ by the medical profession, particularly where conventional or standard modern therapeutic agents failed to cure infections11, 12 . World Health Organization (WHO) estimated that 80% of the world population depends on traditional medicine to treat them13, 14, 15. A similar proportion of the population living in developing countries including Ethiopia rely on herbal medicine on harvested wild plants for their primary health care14, 15, 16 . Honey is the natural sweet substance which is widely used in traditional medicine throughout the world14, 17. It has been successfully used on infections not responding to standard antiseptic and antibiotic therapy and that the full potential of honey has been recognized12. Since ancient times, honey has been known to possess antimicrobial properties which rapidly clears infection and protects wounds from becoming infected, as well as wound-healing activity. Indeed, the in vitro activity of honey against antibiotic-resistant bacteria and the reported successful application of honey in the treatment of chronic wound infections that were not responding to antibiotic therapy have attracted considerable attention18, 19 . However, information regarding on the effectiveness of honey against MRSA is scarce particularly in Sub Saharan Africa including Ethiopia. The present study is therefore, aimed at to assess the in vitro antimicrobial effects of Ethiopian multi-flora honey against MRSA isolated from clinical specimens.
METHODS AND MATERIALS
Study design and period
An experimental study was conducted to assess the antimicrobial effect of Ethiopian multi-flora honey against MRSA at University of Gondar Teaching Hospital from February 2012 to May 2012. Study Area The study was conducted at University of Gondar Teaching Hospital, Gondar. As a teaching hospital and research center, it is also a center that supplies highly competent health professionals and scientists to the nation20 . Sample source and preparation Source and preparation of honey samples Six honey samples viz., white honey, red honey and “tazma mar” each from highland and lowland areas, produced by honeybee (Apis mellifera) and sting-less bee (Apis mellipodae) were evaluated. Honey samples were obtained from local market (farmer) and Amar Associational Organization which distributes refined honey to the local markets of Amhara found in Amhara region of North West Ethiopia, Gondar, where different kinds of flowering plants grow naturally were used. These honey samples were collected in screwed bottles and kept in a cool and dry place (at room temperature). Before the experiment each honey samples were filtered using a sieve to remove debris of honey. Different concentrations of honey solutions were prepared in sterile distilled water and then filtered in a micro porous filter membrane (diameter=47mm, pore size=0.45µm), which is capable of preventing the passage of bacteria and spores. The concentration used for this test was 10%, 15%, 20%, 25%, 30%, 35%, 40% and 45% for white and red honey, 5%, 10%, 15%, 20%, 25%, 30%, 35%, and 40% for “tazma mar”. Source and preparation of test organism (MRSA) and control organisms Four isolates of preserved MRSA were evaluated. Three reference organisms: Staphylococcus aureus (ATCC-25923), Pseudomonas aeruginosa (ATCC-27853) and Escherichia coli (ATCC25922) were included as a control. All these test and control organisms were obtained from the Department of Microbiology, University of Gondar, North West Ethiopia. Suspension of the organism was prepared with normal saline and the inoculum density was adjusted with turbidity of 0.5 McFarland standards21 . General principle of the test Antimicrobial susceptibility test measures the ability of an antimicrobial agent to inhibit bacterial growth in vitro. This ability may be estimated by macro broth or tube dilution, micro broth or well dilution, antimicrobial gradient method, agar dilution tests or disk diffusion tests (Bauer-Kirby Procedure) 21 .
Determination of MIC and MBC
The MICs and MBCs of the six honey samples for MRSA isolates and reference organisms were conventionally determined twice for each isolate by the tube dilution method then sub cultured on agar plate. This technique was done by mixing Nutrient broth with a known volume (2ml) of diluted and filtered honey solution: 5% V/V, 10% V/V, 15% V/V, 20% V/V, 25% V/V, 30% V/V, 35% V/V, 40% V/V and 45% V/V per 10 ml of media were used. A known volume of honey (2ml) was added with the prepared Nutrient broth to get a final volume of 10 ml and then a loop full of standardized bacterial suspension of approximately 104 CFU/ml (2 micro liter/0.002 ml) was inoculated in each tube. After overnight incubation aerobically at 36-37oC the tubes were examined macroscopically for visible evidence of bacterial growth in the form of turbidity by comparing with the control tubes. Two control tubes were employed; one was a row of positive control tubes containing only the broth/growth medium and each of the microorganisms, while the other was a negative control which consisted of a row of tubes containing different concentrations of honey with no organism. After which they were read macroscopically to confer the growth were sub cultured. The last tube which showed visible growth and all the tubes in which there was no growth in nutrient broth or from tube dilution step were sub cultured on dried MSA and MHA media to determine the lowest concentration of the test honey that prevent any visible growth. So the lowest concentration of honey that completely inhibits or prevents visible growth represents the MIC. The MBC was therefore determined at the lowest concentration of honey that can kill 99.9% of the bacteria or that produce a sterile culture.
Pretest and data quality control
Pretest was conducted at University of Gondar teaching hospital laboratory. The method was tested on MRSA and quality control organisms: S. aureus (ATCC-25923), P. aeruginosa (ATCC27853) and E. coli (ATCC-25922). Sensitivity test was done against honey of different concentration and methicillin (for MRSA) for its reliability and validity before it was used for actual experiment. To increase the data quality the experiment was also be under advisors supervision and use of proper sterilization techniques.
Data processing and analyses
The collected and cleared data was analyzed using descriptive statistics. Results were displayed using tables and also expressed in words.
Ethical consideration
The study was conducted after obtaining institutional ethical clearance from the ethical review committee of School of Biomedical and Laboratory Sciences, Collage of Medicine and Health Sciences, University of Gondar.
RESULTS
The mean MICs and MBCs of the six honey samples with clinical isolates of MRSA and control organisms: S. aureus (ATCC-25923), P. aeruginosa (ATCC-27853) and E. coli (ATCC25922) are presented on Table 1. The MIC and MBC results are also illustrated in figure 1 and 2 below. White honey from low land areas showed no antibacterial activity against all the test and control organisms. The mean MIC and MBC of “tazma mar” for all MRSA isolates ranged from 7.5 to 15% (v/v) and 12.5 to 20% (v/v), respectively, and other honey types ranged from 17.5 to 35 and 22.5 to 40% (v/v), respectively. The mean MIC and MBC value of all the four test organisms (MRSA) were 11.25% (v/v) and 16.25% (v/v) for the “tazma mar” honey from low land areas and 9.38% (v/v) and 14.38 % (v/v) for high land areas. The result also revealed that the mean MIC and MBC value for the red honey from low land areas were 23.12 % (v/v) and 28.12 % (v/v) and for high land areas were 33.12 % (v/v) and 38.12 % (v/v); whereas the white honey from high land areas was 17.5 % (v/v) and 22.5% (v/v), respectively. The mean MIC and MBC value of the control S. aureus (ATCC-25923) were 10% (v/v) and 15% (v/v) for the “tazma mar” honey from low land areas; whereas, 7.5% (v/v) and 12.5 % (v/v) for the “tazma mar” honey from high land areas, respectively. The result also showed that the mean MIC and MBC value of the red honey from low land areas were 20 % (v/v) and 25 % (v/v), and from high land areas were 35% (v/v) and 40 % (v/v); whereas 12.5% (v/v) and 17.5% (v/v) for the white honey from high land areas, respectively. The MIC and MBC of P. aeruginosa (ATCC-27853) for “tazma mar” honey from low land areas was 10% and 15% (v/v); whereas high land areas was 7.5% and 12.5% (v/v), respectively. The red honey from the low land areas show the mean MIC and MBC value of 35% (v/v) and 40% (v/v), and white honey from high land areas show 37.5% (v/v) and 42.5% (v/v), respectively. Red honey from high land areas and white honey from low land areas showed no activity against P. aeruginosa (ATCC-27853). The MIC and MBC of E. coli (ATCC-25922) for “tazma mar” from low land areas was 20% and 25% respectively; whereas high land areas was 15% and 20%, respectively. Red and white honey showed no activity against E. coli.
DISCUSSION
Honey one of the oldest traditional medicines, is being used effectively as a dressing for wounds, burns and skin ulcers22. It completely inhibits the growth of gram negative and gram positive bacteria11, 13 . Honey has previously been shown to have wound healing and antimicrobial properties, but this is dependent on the type of honey, geographical location and flower from which the final product is derived24. The present study tested the antimicrobial activity of six honey samples against MRSA isolates and control organisms: S. aureus (ATCC-25923), P. aeruginosa (ATCC-27853) and E. coli (ATCC25922). Even if honey has an antimicrobial property against MRSA, many studies have demonstrated that not all honey samples have the same degree of antibacterial activity. Therefore, the sensitivity of MRSA isolates and control organisms cannot be compared using the results from different studies, as the honeys used in the studies may have had widely differing antimicrobial activity. The MIC and MBC value determined with the MRSA and control S. aureus (ATCC-25923) strains in this study indicate that there is no much difference in sensitivity (effectiveness of honey to inhibit growth or to kill the bacteria) to honey. Hence, honey has potential in the decontamination of wounds colonized by antibiotic resistant strains of bacteria and nonresistant strains. In the present study the mean MIC value of “tazma mar” honey from low land and high land areas against MRSA (11.25 and 9.38 % v/v) were close to those previously determined with an agar well diffusion assay in Ireland that showed a lower MIC was observed (12.5% v/v) for MRSA isolates. For the E. coli and Pseudomonas strains equivalent MICs were observed (12.5% v/v) 24, which are lower than the MIC value of the red and white honey in the present study. In this study the MIC value of “tazma mar” [11.25% (v/v)] which was almost in line with MIC values with the study conducted in Addis Ababa reported that “tazma mar” honey was found to be effective against low concentration (10%) for S. aureus 25 . In contrast, another study12 reported that the MIC value of honey, was 4% (v/v) for S. aureus (ATCC 25923), and 8% (v/v) for P. aeruginosa (ATCC 27853) and study conducted in New Zealand showed the mean MIC value of two honeys against MRSA (2.98 and 3.1% v/v) which has a lower MIC value with the present study. This difference might be due to the variation in antimicrobial activities of honey in different geographical locations and could be attributed to the materials available for honey bees in preparing their valuable honey. This supports the existing traditional practice of using honey to treat wound infections6, 11, 18, 19 . However, the mean MIC and MBC of red honey on MRSA in the present study was found to be higher [23.12% (v/v) and 28.12 % (v/v), and 17.5% and 22.5% for white honey] as compared with a report from Nigeria where the antimicrobial activity of honey was found to be (the MIC and MBC of the honey) effective on S. aureus at 4%, while on P. aeruginosa MIC at 5% and MBC at 6% using the agar diffusion method26. This variation in the antibacterial activity of honey might be due to the type of honey or the source of the nectars (the flowers from which bees gathered nectar to produce the honey), since flora source determines many of the attributes of honey11 and the methodology may have contributed to the difference in the antimicrobial activities of honey. Inoculum density may also contribute to the variation in the antimicrobial activity of honey. In the present study, the percentage by volume of red honey that completely prevents MRSA is ranged from 22.5-35%, P. aeruginosa 35%. A similar study conducted in Malaysia showed that honey was found to be effective against MRSA, inhibited from concentrations of 25-30% using an agar incorporation technique6 . The MIC values obtained in this study demonstrate that two honeys (“tazma mar” from both high land and low land areas) produced by stingless bee (Apis mellipodae) were more effective in inhibiting MRSA, S. aureus (ATCC25923) and gram negative bacteria (P. aeruginosa (ATCC-27853) and E. coli (ATCC25922) in in vitro tests than other honey types produced by honey bee (Apis mellifera). This may be due to the type of bees that produce honey. The sensitivity of strains of MRSA to honey including “tazma mar” was almost similar to that of the control S. aureus (ATCC-25923). Honey also has a range of viscosities; these can be altered depending on the temperature at which they are measured. The color and consistency of honey is not only affected by the source of flower from which the nectar was collected but is also affected by variables such as weather and climatic changes27. In this study, white honey obtained from low land areas had no any antibacterial activity against any of the test and control organisms at 45% (v/v) dilutions. This may be due to the type, geographical difference and low viscosity comparing to other honey types by visual inspection. “Tazma mar” honey showed antibacterial effect against E. coli (ATCC-25922), with the strongest activity seen against MRSA, S. aureus (ATCC25923) and P. aeruginosa (ATCC-27853). The antimicrobial effects of other honey samples were more with MRSA strains and control organism of S. aureus (ATCC-25923) than with the other bacteria tested: P. aeruginosa (ATCC-27853) and E. coli (ATCC-25922). E. coli (ATCC-25922) was not inhibited by 45% (v/v) honey (other than “tazma mar”) solution, which is the highest concentration achievable in this assay. The Staphylococci were more sensitive to the honey than the P. aeruginosa (ATCC-27853) and E. coli (ATCC-25922). The reason for this might be due to difference in cellular organization. The MIC and MBC of P. aeruginosa (ATCC-27853) for “tazma mar” from low land areas was 10% and 15% respectively; whereas from high land areas was 7.5% and 12.5% ,respectively which is similar result to that of Staphylococcus isolates. MRSA, S. aureus (ATCC-25923), and P. aeruginosa (ATCC-27853) were more susceptible for “tazma mar” than E. coli (ATCC25922). The acidic pH of honey (normally pH 3.2 – 4.5) also limits or inhibits the growth of many organisms. Animal bacterial pathogens generally need a pH of 7.2 – 7.4 for optimum growth28. In this study the pH range of the six types of honey was from 3.5–5.0. Moreover, among the six different types of honey, “tazma mar” honey was more acidic as compared to others.
CONCLUSION
Honey had antimicrobial properties against MRSA organisms tested. It has both a bacteriostatic and bactericidal activity when tested in vitro using dilution of honey. The antibacterial potency of “tazma mar” honey on both the test organism MRSA and control bacterial isolates was highly effective when compared to other honey types. The test organism, MRSA and Staphylococcus aureus (ATCC-25923) were found to be more susceptible than other control bacterial strains; Pseudomonas aeruginosa (ATCC-27853) and Escherichia coli (ATCC-25922).
ACKNOWLEDGEMENTS
The authors are indebted to the University of Gondar Teaching Hospital Laboratory and Department of Medical Microbiology for support and facilities during this the study. Also, authors acknowledge the great help received from the scholars whose articles cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Authors are grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript.
COMPETING INTERESTS
We declare that there is no conflict of interest
Englishhttp://ijcrr.com/abstract.php?article_id=1321http://ijcrr.com/article_html.php?did=13211. Chandrashekhar Unakal, Basappa Kaliwal. Phenotypic characterization and risk factors of nosocomial Staphylococcus aureus from Health Care Centers. Adv. in Microbiol., 2012; 2: 122-128
2. Amare Gebrehiwot, Wubishet Lakew, Feleke Moges, Belay Anagaw, Gizachew Yismaw, Chandrashekhar Unakal et al. Bacterial profile and drug susceptibility pattern of neonatal sepsis in Gondar University Hospital, Gondar Northwest Ethiopia. Der Pharmacia Lettre, 2012, 4 (6):1811-1816.
3. Francois P, Schrenzel J. "Rapid diagnosis and typing of Staphylococcus aureus". Staphylococcus: Molecular Genetics/ Book 2008; 2: 19.
4. Baddour MM, Abuelkheir MM, Fatani AJ. Trends in antibiotic susceptibility patterns and epidemiology of MRSA isolates from several hospitals in Riyadh, Saudi Arabia. Annals of Clinical Microbiology and Antimicrobials 2006; 5 (30): 1-11.
5. Shittu AO, Okon K, Adesida S, Oyedara O, Witte W, Strommenger B, Layer F, Nübel U. Antibiotic resistance and molecular epidemiology of Staphylococcus aureus in Nigeria. BMC Microbiology 2011; 11: 92.
6. AL-Haj NA, Amghalia E, Shamsudin MN, Abdullah R, Mohamed R, Sekaw Z. Antibacterial activity of honey against methicillin-resistant Staphylococcus aureus. Research Journal of Biological Sciences 2009; 4(8): 943-947.
7. Klatz R, Goldman R. Community associated MRSA: Anti-Aging Approaches for a Superbug Survival Strategy: Townsend Letter. Anti-Aging Medicine 2009. http://www.worldhealth.net/
8. Stobberingh EE. Antibacterial activity of honey against ESBL-producing strains. Antibacterial activity of L-Mesitran Ointment and L-Mesitran Soft 2010.
9. Mandal MD, Mandal S. Honey: its medicinal property and antibacterial activity. Asian Pacific Journal of Tropical Biomedicine 2011; 1691(11): 154-160.
10. Chandrashekhar Unakal, Gizachew Yismaw, Amare Gebrehiwot, Mengistu Endris and Feleke Moges. Effect of bacteriocin produced from Enterococcus faecium against drug resistant bacterial isolates. International Journal of Biomedical and Advance Research 2012; 3(12): 881-886
11. Molan PC. The antibacterial activity of honey. Bee World 1992; 73: 5-28.
12. George NM, Cutting KF. Antibacterial Honey: in vitro activity against clinical isolates of MRSA, VRE, and other multiresistant Gram-negative organisms including Pseudomonas aeruginosa. Wounds 2007; 19: 231-236.
13. Ashebir M, Ashenafi M. Assessment of the antibacterial activity of some traditional plants on some food-borne pathogens. Ethiopian Journal of Health Development 1999; 13(3): 211–216.
14. Chauhan A, Pandey V, Chacko KM, Khandal RK. Antibacterial activity of raw and processed honey. Electronic Journal of Biology 2010; 5(3): 58-66.
15. Dikasso D, Lemma H, Urga K, Ambaye C, Ayele A, Yersaw K. Investigation of the antibacterial effect of papaya (carica papaya) seeds on three pneumonia causing bacteria. Ethiopian Journal of Health Science 2002; 12(1): 47-53.
16. Abebe D. The development of drug research. EHNRI News Letter 1996; 1: 5-6.
17. Subrahmanyam M, Hemmady A, Pawar SG. Antibacterial activity of honey on bacteria isolated from wounds. Annals of Burns and Fire Disasters 2001; 14 (1): 1-5.
18. Osman OF, Mansour IS, EI-Hakim S. Honey compound for wound care: A preliminary report. Annals of Burns and Fire Disasters 2003; 16(3): 1-7.
19. Kwakman PHS, Van den Akker JPC, Guclu A, Aslami H, Binnekade JM, Boer L, Boszhard L, Paulus F, Middelhoek P, Velde AA, Vandenbroucke-Grauls CM, Schultz MJ, Zaat SAJ. Medical-grade honey kills antibiotic-resistant bacteria in Vitro and eradicates skin colonization. Clinical Infectious Diseases 2008; 46: 1677–82.
20. Five Years Strategic Plan (2010/11 to 2014/15). Gondar University teaching Hospital, 2011.
21. Jorgensen JH, Ferraro MJ. Antimicrobial susceptibility testing: General principles and contemporary practices. Clinical Infectious Diseases 1998; 26: 973–80.
22. Mulu A, Diro E, Tekleselassie H, Belyhun Y, Anagaw B, Alemayehu M, Gelaw A, Biadglegne F, Desalegn K, Yifiru S, Tiruneh M, Kassu K, Nishikawa T, Isogai E. Effect of Ethiopian multiflora honey on fluconazole-resistant candida species isolated from the oral cavity of AIDS patients. International journal of STD and AIDS 2010; 21:1-5.
23. Mulu A, Tessema B, Derbie F. In vitro assessment of the antimicrobial potential of honey on common human pathogens. Ethiopian Journal of Health Development 2004; 18(2):107-111.
24. Sherlock O, Dolan A, Athman R, Power A, Gethin G, Cowman S, Humphreys H. Comparison of the antimicrobial activity of ulmo honey from Chile and manuka honey against methicillin-resistant Staphylococcus aureus, Escherichia coli and Pseudomonas aeruginosa. BMC Complementary and Alternative Medicine 2010; 10: 47.
25. Mogessie A. The in vitro antibacterial activity of ‘Tazma mar’ honey produced by sting less bee. Ethiopian Journal of Health Development 1994; 8(2): 109–117.
