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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241104EnglishN2018February17HealthcareMobile Health - An Effective Nutrition Communication Tool
English0108Sangna RaybardhanEnglish Kalpana C.A.EnglishInformation, education and communication approaches were used in this study to reach the target groups. Nutrition education was provided in the form of text messages integrated with mobile communication, an alternative choice of media already popular among college going girls instead of usual nutrition education practices. 284 college going girls were divided into cases and controls, with proportion of 1:1 ratio, from various institutions with English medium of instruction and using mobile phones were selected from Coimbatore city. A structured and reviewed questionnaire was used to collect background information and to assess the nutritional knowledge status of the target population. A total number of 28 messages were framed. The mHealth (mobile-health) messages were sent using broad band internet connection to the mobile numbers of 142 respondents using Microsoft Excel enabled plug-in for sending bulk SMS for a period of 14 days. The effect of mHealth on the nutritional knowledge of respondents was evaluated by administering a questionnaire. After imparting nutrition education by sending mHealth messages to their mobile phones, there was an increase in the general, therapeutic and adolescent and adult nutrition knowledge of the
experimental group when compared to the control group and statistically significant at 1% level. Mobile phones provided a new communication channel for health promotion and community mobilization. mHealth as a nutrition communication tool effectively increased nutritional knowledge among college going girls. mHealth and development of user friendly mobile apps for nutrition communication is very useful in imparting nutrition messages.
EnglishmHealth, Healthcare, Mobile technology and applications, Wireless technology, Community mobilizationIntroduction: Health and nutritional status of the population are recognized as the prime indicator of development at national and international levels. Indian women in the age group of 15 – 45 years comprise the vulnerable section of the population due to growth spurt when food and nutrient needs are higher and related risk of child bearing ability. Though nutrition interventions have been made in India, significant improvement in nutritional status has not occurred especially in women and girls. Nutritional disorders like anaemia, poor weight gain in pregnancy and poor caring practices in girls are still common in all socio-economic groups.[1] Nutrition education‘s main goal is to make people aware of what constitutes a healthy diet and ways to improve their diets and their lifestyles.[2] Use of mass media has become even more sophisticated as a tool for nutrition education. Mass media has expanded beyond broadcast and print media to include the range of opportunities available on the Internet and through other technology like cellular phones.[3] Cell phones are the most popular mobile device used in mHealth interventions. Distinct advantages offered by cell phones over other mobile tools include their relatively low cost, wide spread use, and onboard processing power to record, store, organize, and broadcast information in real time.[4]] Texting is the dominant mode of communication among teens.[5] With mobile technologies accessible to 95.5 percent of the world population, many believe that mHealth has the potential to transform the face of health service delivery across the globe by offering new means of when, where, how, and by whom health services are provided and accessed.[6] A systematic review of the literature on disease management and prevention services delivered through text messages found evidence to support text messaging as a tool for behaviour change in eight of nine studies with sufficient sample sizes.[7] In this study, the information, education and communication (IEC) approaches were being used to reach the target groups where nutrition education platform has been produced in the form of text messages integrated with mobile communication. The idea was to provide an alternative choice of media which is already popular among college students to impart nutrition education instead of usual nutrition education practices.
With this in view the study was conducted with the following objective:
To assess the socio-economic background, dietary pattern and health status of college going girls.
To study their physical activity and lifestyle pattern.
To develop content for mHealth messages.
To impart nutritional knowledge to the college going girls using mHealth as a tool for nutrition education.
To evaluate the impact of mHealth on the nutritional knowledge of college going girls
Methodology: A total of 284 girls between the age group of 18 – 21 years from various institutions of Coimbatore city with English medium of instruction and using mobile phones were selected as samples. The sample was divided into cases and controls, with the proportion of 1:1 ratio. In this study mHealth was selected as tool for imparting nutrition education. Thus, a total of 142 respondents were included in the cases and the same number of controls was taken. The samples for the study was selected by non-random sampling method called convenience sampling. Convenience sampling is the cheapest and simplest and does not require a list of population. Hence, the investigator selected samples with the inclusion criteria as college going girls of 18 – 21 years, girls using mobile phones, able to understand, read and write in English and exclusion criteria as girls less than 18 yrs and more than 21 yrs, not using mobile phones, unable to understand, read and write in English. A well structured close ended questionnaire was formulated and the details on socio-economic status, lifestyle pattern, physical activity pattern and knowledge on nutrition were collected from them. The section for assessing nutrition knowledge status consisted of 25 questions on general, therapeutic and, adolescent and adult nutrition. Each question had four options and respondents were instructed to choose appropriate answer by tick mark. Data was collected in two phases namely pre-awareness and post awareness phase by administering questionnaire personally to the individual respondent by the investigator herself. Framed the content of mHealth messages and imparted nutritional knowledge to the selected respondents of the experimental group by sending mHealth messages to their mobile phones. Nutrition education was imparted to 142 girls using Microsoft Excel enabled plug-in for sending bulk Short Messaging System (SMS) for a period of 14 days. The basic package of 5000 SMS credits were purchased from Outsourced Marketing, New Delhi. The nutrition education was imparted using the basic mobile phone service of SMS. Each day two text messages were sent, consisting of 160 characters including special characters and spaces. Strictly adhering to the Telecommunication Regulatory Authority of India (TRAI) Regulations, one message between 6:00 – 6:15 PM and the other one between 8:30 – 8:45 PM were sent, keeping in mind the time preference of the respondents as well. The impact of mHealth on the nutritional knowledge of respondents was evaluated by administering questionnaire pertaining to nutrition education. Each question answered correctly was attributed as 1 point. Wrong answers did not receive any score. The total score of the respondents varied from 1 to 25. The collected data were consolidated, tabulated and analyzed statistically using the software SPSS of version 16.0 to assess the effectiveness of mHealth and impact of nutrition education on the selected respondents.
Results: Socio-economic status - Among 284 selected samples, 12.7 per cent belonged to the age group of 18 years; 18 per cent were 19 years, 27.8 per cent were 20 years and 41.5 per cent were 21 years. About 70 per cent stayed in hostels, 37 per cent resided in their homes, 0.4 per cent was paying guests and 1.8 per cent lived in rented houses. It was evident that 2.1 per cent of the respondents belonged to low income group, 15.5 per cent belonged to low middle income group, 26.8 per cent of them belonged to middle income group and 55.6 per cent of them were from high income group.
Health status - Majority (90.8%) were not allergic towards any type of food and the remaining 9.2 per cent were allergic towards a specific kind of food; About 2.8 per cent of them suffered from anaemia, 0.4 per cent was affected by diabetes, 2.5 per cent were hypertensive, 8.0 per cent were suffering from obesity, 6.0 per cent were affected by overweight and the remaining 80.3 per cent were not affected by any kind of diseases. Approximately 87 per cent were not having menstrual problems and the remaining 13 per cent were having menstrual problems with 7 girls having problems related to reproductive health in spite of having regular periods. Only 78.4 per cent of the respondents consulted doctors regarding menstrual problems, and the remaining 21.6 per cent did not consult doctors.
mHealth - Among 142 selected cases, 100 per cent received two text messages daily for a period of 14 days in their mobile phones and 63.4 per cent shared messages while 36.6 per cent did not share the messages. The messages were shared via mobile was 53.3 per cent and messages shared personally was 46.7 per cent. Messages shared by the recipients to less than 5 persons were 77.8 per cent and between 5 to 10 persons were 22.2 per cent. All the respondents understood the meaning of the messages. About 2.8 per cent received messages only at the time between 6 – 6:15 pm, 2.8 per cent received between 8:30 – 8:45 pm, and the remaining 94.4 per cent received at both timings. All the respondents are willing to receive similar kind of mHealth messages in future also. Topic suggested for sending further messages was 2.8 per cent for anaemia, 2.1 per cent wished information on anticancer diet, anticancer foods (2.8 %), antioxidants (4.9 %), arthritis reduction diet (2.1%), balanced diet (7.7 %), cholesterol reduction diet (2.8 %), diet during menstruation (2.1 %), disease prevention (2.8 %), diet for gout (2.1 %), healthy diet (7 %), healthy foods (12.8 %), metabolic syndrome (1.4 %), PCOS (11.9 %), pregnancy (2.8 %), reproductive health (2.8 %), diet for weight gain (7 %), weight loss diet (16.1 %), yoga (7.7%), and no suggestion was 2.8 per cent. Preference to receive messages once a week was 2.8 per cent, thrice a week preferred by 2.8 per cent, 17.6 per cent preferred to receive messages for 10 days, 19.7 per cent preferred 14 days, 14.1 per cent preferred 15 days, 2.8 per cent preferred 20 days, 34.5 per cent preferred 30 days and 5.6 per cent preferred 60 days for receiving messages. Also 85.2 per cent preferred to receive messages at the same given time while 7.1 per cent preferred in the morning and 7.7 per cent preferred at the evening. Majority (95.1 %) opined that message size was sufficient and 4.9 per cent felt that message size was not sufficient. Nearly one-third (31%) preferred to receive increased number of messages while 69 per cent did not wish to receive increased number of messages. Local language was preferred by 33.8 per cent to receive the messages and 66.2 per cent did not wish to receive messages in local languages and 49.3 per cent preferred to receive messages with images and 50.7 per cent preferred to receive messages without images.