26. Omoya, FO, Akharaiyi FC. A Pasture honey trial for antibacterial potency on some selected pathogenic bacteria. Journal of Natural Products 2009; 3(2010):05-11
27. Cooper RA, Molan PC, Harding KG. Antibacterial activity of honey against strains of Staphylococcus aureus from infected wounds. Journal of Royal Society Medicine 1999; 92: 283-285.
28. Molan PC. Potential of honey in the treatment of wound and burns. American Journal of Clinical Dermatology 2001; 2(1): 13-9).
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241511EnglishN2013June18HealthcareA COMPARATIVE EVALUATION OF HBA1C MEASUREMENT IN DIFFERENT ANTICOAGULANT VIALS AND ITS STABILITY ON STORAGE
English8086Devajit SarmahEnglish Booloo SharmaEnglishIntroduction: India has an overwhelming diabetic population and the importance of HbA1c testing is felt. However the need of an additional EDTA sample and due to lack of standardised laboratories in most part of India, samples are stored and transported for testing. The study aims to check the variation in HbA1c measurement in K3EDTA, Na-citrate, lithium-heparin and Na-fluoride/Na2 EDTA anticoagulant vials and check for its stability when sample are stored at 2 – 8°C for 7 days. Methods and materials: HbA1c was measured by cation exchange HPLC based BioRad D - 10 analyser after collection of sample in K3EDTA, Na-citrate, lithium-heparin and Na-fluoride/Na2 EDTA from 25 diabetic and 25 non - diabetic subjects on day 1 and on day 3, day 5 and day 7 of sample collection, after storage at 2 – 8°C. Result: There were no variation in the measured value of HbA1c in these anticoagulant vials (CV = 0.0 – 0.8%). There were no significant differences in the mean values of the HbA1c measured on day 1 and day 7 (8.2 ± 1.16 vs. 8.2 ± 1.18, P = 0.962 in diabetic and 5.3 ± 0.25 vs. 5.3 ± 0.24, P = 0.955 in non - diabetic). There were significant correlations between the HbA1c values measured on day 1 and after 7 days storage (r = 0.991 in diabetic and r = 0.957 in non –diabetic). Conclusion: HbA1c values in fresh and stored whole blood sample does not change when analysed in K3EDTA, Na-citrate, lithium-heparin and Na-fluoride/Na2 EDTA anticoagulant vials.
EnglishHbA1c, K3EDTA, Na-citrate, lithium-heparin and Na-fluoride/Na2 EDTA, prolonged storage.INTRODUCTION
Worldwide the prevalence of type-2 diabetes mellitus (T2DM) has been rising, and about 90 % of the diabetic populations are of T2DM. Of 371 million diabetic people worldwide, 63 millions are Indian, i.e. every sixth diabetic is an Indian, as reported by the International Diabetic Federation (IDF) 2012 report (1). The dramatic economic changes have had a great impact on urbanization and lifestyle of the Indians, which together with genetic predisposition contributed to the rise in diabetes in India (2). Also the presentation of T2DM occurs a decade earlier in Indians when compared to European population (3). Traditionally, for diagnosis of diabetes physicians rely on fasting plasma glucose (FPG) and oral glucose tolerance test (OGTT). Glycated haemoglobin (HbA1c) was done only in a few numbers of cases and it was used only for monitoring the effect of treatment. HbA1c is always considered as a stable indicator of glycaemia for the preceding three months (4). Its potential utility in diabetic care was first reported in 1985 World Health Organisation report (5), and by 2010 all the major expert committee and association across the globe including the American Diabetes Association (ADA) has recommended HbA1c for the diagnosis of Type 2 DM, besides its role in prognosis (6). So, the importance of HbA1c estimation in diabetes has increased manifold in recent years. Most of the commercial kits for HbA1c estimation requires sample to be collected in EDTA anticoagulant. This requires additional sample collection for the patient. So, we estimated HbA1c in blood sample collected in K3EDTA, Na-citrate, lithium-heparin and Nafluoride/Na2 EDTA vials separately and then we checked for any variation in HbA1c values. Also most laboratory uses fresh sample for estimation of HbA1c. As standardized methods for HbA1c estimation like high performance/pressure liquid chromatography (HPLC) etc. are not available in all the laboratories in India, so samples are to be stored and transported to a standardised laboratory for estimation. Thus, the sample requires storage until it is being analysed. It is said that HbA1c has high pre-analytical stability and is stable for 1 week when stored at 4°C and for 1 year when stored at -70°C (7, 8). So, to verify the stability of HbA1c in the above vials when stored at 2 - 4°C, HbA1c was estimated for 7 days in all the different anticoagulant vials, in context to Indian settings.
MATERIAL AND METHODS
The study was conducted from June 2012 to October 2012 in the Central Clinical Laboratory of the R D Gardi Medical College in Ujjain, India. A total of 25 adult Type 2 diabetic cases (diagnosed by ADA criteria or known cases) of either sex in the age group of 25 to 65 years, and 25 adult healthy non - diabetic patients in the same age group of either sex were considered for the present study. Only those subject who were not having any disease other than diabetes that may affect the HbA1c values were selected for the study. They were excluded based on necessary patient history and investigations. Clearance from the ethical committee and consent from the study subjects were obtained. K3EDTA, Na-citrate, lithium-heparin and Nafluoride/Na2 EDTA vacutainer vials manufactured by Becton, Dickinson (BD) India, were used. The creation of the two groups is simply to ascertain the purpose of the study in samples with a normal and a higher HbA1c values separately. 2ml of venous sample were drawn in all the four different vacutainers from each of the diabetic patients and healthy individuals, using standard venipuncture techniques. HbA1c was estimated after 2 hours of blood collection by cation exchange HPLC based BioRad D - 10 dual programme analyzer, manufactured by BioRad, USA. Just after estimation, vials were stored at 2 - 8 oC and then HbA1c measured every alternate day till 7th day in all the vials i.e. on 1st(day of sample collection), 3rd, 5th and 7th day. The results were expressed as mean ± SD. The difference between the initial HbA1c values and the values after storage were determined using paired student’s t-tests while the correlation between the initial HbA1c values in the different anticoagulant vial and the values after storage were determined by Pearson correlation technique. A P-value < 0.05 was considered statistically significant on two-tailed testing for all analysis.
RESULTS
The present study shows no significant change in the measured value of HbA1c when it was measured using vacutainers containing different anticoagulant mentioned above in both the groups, i.e., the group with a normal HbA1c (non-diabetic) and the group with a higher HbA1c values(diabetic). The measured range of HbA1c value in diabetic group was from 7.1% to 11.3%. The mean HbA1c being 8.2% in this group. The range of HbA1c value in non-diabetic group was from 4.5% to 5.6%. The mean HbA1c being 5.3% in this group. The first day (day 1) estimated HbA1c value in the four different anticoagulant vials for the 25 diabetic samples were expressed as mean ± SD. The mean ranges from 7.1 – 11.3% and the SD ranges from ± (0.00 – 0.06), hence the variation was insignificant. The coefficient of variation for the 25 diabetic samples measured on day 1 among four different anticoagulant vials ranges from 0.0 to 0.8%. In the non-diabetic group the measured HbA1c value for day 1 when expressed as mean ± SD, the mean ranges from 4.5 – 5.6% and SD ranges from ± (0.00 – 0.06). Also the coefficient of variation for the 25 non - diabetic samples measured on day 1 among four different anticoagulant vials ranges from 0.0 to 0.8%. Similar results were found for the HbA1c values measured in the four different anticoagulant vials among both the diabetic and non - diabetic group on day 3, day 5 and day 7. The study therefore proves that there was no variation in measurement of HbA1c when it was measured in K3EDTA, Na-citrate, lithium-heparin and Nafluoride/Na2 EDTA vacutainer vials. Figure I and II shows the mean HbA1c measured in different anticoagulant vials among the 25 diabetic samples and non-diabetic samples respectively on day 1, day 3, day 5 and day 7 of testing. The figures depicts that the mean HbA1c varies from 8.2 – 8.22% and 5.3 – 5.32% for diabetic and non-diabetic samples respectively. When the HbA1c was measured in all the four anticoagulant vials on day 3, day 5 and day 7, the mean HbA1c value did not vary in both the diabetic and non - diabetic group. There was no significant differences in the mean values of the HbA1c measurement on day 1 and the values obtained after storage for 7 days (8.2 ± 1.16 vs. 8.2 ± 1.18 in diabetic and 5.3 ± 0.25 vs. 5.3 ± 0.24 in non - diabetic), and the P value being 0.962 and 0.955 for the diabetic group and non - diabetic group, respectively. Figure III and IV shows the correlation between the HbA1c measurement on day 1 and day 7 in the diabetic and non - diabetic group, respectively. There were significant correlations between the HbA1c values measured on day 1 and day 7 after storage in both the diabetic group (r=0.991) and the non - diabetic group (r=0.957). Also the inter assay coefficient of variation for the day 1 and day 7 sample in the diabetic and the non - diabetic group was 14.0 % and 4.6 %, respectively. The study therefore proves that there was no variation in measured values of HbA1c after storage at 2 – 8 oC for 7 days irrespective of the collection of sample in K3EDTA, Na-citrate, lithium-heparin or Na-fluoride/Na2 EDTA vacutainer vials.
DISCUSSION
The study was conducted to determine the variation of HbA1c value when measured in different anticoagulant vials as against only EDTA advocated by most manufacturers. The study also determines the stability of HbA1c in the different vials when sample were stored at 2 - 8 oC for 7 days. This study infers that there was no significant variation in the HbA1c values when it was measured in K3EDTA, Na-citrate, lithiumheparin and Na-fluoride/Na2 EDTA vacutainer vials. The study also confirms the stability of HbA1c measurement in the above vials when the samples were stored at 2 - 8 oC for 7 days. According to 2012 IDF report there are about 54% undiagnosed diabetic in India (1). When it comes to awareness in India only 1/3rd of diabetics under ImproveTM study were aware of HbA1c (9). Even today HbA1c is a very rare test in India, which is because of the cost and lack of standardised laboratory in most part of the country (10). Very recently there is an increase in the numbers of HbA1c test request by the treating physicians. India is a developing economy where almost 70% of the population resides in the rural India. There are seldom any standardised and well-equipped laboratories in rural areas, and sample for testing are often transferred to a nearby town or city for testing after being collected in the rural areas. Sometime even a well-equipped laboratory in remote town has to wait for reagent supply. In these cases the sample for testing has to be stored until it could be analysed. It is realised that HbA1c testing is costly and the use of a separate EDTA vacutainer for testing increases the cost further. Often fasting sugar and HbA1c testing are done on the same day, but sample are collected in a Na-fluoride/Na2 EDTA vial for fasting sugar and an EDTA vial for HbA1c resulting in requirement of more sample volume and extra cost. So, considering these facts our present study seems to very promising when it comes to HbA1c testing. Our study clearly discourages the need for an extra EDTA vial for HbA1c testing, which can be tested in the same Na-fluoride/Na2 EDTA vial used for fasting / post prandial sugar, or in the same K2 EDTA vial used for complete blood counts (CBC), or in the same heparin vial in ICU patient used for blood gas analysis. The cost incurred in HbA1c testing will be reduced, the compliance will increase and this in turn will contribute to a better management of diabetes. Our study also reduces the apprehension of the treating physicians regarding the stability of HbA1c test, which are transported to standardised laboratory quite far from the place of sample collection. Physicians can now rely on the reports of HbA1c received and this in turn will generate faith on HbA1c testing in India, resulting in increase request for HbA1c testing. This is very important for a country like India where more people suffer from diabetic complications due to lack of proper monitoring, especially when diabetic complications are found to occur early in India (10, 11, 12). India is a country where proper diabetic screening and adequate manpower like dieticians and field workers for diabetic awareness is lacking, and so the importance of HbA1c testing is even more in India. We also think that HbA1c should also be used for diagnosis of diabetes in India because this could diagnose many cases which go undetected by routine fasting sugar analysis. But before this a pan India HbA1c study should be conducted to establish a base line HbA1c level for Indians, based on which diagnosis and screening could be practiced (13). Until then HbA1c should be done in almost all cases for monitoring of diabetes and in selected cases for diagnosing diabetes in India. Lack of standardised laboratories is a matter of concern and transportation of sample is widely practiced and we see that our study will help gain confidence of patient and treating physician in HbA1c testing in India. HbA1c is very important in diagnosing and monitoring diabetic in a country like India which is considered the diabetic capital of the world. CONCLUSION Our study shows that HbA1c can be measured any of the K3EDTA, Na-citrate, lithium-heparin and Na-fluoride/Na2 EDTA vials without any change in the measured value. So no extra vial is required and which saves lot of money. It also shows that when appropriate cold storage is maintained the sample remains stable for seven days, which is especially important when samples are to be transported for estimation in a place far from the place of collections.
ACKNOWLEDGEMENT
We are thankful to Dr. V. K. Mahadik, Medical Director of Ujjain Charitable Trust for providing a BioRad D-10 analyser and encouraging us for research in the field of diabetes diagnosis and screening. Authors acknowledge the great help received from the scholars whose articles cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Authors are grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=1322http://ijcrr.com/article_html.php?did=13221. International diabetic federation, IDF Diabetic atlas, 2012, 5th edition. Available at: www.idf.org . Accessed December 20th 2012.
2. Mohan V, Sandeep S, Deepa R, Shah B, Varghese C. Epidemiology of type 2 diabetes: Indian Scenario. Indian Journal of Medical Research 2007; 125: 217-30.
3. Mohan V, Venkatraman JV, Pradeepa R. Epidemiology of cardiovascular disease in type 2 diabetes: The Indian scenario. J Diabetes Sci Technol 2010; 4:58–70.
4. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Eng J Med 1993; 329(14):977- 86.
5. Diabetes Mellitus : Report of a WHO study Group, Technical Report Series 727, Geneva, World Health Organisation, 1985.
6. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2012; 35 (Suppl 1):S64–S71.
7. Sacks DB, Bruns DE, Goldstein DE, Maclaren NK, McDonald JM, Parrott M.Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. Clin Chem 2002; 48:436–472.
8. Little RR, Rohlfing CL, Tennill AL, Connolly S, Hanson S. Effects of sample storage conditions on glycated hemoglobin measurement: evaluation of five different high performance liquid chromatography methods. Diabetes Technol Ther 2007; 9:36– 42.
9. Shashank R Joshi, AK Das, VJ Vijay, V Mohan Challenges in Diabetes Care in India: Sheer Numbers, Lack of Awareness and Inadequate Control. JAPI, 2008; 56:443-450.
10. Joshi SR, Das AK, Vijay VJ, Mohan V. Challenges in diabetes care in India: sheer numbers, lack of awareness and inadequate control. J Assoc Physicians India 2008; 56: 443-50.
11. Mohan V, Venkatraman JV, Pradeepa R. Epidemiology of cardiovascular disease in type 2 diabetes: The Indian scenario. J Diabetes Sci Technol 2010; 4:58–70.
12. Raheja BS, Kapur A, Bhoraskar A, Sathe SR, Jorgensen LN, Moorthi SR, et al. Diab Care Asia-India Study: diabetes care in India - current status. J Assoc Physicians India 2001; 49: 717-22.
13. Sarmah D, Sharma B. Importance and Status of HBA1C in T2DM and its Indian Perspective. Asian Journal of Biomedical and Pharmaceutical Sciences 2012; 2 (12), 1-10.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241511EnglishN2013June18HealthcareINCREASING PREVALENCE OF EXTENDED SPECTRUM BETA LACTAMASES (ESBLS) PRODUCING E.COLI AND KLEBSIELLA SPP IN OUTPATIENT DEPARTMENTS (OPDS) PATIENTS IN URINARY TRACT INFECTIONS (UTIS) IN TERTIARY CARE HOSPITAL
English8793Gopal KashyapEnglish Sweta GuptaEnglish Ved Prakash MamoriaEnglish Pushpa DurlabhjiEnglish Dinesh JainEnglishBackground: Extended-spectrum β-lactamases (ESBLs) are plasmid-mediated group of fast growing enzymes synthesized by the Gram negative bacteria that are causing medicinal crisis. At present, ESBLs has been increasing as a serious pathogen having the property multidrug resistance. So, The present study was undertaken to find out the prevalence of ESBLs positive E. coli and Klebsiella in urinary isolates obtained from various In-patient Departments (IPDs) , Outpatient Departments (OPDs) and Intensive Care units (ICUs). Methods: Processing of 251 non- repetitive urine samples received during a period of about one year for detection of ESBLs positive Escherichia coli and Klebsiella spp. was done. All suspected isolates of ESBLs producers were confirmed by the Double Disc potentiating discs test, Double disc synergy test and E-Test. Results: Out of Two fifty one urinary isolates of Escherichia coli and Klebsiella spp. 93 (37.1%) were confirmed as ESBLs producers and 158(62.9%) were non ESBL producers by all the three tests of confirmation. 61 out of 93 (65.6%) were from OPDs and in all IPDs maximum ESBLs producing urinary isolates were obtained from Medicine wards 12/93 (12.9%). Conclusion: Results indicate that now ESBL producers are increasing in community. So, routine ESBL detection should be made mandatory not only in indoor patient but also in outdoor also. Appropriate use of third generation cephalosporins must be encouraged to reduce the risk of multidrug resistant bacteria and to make an antibiotic policy.
EnglishExtended-spectrum ?-lactamases, Gram negative bacteria, E. coliINTRODUCTION
Urinary tract infection (UTI) is one of the most common infectious disease ranking next to Respiratory tract infection [1] and is an important cause of morbidity and mortality. UTI is also the most common hospital acquired infection approx. 35% of total infection.[2] Bacteria are the major causative organism of UTI and E.coli is the most prevalent-causative bacteria of UTI in community as well as hospital acquired UTIs. [3,4] followed by Klebsiella, Staphylococcus, Proteus & Pseudomonas. These bacteria along with other members of Enterobacteriacae are found to produce an arsenal of enzymes known as extended spectrum β- lactamases. UTI can usually be treated with a short course of antibacterial therapy.[4] β-lactamases are enzymes which open β-lactam ring (4 carbon atom ring) of penicillin/cephamycins (i.e cefoxitin & cefotetan). β-lactam antibiotics have 4 atom ring known as β-lactam ring. β-lactamases break the β lactam ring open and therefore deactivate the antibacterial activity of drugs. Gradually with time the property of inactivating the antibiotics spread to other groups of bacteria in Enterobacteriacae and also larger group of antibiotics were inactivated. This property was first documented in 1983 in Germany in K. Pneumoniae [5] & spread quickly to Europe and US and was later known as Extended spectrum β-lactamases.[6,7] New threat was proposed by Amp C β- lactamases as they confer resistance to cephamycins (7-2 methoxy cephalosporin) and not affected by commercially available β lactamases inhibitors with loss of outer membrane porins provide resistance to carbapenems [8] ESBLs become clinically important because they destroy cephalosporins given as first line antibiotics in hospital. This may lead to inappropriate treatment and increased mortality. ESBLs producers are multi-resistant to nonlactam antibiotics such as quinolones, tetracyclines, amino glycosides and trimethoprim/cotrimoxazole, narrowing treatment options due to plasmid mediated transfer of resistance and provides therapeutic challenges. [9] Detection of ESBL production by urinary isolates is therefore very important to ensure appropriate antibiotic treatment. As the prevalence of ESBLs differs significantly both geographically and with different risk factors in patients, knowledge of these variations can help in appropriate and timely antibiotic therapy as well as avoidance of preventable antibiotic use. With reports of high prevalence of ESBL producers and lack of information in India, the present study was carried out to find out the distribution of ESBL producing bacteria isolate from urine in different units of a tertiary care hospital in Jaipur and in community acquired UTIs presenting to this hospital.