After imparting nutrition education by sending mHealth messages to their mobile phones, there was an increase in the knowledge on general nutrition, therapeutic nutrition, adolescent and adult nutrition of the experimental group when compared to the control group, except question number 9 on better way of cooking method, which college going girls were already aware about. The findings are statistically significant at 1% level.
Discussion: Adolescents require the knowledge and support to develop a healthy lifelong relationship with food.[8] Nearly 50 per cent of adolescent girls aged 15–19 in India are underweight, with a body mass index of less than 18.5, and more than one quarter are underweight in 10 other countries. Such under-nutrition renders adolescents vulnerable to disease and early death and has lifelong health consequences.[9] The onset of over three fourths of eating disorders (76%) occurs between the ages of eleven and twenty.[10] In a study conducted among adolescents in Pune, reported prevalence of anaemia in 51% of girls which was statistically highly significant compared to boys (13%).[11] Overall, information and communication technologies have a potentially major role to play in health information systems. Technology in healthcare can improve access for geographically isolated communities; aid in data sharing; provide visual tools linking population and environmental information with disease outbreaks; and is an electronic means for data capture, storage, interpretation and management.[12] mHealth (mobile-health) is the use of mobile and wireless technologies to support the achievement of health objectives. mHealth can be utilized for a wide variety of purposes, including health promotion and disease prevention, health care delivery, training and supervision, electronic payments, and information systems.[13] One of the most promising aspects of mHealth is its potential for enhancing the smart integration of health services and the continuity of care across provider, place, and time by making information available at the right place and at the right time. Vast majority of mHealth interventions are currently implemented in either pilot programs or at limited scale, a growing number of mHealth systems are reaching significant scale and/or being adopted by national governments, including ministries of health (MOH) in countries like Rwanda, South Africa, Uganda, Ghana, Kenya, Tanzania, Malawi, Bangladesh and India.[14] Cole-Lewis and Kershaw (2010) found evidence to support text messaging as a tool for changing behaviour or improving clinical care outcomes in eight of the nine sufficiently powered studies they reviewed. The authors noted that these changes were found across different ages, ethnicities, and nationalities. Health promotion campaigns using mHealth technologies most frequently make use of text messaging technology to send information on pertinent health issues to target populations.[15] Health-related functions of text messaging interventions can include health behaviour reminders, prompts to schedule or confirm an appointment, notification of a laboratory result or health status report, requests for data, encouragement to engage in positive behaviours, or information and resources to improve self-efficacy. The goal of these interventions is to promote efficiencies in care management practices and, ultimately, improve individual and population health outcomes.[16] Overall, recent research on the use of text messages related to sexual health suggests that text messaging offers promise for reaching teens about health information, referrals, and testing reminders.[17]
Conclusion: Information, education and communication approaches were used in this study to reach the target groups. An intervention of mHealth as tool was used for imparting nutrition education by sending messages on general, therapeutic and, adolescent and adult nutrition to their mobile phones, an alternative choice of media already popular among college going girls instead of usual nutrition education practices. After imparting nutrition education, there was an increase in the general, therapeutic and, adolescent and adult nutrition knowledge of the experimental group when compared to the control group and statistically significant at 1% level. Mobile phones provided a new communication channel for health promotion and community mobilization. mHealth as a nutrition communication tool effectively increased nutritional knowledge among college going girls. mHealth and development of user friendly mobile apps for nutrition communication is very useful in imparting nutrition messages .
Acknowledgement: Authors expresses their gratitude and thanks to all the respondents of various academic institutions for their rendered cooperation and support in the successful completion of the study.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=2433http://ijcrr.com/article_html.php?did=2433
Patil, R.S. (2011). “Impact of IEC activity on women’s knowledge through health exhibition arranged on women’s day”, National Journal of Community Medicine, Vol2 Issue 2 July-Sept, pp-260,261.
Eat Well. (2011). “Review of policy actions, data available for their analysis and existing evaluations throughout Europe”. Deliverable 1.1 of Eat Well for the European Commission.
McNulty Judiann. (2013). “Challenges and Issues in Nutrition Education”,
Riley, Pamela. (2010). “mHealth: The Tool You Can’t Afford to Do Without.” Presentation from SHOPS and mHealth Alliance Hold Online Conference: Using Mobile Technologies to Improve Family Planning, Maternal Health and Newborn Services in the Developing World.
Lenhart, Amanda. (2012). “Teens, Smartphones & Texting.” Washington, DC: Pew Internet and American Life Project.
Rebecca Levine, Alison Corbacio, Sarah Konopka, Uzaib Saya, Colin Gilmartin, JoAnn Paradis, and Sherri Haas.(2015). “mHealth Compendium”, Volume Five. Arlington, VA: African Strategies for Health, Management Sciences for Health.