MATERIAL AND METHOD
The present study was carried out in the Department of Microbiology, Mahatma Gandhi Medical College and Hospital, Jaipur (Rajasthan).The test group selected was the population of patients from various Out Patient Departments, different wards, and Intensive care units in the hospital regardless of their age, sex, occupation, religion and ethnicity. A Proforma was filled accordingly. Sample collection Processing of 251 non- repetitive urine samples received during a period of about one year for detection of ESBLs positive Escherichia coli and Klebsiella spp. was done. Sample was collected with Universal precautions by prescribed sterile technique. Samples were transported to the laboratory as soon as possible maintaining optimum transportation conditions. Routine microscopy of all urine samples was done and samples with more than /equal to 5 white blood cells /HPF were selected. Sample culture All culture Medias were obtained from Hi media Laboratories Mumbai, India. Primary inoculation was done on the Blood agar, MacConkey agar which was incubated 18-24 hrs at 370C aerobically. Escherichia coli and Klebsiella spp. from samples were finally identified by standard techniques based on Colony morphology, Gram’s staining, Hanging drop for motility and Biochemical tests as per CLSI guidelines. Antimicrobial susceptibility test using modified Kirby-Bauer disk diffusion method was done of all isolates of Escherichia coli and Klebsiella spp. All the strains identified were tested for ESBLs production as per CLSI guidelines. Following criteria were used in isolates of Escherichia coli and Klebsiella spp. for selection of ESBLs producers: Screening Isolates of Escherichia coli and Klebsiella spp. were examined for their susceptibility to 3rd generation cephalosporins Cefotaxime and Ceftazidime antimicrobial discs.
In our isolates of Escherichia coli and Klebsiella spp. the diameter of zone of inhibition was measured for Cefotaxime (30µg) & Ceftazidime (30µg) antimicrobial discs. Diameter of ≤ 22mm for Ceftazidime and/or ≤ 27mm for Cefotaxime was considered as ESBLs suspects as per NCCLS guidelines. [10] All suspected isolates of ESBLs producers of Escherichia coli and Klebsiella were confirmed by the Double Disc potentiating discs test, double disc synergy test and few suspected isolates were also be confirmed by E-Test. Quality control with Standard strains for Escherichia coli ATCC 25922 and Klebsiella spp. 700603 was also done.
RESULTS
The present study was under taken to detect the prevalence and antimicrobial susceptibility of ESBLs positive Escherichia coli and Klebsiella spp. in urinary isolates obtained in Department of Microbiology, Mahatma Gandhi Medical College, and Jaipur. The samples were obtained from OPDs, IPDs and ICUs of various Department from Mahatma Gandhi Hospital,Jaipur. 251(Two fifty one) urinary isolates of Escherichia coli and Klebsiella spp. were processed for ESBL detection. In primary screening of 251 isolates 97 were found to be resistance to Cefotaxime and/or Ceftazidime antibiotic discs. Those 97 suspects of ESBL producing Escherichia coli and Klebsiella spp.in urinary samples were further tested for confirmation by Double Disc Synergy test and Double Disc Potentiation test .Out of 97 suspects of ESBL producing Escherichia coli and Klebsiella spp.in urinary samples 75 (77.32%) were confirmed by Double Disc Synergy test and 90 (92.78%) were confirmed by Double Disc Potentiation test.25 suspected ESBL producing urinary isolates were tested with E-Test. All except four isolates were tested positive by E-Test. 4(four) isolates were not confirmed positive by any of the three tests hence they were considered non ESBLs producers. Out of 251(Two fifty one) urinary isolates of Escherichia coli and Klebsiella spp. 93 (37.1%) were confirmed as ESBLs producers and 158(62.9%) were non ESBL producers by all the three tests of confirmation. Out of 93 confirmed ESBLs producers Escherichia coli (89/93) (95.7%) was the predominating organism.52/93 i.e. 56% of ESBLs producing isolates were obtained from female patients. Maximum ESBLs producing isolates were from patients of 20-40 yrs age group followed by 10-20 yrs age group. Maximum ESBLs producing urinary isolates i.e. 61/93 (65.6%) were from Outpatient Departments of various clinical disciplines. Of all In-patient Departments maximum ESBLs producing urinary isolates were obtained from Medicine wards 12/93 (12.9%).
DISCUSSION
ESBLs are an example of the increasing number and diversity of the enzymes that inactivate β- lactam antibiotics. Multi drug resistance and ESBLs enzymes producing E.coli & Klebsiella spp. are major threat to treat urinary tract infections. A dramatic increase in the frequency of ESBL producing E.coli & Klebsiella spp. has been observed in last decade. Frequent and inappropriate use of antibiotics in human led to increasing resistance rate making the treatment of urinary tract infections more complex. ESBLs has become a major problem worldwide as is confers resistance to the third generation broad spectrum cephalosporins. Although CLSI guidelines exist for detection of E.coli & Klebsiella spp., no such recommendation exists for other ESBLs producing organisms. Failure of empirical therapy, which is usually, initiated with third generation cephalosporins due to resistance of ESBL producing E.coli & Klebsiella spp. lead to increase in mortality rate in Hospital settings.
Emphasized must be laid on developing rapid screening method for ESBL detection by clinical laboratories so as to report ESBLs producing organisms in appropriate time. Combination of Antibiotics with their clavulanate salt confirms ESBLs production. Clinical microbiologist play an important role in devising ways and means of rapidly identifying these ESBLs producing organisms and help institutions to initiate appropriate therapy. Detection become more important by the fact that resistance to one of the 3GC cephalosporins means therapeutic resistance to all cephalosporins up to 3GC even when in vitro sensitivity may be detected otherwise. In this study observed that female have a higher probability (56%) of predisposition to UTIs. These findings were in accordance with the study by Fennell et al (2008) from Ireland and it was 65.5%.Another study by Babypadmini S et al (2004) from India where they found 56.62 %.[11,12] Therefore our study correlate with various other studies which shows higher percentage of isolates were from female patients. [11,12,13] Most of the patients in our study were from the age group 20-40yrs (43 %), which shows that UTI is more common in middle age group person in our population compare to Tada Dharmistha G et al 2012 study in which most of the patients were from the age group 10-20 yrs (30%).[13] The prevalence of ESBLs production in India varies from 5-60%in urinary isolates. In present study the prevalence of ESBLs production was 37% which correlates with MS Kumar et al and S Jalalpour. [17,18] The prevalence of ESBLs producers organisms are on the rising trend as seen in various studies since 2002 to 2012. The prevalence of ESBLs producing E.Coli is 35.45% which correlates with Babypadmini S et al & Shila Jalalpour. Prevalence of Klebsiella spp. is 1.59% which correlates with Joseph Gangoue et al. [12,18] Our study showed that most of the ESBLs producing isolates were from the Out Patient Departments (Community Acquired).Various studies show that prevalence of Community Acquired UTIs is increasing in recent times. In the beginning ESBLs were in a good number identified to be a hospital based crisis but it is now becoming more common along with community acquired isolates, especially Esch. coli (Shila Jalalpour(2011) Iran[18] Parul Agarwal et al 2008 Pune [22]. In the present study Esch.coli and Klebsiella spp. were found 35.45% and 1.59% respectively. This was due to illogical and ample use of third generation cephalosporins in both the hospital and community and is alleged to be the main cause of mutations in these enzymes that lead to the appearance of the ESBLs. [23] Initially ESBL producers were restricted to hospital –acquired infections only, but they have now also been isolated from outpatient departments. Major outbreaks involving ESBL producing strains have also been reported from all over the world.
CONCLUSION
Considering various findings of the present study, it can be concluded that Extended Spectrum beta lactamases are gradually increasing in community in India. ESBL producing organisms have become clinically important in last two decades because of increasing trend in prevalence leading to increase in antimicrobial resistance. Increase antimicrobial resistance result in increase morbidity, mortality and cost of health care. In order to prevent and control the emergence of antimicrobial resistance in ESBL producing organisms it is of utmost importance to limit the misuse and overuse of antibiotics especially broad spectrum antibiotics. ESBL producing strains were previously common in Inpatient Departments few years back but nowadays they are commonly isolated in Outpatient Departments therefore early detection is of clinical importance for effective management of patients. To conclude, early and sensitive methods to detect ESBL producing strains should be practiced so that appropriate antibiotics may be given to treat the patients and further decrease the spread of ESBL producing microorganisms. It is also utmost important to formulate appropriate hospital antibiotic policies and taking adequate precautionary measures to decrease the spread of ESBL producing microorganisms.
ACKNOWLEDGEMENT
Authors acknowledge the great help received from the scholars whose articles cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Authors are grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=1323http://ijcrr.com/article_html.php?did=13231. Nachimuthu R ,Chethpalayam SS,Balasubramanium V,Ravichandran Palamappam K,Kannan VR.,2008.Urinary tract Infection and Antimicrobial susceptibility patternof Extended Spectrum Beta Lactamase producing Clinical isolates,Adv in Biol Research.,2(5-6):78- 82.
2. Bailey and Scott?s Diagnostic Microbiology.12th Edition .
3. Walter E. Stamm, Urinary Tract Infection,Pyelonephritis,and Prostatitis. Harrison’s Principle of Internal Medicine.17th Edition(Vol 2):1820-1827
4. Paterson, D.L., W.C. Ko, Von Gottberg, et al., 2001.Outcome of cephalosporin for serious infection due to apparently susceptible organisms producing extended spectrum Beta-lactamases: implications for the clinical microbiology laboratory, J.Clin Microbiol.,39:2206-2212.
5. Knothe H, Shah P,Kremery V et al.(1983).Transferable resistance to cefotaxime,Cefoxitin,Cefamandole and Cefuroxime in clinical isolates of Klebsiella pneumoniae and Serratia marcescens.Infection II(6):315-317
6. Quinn JR,Miyashiro D,Sahm D et al.Novel plasmid-mediated beta-lactamase (TEM10) conferring selective resistance to ceftazidime and aztreonam in clinical isolates of Klebsiella pneumoniae.Antimicrob Agents Chemother 1989;33:1451-6.
7. Jacoby GA ,Medeiros AA,O Brien TF, et al. Broad spectrum transferable beta lactamases.N Eng J Med 1988;319:723-4
8. Phillipon A,Arlet B,Jacoby GA.2002.Plasmid-Determined AmpC-Type β-Lactamases.Antimicrob Agents Chemother.,2002;46:1-11.
9. Matsumoto, Y., and M. Inoue. 1999. Characterization of SFO-1, a plasmidmediated inducible class A beta-lactamase from Enterobacter cloacae. Antimicrob. Agents Chemother. 43:307-31.
10. Rosenthal VD, Maki DK, Jamulitrat S, et al. International Nosocomial Infection Control Consortium report ,data summaryfor2003-2008,issued June 2009.Am J Infect Contr2010;38:95-106.
11. Jerome Fennell, Akke Vellinga et al (2012) “Increasing prevalence of ESBL production among Irish clinical Enterobacteriaceae from 2004 to 2008: an observational study”; BMC Infectious Diseases 2012, 12:116
12. Babypadmini S, Appalaraju B. Extendedspectrum β-lactamases in the urinary isolates of Escherichia coli and Klebsiella pneumoniae – prevalence and susceptibility pattern in a tertiary care hospital. Indian J Med Microbiol 2004; 22(3): 172-74.
13. Tada Dharmishtha G, Gandhi Paragi J, Patel Kiran N.A study on antibiotic related resistance in UTI patients: a comparison between community acquired and hospital acquired E. Coli. National Journal of Community Medicine. Vol 3 Issue 2 AprilJune 2012 Page 255.
14. Subha A, Ananthan S. Extended-spectrum β-lactamase (ESBL) mediated resistance to the third generation cephalosporins among Klebsiella pneumoniae in Chennai. Indian J Med Microbiol 2002; 20:92-95
15. Joseph Gangoue P, Branka bedenic et al . Extended spectrum β-lactamases producingEnterobacteriaceae in Yaunde,Cameroon.J Clin Microbio,july 2005,3273-77.
16. Ananthan S, Subha A. Cefoxitin resistance mediated by loss of porin in clinical strains of Klebsiella pneumoniae and Escherichia coli. Indian J Med Microbio, (2005) 23(1):20-23
17. MS Kumar, V Lakshmi, R. Rajagopalan. Occurrence of Extended –spectrum β- lactamases among Enterobacteriaceae ssp. Isolated at a tertiary care institute. Indian J Med Microbio, (2006) 24(3): 208-211
18. Shila Jalalpour (2011) “ Survey frequency of extended spectrum beta-lactamases (ESBLs) in Escherichia coli and Klebsiella pneumonia strains isolated from urinary tract infection in Iran”; African Journal of Microbiology Research vol 5(22) pp. 3711- 3715, 16, December 2011.
19. Husam S. Khanfar, Khalid M. Bindayna, Abiola C. Senok, and Giuseppe A. Botta. Extended spectrum beta-lactamases (ESBL) in Escherichia coli and Klebsiella pneumoniae: trends in the hospital and community settings. J Infect Dev Ctries 2009; 3(4):295-299.
20. S. Meier, R Weber et al “Extendedspectrum β-lactamase-producing gramnegtive pathogens in community acquired urinary tract infections: an increasing challenge for antimicrobial therapy”; Infection(2011) 39:333-340.
21. Shakti Rath, Debasmita Dubey , Mahesh C. Sahu,et al.Surveillance of multidrug resistant Escherichia coli in a hospital in India.
22. Agrawal P, Ghosh A N, Kumar S, Basu B, Kapila K. Prevalence of extended-spectrum β-lactamases among Escherichia coli and Klebsiella pneumoniae isolates in a tertiary care hospital. Indian J Pathol Microbiol 2008;51:139-42
23. Chaudhary, U, Aggarwal, R.Extended spectrum beta lactamases(ESBL)- An emerging threat to clinical theraputics, Indian Journal of Medical Microbiology,2004;.22(2): 75-80.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241511EnglishN2013June18HealthcareANTHROPOMETRIC ASSESSMENT OF SCHOOL CHILDREN IN AGE GROUP 10-18 YEARS AT JAIPUR
English9499Indu MohanEnglish Archana PaliwalEnglish Veerbhan SinghEnglish S.L.BhardwajEnglish Bhupendra Nath SharmaEnglishBackground: To determine health status by anthropometric measurements. Material and Methods: A total of 720 students between 10-18 years of age, of Rajkiya Uccha Madhyamic Vidhyalaya in Jagatpura of Jaipur. Demographic details including age assessment, body height, body weight and BMI were estimated. Results: Mean BMI observed is higher in girls (14-18 years) as compared to boys. By BMI for age criteria 97th percentile). Short stature < 3 percentile was observed in 180 (27.44%) students, of these, 123 (68.4%) were boys, 57(31.6%) were girls. Tall stature (>97percentile) were observed in 8 (1.22%) students including 5 (1.38%) boys and 3 (1.02%) girls. Conclusion: It can be concluded that nutritional status of the study population in present study is better as compared to the rural population of other studies. We recommend that these data should be used as a growth reference for Indian children and adolescents of Jaipur zone.
EnglishBody mass Index, anthropometry, Nutritional statusINTRODUCTION
Schools occupy a vital place in the community. According to modern concept, school health service is an economic and powerful means of raising level of community health. It has developed during past 70 years from the little bit awareness of medical examination of children to the current scenario where comprehensive concept of ample care of all content of the health i.e. Mental, physical, social and well being of the children during the school going age are being considered.[1] India is going through a nutritional transitional phase and is now facing the double burden of nutritional disorder among school age children. Poor rural and urban slum population have a high prevalence of under nutrition while newly rich urban, middle, and high income population suffer from emerging problem of obesity due to changing life style and unhealthy dietary habit. Hence there is a strong need for identifying children at risk of becoming obese and children who are undernourished so that appropriate intervention can be taken. [2] The nutritional status during adolescent age is an important determinant of health outcome. It was well documented that short stature in adolescent indicates prolonged under-nutrition and is associated with lower lean body mass, deficiency in muscular strength and productivity. Childhood health and nutritional status is an important determinant for planning and development of future manpower. [3]
The assessment of pattern of growth during the adolescent period is based on set of standard physical or anthropometric measurement. This measurement not only indicate the general pattern of growth during adolescent period but also reflects a population specific growth pattern, which can serve as model for nutritional assessment of the population in this age group. [4] Reference information can play central role for monitoring growth of adolescents and it may be useful to diagnose under nutrition, overweight and obesity and other growth-related problems. Recognition of importance of overall adolescent development is vital to programming for adolescent health, so that it is important to know the actual health status of adolescent and their varied problems. Anthropometric measurement under school health surveys offers an excellent opportunity to screen a large segment of population. Adolescent health has recently drawn greater attention in India. Therefore, this study is being undertaken to evaluate Anthropometry and nutritional status of adolescents of jaipur.
MATERIAL AND METHODS
Study Area- This study was carried out in Government Senior Secondary school, Jagatpura located in urban area of Jaipur. Study Population-A total of 720 students between 10-18 years of age were included in the study. 400 were males and 320 were females. 56 students (38 boys and 26 girls) were not evaluated due to absence from school during the study period. Nature of the study-This is a cross sectional study. Selection of the study population-School was randomly selected from a list of all the schools. Children between ages 10-18 years were included. Sampling-All the students from class V to XII were studied. Procedure Before starting the survey, head master of the school was contacted and nature and purpose of the study was explained in detail. Due permission was taken from the school authorities to conduct the study. Details of the students for class V to XII were taken. Verbal consent was taken from the participants, study objectives were explained to them. The study procedure was carried out during such a time that their routine study was not affected. Absent students on particular day of study were enlisted and called separately during the study period. Demographic details were estimated - Age assessment- Age assessment was done as per the birth data recorded in the school. Assessment of healthAnthropometric Measurement-Body height and body weight were measured as follows. (A) Body HeightThe standing body height was recorded with a marked vertical measuring scale (stadiometer) with a wooden sliding head piece. Subjects were made to stand upright in erect posture, shoes removed, heels together, the buttocks, shoulders and back of head touching the wall. The head was to be held comfortably erect, with the lower border of the eye in the same horizontal plane as the external auditory meatus. The head piece of the scale was gently lowered, pressing the hairs and making contact with the top of the head. Height was recorded to the nearest 0.5 centimetre. (B) Body weightBody weight of each student was recorded on a platform type of digital weighing machine with minimum clothes and shoes removed. The subject was made to stand on the weighing scale keeping both feet astride on each side of scale and weight was recorded to the nearest of 0.1 kilograms. The weighing scale was checked prior to use for its accuracy. Average of the three readings was taken C)Body mass Index- It was calculated as given below Weight in kgs Height in meters2 Statistical analysis- The findings were recorded in excel sheet and were analysed. Appropriate test of significance were applied.
RESULTS
A total of 720 students were identified in 6th to 12th class for this study. Out of these, 656 were included in the study, remaining 64 student were absent on the days of school survey. Out of these 656 student 362 (55.18%) were boys while 294 (44.82%) were girls. Height, weight and BMI in different age group were recorded. In the present study the mean height for boys and girls was almost equal till age of 14 years subsequently the mean height in the age group 15-18 years was higher in boys as compared to girls. Mean weight observed in both sexes was almost equal in both the groups. Mean BMI is equal till age of 13 year in both the sexes; subsequently Mean BMI observed is higher in girls (14-18 years) as compared to Boys. By BMI for age criteria 97th percentile). Short stature < 3 percentile was observed in 180 (27.44%) students out of these, 123 (68.4%) were boys, 57(31.6%) were girls. Tall stature (>97percentile) were observed in 8 (1.22%) students including 5 (1.38%) Boys and 3 (1.02%) girls.