Cole-Lewis, H., and T. Kershaw. (2010). “Text Messaging as a Tool for Behaviour Change in Disease Prevention and Management.” Epidemiologic Reviews, vol. 32, no. 1, pp. 56–69
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Don Lewis, Health Informatics Consulting , Nicola Hodge Health Information Systems Knowledge Hub, School of Population Health, University of Queensland, Duminda Gamage Research Assistant Professor Maxine Whittaker Health Information Systems Knowledge Hub, School of Population Health, University of Queensland. (2011). “Understanding the role of technology in health information systems”, Health Information Systems Knowledge Hub, Working Paper series, Number 17, June 2011.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241104EnglishN2018February17HealthcareCryptosporidiosis in a Child with Acquired Immunodeficiency Syndrome: A Case Report
English0911Nanthini Devi P.English Gomathi S.EnglishCryptosporidiosis is caused by the coccidian parasite Cryptosporidium and has a tendency to cause diarrhoea with dehydration in immunocompetent and immunocompromised individuals. Here we describe the clinical course of a 4 year old male child who was HIV(Human immunodeficiency virus) reactive and improvement was seen after a course of Nitazoxanide.
EnglishCryptosporidium, Diarrhoea, Acquired immunodeficiency syndromeIntroduction
Cryptosporidiosis is an infection with the coccidian parasite Cryptosporidium and is a significant opportunistic disease among HIV-infected individuals and [1]. In developing countries like India, 2-19% of diarrheal diseases can be attributed to Cryptosporidium. It is spread through the fecal-oral route, often through contaminated water [2]. The age group most commonly affected is children from 1 to 9 years old [3]. Cryptosporidium causes prolonged diarrhoea in HIV patients regardless of the age group [4]. Here we present a case of chronic diarrhoea in a four year old male child with Acquired Immune Deficiency Syndrome (AIDS) and mile stone delay.
Case history:
A 4 year old known HIV positive boy with milestone delay had diarrhoea and vomiting for one week. He experienced ten episodes of watery, non-bloody diarrhoea per day. He had similar illness in the past but stool examination was not done. His parents were also HIV positive. The child was on Anti-retroviral therapy (ART) but on irregular treatment.
His vital signs showed blood pressure to be 86/54 mm Hg, pulse rate of 120 beats per minute and respiratory rate of 16 per minute. The laboratory investigations revealed Serum sodium-130 mmol/L), Serum potassium-4.5mEq/L,Chloride-111mEq/L,Bicarbonate-13 mmol/L, Serum calcium-8.4 mg/dl, Blood glucose-98 mg/dl. The total count was 20800 cells/mm3(56% neutrophils, 36% lymphocytes, 7%monocytes, 1% eosinophil, 1% basophil). The hemoglobin level was 8.2 g/dL, platelets 468,000/mm3 and red blood cell count-4.1 million /mm3. The urine routine examination showed no albumin, no sugar and 1-2 pus cells per high power field. There was no growth in blood and urine culture.
The stool wet mount examination showed numerous spherical and refractile oocysts about 5 micrometer diameter. Modified Acid fast bacilli staining showed pink coloured oocysts of Cryptosporidium with distinct oocyst walls. Giemsa staining revealed the presence of purple coloured oocysts. Hot safranin staining showed pink coloured oocysts.
The child was treated with intravenous fluids, zinc supplements and a course of Nitazoxanide. The stool episodes reduced after treatment. The parents were advised to continue ART to the child for immune reconstitution. Health education was provided to the parents regarding hygienic practices and importance of regular ART.
Discussion:
Cryptosporidiosis is caused by the enteric pathogen Cryptosporidium, a genus of protozoan parasites in the phylum Apicomplexa [5]. There are more than 26 known Cryptosporidium species which can be differentiated by morphology, host specificity and molecular biology studies [6]. The majority of human cryptosporidiosis worldwide are mainly caused by two species C. parvum and C. hominis.[7].Cryptosporidium spp. is increasingly being recognized as an important pathogen causing diarrhea in children nowadays, with the highest morbidity and mortality reported in children less than 5 years in developing countries [8].It can affect both immunocompetent and immunocompromised individuals, resulting in watery diarrhea and extreme dehydration [9]. Cryptosporidiosis is a potential threat to HIV-infected individuals with a risk of infection of around 10% in developed countries. Patients can have chronic watery diarrhea lasting for more than two months and shed oocysts in stool during the entire period [10,11]. Early childhood infection with Cryptosporidium can result in delayed growth and cognitive decline[12]. Cryptosporidium was first recognized as a human parasite in 1976, in a three year-old child with enterocolitis. But it became recognized as an important human pathogen after the HIV pandemic in the 1980s [13]. The first case of cryptosporidiosis in a homosexual man with AIDS was reported back in 1982 [14]. Since then, there have been many reports of Cryptosporidium as an important pathogen in AIDS. Currently, Cryptosporidios is listed as an AIDS-defining illness (Clinical Category C) by the Centers for Disease Control and Prevention [15]. The infection in HIV infected individuals is life- threatening and involves infections of the gastrointestinal tract in addition to hepatobiliary and respiratory tract infections [16,17].