DISCUSSION
Adolescent health is one of the most challenging issues in modern era. India is undergoing a rapid epidemiological transition. The increasing prevalence of non communicable diseases is adding to the burden of both sides of malnutrition (under nutrition and obesity). If the factors related to life style remain unnoticed during adolescence, they manifest themselves as serious medical problem in advanced stage in adult life leading to life threatening morbidities and high mortality in young age. It is agreed worldwide that the information on health status of adolescents from developing world (Particularly at community level) is grossly lacking. [5] In India several studies have been carried out on the Anthropometric measurement of adolescent. These studies report a wide range of data related to growth and malnutrition issues in adolescents but data are grossly inadequate. Proper understanding of physical condition of adolescent will contribute significantly towards formulating and implementing strategies to improve wellbeing in this group and inturn building healthy nation. With this background, this cross sectional study was conducted to evaluate the health status of adolescent (10-18 years of age) on 720 student of class 5th to 12th of govt. school of Jagatpura of Jaipur, during Dec. 2011 to June 2012, A total of 720 students were identified from 6th -12th class for this study. Out of these 656 students were included in the study, remaining 64 students were absent on the days of school survey. Out of these 656 students, 362 (55.18%) were boys while 294 (44.82%) were girls. We observed that boy: girl ratio was equal till the age of 11 years. Subsequently it was 9.45% v/s 7.45% in 12 years age group, 6.71% V/s 4.27% in 13 years age group, 7.47% v/s 6.86% in 14 years, 7.47% v/s 5.18% in 15 years, 10.52% v/s 8.69% in 16 years, the same thing is observed in 17-18 years age group also. This indicates the female population in higher class is declining as compared with male population. Possible reasons could be that parents give more preference to males as compared to females. Another possible reason could be that parents of girls of ≥ 14 years were hesitant to send their girls to school. This observation indicates that there is preference for male education compared to female education in this socioeconomic group. Anthropometric Measurement Height (Boys) In the present study Mean height (cms) for adolescent boys at age 10–18 years were 133.0±11.20, 139.18±9.72, 143.89±8.71, 149.47±8.41, 152.37±7.49, 159.1±5.42, 158.54±4.93, 160.05±5.73, 160.09±4.87 respectively. This data when compared with Marwah et al [6] study to our study, the mean height of adolescent boys in present study are lower. Possible reasons could be that Marwah et al have included students of upper socioeconomic status. Similarly when data of present study compared with study by Agarwal D K [7] shows similar result. The study by Agarwal D K was also done on affluent class. Present study shows similar results till age of 14 years, subsequently the mean height in present study is lower. At this age there is growth spurt; large family size and low level of education of parents possibly were responsible for this failure to gain height. Weight (Boys) Mean weight (Kg.) of adolescent boys at age (10-18 years) in the present study were 26.36±6.8, 30.49±6.98, 32.62±6.85, 34.75±7.28, 37.11±5.59, 43.37±5.51, 43.54±5.31, 45.25±5.81, 45.00±4.47 respectively.The mean weight in the present study were less for all ages on comparison with Agarwal D K and Marwah et al study. [6,7] Agarwal and Marwah studies have higher mean weight compared to the present study. The possible difference could be that the present study population belongs to middle and upper lower socioeconomic strata. Body Mass Index (BMI for Boys) When BMI for different ages in boys was calculated in present study, it was found that Mean BMI at age 10-18 year were 14.54±1.92, 15.57±168, 15.61±1.97, 15.40±1.95, 15.93±1.80, 17.08±1.53, 17.29±1.62, 17.61±1.59, 17.51±0.83 respectively. Marwah et al and Anand K showing similar result from present study. [6,8] Height (Girls) Mean Height of girls at 10-18 year were found 133.9±7.85, 138.1±8.68, 143.57±8.00, 147.86±7.82, 152.34±9.85, 156.19±4.66, 154.23±7.38, 157.60±6.95, 155.00±6.3 cm respectively in present study. Mean Height were compared with other similar studies by Agarwal D K et al ,Marwah et and Chaturvedi S.[6,7,9] In the present study the mean height is lower as compared to Marwah and Agarwal study which was conducted in affluent class. [7, 8] Mean height for girls in present study compared to study by Chaturvedi S [9] is higher. The possible explanation could be that Chaturvedi S has included study population from rural Govt. School. Weight (Girls) Mean Weight of adolescent girls at age 10-18 year in the present study 27.54±4.60, 22.87±4.57, 33.18±5.46, 35.04±6.53, 39.71±6.30, 42.98±5.56, 42.08±6.91, 46.00±8.26, 43.71±5.92 respectively. The mean weight in Marwah and Agarwal study is higher compared to present study. [6,7]Possible reasons are that both studies were performed in affluent class. In the present study the mean weight is higher as compared to study by Chaturvedi. [9] The possible higher mean weight observed in the present study compared to study by Chaturvedi could be that they have included children from rural Govt. School, where nutritional status may be poor as compared to our study.
Body Mass Index (BMI for Girls)
In the present study Mean BMI (Kg/M2) at age 10-18 years were found 15.30±1.82, 15.11±1.57, 16.05±1.98, 15.88±1.82, 17.11±2.48, 17.64±2.42, 17.57±2.06, 18.44±2.71, 18.11±1.60 respectively. Mean BMI in Marwah and Anand study is higher as compare to the present study.[6,8] Which is related to the higher affluent class population in their study. The Mean BMI in the present study is higher as compared to
Chaturevedi Study, again related to the same factors as for height and weight in boys and girls. [9] The Mean height increases with age in both sexes. Uniform gaining heights were observed in both sexes till age of 14 year. In the present study the mean height for male and female was almost equal till age of 14 years. Subsequently the mean height in the age group 15-18 years was higher in boys as compared to girls. In the age group 14 to 18 year boys were taller than girls. Mean weight observed in both the sexes was almost equal in all age group (expect minor variation). Mean BMI was equal till age of 13 years in both the sexes, subsequently in 14 to 18 years age group the mean BMI was higher in girls as compared to boys.
CONCLUSION
By viewing the above observation, it can be concluded that nutritional status of the study population in present study is better as compared to the rural population by Chaturvedi S but less as compared to the urban affluent population study by Marwah and Agarwal. Mean BMI observed is higher in girls as compared to Boys. Malnutrition related with low weight more prevalent in study population, so there should be some awareness programme arranged in this population to combat malnutrition. Short stature < 3 percentile was observed in 27.44% students out of these, which again indicate growth failure in study population. Early identification and timely intervention will help this adolescent population. The limitations of this study include absence of longitudinal data. The significant differences we report compared with earlier Indian studies underscores the need for regular updating of growth charts. We recommend that these data should be used as a growth reference for Indian children and adolescents of Jaipur zone.
Englishhttp://ijcrr.com/abstract.php?article_id=1324http://ijcrr.com/article_html.php?did=13241. Park K, School Health Survey. In. “K Park’s text book of Preventive and Social Medicine 21st edition” 2011, Editors, K Park, Publisher : Banarasi Das Bhanot, Jabalpur: p 532-533.
2. Bowman SA, Gortmaker SL, Ebbeling CB et al. Effect of fast food consumption on energy intake and diet quality among children in a household survey .Pediatrics 2004; 113: 112- 118.
3. Bisai S, Bose K, Ghosh D,De Kl. Growth Pattern and prevalence of underweight and stunting among rural adolescent. J Nepal Pediatric Society 2011; 31 (1): 17-24.
4. Banerjee SR, Chakrabarty S, Vasulu TS et al Growth and nutritional status of Bengali adolescent girls. Ind. Jr. of Pediatr 2009; 71: 391-399.
5. Robert Wm. Blum ,William H. Gates, Farah Qureshi, MHS Morbidity and Mortality among Adolescents and Young Adults in the United States. Astra Zeneca Fact Sheet 2011
6. Marwaha RK, Tandon N, Ganie AM etal. National wide reference data for height, weight and body mass index of indian school children. The National Med Jr. of India 2011 (24); 5: 269-277.
7. Agarwal DK, Agarwal KN, Upadhaya SK et al. Physical and sexual growth pattern of affluent indian children from 5-18years of age . Ind. Pediatr 1992; 29: 1203-68.
8. Anand k, Kant S, Kapoor SK. Nutritional status of adolescent school children in north india. Indian Pediatr 1999; 36: 810-15.
9. Chaturvedi S, kapil V, Gnanasekaran et al .Nutrient intake among adolescent girls belonging to poor socio-economic group of rural area of Rajasthan. Indian Pediatr 1996; 33: 197-201.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241511EnglishN2013June18HealthcareBICIPITAL RIB - A CASE REPORT
English100103Jyothi K.C.English K ShanmuganathanEnglish C.M. NanjaiahEnglish N.M. ShamasundarEnglishIntroduction: Bicipital rib results due to fusion of cervical rib with the first or the first rib with the second rib. Its incidence has been reported to be 0.3% based on chest radiography. Observation: During routine course of osteology teaching we noticed left sided first rib which had fused with the second rib on its superior surface, 1.5 cm from the tubercle of first rib obliterating the first intercostals space anteriorly. Single articular facet was present on the heads and tubercles of both the ribs. Conclusion: A Rib anomaly usually indicates an underlying systemic disease and might need surgical intervention. First rib anomaly is an uncommon cause of thoracic outlet syndrome hence should not be neglected. The present paper is an attempt to highlight its morphological implications and clinical significance.
EnglishBicipital rib, Anomalous ribs, fusion of ribs, Synostosis of ribs.INTRODUCTION
The rib is composed of highly vascular cancellous bone in a flattened tube of compact bone which is thicker on its two surfaces and thinner at its borders. Anomalous ribs are rare anatomic entity usually discovered as an incidental finding on routine radiographs. The first rib may be rudimentary or fuse with cervical rib or with second rib to form bicipital rib. Its incidence has been reported to be 0.3% in a study based on chest radiography. Any rib anomalies whether normal variants such as cervical rib, pelvic rib, bifid rib, bicipital ribs or pathological, often indicates an underlying systemic disorder and hence should not be neglected. A rare but well documented cause of thoracic outlet syndrome is a congenital anomalous first rib which is connected to the second rib by synarthrosis. This study is not only of interest to anatomists from academic point of view but also of importance to radiologists and surgeons who deal with this region. The present paper is a sincere attempt to explain its embryological basis, morphological and clinical implications.
CASE REPORT
During the routine course of osteology discussion with undergraduate students in Anatomy department, JSS Medical College, Mysore, we noticed a bone specimen displaying fusion of two ribs of left side. The specimen was examined in detail and relevant anatomical features and various measurements were recorded.
OBSERVATION
The morphological examination revealed that the specimen was a fusion of first and second ribs. The first rib had fused with superior surface of the second rib from a point 1.5 cm from tubercle of first rib to form a conjoint shaft, obliterating the first intercostal space completely anterior to the fusion. Single oval articular facet was seen on the heads and tubercles of both the ribs. Conjoint shaft showed a depressed area on its superior surface with a less prominent scalene tubercle on the inner border and a tuberosity close to the outer border. Neck of the first rib showed remarkable deep oblique groove on its superior aspect. The maximum gap separating the neck region of the two ribs was 4.5 mm. The anterior end of the conjoint shaft showed concave facet for the costal cartilage. The inferior surface exhibited a smooth contour with presence of costal groove in the lower rib towards outer margin.
DISCUSSION
In the present case report, the deformed rib is bicipital rib that is synostosis of first and second thoracic ribs and the same kind has been reported by Deepak S1 , Anita R et al2 and Gupta V et al3 . Common congenital rib anomalies can be classified in to numerical and structural. Numerical anomalies include supernumerary ribs like cervical, lumbar, pelvic or sacral and deficient pairs like 11 pairs. Structural abnormalities include short ribs; bifid rib, fused or bridged ribs and pseudoarthrosis of first rib1, 2 . The fusion anomalies of the thoracic ribs can be classified in to three types: (a) Fused anterior ends and shaft but separate posterior ends called bicipetal rib, (b) Fused shafts but separate anterior as well as posterior ends called bridged rib, (c) fused posterior ends but separate shafts as well as separate anterior ends called forked rib2 . Malexpression of some myogenic determination factors such as Myo D, myogenin, Myf 5 and MRF 4 could be the potential cause of such anomalies which are detected in the medial half of somites prior to the myotome formation2 .
Du Plessis quoted that anomalous first thoracic rib is usually poorly developed and ends freely in the muscles or joins with the second rib by synostosis 4 . According to Glass RBJ5 anomalous ribs are the initial indication of previously unsuspected systemic disease and can yield important diagnostic clues in the work-up of patients with congenital bone dysplasia, metabolic disorder, iatrogenic conditions, trauma, infections, abuse and neoplasia. Few of them are reported: Cervical rib arises from seventh cervical vertebra and they resemble hypoplastic first thoracic ribs. Its prevalence is reported to be 0.2% - 0.8%. It is most commonly associated with klippel – Feil syndrome. Increased numbers of ribs are seen in trisomy 21 and with VATER association. 11 pair of ribs is usually associated with cleidocranial dysplasis and campomelic dysplasia. Short rib constitutes an integral part of several syndromes such as short rib – polydactylyl syndrome, thanatophoric dysplasia, achondroplasia etc. Diminished bone density is associated with osteogenesis imperfect. Increased bone density is seen in tuberous screrosis, osteopetrosis. Abnormal rib shape such as rib notching is commonly seen with coarctation of aorta. Slender ribs are seen in trisomy 18, neurofibromatosis and widened ribs is commonest feature of mucopolysacharidoses and in thalassemia major5 . Jaw cyst- Basal cell nevus- bifid rib syndrome or Gorlin – Goltz syndrome is a rare autosomal dominant disorder associated with multiple odontogenic keratocysts in the jaw and basal cell carcinoma of skin with bifid rib. The fourth rib has been reported to be commonly bifid. Other rib anomalies include agenesis, supernumerary ribs, distorted shape, and fusion of adjacent rib5, 6 . A rare but well documented cause of thoracic outlet syndrome (TOS) is congenitally fused first and second rib by synarthrosis which may manifest with vascular symptoms due to subclavian vein and arterial compression7 . Most cases of TOS resulting from first rib aberrations involve hypoplasia of the first rib with fusion at the anterior margin of the second rib, frequently with bony exostosis at this fusion to which scalenus anticus muscle inserts. The exostosis may thereby press surrounding neurovascular structures. Two cases of TOS associated with subclavian artery compression caused by rudimentary first ribs have been reported. Transaxillary first and second rib resection resulted in relief of symptoms of TOS8 . A medicolegal autopsy of three day old baby girl had revealed multiple rib anomalies with Patent ductus arteriosus. Hence apart from the standard methods of evaluation of ribs like computerized tomography and magnetic resonance imaging, autopsies should be made available to teach and study ribs9 . Rashid reported a case of sacral rib which was found incidentally on pelvic radiograph which appeared as large bony protuberance arising from right sacral region. This should be distinguished from post traumatic ossification and avulsion injuries to avoid unnecessary additional investigations. He concluded saying that sacral rib should be known by every radiologists as an incidental finding for which no further action is required10 . Development and Comparative anatomy The bony portion of each rib is derived from sclerotome cells that remain in the paraxial mesoderm and grow out from costal process of thoracic vertebrae. Cervical ribs occur in 1% of the population and are usually attached to the seventh cervical vertebra11 . Cervical ribs are normal in fishes, reptiles, tetrapods and birds and extend from neck to tail base. In snakes ribs are highly developed and are important in locomotion12. A typical tetrapod rib is bicipital; that is it exhibits two heads tuberculum and capitulum13 .
CONCLUSION
Bicipital rib is a rare congenital anomaly usually detected on radiography. Any rib abnormality pathological or normal variant often indicates an underlying systemic disease and also an uncommon cause of thoracic outlet syndrome which necessitates surgical intervention. Knowledge and awareness of such anomalies is important for clinicians, surgeons and radiologists.
ACKNOWLEDGEMENTS
Authors acknowledge the immense help received from Dr Pushpalatha, Associate professor and Dr G Saraswathi, Professor, Department of anatomy JSS Medical College in writing this article. 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.
Englishhttp://ijcrr.com/abstract.php?article_id=1325http://ijcrr.com/article_html.php?did=13251. Deepak S, Dakshayani KR. An unusual Case of a Bicipital Rib – A Report. Anatomica Karnataka. 2011; 5(1): 50-52.
2. Anita R, Archana R, Jyoti C, Punita M. Synostosis of First and Second Rib – Case Report. Jornal of Anatomical Society of India. 2009; 58(2): 189- 191.
3. Gupta V, Suri RK, Rath G, Loh H. Synostosis of first and second thoracic ribs: Anatomical and radiological assessment. International Journal of Anatomical Variations. 2009; 2: 131 – 133.
4. Plessis DJ. Bones In: A synopsis of surgical anatomy. 11th edition; KM Varghese Company Wadela, Bombay; 1975, 224-250.
5. Glass RBJ, Norton KI, Mitre SA, Kang E. Pediatric Ribs: A spectrum of Abnormalities. Radiographics. 2009; 22: 87 – 104.
6. Rai S, Gauba K. Jaw cyst- Basal cell nevus - Bifid rib syndrome: A case report. J Indian Soc Pedod Dent. 2007: 137 – 139.
7. Siegel RS, Steichen FM. Cervicothoracic Outlet Syndrome. The Journal of Bone and Joint Surgery. 1967; 49(6): 1187-1192.
8. Nguyen T, Baumgartner F, Nelems B. Bilateral Rudimentary First Ribs as a cause of Thoracic outlet syndrome. Journal of the National Medical association. 1997; 89(1): 69-73.
9. Durak D, Bulent E, Fedakar R, Turkmen N. Congenital anomalies of the ribs: an autopsy case report. Bratisl Lek Listy. 2009; 110(9): 580-581.