Conclusion:
This case is important because it highlights the mother to child transmission of HIV. In pediatric populations, prevalence data are still underestimated, due to the absence of advanced laboratory diagnostic tools. In the poorest areas, Cyptosporidiosis, enhanced by malnutrition, causes growth failure and further immune derangement, leading to wasting and enhancing children mortality.
With the widespread use of ART, Cryptosporidiosis is no longer the dangerous condition it once was in AIDS patients, it continues to be a dangerous threat to AIDS patients in developing countries where ART is not available. The case report shows that health education should be provided to HIV positive parents regarding antenatal screening, regular ART, hygienic practices to cut down the prevalence of HIV and HIV related diseases.
Abbreviations:
HIV-Human Immunodeficiency virus
AIDS-Acquired immunodeficiency Syndrome
ART-Anti retroviral therapy
Acknowledgement: Authors acknowledge the immense help from the scholars whose articles are cited and included in the 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.
Source of funding: none
Conflict of interest: none
Englishhttp://ijcrr.com/abstract.php?article_id=2434http://ijcrr.com/article_html.php?did=24341. Fayer R. Cryptosporidium: a water-borne zoonotic parasite. Vet Parasitol. 2004 Dec 9, 126(1-2):37-56.
2. Desai NT, Sarkar R, Kang G. Cryptosporidiosis: An under-recognized public health problem. Trop Parasitol 2012, 2:91-8
3. Snelling WJ, Xiao L, Ortega-Pierres G, Lowery CJ, Moore JE, Rao JR, et al. Cryptosporidiosis in developing countries. J Infect Dev Ctries 2007 Dec 1,1(3):242–56. pmid:19734601
4. Wanyiri JW, Kanyi H, Maina S, et al. Cryptosporidiosis in HIV/AIDS Patients in Kenya: Clinical Features, Epidemiology, Molecular Characterization and Antibody Responses. The American Journal of Tropical Medicine and Hygiene. 2014, 91(2):319-328. doi:10.4269/ajtmh.13-0254.
5. White AC Jr. Cryptosporidiosis (Cryptosporidium species). Bennett JE, Dolin R, Blaser MK, eds. Principles and Practice of Infectious Diseases. 8th ed. Philadelphia, Pa: Elsevier Churchill Livingstone; 2015. Chapter 284, pages 3173-83.
6. Ryan U, Fayer R, Xiao L. Cryptosporidium species in humans and animals: current understanding and research needs. Parasitology. 2014 Nov, 141(13):1667-85.
7. Xiao L, Fayer R, Ryan U, Upton SJ. Cryptosporidium taxonomy: recent advances and implications for public health. Clin. Microbiol. Rev. January 2004 ,17(1): 72-97
8. Bhattacharya, MK, Teka T, Faruque AS, Fuchs GJ. .Cryptosporidium infection in children in urban Bangladesh. J. Trop. Pediatr.1997, 43:282-286.
9. Hunter PR, Nichols G. Epidemiology and Clinical Features of Cryptosporidium Infection in Immunocompromised Patients. Clinical Microbiology Reviews. 2002, 15(1):145-154.
10. Bouzid M, Hunter PR, Chalmers RM , Tyler KM. Clin. Microbiol. Rev. 2013 , 26(1): 115-134
11. Ghazy AA, Abdel- ShafyS , Shaapan RM. Cryptosporidiosis in Animals and Man: 1. Taxonomic Classification, Life Cycle, Epidemiology and Zoonotic Importance. Asian Journal of Epidemiology.2015, 8: 48-63.
12. Leitch GJ, He Q. Cryptosporidiosis-an overview. Journal of Biomedical Research. 2011, 25(1):1-16.
13.Iqbal A, Lim YAL, Mahdy MAK, Dixon BR, Surin J. Epidemiology of Cryptosporidiosis in HIV-Infected Individuals: A Global Perspective. 2012,1:431.
14.Tzipori S, Widmer G. A hundred-year retrospective on cryptosporidiosis. Trends in parasitology. 2008, 24(4):184-189.
15. Centers for Disease Control and Prevention (1992) 1993 revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR Recomm Rep. 1992 Dec 18;41(RR-17):1-19.
16. Tali A, Addebbous A, Asmama S, Chabaa L, Zougaghi L. Respiratory cryptosporidiosis in two patients with HIV infection in a tertiary care hospital in Morocco. Ann Biol Clin 2011, 69(5): 605-8.