10. Rashid M, Khalid M, Malik N. Sacral rib; a rare congenital anomaly. Acta Orthop Belgica.2008; 74(3): 429-431.
11. Sadler T W. In: Langman’s Medical Embryology. 11th Edition; Lippincott Wiliams and Wilkins; 2009, 144-145.
12. Romer AS, Parsons TS. In: The vertebrate body.5th Edition; WB Saunders Company Philadelphia, London; 1978, 148-149.
13. Kent GC. In; Comparative Anatomy of the vertebrates. 4th Edition; CV Mosby Company Saint Louis; 1978, 139-140.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241511EnglishN2013June18HealthcareDEXMEDETOMIDINE AND BUPRENORPHINE AS ADJUVANT TO SPINAL ANAESTHESIA - A COMPARATIVE STUDY
English104110B. MaharaniEnglish M. Sathya PrakashEnglish Paramesh KalaiahEnglish N.C. ElangoEnglishBackground: Dexmedetomidine – an α2 agonist, Buprenorphine – an opioid receptor agonist and antagonist can be safely used as adjuvants to spinal anaesthesia. There are no studies comparing dexmedetomidine and buprenorphine when used as adjuvants in subarachnoid block. Aim: The objectives of the study: To evaluate and compare the onset and duration of sensory and motor block, perioperative analgesia, side effect profile of dexmedetomidine and buprenorphine when used as adjuvant to bupivacaine in spinal anaesthesia for surgeries below the level of umbilicus. Materials and methods: Sixty patients of ASA I & II scheduled for lower abdominal & lower limb surgeries were randomly allocated in to two groups (group A & group B) and received the following drugs ? Group A – 15 mg of 0.5% Hyperbaric bupivacaine + 10 μg of Dexmedetomidine ? Group B – 15 mg of 0.5% Hyperbaric bupivacaine + 60 μg of Buprenorphine. Sensory and motor blockade characteristics (onset time, time to reach maximum level and regression), time for rescue analgesia and side effects were recorded. Observed parameters were statistically analyzed by using independent sample ‘t’ test (SPSS version 12). PEnglishDexmedetomidine, Buprenorphine, Bupivacaine, Lower abdominal surgery.INTRODUCTION
Spinal Anaesthesia (Subarachnoid block) is the most commonly used anaesthetic technique for wide variety of elective and emergency surgical procedures below the level of umbilicus. It is very economical, safe and easy to administer.[1] The common problems with lower abdominal surgeries under spinal anaesthesia are visceral pain, nausea and vomiting.[2] This can be overcome by the addition of adjuvant to local anaesthetics for subarachnoid block. Various adjuvants like clonidine, dexmedetomidine (α2 agonist), morphine, tramadol, fentanyl, buprenorphine (Opioids) and magnesium (NMDA antagonist) are added to increase the duration of sensory and motor block, to improve intraoperative analgesia, to delay the regression of sensory block and postpone the time to first analgesic request.[3] But there are certain advantage and disadvantages with each adjuvant. Hence studies are conducted to identify safer and effective spinal adjuvant. Buprenorphine is µ and κ opioid receptor mixed agonist & antagonist. Buprenorphine when given intrathecally has analgesic action by its action on opioid receptors.[4] But side effects like delayed respiratory depression, pruritis and vomiting had made the need to find an alternative analgesic devoid of the side effects and better clinical efficacy.[5] Dexmedetomidine a novel drug is being used in anaesthetic practice for its sedative, anxiolytic, analgesic, neuroprotective and anaesthetic sparing effect. It has additional advantages like minimal respiratory depression, cardioprotection, neuroprotection and renoprotection.[6] Dexmedetomidine prolongs motor and sensory block when used as adjuvant to local anaesthetic for spinal anaesthesia.[7] It is used in the dose of 3 to 15 mcg as adjuvant to spinal anaesthesia. [8] There are no studies comparing buprenorphine and dexmedetomidine when used as adjuvants in subarachnoid block. Hence this present study was carried out with the following objectives: Aim: To evaluate and compare the onset and duration of sensory and motor block, perioperative analgesia, side effect profile of dexmedetomidine and buprenorphine when used as adjuvant to bupivacaine in spinal anaesthesia for surgeries below the level of umbilicus. MATERIALS AND METHODS The study was approved by institutional ethical committee, written informed consent was obtained from the patients participating in the study. This was a randomized prospective interventional study. Convenient sampling method was followed and the study was conducted on 60 patients of either sex, belonging to ASA-I & II (American Society of Anesthesiologists physical status), between the age group of 18-60 years who were enrolled for lower abdominal and lower limb surgeries. The patients with history of hypertension, heart disease, renal failure, sedative drug consumption, allergic to the local anaesthetics and patients belonging to ASA III & IV, refusal to spinal anaesthesia were excluded from the study. The patients were randomly allocated into two groups (Group A & B) of 30 each. Group A received 15mg of hyperbaric bupivacaine with 10 µg of dexmedetomidine and Group B received 15 mg of hyperbaric bupivacaine with 60 µg of buprenorphine. All patients were kept nil by mouth for 8 hours prior to surgery. The patients were not premedicated as it may interfere with the study parameters. The baseline blood pressure, pulse rate, respiratory rate were observed. IV access was secured with 18gauge cannula. After preloading with ringer lactate solution (10ml/kg of Body weight), the patients were placed in right lateral position and lumbar puncture was performed at L3-L4 space with 26gauge spinal needle with all aseptic precautions. Ensuring free flow of C.S.F, the appropriate drug for that designated group was injected and the patients were made to lie down in supine position. Blood pressure, pulse rate and Spo2 were recorded immediately after subarachnoid block and thereafter every 5 minutes till the end of surgery. Oxygen was administered through a face mask if the pulse oximetry reading decreased below 95%. Intraoperative hypotension was considered to be present whenever systolic blood pressure decreased to less than 20% of baseline and it was managed with bolus of I.V fluids and incremental doses of I.V ephedrine. Bradycardia defined as heart rate less than 50 bpm and was treated with I.V atropine. Any untoward incident and side effects like nausea, vomiting, respiratory depression, pruritis and shivering during the study period were carefully observed, recorded and managed symptomatically. Onset of sensory block was assessed by loss of pinprick sensation to 23gauge hypodermic needle and dermatomal levels were tested. Modified Bromage scale (0- No block, 1- Inability to raise extended leg, 2- Inability to flex knee, 3- Inability to flex ankle and foot) was used to assess the motor blockade. The following parameters were observed and recorded: onset of sensory blockade to T10 level, maximum sensory block level, time for maximum level sensory block, onset of motor blockade to modified bromage 3, time for complete motor block, regression of motor block to modified bromage 0, regression of sensory block to S1 level, duration of sensory and motor block. Sedation was graded according to Ramsay sedation score. Post operative pain and time for rescue analgesia were recorded by using Visual Analogue Scale. Injection Diclofenac 100mg was given intramuscularly as rescue analgesic. No intraoperative sedation was given, as the patients were comfortable throughout the surgery. Statistical analysis was done by SPSS version 12. Parametric data were reported as arithmetic mean ± standard deviation and analyzed by independent sample ‘t’ test. The comparison was studied using Chi-square or the Fisher’s exact test as appropriate, with P value reported with the 95% confidence interval. PEnglishhttp://ijcrr.com/abstract.php?article_id=1326http://ijcrr.com/article_html.php?did=13261. Fischer HBJ. Regional anaesthesia and analgesia. In: Pinnock CA, Rowbotham D, Parr SM, Lin D, Appadu BL, Fischer HBJ. Fundamentals of Anaesthesia. London: Greenwich medical media limited; 1999. pp. 240.
2. Alahuhta S, Kangas-Saarela T, Hollmén AI, Edström HH. Visceral pain during caesarean section under spinal and epidural anaesthesia with bupivacaine. Acta Anaesthesiol Scand. 1990; 34: 95–8.
3. Buvanendran A, Kroin JS. Useful adjuvants for postoperative pain management. Best Pract Res Clin Anaesthesiol 2007; 21: 31– 49.
4. Agarwal K, Agarwal N, Agrawal V, Agrawal A, Sharma M, Agarwal K. Comparative analgesic efficacy of buprenorphine or clonidine with bupivacaine in the caesarean section. Indian Journal of Anaesthesia 2010; 54: 453-7.
5. Gadsden J, Hart S, Santos AC. Post cesarean delivery analgesia. Anaesth Anal 2005; 101: 62-9.
6. Panzer O, Moitra V, Sladen RN. Pharmacology of sedative analgesic agents: dexmedetomidine, remifentanil, ketamine, volatile anaesthetics, and the role of peripheral µ (mu) antagonists. Crit Care Clin 2009; 25: 451-69.
7. Kanazi GE, Aquad MT, Jabbour-Khoury SI, Aljazzar MD, Alameddine MM, AlYaman R et.al. Effect of low dosedexmedetomidine or clonidine on the characteristics of bupivacaine spinal block. Acta Anaesthesiologica Scandinavica 2006; 50: 222-7.
8. Hala EA, Eid MD, Mohamed A, Shafie MD, Hend Youseef MD. Dose related prolongation of hyperbaric bupivacaine spinal anaesthesia by dexmedetomidine. Ain Shams Journal of Anaesthesiol 2011; 4: 83-95.
9. Al-Ghanem SM, Massad IM, Al-Mustafa MM, Al-Zaben KR, Qudaisat IY, Qatawneh AM et al. Effect of adding dexmedetomidine versus fentanyl to intrathecal bupivacaine on spinal block characteristics in gynecological procedures. Am J Appl sci 2009; 6: 882-7
10. Dixit S. Postoperative analgesia after caesarean section: an experience with intrathecal buprenorphine. Indian J Anaesth 2007; 51: 515-8
11. Gupta R, Bogra J, Verma R, Kohli M, Kushwaha JK, Kumar S. Dexmedetomidine as an intrathecal adjuvant for postoperative analgesia. Indian J Anaesth 2011; 55: 347- 51
12. Eisanach JC, De Kock M, Klimscha W. α- 2 adrenergic agonists for regional anesthesia. Anesthesiology 1996; 85: 655- 74.
13. Lawhead RG, Blaxall HS, Bylund BD. Alpha-2A is the predominant α-2 adrenergic receptor subtype in human spinal cord. Anesthesiology 1992;77: 983- 91.
14. Smith MS, Schumbra UB, Wilson KH et al. Alpha 2 adrenergic receptor in human spinal cord: specific localized expression of mRNA encoding alpha-2 adrenergic receptor subtypes at four distinct levels. Brain Res 1995; 34: 109-17.
15. Yaksh TL, Jage J, Takano Y. Pharmacokinetics and Pharmacodynamics of medullar agents. The spinal actions of α - 2 adrenergic agonists as analgesics. In: Atikenhead AR, Benad G, Brown BR, et al. Baillieres Clinical Anaesthesiology, Vol. 7, No. 3. London: Bailliere Tindall; 1993.pp. 597-614.
16. Smith C, Birnbaum G, Carter JL, Greenstein J, Lublin FD. Tizanidine treatment of spasticity caused by multiple sclerosis. Neurology 1994; 44 (9): 34-43.
17. Keniya VM, Ladi S, Naphade R. Dexmedetomidine attenuates sympathoadrenal response to tracheal intubation and reduces perioperative anaesthetic requirement. Indian J Anaesth 2011; 55: 352-7
18. Hall JE, Uhrich TD, Barney JA, Shahbaz RA, Ebert TJ. Sedative, amnestic and analgesic properties of small dose dexmedetomidine infusions. Anaesth Analg 2000; 90: 699-705
19. Aanta RE, Kanto JH, Scheinin M, Kallio A, Scheinin H. Dexmedetomidine, an α2- adrenoreceptor agonist, reduces anaesthetic requirement for patients undergoing minor gynaecological surgery. Anaesthesiology 1990; 73: 230-5
20. Fauzia A. Khan, Gauhar A. Hamdani. Comparison of Intrathecal Fentanyl and Buprenorphine in Urological Surgery. JPMA 2006; 56(6): 277-82
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241511EnglishN2013June18HealthcareEFFECT OF PLAY INTERVENTION IN THE REDUCTION OF ANXIETY AMONG PREOPERATIVE CHILDREN
English111117Nisha K.English Umarani J.EnglishAn important index used to estimate the Nation’s health is, the health status of children in the country. Children are more vulnerable due to their lack of knowledge of procedures, a lack of control, a lack of explanation in child-appropriate terms, and a lack of pain management. Hospitalized children may experience high level of anxiety due to many different factors both physical and psychological factors. The present study aimed to determine the effectiveness of play intervention on anxiety among children admitted in preoperative wards of selected hospitals at Mangalore. The objectives of the study were to determine the effectiveness of play intervention among experimental group. The study design was two group pre-test post- test design. The sample comprised of 60 preoperative school age children in the age of 6-12 years who were selected by Purposive sampling technique and divided into experimental and control group. Pretest anxiety was assessed and play intervention(video game) was given to the experimental group along with the routine care and only routine care to the control group. The data was collected by using demographic proforma and numerical state anxiety scale. The study result showed that the calculated ‘t’ value ( t= 4.225) was greater than the table value (t58 = 1.671) at 0.05 level of significance. The pre-test anxiety score was independent of all the demographic variables such as age, gender, religion, type of family, residence, care giver present during hospital stay, past child reactions to any procedures. The finding of the study shows that the play intervention was effective in reducing the anxiety among preoperative children.
EnglishEffectiveness, school age children, anxiety, play intervention.INTRODUCTION
An important index used to estimate the Nation’s health is the health status of children in the country1 . Unfortunately, even the healthiest baby can get sick2 . Surgery can be a threatening experience for everyone, especially for children. Hospitalized children may experience high level of anxiety due to many different factors both physical and psychological factors1 . It is not surprising therefore that up to 65% of children experience significant anxiety associated with the preoperative period2 . A child’s surgery is often a very significant and memorable event in the life of the entire family and especially the child’s personal history3 . Preoperative anxiety is an extremely unpleasant sensation for children4 . Preoperative anxiety refers to anxiety regarding the events that take place prior to surgery5 . In India approximately 3 million of children undergo surgery, among them boys are more than girls and the ratio is 7:46 . Up to 25% of children have been noted to require physical restraint7 . Loss of freedom can produce stress and anxiety in children8 . Play therapy in a hospitalized setting is innovative and concisely accomplishes the task of supporting children emotionally in their time of chaos, fear, and pain9 . The nurses play an important role in helping the parent and child cope with their anxiety and stress7 . The anxiety caused by the hospital environment and surgical procedure may be harmful during the preoperative period because it might affect cognitive, social, and affective development, in addition to increasing negative behaviours during the child’s postoperative period10. The pharmacological and non pharmacological therapy is used to reduce the anxiety of the child11. Play is an important part of child life and it is an important aspect to foster the growth and development of a child12. Play comes naturally to children and is often their favourite activity. Providing an environment conducive to play activities like giving a toys or using of handheld game technology to make the environment less threatening, has been shown to reduce anxiety and this also help in getting child cooperation with medical procedures and anaesthesia induction13 . A study was conducted to identify the effect of play on pre-operational anxiety among children. There was a significant reduction in the trend of anxiety increment after surgery in the intervention group in comparison to the control group. Attending in playrooms and using play activities might have reduced the trend of increment in the anxiety level induced by surgical procedures6 . The influence of play activity among children between 5 and 12 years of age undergoing medical procedures at the outpatient surgical centre revealed that during the preoperative period, children who participated in playful activities in the recreation room had their anxiety reduced in comparison with those that only stayed in the preoperative holding area14 . The child copes up with the anxiety in different ways. So the investigator felt the need of using a distracter as diversion therapy. A conceptual framework is an interrelated concepts or abstractions assembled together in a rational scheme by virtue of their relevance to a common theme. The conceptual framework used in the present study was adapted from the General Systems Theory introduced by Ludwig Van Bertalanffy (1968)15,16 .
MATERIAL AND METHODS
The study design chosen was two group pre-test post- test design. The population of the study was school age children at selected private hospitals at Mangalore. Permission from the institution ethics committee was obtained prior to the study. The parents of the children gave written consent for the study. Purposive sampling technique was used for selecting the study subjects. The sample comprised of 60 school age children of 6-12 years who got admitted in the preoperative ward subjected to surgery within 24 hours and divided into 30 for experimental and 30 for control group. The tool used for the study was demographic proforma and Numerical State Anxiety Scale. After a brief self introduction, the investigator explained the purpose of the study and obtained informed consent from the parents. On the first day the investigator observed the setting, structure, and the appliances for use. The investigator obtained consent from the parents to participate in the study. The parents were interviewed on the basis of baseline proforma. The investigator made the children comfortable on the bed comfortably. Pretest was assessed for both experimental and control group using numerical state anxiety scale. Then the experimental group children were provided with standard care and play intervention [video game] half an hour in the morning and half an hour in the evening for one day prior to surgery and the children in the control group was given only standardized care. Post test was assessed to both groups using Numerical State Anxiety Scale. The data was analyzed by descriptive and inferential statistics.
RESULT
In experimental group highest percentage (43.3%) of children were in the age group 8- 10yrs, where as in control group majority (36.3%) of children were in the age group 10- 12yrs. Highest percentages of children were females (53.3%) in the experimental group and in the control group (50%). Majority of the children were in joint family the experimental group (50%) and the control group majority (43.3%). Most of the children in experimental group were from rural area (53.3%) and in the control group children were (50%) from both rural and urban area. Highest percentages of care giver present in the experimental group were (33.3%) both mother’s and father’s whereas in control groups (36.3%) were mothers. With regard to past reaction to any other procedure is minimal with the percentage of (56.3%) in the experimental group and (50%) control group. The experimental and control group (100%) has not under gone any distraction technique during hospital stay. Figure.1. depicts that all the children in the experimental group and control group were having a lot anxious. In the post-test of experimental group 80% of them had medium anxious level and 20% were having little anxious. In the post test score of control group 87% were having a lot anxious, 13% had medium anxious and pre-test remained the same even in the experimental group. The post-test level of anxiety in the experimental group was found to be lower than the control group. Computed paired ‘t’ test showed the effectiveness of play intervention in reducing the anxiety in the experimental group. Table.1and 2 showed that the mean post-test anxiety score (3.43±1) was lower than mean pre-test score (6.4± 0.5). The calculated ‘t’ value ( t= 4.225) was greater than the table value (t29 = 1.699) at 0.05 level of significance. To test the effectiveness of play intervention, statistical significance between the post- test anxiety scores in the experimental and control group, unpaired ‘t’ test was computed. The mean score of experimental group (3.43±1) was lower than mean of control group (4.43 ± 0.83). The calculated ‘t’ value (t= 4.225) was greater than the table value (t58 = 1.671) at 0.05 level of significance. Hence the research hypothesis was accepted. Hence there is a significant difference in the anxiety score of children between experimental and control group. The associations of the pre-test anxiety score with selected demographic variables were found out by using Chi-square test. The data presented in experimental group shows there was a no significant association of the pre-test anxiety score with selected demographic variable as the calculated value is less than the table value at 0.05 level of significance, but for the gender, table value is lower than the calculated value. Hence the hypothesis was accepted as there was a significant association between gender and anxiety. The data presented in the control group shows there was a no significant association of the pre-test anxiety score as calculated value is less than the table value at 0.05 level of significance. Hence the hypothesis is rejected as, there is no significant association between anxiety level and selected demographic variables.
DISCUSSION
The pre-test anxiety scores in both control and experimental group showed that the entire sample had alot anxious. But in the post-test, anxiety level in the experimental group showed that majority (80%) of the sample experienced medium anxious and 20% little. In the control group majority (90%) was found to have medium anxious and 10% experienced alot anxious. A study was done to evaluate the level and prevalence of anxiety at the preoperative period using the YPAS-m in preschool children. The study result showed that their is significant difference in the level of anxiety in experimental and control group17 . Effectiveness of play intervention is calculated using unpaired t test. The mean score of experimental group (3.43±1) was lower than mean of control group (4.43±0.83). The calculated ‘t’ value ( t= 4.225) was greater than the table value (t58 = 1.671) at 0.05 level of significance. This study is supported by another study done among children between ages of 3–6 yr who were randomized into two equal groups. The anxiety of each child was assessed using the Modified Yale Preoperative Anxiety Scale. The experimental group was provided with a toy and standard care and control group by only standard care. The results showed significantly less anxiety in children who received a toy than the other group who did not18 . A study was done with a total of 150 children aged 2-16 yrs, the sample was divided into two groups; experimental group were provided with standard care and play room activity and control group with standard care. The State-Trait Anxiety Inventory was used to assess anxiety. The analysis showed that 51.1% of children in experimental group were having reduced anxiety19 . For determine the association between level of anxiety among children in preoperative wards with selected demographic was done there were no significant association between anxiety level and selected demographic variables in control groups. But in experimental group the gender of children shows significant association. This study was supported by a study in which the children of age group 3-7 yrs showed a significant association between anxiety level and age and gender20 . The present study was confined to a specific geographical area which obviously imposes limits to any larger generalization. The study was confined to a small number of subjects. However it could be done on more samples for larger generalization. Anxiety was assessed using only Numerical State Anxiety Scale. Play intervention was given just, a day prior to surgery.
CONCLUSION
The present study highlighted the effectiveness of play intervention on anxiety as a nonpharmacological and cost effective intervention for children. Anxiety is a situation where all children will face in all age group. Diversion therapy is chosen as the primary intervention for decreasing the anxiety level of children in preoperative ward because it provides a simple approach in reducing anxiety. A better understanding of health issues associated with the anxiety among school children has constituted a challenge for clinician and researchers. So there is a great lot scope for exploring this area. Research should be conducted to identify the scope of play intervention to alleviate anxiety among children
Englishhttp://ijcrr.com/abstract.php?article_id=1327http://ijcrr.com/article_html.php?did=13271. Marlow DR, Redding BA. Text book of Pediatric Nursing. 6th ed. Pennsylvania: WB Saunders Publication; 2008.p. 386-8.
2. Wilson D andHockenberry MJ. Nursing Care of Infants and Children. 8th ed. New Delhi: Elsevier Pvt Limited; 2007.p. 456-9.
3. Kain, Z. N., and Caldwell-Andrews, A. (2005). Preoperative psychological preparation of the child for surgery: An update. Anesthesiology Clinics of North America, 23, 597-614.
4. Cooke M, Chaboyer W, Hiratos M, Schluter P. The effect of music on pre-operative anxiety in day surgery. Journal of Advanced Nursing. 2005;52(1):47-55.
5. Peter J. D, Franklyn P. and Etsuro K. Smith’s Anesthesia for Infants and Children, 8th ed. Elsevier Pvt Limited;philadelfia;2007.457-8
6. Wright k.d , Sherry H. S, Allen F G etl.( 2007) Prevention and Intervention Strategies to Alleviate Preoperative Anxiety in Children. A critical review. Behavior Modification; 2007, 31:52-79.