17. Chen X-M, LaRusso NF. Human intestinal and biliary cryptosporidiosis. World Journal of Gastroenterology. 1999,5(5):424-429.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241104EnglishN2018February17HealthcareAnalysis of Registered Cardiovascular Clinical Trials in India
English1220Ranjana BhartiEnglish Narendra SinghEnglishBackground: Cardiovascular diseases (CVDs) are reported as the leading cause of death in the India. The landscape of CVDs clinical trials (CTs) are helpful in understanding the trends in progression of RandD and also offer insights of emergence of new technologies over a span of reporting years.
Method: Data was collected for CVDs CTs from database of clinical trial registry India (CTRI) by using keyword “cardiovascular” since 01/01/2008 to 31/08/2017. Data collected for each CTs includes health condition, clinical trial phase (phase I, II, III, IV), study design (randomized/non randomized), type of trials (interventional/observational), study type (drug/ayurveda/medical device/yoga/behavioral) institution type (public/private/partnership), sponsors and monetary support (domestic/international and government/industry/ academia/hospitals), publications (published/not published) and postgraduate thesis (yes/no) and year of registration. Result were analysed in terms of percentage of CTs i.e. n=239 using above mentioned indicators.
Results: The study found239 CTs of which majority of them were belong to Phase III (34%) and interventional (69%). Considering the study design, mostly CTs were randomized, parallel group, placebo controlled (25.9%) and conducted in hospitals (29%). For focused health condition, 17.5% associated with diabetes and 15.4% with coronary artery disease. From 2008, 15.8% postgraduate thesis trials had been registered with CTRI but non publication of CTs are highly prevalent. Numerous registered CTs was unclear phase (36%). With regard to type of study, CTs deals with drugs (81%), medical device (19.3%), Ayurveda, yoga, naturopathy and laughing therapy.
Conclusion: The CVDs CTs are low in India and poor access to treatment and out of pocket expenditure are key issues of CVDs management and there is need for effective and inexpensive care with indigenous radical change.
EnglishClinical trials, Cardiovascular, Clinical trial registry, IndiaIntroduction
Cardiovascular diseases (CVDs) are major cause of the highest mortality and morbidity globally. According to WHO report, CVDs alone account for 26 percent of all deaths in 2014. Chronic respiratory diseases (CRDs), cancer and diabetes accounted for 13, 7 and 2 percent respectively [1].The potentially productive years of life lost (PPYLL) due to CVDs in the age group of 35-64 yrs. was 9.2 million in 2000 and is expected to increase 17.9 million in 2030 [2].Despite the high burden of CVDs, the trends in research and development (RandD) have not been analyzed systematically. The study deals with the analysis of evidence based practice (EBP) in the form of clinical trials (CTs) which provides significant information for understanding the progression of RandD and offer insights of emergence of new technologies in the field of CVDs. CTs possess huge potential for benefiting patients, improving therapeutic treatments and ensuring advancement in medical technology[3]. India is counted in a preferred destination for clinical trials due to its preponderance of high diseases and its genetically diverse population. A study by Mondal et al (2015) has analyzed that the low cost of clinical labors, availability of expert researchers, large market opportunities and presence of numerous clinical research organizations (CROs), make India an attractive destination for conducting CTs[5]. The paper also investigate the active player involved, focused health condition and nature of RandD on CVDs in India. The “Declaration of Helsinki” in World Medical Association (WMA) 2013, states that “every research study involving human subjects must be registered in a publicly accessible database before recruitment of the first subject” [4]. Drug controller general India (DCGI) made it necessary to register all CTs in clinical trial registry India (CTRI) before enrollment of participants, whether they belong to any category i.e. drugs, vaccine, therapy, Ayurveda, preventive measures, yoga based, naturopathy, behavioral, nutraceuticals, medical device, surgical methods, physiotherapy, observational as well as trials being conducted in the purview of the department of AYUSH. CTs registration will certify responsibility, transparency and availability of trials [3]. As per June 2017, CTRI has registered 8950 trials, out of which 3318 are prospective and 5604 are retrospective registrations [4].
Method and Materials
Data sources and extraction: The study is based on secondary data source. Data was collected for CVDs CTs from database clinical trial registry India (CTRI) maintained by Indian council of medical research (ICMR) by using keyword “cardiovascular” during the period of01/01/2008 to 31/08/2017.Data collected for each CTs includes health condition, CTs phase (phase I, II, III, IV), study design (randomized/non randomized), type of trials (interventional/observational), study type (drug/ayurveda/medical device/yoga/behavioral), intervention, institution type (public/private/partnership), sponsors and monetary support (domestic/international and government/industry/ academia/hospitals), publications (published/not published) and postgraduate thesis (yes/no) and year of registration. Descriptive analyses was used in the study and result were analysed in terms of percentage of total CTsusing above mentioned indicators.
Results
Percentage share by phase wise registered CVDs CTs
By using keyword “cardiovascular”, the search extract 275 CTs registered during the period of 01/01/2008 to 31/08/2017 in which 239 CTs have been found relevant to the field of CVDs. Figure 2 shows the percentage share by phase wise registered CVDs CTs in India. The phase I is dedicated to test new drugs or new forms of treatment in a small group of healthy volunteers to test the safe dose for the drug and its pharmacokinetics study, specifically in the country where the drugs or new chemical entity (NCE) was originally developed and then outsources to other countries [5][6], but very less number of CTs are going in this phase and almost similar results were seems in phase II CTs, also called as exploratory trial. This exploratory phase is carried out to test the efficacy of drug for particular disease and to explore and collect more information regarding side effects and doses with maximum efficacy. As shown in figure 2, the phase III is attracted maximum CTs industry (34%). This phase is also called confirmatory trials and conducted to confirm and obtain sufficient data regarding efficacy and therapeutic dose of the drug on larger group (approximately 1000 - 3000) against standard treatment. Drug development technology is not involved in this phase and as the above mentioned figure show in India, larger number of CTs are going on in this phase and very few industry undertake phase I. The phase IV trials are known as post marketing surveillance (PMS). This phase is conducted upon wide numbers of people after the drug is made available to doctors. The practitioners start prescribing drugs against specific clinical condition and observe the long term benefits and risk of the medicine and also gather information about its safety and side effects [6] [7].
Characteristics of registered CVDs CTs
CVDs are considered as life style diseases or high burden diseases of India and shares some common risk factors including use of tobacco and excessive alcohol consumption, stress, physical inactivity, unhealthy diet, working nature of the people and other environmental factors [8], it leads to high blood pressure, obesity, raising blood sugar level, increased blood lipid content etc. Thus, CVDs is associated with many diseases (Table 1) e.g. diabetes, hypertension, obesity, COPD etc. The maximum CTs are being conducted in the condition of CVDs with diabetes (17.5%) and coronary artery disease (15.4%). Table 2 shows registered CVDs CTs settings and phases, it represents phase of CTs, type of institutions, number of publications and postgraduate thesis. To explore the results, Hospitals conducted large number of CTs (29%), Medical colleges (17.5%), Industry (14.6 %), CROs (8.7%) and then university (7.5%) and research institutions (7.1%) respectively. Organizations are taking advantage of large patients pool, highly skilled medical researches, low cost of drug development and timely completion of CTs in India, and CROs are also expanding their programs in India due to these attractive benefits [5].The total number of 239 CTs has been found to be concluded and out of which only few have been reported to be published (35/239, 14.6%).After completion of any CT, documentation in the form of publication is very essential, as it may use for further research and evidence based practices. Many CTs were being conducted for postgraduate thesis(38/239, 15.8%) but it seems that, most of the CTs are also not published and this highlight need of increasing awareness regarding documentation of CTs among CVDs researchers and academician. Other than this, numerous CTs was unclear phase (87/239, 36%) in registered CVDs CTs. Considering the type of trial, most of the CTs were interventional study (165/239, 69%) while only 43/239 (17.9%) were observational study (figure 3). Similarly, in study design, maximum number of registered CVDs CTs were randomized, parallel group, placebo controlled (62/239, 25.9%), single arm trial (39/239, 16.3%) and randomized, parallel group (38/239, 15.8%) respectively. CTs are need of the hour and randomized controlled trials (RCTs) are the important standard for establishing the advantage of a new treatment over an existing standard treatment (placebo) [9].
Percentage share by type of study in registered CVDs CTs
The effective management of non-communicable diseases (NCDs) or CVDs, demands periodic checkups,long term monitoring and life time treatments with drugs. The study found four major categories on which CVDs CTs going on in India from 01/01/2008 to 31/08/2017; Drugs and Vaccines, Medical devices, Ayurveda, Naturopathy, Yoga and laughing therapy (figure 5).
Drugs and Vaccines
Drugs are act as backbone in CVDs treatment. The study found74 CTs are on drugs, in which maximum number of CTs are going in phase III (81%) by Industry, hospitals, clinical research organizations and medical colleges (Table 3). Many CTs were belong to study of aliskiren (monotherapy or combination; dosage variation)and Serelaxin for myocardial infarction. alirocumab for hypercholesterolemia; aspirin and rivaroxaban for venous thromboembolism; aleglitazar, rivaroxaban, darapladib, lixisenatide and atorvastatin for acute coronary syndrome; azilsartan medoxomil for hypertension; canagliflozin on renal and CVDs in participants with diabetic nephropathy etc. CVDs research with concomitant diseases i.e. diabetes mellitus, obesity, congestive heart failure are very essential for effectively manage the disease. One of the institute is also studying the role of influenza vaccine in reducing heart attack, stroke, hospitalization and death in patients of heart failure.