7. Lumley MA, Melamed BG, Abeles LA. Predicting children's presurgical anxiety and subsequent behavior changes.Source;jpj, 1993 Aug;18(4):481-97.
8. Julie L. Lerwick. The Impact of ChildCentered Play Therapy on Anxiety Levels in Pre Neurosurgical Pediatric Patients; Anesthesiology Clinics of North America, 23, 58-7.
9. Li, H. C., Lopez, V., and Lee, T. L. (2007). Effects of preopertive therapeutic play on outcomes of school-age children undergoing day surgery. Research in Nursing and Health, 30, 320-332.
10. Susan C. Reinhard. Barbara G. Nirvana Huhtala P. Ann B. Supporting Family Caregivers in Providing Care. Bookshelf ID: NBK2665PMID: 21328765.
11. Browne NT, Flanigan LM, McComiskey CA, Pieper P. Nursing Care of the Pediatric Surgical Patient. Boston, Mass: Jones and Bartlett Publishers; 2007:3-16.
12. Golden L, Pagala M, Sukhavasi S, Nagpal D, Ahmad A, Mahanta. Giving toys to children reduces their anxiety about receiving premedication for surgery. AnesthAnalg. 2006;102:1070-2.
13. Ammed M.J, Farrell M.A, Karala A etl, preoperative anxiety in children risk factors and nonpharmacolcogical management. M.E.J. ANESTH .2011, 21 (2).
14. Weber Fernanda Seganfredo. The influence of playful activities on children's anxiety during the preoperative period at the outpatient surgical center. J. Pediatr. (Rio J.) [serial on the Internet]. 2010 June [cited 2013 May 18] ; 86(3): 209-214. Available from:http://www.scielo.br/scielo.php?script =sci_arttextandpid=S0021755720100003000 08andlng=en. http://dx.doi. org/10.1590/ S0021-75572010000300008.
15. Polit DF, Hungler BP. Nursing research principles and methods. 6th ed. Philadelphia: Lippincott; 1999. 16. Talbot LA. Principles and practice of nursing research. St. Louis: Mosby; 1995
17. Talbot LA. Principles and practice of nursing research. St. Louis: Mosby; 1995 Kain ZN, Mayes LC, Cicchetti DV, Bagnall AL, Finley JD, HofstadterMB. The Yale Preoperative Anxiety Scale: how does it comparewith a ”gold standard”AnesthAnalg. 1997;85:783-8.
18. Clatworthy, S. (1981). Therapeutic play: Effects on hospitalized children. Journal of the Association for the Care of Children’s Health, 9(4), 108-114.
19. Caprilli, S., Anastasi, F., Grotto, R., Abeti, M. S., andMesseri, A. (2007). Interactive music as a treatment for anxiety and stress in children during preoperative period: A randomized prospective study. Journal of Developmental and Behavioral Pediatrics, 28(5), 399-403
20. Li, H. C., and Lopez, V. (2008). Effectiveness and appropriateness of therapeutic play intervention in preparing children for surgery: A randomized controlled trial study. Journal forSpecialists in Pediatric Nursing, 13(2), 63-73.
Data in table 2 shows that, the mean anxiety score of experimental group (3.43±1) was lower than mean of control group (4.43±0.83). The calculated ‘t’ value ( t= 4.225) was greater than the table value (t58 = 1.671) at 0.05 level of significance. Hence the hypotheses was accepted as there was a significant difference in the anxiety score of children between experimental and control group
Figures 1 show that in experimental group and control group were having 100% of a lot anxious. The post-test of experimental group were 80% of them had medium anxious level and 20% were has little anxious. In post test score control group 87% of sample were a lot anxious, 13% had of sample had medium anxious and pre-test remained same even in the experimental group.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241511EnglishN2013June18HealthcareMASSIVE HEMOPERITONEUM SECONDARY TO CORPUS LUTEAL CYST RUPTURE WITH NODULAR HEPATIC CIRRHOSIS- INTRAOPERATIVE DIAGNOSIS- CASE REPORT
English118122Nayak Samir R.English Kasimbi G.English Soren K. DilipEnglish Aswini V.English Rao Bhaskara GanniEnglishRupture of an ovarian cyst is a common occurrence in women of reproductive age. Bleeding from ruptured corpus luteum may vary from mild hemorrhage to massive hemoperitoenum leading to shock necessating urgent surgical intervention. We present a 21 year female admitted with gross pallor, fainting attacks, abdominal distension .she had 6 weeks history of amenorrhoea.Clinically and sonologically the patient was diagnosed as ruptured ectopic pregnancy with massive hemoperitoneum but urine pregnancy test was negative. The laparoscopy revealed gross hemoperitoneum, ruptured left ovarian cyst with grossly nodular cirrhotic liver. There was no prior history or treatment suggestive of hepatic cirrhosis. The massive hemoperitoneum from luteal cyst rupture was secondary to deranged coagulation mechanism due to nodular cirrhotic liver. The laparoscopic procedure recorded, the journals regarding the topic searched and reviewed.
EnglishCorpus luteal cyst,hemoperitoneum, cirrhotic liverINTRODUCTION
Ovarian cyst occurs during reproductive years, at end of menstrual cycle, or during pregnancy. The usual manifestations are palpable adnexal mass, abdominal pain if torsion or rupture of the cyst occurs. The presentation of ruptured luteal cyst may vary from no symptoms to symptoms and sign of acute abdomen. Ruptured corpus luteal cyst in some instances causes massive intraperitoneal hemorrhage leading to death [1] Predisposing factors for massive hemoperitoneum from ruptured ovary are abdominal trauma, bleeding diathesis, anticoagulation therapy, or patient with dialysis, recent sexual intercourse [2] A young female admitted with provisional diagnosis of ruptured ectopic pregnancy and gross hemoperitoneum. Diagnostic laparoscopy revealed gross hemoperitoneum with ruptured corpus luteal cyst.Uterus and both the tubes were found normal. To be surprise, there was grossly nodular cirrhotic liver with enlarged spleen. The massive hemoperitoneum with rupture ovarian cyst was secondary to thrombocytopenia due to nodular cirrhotic liver. The patient was not aware of hepatic cirrhosis or she was not having any symptoms related to cirrhosis. Nodular liver and splenomegaly was diagnosed intraoperatively. This type of presentation is not mentioned earlier.
PATIENT AND METHODS
21-year female presented to the emergency department with complain of severe abdominal pain of 8 hours duration .She had fainting attack two times with reeling of head. She had history of amenorrhea for 6 weeks. The pain was severe at periumblical and suprapubic region . She denied any vaginal bleeding or discharge. Her gynaeic history was irregular periods occurring 25 to 45 days interval. She was sexually active , had 2 children and tubectomised. At admission she was drowsy and clinically gross pallor. Her blood pressure was 90/60 mmHg. Pulse rate was 120 / minute, respiratory rate was 22/ minute,temperature 99degree farenhit.There was no petechial hemorrhage over skin. She was anicteric. Cardiovascular examination –heart rate was 120/ minute with normal 1st and second heart sound. Lungs were clinically clear. There was mild abdominal distension with diffuse tenderness in all quadrants. Free fluid was noticed on percussion.On vaginal speculum examination there was no blood in the vaginal vault. The cervical os was closed. Uterus size could not be ascertained due to tenderness. The left adnexae was more tender on bimanual palpation. The patient laboratory values were Hb % - 5 gm /dl, platelet count -33000/cmm. Total WBC 8,000/cmm.Urine pregnancy test was found to negative.Pelvic sonogram was performed which revealed uterus 7.2x 5.8x 4.1 cm. The endometrial echo was 1.2 cm thick and no intrauterine pregnancy. The left adenaxa measured 4.5 x 5.6 cm.Gross amount of fluid seen in abdomen. The final sonological impression was ruptured ectopic pregnancy with gross hemoperitoneum. The patient was taken to the operating room with a presumptive diagnosis of a ruptured ectopic pregnancy.Laparoscope done keeping camera port at umblicus. Hemoperitoneum of approximately 2 .5 liters with blood clots in the pelvis was seen.Fallopian tubes, the right ovary and the uterus were normal. A left ovarian cyst size 6x5 cm resembled a corpus luteum with a small rupture with ongoing bleed. Liver was grossly cirrhotic with enlarged spleen.Left ovarian cystectomy was performedachiving excellent homeostasis. The laparoscopic procedure was uneventfull.She was transfused with 2 units of packed red blood cells and 3 packets of platelets. Injection VIT K was supplemented. She was discharged on 4th postoperative day to home in stable condition after taking the opinion from the medical gastroenterologist regarding nodular liver. The histopathology report showed corpus luteum cyst with hemorrhage.
DISCUSSION
Acute lower abdominal pain, dizziness, fainting attack in a reproductive age group with history of amenorrhea, the ectopic pregnancy may be the first provisional diagnosis. A ruptured ovarian cyst can produce massive hemoperitoneum, with clinical symptomatology and son graphic features that closely mimic those of other disorders, in particular ectopic pregnancy. [1] Ovarian hemorrhage from corpus luteum of menstruation or pregnancy can be life threatening surgical condition which occurs at all stages of a woman reproductive life. A corpus luteal cyst predispose to rupture, delay in menses and pregnancy – increase risk of abortion and ectopic pregnancy[2 3] Negative pregnancy test may not exclude ruptured ectopic pregnancy [4].Pelvic sonogram plays a pivotal role in the diagnosis and management of lower abdominal pain in reproductive age group[5]. The sonogram performed by radiologist did not reveal an intrauterine gestational sac and the presence of clots in cul-de-sac fluid was noted. Moreover, it was highly suggestive of ectopic pregnancy in the left adnexa. If the patient is clinically unstable, large amount of free fluid in abdomen and pelvis differentiating between a ruptured ectopic and a ruptured hemorrhagic corpus luteum is unimportant, since in either case laparotomy/laparoscopy is indicated[3] Laparoscopy surgery for diagnosis and treatment of women with ruptured hemorrhagic corpus luteum appears superior to laparotomy [6]. We did diagnostic and then therapeutic procedure for our case. Diagnostic laparoscopy with documentation showed hemorrhagic ovarian cyst, hemoperitoneum and nodular cirrhotic liver. The intraoperative diagnosis changed from ruptured ectopic pregnancy to significant hemorrhage from hemorrhagic ovarian cyst. The massive hemoperitoneum resulted from thrombocytopenia due to nodular cirrhotic liver Review of literature reported rupture of corpus luteal cyst occurred during the secretory phase and most women reported recent sexual intercourse prior to the onset of pain. There have been case reports of luteal cyst rupture with massive hemoperitoneum during dialysis, thrombolytic therapy, patient with Hb SC disease, and patient on anticoagulation therapy.[7,8,9,10] In our patient the past history was nil significant.Luteal cyst rupture with gross hemoperitoneum and the incidental finding of nodular hepatic cirrhosis in laparoscopy not earlier mentioned. Thrombocytopaenia is common finding in patient with sever liver disease. Thrombocytopaenia of less than 30,000 associated with spontaneous bleeding is usually not sen in uncomplicated cirrhosis[11].In the reported case, blood platelet count was significantly decreased to 30,000/cmm with elevated PT and APTT. This deranged coagulation profile was the precipitating factor for massive haemoperitoneum following rupture of luteal cyst.
CONCLUSION
Rupture ectopic and ruptured luteal cyst are the important cause of hemoperitoneum in the reproductive age without history of trauma. In a setting of massive haemoperitoneum intervention is unavoidable but the exact cause/predisposing factor may go unnoticed with convetional approach where seeing a cirhhotic liver is difficult with lower abdominal inscision.Laparoscopy in an otherwise healthy woman may unmask the underlying pathology like liver disease related bleeding derangements and facilitates further management.
Sources of Conflict NIL
ACKNOWLEDGEMENT
Authors acknowledge the great help received from the scholars whose articles cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Authors are grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=1328http://ijcrr.com/article_html.php?did=13281. Hallatt JG, Steele CH Jr, Snyder M. Ruptured corpusluteal cyst with Hemoperitoneum: A study of 173 surgical cases. Am J Obstet Gynecol. 1984 May 1;149(1):5-9
2. Sivanesaratnam V , Singh A, Rachagan SP, Raman S.Intraperitoneal hemorrhage from a ruptured corpus luteum. A cause of acute abdomen. In women med J Aust. 1986 APR 14:144(8):411-4
3. Aggarwala Anjal,Goel Poonam,Wanchu Madhavi,Malhotra Rimpy,Malhotra sarala.Ruptured corpus luteum with hemoperitoneum.Journal obst and gynaecology india 2004:54:488-90
4. Yi-An A,Gino Farina, halene Lhamon.Ruptured ectopic pregnancy with a negative urine pregnancy test. The journal of urgent care medicine 2007:26-28
5. Lawrence A Cicchiello, Ulrike M Hamper, Leslie M Scoutt ultrasound evaluation of gynecologic causes of pelvic pain. Obstet Gynecol Clin North Am 2011 Mar ;38 (1):85-114, Teng SW, Tseng JY, Chang CK, Li CT, Chen YJ, Wang PH Comparison of laparoscopy and laparotomy in managing hemodynamically
6. stable patients with ruptured corpus luteum with hemoperitoneum. J Am Assoc Gynecol laparoscope 2003 Nov;10(4):474-7
7. Muller CH, Zimmermann K, Bettex HJ. Near-fatal intra-abdominal bleeding from a ruptured follicle during thrombolytic therapy. Lancet Jun 15 1996;347(9016):1697. [Medline].
8. Gupta N, Dadhwal V, Deka D, Jain SK, Mittal S. Corpus luteum hemorrhage: rare complication of congenital and acquired coagulation abnormalities. J Obstet Gynaecol Res Jun 2007;33(3):376- 80.[Medline].
9. V. Andikyan, J. Ronald, C. Bowers. Massive hemoperitoneum secondary to ruptured corpus luteum cyst of pregnancy in 17-year old female with Hemoglobin SC disease. The Internet Journal of Gynecology and Obstetrics 2010;12 Number 2:351
10. Fraley DS, Johnston JR, Bruns FJ, Adler S, Segel DP. Rupture of ovarian cyst: massive hemoperitoneum in continuous ambulatory peritoneal dialysis patients: diagnosis and treatment.Am J Kidney Dis. 1988 Jul;12(1):69-71.
11. Ahmadhameed, Samina Naeem, A. Saeed Shaikah Irfan Khursheed,Ambreen Hamid,I.A Naveed. An Assessment Of Coagulation Parameters In Liver Cirrhosis medica/Biomedica
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241511EnglishN2013June18HealthcareA STUDY OF BRANCHING PATTERN OF THE LATERAL CORD OF THE BRACHIAL PLEXU
English123131Prathap K.J.English Radhika P.M.English Jyothi K.C.English Shailaja ShettyEnglish Poonam D.N.EnglishBackground: The anatomical variations in different parts of the brachial plexus have been described in the literature. The knowledge of anatomical variations of brachial plexus is essential because these nerves could be injured during the surgical procedures. The present study is aimed at assessing the branching pattern of the lateral cord of brachial plexus. Materials and Methods: The present descriptive study was carried out by dissecting 50 upper limbs in 25 cadavers during the study period of two years in the department of anatomy, M.S.Ramaiah Medical College, Bangalore. The formation and the branching pattern of the lateral cord were studied, any variations found were noted and photographs were taken. Observation and Results: Out of 50 upper limbs studied, fusion of ventral division of all the three trunks was detected in 1 limb (2%); variations in branches of lateral cord were detected in 5 limbs (10%). In the remaining limbs there was normal formation and branching of lateral cord was seen. Conclusion: The knowledge of branching pattern of the lateral cord of brachial plexus is of important not only to the anatomist, but also to the anesthetists, orthopaedician , neurosurgeons, plastic and reconstructive surgeons during surgical procedures involving the axilla in order to prevent inadvertent injuries.
Englishbrachial plexus, lateral cord variation, musculocutaneous nerve, axillary surgery.INTRODUCTION
Contrary to what might be expected, variations of the brachial plexus are not very uncommon. It has been reported in the literatures that the variations in the brachial plexus are found in its formation, along its course and in its branching pattern in around 13% of cadavers1 . Brachial plexus is formed by a complex process of union, separation, reunion and finally reseparation of nerve fibres on their way to their destiny. This intricate anastomosing and separation of the brachial plexus is because of neuronal sorting2 . Brachial plexus is formed by the union of the ventral rami of the lower four cervical nerves (C5, C6, C7, and C8) and the greater part of first thoracic nerve (T1). It supplies the muscles of the pectoral girdle and upper limb. The C5 and C6 roots fuse to form the upper trunk, the C7 root continues as the middle trunk and the C8 and T1 roots join to form the lower trunk. Each trunk, soon after its formation, divides into anterior and posterior divisions. The anterior divisions of the upper and middle trunks joins to form the lateral cord, the anterior division of the lower trunk continues as the medial cord and the posterior divisions of all the three trunks joins to form the posterior cord. The various branches from these cords supply the upper limb. The lateral cord gives three branches: a) the lateral pectoral nerve b) musculocutaneous nerve and c) the lateral root of the median nerve3 .
Knowledge of branching pattern of lateral cord of brachial plexus and its variations is important because these variants are of significance for the surgeons to prevent inadvertent injuries during surgical procedures like radical neck dissection, surgical exploration of axilla and arm. The present study was taken to note the variations present in the branching pattern of the lateral cord of the brachial plexus. Further, an attempt was made to discuss these variations and their clinical significance.
MATERIALS AND METHODS
The material for the present study comprised of 50 upper limbs which belonged to 25 adult human cadavers, which were obtained from the Department of Anatomy, M.S.Ramaiah Medical College, Bangalore. The brachial plexus was dissected and exposed according to the methods described by G.J. Romanes in Cunningham’s Manual of Practical Anatomy4 . The trunks, divisions, cord, branches were observed and any variations found were noted and photographed.
OBSERVATIONS
1. Formation of Lateral cord: In 49(98%) limbs, the lateral cord was formed in the normal pattern i.e, by the union of the ventral divisions of the upper and middle trunk (C5 C6 and C7). In one of the limb, ventral division of all the 3 trunks joined to form the lateral cord (C5 to T1).Fig1
2. The Branching Pattern The normal branching pattern of the lateral cord was encountered in 45 (90%) limbs, in the remaining 5limbs (10%) being variants in one form or the other. (Vide infra) (i) The lateral pectoral nerve The lateral pectoral nerve was seen to arise normally from the lateral cord in 49/50(98%) limbs. In one of the limb1/50(2%) it was arising from the median nerve (undivided lateral cord).Fig 2
(ii) The Musculocutaneous nerve (MCN) The MCN depicted a normal origin from lateral cord in 48/50(98%) limbs. MCN was absent in two cases. In one of the limb the muscles of anterior compartment of arm were supplied by an additional lateral root of median nerve (LRMN2) and median nerve. LRMN2 gave a branch to coracobrachialis and Median nerve gave the innervations to Biceps Brachii, Brachialis muscles and also gave Lateral cutaneous nerve of forearm. Fig 3. While in the other limb all the muscles of anterior compartment of arm were solely supplied by the median nerve. Fig 2.
The communication between the Musculocutaneous nerve and the median nerve were observed in three cases – In one of the limb, the fibers of the lateral root of Median nerve passed through the Musculocutaneous nerve and join the median nerve (MN) in the middle of the arm by a communicating Branch - Fig 4 While in two specimens, the lateral root fibers of Median nerve passed along the musculocutaneous nerve and after some distance separated from it to form the lateral root of median nerve - Fig 5
(c)Lateral Root of Median Nerve (LRMN): The lateral root of median nerve depicted a normal origin from lateral cord in 47/50(96%) limbs. In one of the limb there were two lateral roots of median nerve. In other limb there was no lateral root of median nerve (undivided lateral cord). In another limb, the median nerve was formed by three roots: one from lateral root, one from medial root and one from musculocutaneous nerve. So the total number of variations detected in formation and branching pattern of lateral cord was 6/50(12%).
DISCUSSION
The lateral cord is formed by the union of anterior division of upper and middle trunk of brachial plexus. Hence the lateral cord contains the fibers from fourth, fifth, sixth and seventh cervical ventral rami3, 5, 6 . The lateral cord gives three branches a) the lateral pectoral nerve b) musculocutaneous nerve and c) the lateral root of the median nerve. The lateral pectoral nerve supplies the pectoralis major muscle. The musculocutaneous nerve is a mixed nerve; it supplies coracobrachialis, biceps brachii and the brachialis muscles in the anterior compartment of the arm and then continues as the lateral cutaneous nerve of the forearm. The lateral root joins the medial root of the medial cord to form the Median nerve, which lies in front of third part of the axillary artery 3, 5, 6 . In the present study, the lateral pectoral nerve was arising from the median nerve in one of the limb 1/50(2%).Fig 2. It has been noted that variations in the MCN are quite common. It may be absent, short or doubled. Normally the MCN emerges from the lateral cord, but in some cases it arises from the lateral and posterior cord or from median nerve2 . In the present study, we observed the absence of MCN in 2/50 (4%) limbs. The present study is compared with previous authors who have reported the similar kind of variations (Table 1).
Venieratos and Anagnostopoulou have classified the communication between MCN and MN into 3 types considering the coracobrachialis muscle as the reference point. Type I: the communication was proximal to the entrance of the musculocutaneous nerve in to the muscle. Type II: the communication was distal to the muscle. Type III: the nerve and the communicating branch did not pierce the muscle12 . The variations observed in the present study were compared to Venieratos and Anagnostopoulou classification. The communication between the Musculocutaneous nerve and Median nerve were observed in three specimens- Table 3.
Type I: No communication between median nerve and musculocutaneous nerve. Type II: The fibres of lateral root of median nerve pass through the musculocutaneous nerve and join the median nerve in the middle of the arm. Type III: The fibres of lateral root of median nerve pass along the musculocutaneous nerve and after some distance leave it to form the lateral root of median nerve. Type IV: The musculocutaneous fibres join the lateral root of the median nerve and after Some distance musculocutaneous nerve arises from the median nerve. Type V: The musculocutaneous nerve is absent and the entire fibres of musculocutaneous nerve pass through the lateral root and fibres to the muscles supplied by musculocutaneous nerve branch out directly from the median nerve. The variations observed in the present study were compared to Le Minor’s classification.
These communications are due to the errors in the course of some inappropriately placed nerve fibers. These nerve fibers in order to get to their proper destiny, the bundle of nerves fibers leave the inappropriate nerve trunk and join the proper nerve trunk. So this hitch hiking course of the nerve fibres of lateral cord may be nature’s way of correction to find its appropriate destination2 .
EMBRYOLOGICAL SIGNIFICANCE
To understand the variations in the branching pattern of the lateral cord a thorough knowledge of the development and innervations of upper limb musculature is required. Muscles of the limbs are derived from somites opposite the developing limb buds. Somites have a specific effect on the position of the developing spinal nerves, which preferentially grow through the cranial half of sclerotome of somite. Spinal nerves are derived from two different sources, the neural crest give rise to sensory component and the neural tube give rise to motor component of spinal nerve14 . These nerves are in intimate contact with the differentiating mesenchyme that forms a myotome mass of limb bud which is a prerequisite for their complete functional differentiation15 . Later, there is a caudal migration of the developing upper limb bud and intrinsic migration of its individual muscles which leads to the modification of the primitive segmental arrangement of the nerves entering the limb buds resulting in the formation of plexus16 . These developing axons are guided by expression of chemoattractants and chemorepulsants regulators in a highly coordinated manner14. Misexpression of any of viz. N-CAM, L1 and Cadherins signalling molecules between mesenchymal cells and neuronal growth cones can lead to variation in the formation and distribution of particular nerve fibres. Once formed, these variations would persist postnatally17. It has also been stated that “The growth as well as the pathfinding of nerve fibres towards the target is dependent upon concentration gradient of a group of cell surface receptors in the environment”18 . Variation of nerves can be the one of the cause of a nerve palsy syndrome due to its different relationship with the surrounding structure. Descriptions of the normal and variations of the course and distribution of the lateral cord of brachial plexus are important to the anaesthetist while performing nerve block procedures of infraclavicular part of the brachial plexus. The knowledge of variation in the lateral cord of brachial plexus is of immense importance for the following: 1. For neurosurgeons for treating tumors of nerve sheaths such as schwannomas, neurofibroma and non neuronal tumors like lipoma, also while dealing with patients of nerve entrapment syndromes of the upper limb and while performing neurolization of the brachial plexus lesions. 2. For orthopaedician operating on cervical spine, shoulder arthroscopy by anterior glenohumoral portal and shoulder reconstructive surgery. Knowledge of such anomalies is also important during treatment of fractures, during internal fixation of humeral fracture from common anterior approach to avoid injury to these nerves. 3. For surgeons during surgical procedures of the axilla and the shoulder, a surgeon is exposed to the topographical anatomy of the neural structures and awareness of such variations may be of immense clinical help. 4. For plastic surgeons while performing myocutaneous flap surgeries8,10,14,19 .
CONCLUSION
The knowledge of variations in brachial plexus anatomy should be kept in mind by not only anatomists but also to the anesthetist, neurosurgeons, orthopedicians, plastic and reconstructive surgeons. These variations have recently become significant because of newer imaging techniques such as computed tomography and magnetic resonance imaging in the field of diagnostic medicine.
ACKNOWLEDGEMENTS
Authors acknowledge the immense help received from Mr. K. Youvaraj, in drawing line diagram and editing the photos in this article. 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.
Englishhttp://ijcrr.com/abstract.php?article_id=1329http://ijcrr.com/article_html.php?did=13291. Fregnani JH, Macéa MI, Pereira CS, Barros MD, Macéa JR. Absence of the musculocutaneous nerve: a rare anatomical variation with possible clinical-surgical implications. Sao Paulo Med J.2008 Sep;126(5):288-90.
2. Bergman RA, Afifi AK, Miyauchi R. Opus III: Nervous System: Alphabetical Listing of Nervous system: M, Musculocutaneous nerve. In: Bergman RA, Afifi AF, Miyauchi R, editors. Illustrated Encyclopedia of Human Anatomic Variation. Available from: URL: http://www.anatomyatlases.org/AnatomicV ariants/NervousSystem/Text/Musculocutan eousNerve.shtml
3. Johnson D, Ellis H. Pectoral girdle and upper limb. In: Susan standring, editor. Gray’s anatomy. 39th edn. Edinburgh: Elsevier Churchill Livingstone; 2005. p 877
4. G.J.Romanes,Cunningham's Manual of Practical Anatomy, upper and lower limbs,15th edn.Vol 1, Oxford medical publications 2008, 28-30
5. R.J.Last, Anatomy Regional and Applied, 7 th edn,ELBS, Churchill Livingstone, 1984, 63-65
6. Richard S Snell. Clinical anatomy by regions, 8th edn, 2008, Lippincott Williams and wilkins, Baltimore, 446-450.
7. Rao PV, Chaudhary SC. Absence of musculocutaneous nerves: Two case reports. Clin Anat 2001; 14:31-35.
8. Pattanshetti SV, Jevoor PS, Shirol VS, Dixit D, Bhimalli S. A study of the formation and branching pattern of brachial plexus and its variations in adult human cadavers of north Karnataka. J Sci Soc 2012;39:70-77
9. V Budhiraja, R Rastogi, A K Asthana, P Sinha, A Krishna, V Trivedi. Concurrent variations of median and musculocutaneous nerves and their clinical correlation – a cadaveric study. IJAE 2011;116(2): 67-72.
10. Malukar O, Rathva A. A Study of 100 Cases of Brachial Plexus, National Journal Of Community Medicine. 2011; 2 (1):166- 170.
11. Remya k, Krishnamurthy A, Kavitha k. Communication between the musculocutaneous and median nerve : occurrence on both sides. Nujhs. 2011, 1(4): 55-56.
12. Venieratos D, Anagnostopoulou S. Classification of communications between the musculocutaneous and median nerves. Clin Anat 1998;11: 327–331.
13. Le Minor, J.M. (1992) : A rare variant of the median and musculocutaneous nerve in man. Archieves Anatomy Histology Embryology. 73 : 33 – 42.
14. Abhaya, A; Khanna J. and Prakash R Variation of the Lateral Cord of Brachial Plexus Piercing Coracobrachialis Muscle. J Anat. Soc. India. 2003; 52(2):168-170
15. Saddler TW - Langman’s Medical Embryology. In: Muscular system. 10th ed. Philadelphia Lippincott Williams & Wilkins, 2006: 146-47.).
16. Moore KL, Persuad TVN. The Developing Human. Clinically Oriented Embryology. 8th Ed., New Delhi, Elsevier. 2009; 365– 371.
17. Satyanarayana N, Sunitha P, Arul moli R, Chandralekha G, Ravindranath G.Unusual variation of the lateral cord of brachial plexus and absent musculocutaneous nervea case report. IOSR Journal of Pharmacy (IOSRPHR) 2012;2(4):23-25.
18. Williams PL, Bannister LH, Berry MM, Collins P, Dyson M, Dussek JE et al - Gray’s Anatomy. In: Embryology and development. 38th ed. London Churchill Livingstone, 1999: 231-32
19. Gupta C, D’Souza AS, Shetty P, Vidya P, Arunashri. A morphological study to note the anatomical variations in the branching pattern of the lateral cord of the brachial plexus. J. Morphol. Sci. 2011;28(3):161- 164.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241511EnglishN2013June18HealthcareESTIMATION OF TIME SINCE DEATH BY GASTRIC CONTENTS
English132136Viras PatelEnglish Dharmesh SilajiyaEnglish Kalpesh ShahEnglish Anand MenatEnglish Mehul TandelEnglish Sandip RalotiEnglishThe time of death estimation plays important role in solving both criminal and civil cases. The inspection of the gastric contents must be part of every postmortem examination because if the time of taking last meal is known, the approximate time of death can be made out indirectly. The rate of gastric emptying varies in man from 2.5 to 6 hours. The length of time required to empty the stomach is variable as it depends upon a host of factors like nature and consistency of food, motility of stomach, contents, environment, emotional/psychological factors and residual variations. The aim of this study is to determine approximate time of death by examination of gastric contents in deceased body brought to mortuary at Civil Hospital Ahmedabad, Gujarat. Present study was conducted on total 100 deceased persons (70 males and 30 females) whose time of death and time of last meal were known. Gastric contents were examined and divided in three categories; semi-digested identifiable food particles, semi-digested un-identifiable food particles, empty stomach. These findings were compared with time interval between last meal and time of death. In present study the identifiable semi-digested food particle were found more commonly in those persons who died 0-2 hours after last meal, un-identifiable semi-digested food particle were found more commonly in those persons who died 2-6 hours after last meal and empty stomach were found more commonly in those persons who died more than 6 hours after last meal. From present study we conclude that indirect estimation of time since death can be possible from examination of gastric content but due to variability of gastric emptying in different individuals we can’t exactly define time since death.
EnglishGastric contents, Gastric emptying, Identifiable food particles, Un-identifiable food particles, Indirect estimation of time since death.INTRODUCTION
It is very important from medico-legal point of view that a medical jurist should always be prepared to give an opinion as to the time which elapsed since death, when a body is brought to him for post-mortem examination1 and it is also plays important role in solving both criminal and civil cases2 . The point to be noted in ascertaining the time are warmth or cooling of the body, the absence or presence of cadaveric hypostasis, rigor mortis and the progress of decomposition. All these point discussed at full length in every Forensic Textbook, but it must be remembered that the conditions producing these changes vary so much in each individual case, that only very approximate time of death can be given. In addition to these, the time of death can be ascertained to some extent from the contents of stomach bladder and the intestines.1 The original hypothesis was founded on belief that food spent a fairly uniform time in a stomach before being released into the duodenum.3 The rate of gastric emptying varies in man from 2.5 to 6 hours.1 If the time of taking last meal (quantity as well as quality) is known, the approximate time of death can be made-out indirectly. The length of time required to empty the stomach is variable as it depends upon a host of factor like nature and consistency of food, motility of stomach, contents, environment, emotional /psychological factors and residual variations.4
AIM OF STUDY
To determine approximate time of death by naked eye examination of gastric contents of the deceased body.
MATERIAL AND METHODS
Present study was conducted on total 100 deceased persons (70 males and 30 females) brought to mortuary at Civil Hospital Ahmedabad, Gujarat. The present study includes the cases whose time of death and time of last meal were known. The included subjects were mostly the cases of sudden death (Accidental spot death, Myocardial infarction, etc.) and; the other cases whose time of death and time of last meal were not known excluded from this study. For examine the gastric contents; the stomach was removed after applying double ligatures at each end, and was placed in clean dish. It was opened along its greater curvature, from cardiac to pyloric end, then gastric contents examined.5 After examined, contains divided in three categories; category I: semi-digested identifiable food particles, category II: semi-digested unidentifiable food particles and category III: empty stomach. These findings were compared with time interval between last meal and time of death.
RESULTS
Amongst 100 deceased bodies studied, Category I gastric contents (semi-digested identifiable food particles) was found in 19 cases out of which 16 cases had taken their last meal about 0 to 2 hours before death, 2 cases had taken 2 to 4 hours before, 1 case had taken 4 to 6 hours before and no one had taken last meal more than 6 hours before death. Category II gastric contents (semi-digested unidentifiable food particles) was found in 53 cases out of which 7 cases had taken their last meal about 0 to 2 hours before death, 26 cases had taken 2 to 4 hours before, 14 case had taken 4 to 6 hours before and 6 cases had taken last meal more than 6 hours before death. Category III gastric contents (empty stomach) was found in 28 cases out of which 0 cases had taken their last meal about 0 to 2 hours before death, 1 cases had taken 2 to 4 hours before, 4 case had taken 4 to 6 hours before and 29 cases had taken last meal more than 6 hours before death.
DISCUSSION
The examination of gastric contents is an essential component of a forensic autopsy and discovery of pathology, or evidence, of the ingestion of drugs and poisons is of obvious significance. The identification of the last meal is also of recognized value, but the use of this observation to estimate the time interval between the eating of the last meal and death is a more controversial area, particularly when it is used to calculate the time of death from the time of a known last meal.6 The medical examiner can often use the contents of the victim’s stomach to help determine time of death.7 However, the rate of emptying of stomach varies in healthy persons. The emptying of stomach depends on the: consistency of food, motility of the stomach, osmotic pressure of the stomach contents, quantity of food in the duodenum, surroundings in which food is taken, emotional factors and residual variations.1
A carbohydrate meal leaves the stomach more rapidly than a protein meal, because carbohydrates are reduced to a semi-fluids state rapidly and a protein meal leaves the stomach more rapidly than fatty meal. Fluids and semi-fluids leave the stomach very rapidly (within 2 hours), after being swallowed. If water is ingested with solid meal, the water is emptied rapidly and separately and is not influenced by either the weight/total calories of the accompanying solid meal. Milk leaves rapidly, whereas meat and pulses are retained longer.8 ‘dals’ usually retain their form up to 2 hours and ‘rice’ grains up to3 hours.4 According to Pekka Saukko and Bernard Knight3 (2004) the physiological process of digestion of an ‘average’ meal lasted some 2 to 3 hours, Modi1 (2011) gives 2.5 to 6 hours in man. Adelson9 (1974) stated that stomach begins to empty within 10 minutes of swallowing, that a light meal leaves the stomach by two hours, heavy meal takes 4-6 hours. All these values, however, are subject to considerable variation. Stomach contains which are identifiable by naked eye are usually ingested within two hours period.8 If a victim’s stomach contains largely undigested food material, then the death likely occurred within an hour or two of the meal. If the stomach is empty, the death likely occurred more than four hours after eating.7 In present study among gastric contents of 100 deceased persons (70 males and 30 females) examined: semi-digested identifiable food particles were found more commonly in those persons who died 0-2 hours after last meal, semi-digested un-identifiable food particles were found more commonly in those who died 2-6 hours after last meal and empty stomach were found more commonly in those who died more than 6 hours after last meal.
CONCLUSION
If the medical examiner can find out through witness statements when the last meal was consumed, he can use this to determine the time of death. If a man is found dead in a hotel room and the medical examiner determines that his stomach is full of undigested identifiable food materials. If he had dinner with a business associate from 9 to 10 pm, then returned to his room, the finding of gastric contents would indicate that the death occurred shortly after he returned to his room. The medical examiner might place the time of death between 10 pm and midnight. These calculations depend on a number of factors. Heavy meals and those rich in protein and fat digest more slowly than do small meals and those high in carbohydrates, sugars and liquids. The consumption of alcohol or many sedative and narcotic drugs, as well as some medical conditions, tend to slow digestion and gastric emptying, while other drugs and medical conditions hasten these processes. Also, there is great individual variation in rate of digestion. Therefore, gastric contents are of marginal help in time of death determination. To elaborate this study, individual can do this study on the new way with the help of exact time of death, exact quantity and quality of last food, intestinal contents, history of man who died, etc. So from this study we can calculate approximate time of death indirectly by examine gastric content but due to various factors affecting gastric emptying in different individuals we can’t define exact time of death. This may use as support to other procedure to estimate time since death.
ACKNOWLEDGEMENT
Authors acknowledge the great help received from the scholars whose articles cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Authors are grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=1330http://ijcrr.com/article_html.php?did=13301. Justice K Kannan, Dr K Mathiharan, Modi’s textbook of medical jurisprudence and toxicology, 24th ed, 2011: 14; 354.
2. Jatti, Vijaya Kumar B., Dharmaraya Ingale, and Chandrashekhar Karpoor. "Estimation of time since death by gastric contents: An overview." Indian Journal of Forensic Medicine andToxicology 4.2 (2010).
3. Saukko, P., and B. Knight. "The pathophysiology of death." Knight’s forensic pathology. 3rd ed. London: Edward Arnold (2004): 83.
4. Vij, Krishan. Textbook of Forensic Medicine and Toxicology: Principles and Practice, 5/e. Elsevier India, 2008: 94.
5. Reddy, K. S. "The essentials of forensic medicine and toxicology." Journal of Punjab Academy of Forensic Medicine and Toxicology 31st ed; (2012): 5; 103.
6. Horowitz, M., and D. J. Pounder. "Is the stomach a useful forensic clock." Australian and New Zealand journal of medicine 15.2 (1985): 273-276.
7. Lyle, D. P. Howdunit Forensics. Writer's Digest Books, 2008. Chapter 5.
8. Reddy, K. S. "The essentials of forensic medicine and toxicology." Journal of Punjab Academy of Forensic Medicine and Toxicology 31st ed; (2012): 7; 163.
9. Adelson, Lester. "The pathology of homicide." Springfield, IL: Charles C. Thomas (1974): 188-318.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241511EnglishN2013June18HealthcareUNILATERAL HIGHER TRIFURCATION OF BRACHIAL ARTERY- A CASE REPORT
English137139B.M. BannurEnglish Sahana B.N.English G A HadimaniEnglish B.G. PatilEnglishIntroduction: The brachial artery is the principal artery of the arm. Variations in course and branching patterns of brachial artery are important for physicians, plastic and vascular surgeons and radiologists. Case Report: In the present case, unilateral trifurcation of brachial artery into radial, ulnar and superior ulnar collateral artery was observed in the right upper limb of an adult female cadaver. Conclusion: Our case appears to be unique in that the brachial artery was trifurcating at a higher level into ulnar, radial and superior ulnar collateral arteries. Health specialists must be aware of the possible variations of the brachial artery as it has several clinical applications.
EnglishTrifurcation, Brachial artery, Superior ulnar collateral artery.INTRODUCTION
Arteries are muscular and or elastic cylindrical tubes that conduct blood away from the heart. Arteries emit terminal and collateral branches. Terminal branches appear when the main artery divides and no longer exists, for instance, as the brachial artery divides into the radial and ulnar arteries. Collateral branches occur when the main artery gives off other vessels but still continues ahead as the same vessel1 . The brachial artery is the principal artery of the arm. It is a continuation of the axillary artery, begins at the distal (inferior) border of the tendon of teres major and ends about a centimetre distal to the elbow joint (at the level of the neck of the radius) by dividing into radial and ulnar arteries2 . At first it lies medial to the humerus, but gradually spirals anterior to it until it lies midway between humeral epicondyles. It is superficial in its course and is related to important nerves; median, ulnar and radial nerves3 . Collateral branches of brachial artery are profunda brachii, nutrient, superior, middle and inferior ulnar collateral, deltoid and muscular arteries. Radial and ulnar arteries are the terminal branches. One of the several clinical applications of the brachial artery, besides blood pressure monitoring and arterial puncture for gasometry, is the measure of its flow mediated dilation (FMD). Another invasive procedure using brachial artery is ventriculography, when femoral access is not possible1 . Hence, the awareness of the variations in course and branching patterns of brachial artery are important for physicians, plastic and vascular surgeons and radiologists.
CASE REPORT
Unilateral trifurcation of brachial artery was observed during routine dissection of an adult female cadaver in the dissection hall of anatomy department, Shri B M Patil Medical College, Bijapur. In this case it was observed that in the right upper limb the brachial artery divided into radial, ulnar and superior ulnar collateral artery in the middle third of the arm. The part of the brachial artery proximal to this division gave origin to the profunda brachii artery and the branches to the neighbouring muscles. The radial artery so formed had a superficial course in the arm and crossed the median nerve few centimetres below its formation to the lateral side of arm. It then entered the cubital fossa and ran deep to the brachioradialis where it gave off the radial recurrent artery before continuing into the forearm. The main trunk of brachial artery continued down superficially as the ulnar artery and was crossed by the median nerve from lateral to medial side in the arm just before entering the cubital fossa. The inferior ulnar collateral artery began 4 cm proximal to the elbow from this ulnar artery. In the cubital fossa it was deep to the deep head of pronator teres and gave off the common interosseous artery and continued into the forearm. The superior ulnar collateral artery normally arises a little distal to the mid-level of the upper arm from the brachial artery. But in our case it began at a little higher level along with the ulnar and radial artery. It accompanied the ulnar nerve and had a normal course in the arm.
DISCUSSION
Variations in the arterial patterns of upper limb in adult human body have been frequently observed either in routine dissections or in clinical practice4 and have been reported by several authors. Our case appears to be unique in that the brachial artery was trifurcating at a higher level into ulnar, radial and superior ulnar collateral arteries whereas the cases reported earlier are mostly related with higher bifurcation of brachial artery into radial and ulnar artery or trifurcation of brachial artery into ulnar, radial and radial recurrent or common interosseous artery. In 2012 Shewale SN et al reported a case of unilateral bifurcation of brachial artery at its commencement into radial and ulnar artery in a male cadaver5 .
In 2011C K Reddy et al reported bilateral trifurcation of brachial artery in an adult female cadaver into radial, ulnar and common interosseous artery near the neck of the radius6 . In 2010 Harbans Singh et al reported a case of higher bifurcation of brachial artery 7.5 cm above the cubital fossa with superficial course of radial artery in forearm in the right upper limb of an adult male cadaver4 . In 2002 Patnaik et stated that there were 26% variations in the branching pattern of brachial artery in a study done on 50 upper limbs but only one case of trifurcation of brachial artery was reported7 . In 2001 Patnaik et al reported a case of unilateral trifurcation of brachial artery in a male cadaver into radial, ulnar and radial recurrent artery near the neck of radius8 .
CONCLUSION
Anatomical variations are quite common, due to the several influences during human body formation. Health specialists must be aware of the possible variations of the brachial artery.
The present variation may cause difficulties in recording blood pressure.
These arteries may be injured during orthopaedic and plastic surgeries.
Being superficial, (i) they may be mistaken for a vein and (ii) are more susceptible to trauma and thus bleeding.
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/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=1331http://ijcrr.com/article_html.php?did=13311. Rossi Junior WC, Esteves A, Simões JS, Fernandes GJM. Bilateral high division of the brachial artery in one human male cadaver: case report. J. Morphol Sci 2011; 28(3):204- 7.
2. Standring S. Upper arm. In: Standring S, editor. Gray's Anatomy, 39th ed. Churchill Livingston: Elsevier; 2005.p.856.
3. Vandana R, Suresh NM et al.Variation in course and branching pattern of brachial artery. Anatomica Karnataka 2012;6(3):42-8.
4. Singh H, Gupta N, Bargotra RN, Singh NP. Higher bifurcation of brachial artery with superficial course of radial artery in forearm. JK Science 2010;12(1):39-40.
5. Shewale SN, Sukre SB, Diwan CV. Bifurcation of brachial artery at its commencement- A case report. Biomedical research 2012;23(3):453-6.
6. Reddy CK, Syed NA, Phukon MJ, Dutta R. Bilateral trifurcation of brachial artery- A case report. Int Biol Med Res 2011;2(4):1193-4.
7. Patnaik et al. Branching pattern of brachial artery- A morphological study. J Anat. Soc. India 2002;51(2):176-86.
8. Patnaik VVG, Kalsey G et al. Trifurcation of brachial artery- A case report. J Anat. Soc. India 2001;50(2):163-5.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241511EnglishN2013June18HealthcareANATOMICAL VARIATION OF THE ORIGIN OF THE LEFT VERTEBRAL ARTERY A CASE REPORT
English140143Vikram N.English M.B. PatilEnglish Basavaraj B.English Y.D. BadigerEnglishIntroduction : The vertebral arteries begin in the root of the neck as the first branches from the supero-posterior aspect of the subclavian arteries. The vertebral arteries ascend the neck to enter the cranial cavity to supply blood to the brain. The two vertebral arteries are usually unequal in size; the left isfrequently larger than right one. Case Report: During an anatomy dissection, an anatomical variation of the origin of the left vertebral artery was observed in a 77-year-old male cadaver. . The aortic arch was giving origin to the left vertebral artery (6 mm in diameter), which was located between the origins of the left common carotid and left subclavian arteries. No other congenital variations were found. The left vertebral artery in our case enters the third cervical foramen transversarium. Conclusion : The anatomic and morphologic variations of the left vertebral artery are significant for diagnostic and surgical procedures in the head and neck region. It is of clinical importance to know the origin and course of prevertebral segment of the vertebral artery in detail and being aware of the possible variations to prevent complications.
EnglishINTRODUCTION
The vertebral arteries begin in the root of the neck as the first branches from the superoposterior aspect of the subclavian arteries. The vertebral arteries ascend the neck to enter the cranial cavity to supply blood to the brain. The two vertebral arteries are usually unequal in size; the left is frequently larger than right one 1 . The vertebral arteries pass through the foramina transversaria of the first six cervical vertebrae on both sides, penetrate the posterior atlanto-occipital membrane and enter the cranial cavity through the foramen magnum. Vertebral arteries unite at the caudal border of the pons to form unpaired basilar artery. This vessel courses along the ventral aspect of the brainstem 2–4 . The different variations of the branches arising from the arch of aorta are well known and documented by several authors 5 .
We discussed, observed and compared our finding to the literature and came to the conclusion, that we found an anatomical variation of the origin of the left vertebral artery. A few pictures of the structures in the superior mediastinum were taken with all branches of the arch of the aorta, including anatomical variation of the origin of the left vertebral artery’s anatomy (Figure 2). In our cadaver, the arch of aorta had four branches arising from its superior surface. The aortic arch was giving origin to the left vertebral artery (6 mm in diameter), which was located between the origins of the left common carotid and left subclavian arteries. No other congenital variations were found. The left vertebral artery in our case enters the third cervical foramen transversarium (Figure 2).
DISCUSSION
In the typical pattern three branches arise from the arch of aorta and they are: brachiocephalic trunk, left common carotid artery and left subclavian artery. However, in approximately 6% of the population the left vertebral artery arises from the arch of aorta, usually between left common carotid and left subclavian artery 6 . The right vertebral artery can arise from the first part of the right subclavian artery (1% cases), directly from the arch of aorta (3%), from right common carotid artery or from brachiocephalic trunk 7 . The left vertebral artery may arise directly from the left common carotid artery, from the root of the left subclavian artery, and may arise from the arch of aorta. According to few research studies the frequency of origin of the left vertebral artery from the aortic arch was 5.6% 8 . The left vertebral artery can enter the foramina transversaria in the second true seventh cervical vertebra. The left vertebral artery usually enters the sixth cervical foramina transversaria (88%), only in 5–7% cases the left vertebral artery will enter seventh or fifth cervical vertebra 7 . The present case discusses discovering the origin of the left vertebral artery arising from the upper surface of the arch of aorta and it was located between the origins of the left common carotid and left subclavian arteries. In cases where the left vertebral artery arises from the arch of the aorta between the left common carotid artery and the left subclavian artery, it generally enters the foramen transversarium of C4–C5 rather than C6 . We found the atypical branching of the arch of aorta, and there were no other variations or anomalies found. The left vertebral artery in our case entered C3 foramen transversarium. According to the literature, most patients with anatomic variation of the left vertebral artery are clinically asymptomatic. Some patients complained of dizziness, but this was thought to have no association to the anomalous origin of the left vertebral artery. The most important benefit of detecting variations in the origin of the left vertebral artery and other arteries is diagnostic improvements before vascular surgeries of supraaortic arteries. The knowledge of potential left vertebral artery origin variants is necessary
CASE REPORT
During an anatomy dissection, an anatomical variation of the origin of the left vertebral artery was observed in a 77-year-old male cadaver. The thoracic cavity was opened and structures in the superior mediastinum were dissected. We observed all the branches of the arch of aorta, starting from right to left; first branch on the right side located in the superior mediastinum was the brachiocephalic trunk with two branches –right common carotid artery and right subclavian artery. The second branch we found was the left common carotid artery and the third branch was the left subclavian artery. These branches coursed to the left. Between previously mentioned arteries on the left side, we observed an additional branch arising from the arch of aorta. (Figure 1)
DISCUSSION In the typical pattern three branches arise from the arch of aorta and they are: brachiocephalic trunk, left common carotid artery and left subclavian artery. However, in approximately 6% of the population the left vertebral artery arises from the arch of aorta, usually between left common carotid and left subclavian artery 6 . The right vertebral artery can arise from the first part of the right subclavian artery (1% cases), directly from the arch of aorta (3%), from right common carotid artery or from brachiocephalic trunk 7 . The left vertebral artery may arise directly from the left common carotid artery, from the root of the left subclavian artery, and may arise from the arch of aorta. According to few research studies the frequency of origin of the left vertebral artery from the aortic arch was 5.6% 8 . The left vertebral artery can enter the foramina transversaria in the second true seventh cervical vertebra. The left vertebral artery usually enters the sixth cervical foramina transversaria (88%), only in 5–7% cases the left vertebral artery will enter seventh or fifth cervical vertebra 7 . The present case discusses discovering the origin of the left vertebral artery arising from the upper surface of the arch of aorta and it was located between the origins of the left common carotid and left subclavian arteries. In cases where the left vertebral artery arises from the arch of the aorta between the left common carotid artery and the left subclavian artery, it generally enters the foramen transversarium of C4–C5 rather than C6 . We found the atypical branching of the arch of aorta, and there were no other variations or anomalies found. The left vertebral artery in our case entered C3 foramen transversarium. According to the literature, most patients with anatomic variation of the left vertebral artery are clinically asymptomatic. Some patients complained of dizziness, but this was thought to have no association to the anomalous origin of the left vertebral artery. The most important benefit of detecting variations in the origin of the left vertebral artery and other arteries is diagnostic improvements before vascular surgeries of supraaortic arteries. The knowledge of potential left vertebral artery origin variants is necessary and beneficial for planning aortic arch surgery or endovascular interventions.
CONCLUSION
The anatomic and morphological variations of the left vertebral artery are significant for diagnostic and surgical procedures in the head and neck region. It is of clinical importance to know the origin and course of prevertebral segment of the vertebral artery in detail. The information of potential left vertebral artery origin variants is essential and useful for planning aortic arch surgery or endovascular interventions. Hence, physicians and surgeons should be aware of these possible variations to prevent complications.
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/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=1332http://ijcrr.com/article_html.php?did=13321. Donald PJ. Surgery of the skull base. Philadelphia, Lippincott-Raven. 1998; 534– 535.
2. Clemente CD. Anatomy–A Regional Atlas of Human Structure. 4th Ed., BaltimorePhiladelphia-London-Paris-Bangkok-Buenos Aires-Hing Kong-Munich-Sydney-TokyoWroclaw, Williams & Wilkins. 1997; 458– 459.
3. Drake RL, Vogl AW, Mitchell AWM. Gray’s Anatomy for Students. 2nd Ed., EdinburgLondon-Melbourne-New York, Churchill Livingstone. 2005; 976.
4. Moore KL, Dalley AF. Clinically Oriented Anatomy. 4th Ed., Philadelphia- BaltimoreNew York-London-Buenos Aires-Hong Kong-Sydney-Tokyo: Lippincott Williams & Wilkins. 1999; 893–894.
5. Nayak SR, Pai MM, Prabhu LV, D’Costa S, Shetty P. Anatomical organization of aortic arch variations in the India: embryological basis and review. J Vasc Bras. 2006; 5: 95– 100.
6. Koenigsberg RA, Pereira L, Nair B, McCormick D, Schwartzman R. Unusual vertebral artery origins: examples and related pathology. Catheter Cardiovasc Interv. 2003; 59: 244–250.
7. Kubikova E, Osvaldova M, Mizerakova P, El Falougy H, Benuska J. A variable origin of the vertebral artery. Bratisl Lek Listy. 2008; 109: 28–30.
8. Yamaki K, Saga T, Hirata T, Sakaino M, Nohno M, Kobayashi S, Hirao T. Anatomical study of the vertebral artery in Japanese adults. Anat Sci Int.2006; 81: 100–106.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241511EnglishN2013June18TechnologyPROPAGATION OF THE SHOCK WAVES IN THE EARTH'S ATMOSPHERE
English144153Rajan SinghEnglish Mukesh ChandraEnglish Kapil KumarEnglishPropagation of shock waves in non-uniform medium with various density distributions has been discussed. Plane shock waves as it propagates vertically upward in the static atmosphere of the earth are also studied. The variation of Mach number and the velocity of the shock waves are obtained analytically by using Whitham’s Rule. It is found that shock velocity increases as the shock wave propagates in the atmosphere with decreasing density normal to plane of the shock front.
EnglishShock wave, pressure, density, velocity, Mach number, propagation, adiabatic and isothermal atmosphere.1. INTRODUCTION
Bhatnagar and Sachdev [1] have obtained a relation between the density, pressure and Mach number by using Whitham's Rule to the propagation of the shock waves in the nonhomogeneous medium. Kopal and Carrus [2], Hardy and Grover [3] have been studied the problem of propagation of the shock waves in a non-uniform medium with various density distributions and found the behavior of the fluid flow in the presence of the shock waves. Hayes [4] investigated the vorticity jump across a gas dynamics discontinuity by considering the radiative heat transfer into account and concluded that for an optically thin gas, vorticity is unaffected in pseudo-stationary flows. Kanwal [5, 6] employed the theory of generalized functions and differential geometry to study the propagation and deformation of wave front in stationary three dimensional gas flows. With minor changes the experimental data for temperature distribution given by Mitra [8] has been used. In this paper, we have studied the problem of propagation of the shock waves in the earth's atmosphere and also used the Whitham's rule. The experimental data for temperature distribution given by Mitra [8] has been used for minor changes
wherein a0 is the earth's radius, x0 is the vertical distance from the surface of the earth and s g is the value of g 0 at the surface of the earth. Using the variation of the Mach number of the shock and the different temperature distribution of the earth's atmosphere is obtained. The results are combined to find the variation of shock velocity as the shock propagates in the atmosphere. It is found that the shock velocity increases as the shock propagates into the medium which become rarer and rarer with the distance measured from the surface of the earth. As the shock velocity increases with the distance high velocity of the shock causes the fluid velocity to be greater than the escape velocity in the upper atmosphere. But at such a height, the density of the fluid is so small that every small quantity of the fluid escapes from the earth's gravity. Moreover the turbulent motion of the gases in the atmosphere and the effects of the magnetic field and solar radiation, which have not been taken into account, are disturbing the atmosphere. But in all the discussion leads us to a physical picture of the shock wave propagation in the earth’s atmosphere.
Let us assume that there is an intense explosion at the surface of the earth, due to which a strong shock wave propagates in the atmosphere. The radius of the earth is greater than the height of the atmosphere; therefore it can be considered that layers of the atmosphere are planer and the path of the shock wave is one dimensional. Taking X-axis to be normal to the surface of the earth, let gs , Ts , ps , ? s and go, To, po, ?0 be the acceleration, absolute temperature, pressure and density due to gravity at the surface of the earth respectively and at distance xo from the surface. The pressure variations in equilibrium conditions is given by [8]
Wherein R is the distance of the shock front from the surface of the earth and c is the dimensionless sound velocity. The equation (2.8) gives the relation between p, c and M. If the absolute temperature is given, one can find pressure from equation (2.1) and M may be calculated from the relation (2.8). Now the atmosphere can be adiabatic or isothermal or the temperature may be monotonically increasing or decreasing in it. Therefore the relation (2.8) has been studied for different cases.
3. ADIABATIC ATMOSPHERE
The earth's atmosphere is extremely transparent to the radiation from the sun, and is hardly heated by it. Thus almost all the radiation from the sun falls on the surface of the earth. The radiation
falling on the surface of the earth is reflected back to the atmosphere in the form of infrared rays. The infrared rays are absorbed by the carbon dioxide and water vapors in the lower part of the atmosphere. Thus near the surface of the earth, the temperature falls rapidly with the height. This rapid fall produces instability in the density of the atmosphere and there are strong airs current in this region. They stabilize the fluctuations in the temperature. As the rate of conduction of heat in the gases is very small, therefore an adiabatic equilibrium condition is setup. This state occurs in the troposphere. For the adiabatic atmosphere, one has in terms of the dimensionless pressure, density and temperature
4. ISOTHERMAL ATMOSPHERE
In this case there .are no external forces acting on the atmosphere, there will be no motion of the air. Since conduction of heat from one part of the atmosphere to the other is slow in the absence of the external forces the atmosphere will attain uniform temperature after sufficient length of time. Let T1 be uniform dimensionless temperature, p1 be the pressure at r = r1 is the height of isothermal atmosphere from the surface of the earth, then the equation (2.1) reduces in the form
5. MEDIUM WITH MONOTONICALLY INCREASING TEMPERATURE
In the upper part of the atmosphere, ultraviolet rays of the sun cause some of the air to ionize, which combines with oxygen and forms ozone. Ozone is found at the height of 10 km. to 15 km. from the surface of the earth. It observes the heat of sun and thus the atmosphere is heated by it. The heat absorbed up to the height of 30 km. is negligible, but beyond 30 km. the temperature of the atmosphere starts
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in the 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 reviewers for their useful comments that lead the improvement of the manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=1333http://ijcrr.com/article_html.php?did=13331. Bhatnagar, P.L., Sahdev, P.L., Nuovo Cimento, 44, (1966), pp. 5-15
2. Carrus, P.A., Fox, P.A., Kopal, Z., Hoas, F. Ap. J., (1951), pp.113.
3. Grover R. and Hardy, J.W.: App. J.(1966),143.193,496,48
4. Hayes, W.O. The vorticity jump across a gas dynamics discontinuity. J. Fluid Mech, 2(1957), p.597-600.
5. Kanwal,R.P. Propagation of curved shocks in pseudo [1] stationary three dimensional gas flows. Illinois; J.Math, 2( 1958), p.129- 136.
6. Kanwal, R.P. Flows behind shock waves in conducting gases, Proc. Roy. Soc., 257 (1960), p.263268.
7. Kolobkov, N. Our Atmospherics Ocean Foreign Language Publishing, House Moscow,(1960),p.41.
8. Mitra, S. K. Upper atmosphere, Asiatic Society, Calcutta ( 1952).