Medical device
The medical devices plays very essential part in CVDs treatment. Phase II, III and IV includes 19.3% CTs are going on medical devices to treat aortic valve stenosis and coronary artery disease. The CTs deals with evaluation of sirolimus eluting bioresorbable vascular scaffold system (BVS), daffodil pericardial bioprosthesis, BioMime™ - sirolimus eluting stents, NUVANT MCT system external loop record and hydra trans aortic valve etc. Analysis on blood clot related complications between current generation valve vs previous generation valve are also carrying out.
Ayurveda
Ayurveda is one of the alternative and significant system of medicine requiring generation of high quality evidence for rational practice [11]. The analyses found very few CTs evaluating ayurveda for CVDs e.g. efficacy of hridayarnava rasa on hyperlipidaemia, effects of barley flour consumption and effect of Black seeds (nigella sativa) on diabetes and heart related illness etc.Another CTs is going on healthy aged people by giving an ayurvedic herbal extracts drug to see its effects on enhancing and maintaining healthy state.
Yoga, Naturopathy and laughing therapy
In addition to the incorporation of treatment by drug, vaccine, medical device and Ayurveda, yoga is also an important member to prevent and treat lifestyle diseases or CVDs. Yoga has been described as action leading to the union of the body and the mind which improves physical, mental and spiritual well-being [10].The study found 12 CTs in different phases and all were linked with either laughter therapy or naturopathy. The findings deal with cardiac rehabilitation programs, effect of yoga on patients going in heart surgery and after heart attack, effect of yoga on lung, heart functions and stress in breast cancer patients undergoing radiotherapy and effect of naturopathy and yoga on inflammation and utilization of insulin in patients with high risk of CVDs and effect of functional foods, yoga and laughing therapy in hypertensive women.Table 4 is showing active players involved in the clinical research for medical devices, ayurveda, yoga, laughing therapy, naturopathy and vaccine. In addition physiotherapy, biologicals, nutraceuticals and stem cell therapy are also important areas in which cardiovascular CTs are going on and might be helpful in exploring the new ways to deal with CVDs in India.
Discussion
Registered CVDs CTs during the period from January 2008 to August 2017 were recognised and analysed. The study observed that very low number of CVDs CTs are going on in India. CVDs are associated with many diseases e.g. high blood pressure, obesityand also responsible for leading cause of diabetes related morbidity and mortality [12]. Yoga and laughing therapy are also considered as effective way to deal CVDs [13] but very less number of interventions were found in these categories. Therefore, in the view of above, it can be said that to treat and explore new methods to eradicate the disease and maintain healthy lifestyle, there is an urgent need of less expensive, innovative modes for reducing CVDs and its associated complications through clinical interventions and public health policies.
Conclusion
Despite the high burden NCDs, the study found less number of CTs (n=239) being conducted in the field of CVDs, although an increasing trend over a span of years. Indian active players are mainly focused on Phase III CTs that involve testing of established drugs and minimize participant’s risk. Large patient’s pool, highly skilled medical researchers, low cost of drug development and timely completion of CTs made India an attractive destination of CTs but there is also need to increase the phase I and phase II CTs and come up with the essential changes for effective CVDs management. Most of the CTs were interventional, randomized, parallel group, placebo controlled and were conducted in hospitals. Non-publication of CTs in CVDs research are highly prevalent and large number of CTs had an unclear phase. Furthermore, the type of study found many CTs on drugs to assess the safety and efficacy and also includes analysis by monotherapy or combination; dosage variation of drugs. Even though poor access to drugs, medical device and out of pocket expenditure are key issues of CVDs management and the demand for effective and inexpensive treatment for CVDs will exert major pressure on Indian healthcare system. Additionally, very less number of CTs are found in Ayurveda, yoga, naturopathy and laughing therapy. These categories are also considers as an important member to prevent and treat lifestyle diseases or CVDs. In this context, CVDs research should be concentrated on primary prevention, effective and inexpensive health care services, epidemiology and clinical research.
Acknowledgement
Author acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The author is 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. The author is thankful to Central University of Gujarat (CUG), Gandhinagar for infrastructural support and University Grant Commission (UGC), Government of India for fellowship support. The author is also grateful to her research supervisor Dr. Parvathi. K. Iyer, Asst. Professor, CUG, Gandhinagar for constant guidance and encouragement.
Source of funding No funding source
Conflict of interest No conflict of interest.
Englishhttp://ijcrr.com/abstract.php?article_id=2435http://ijcrr.com/article_html.php?did=2435
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241104EnglishN2018February17HealthcareReflection of Syrian Refugees to Pediatric Surgery
English2124Metin GunduzEnglish Tamer SekmenliEnglish Ilhan CiftciEnglishObjective: Migration is an emergency in all aspects. Since the war began many of Syrian refugees were treated in our country. We aimed to evaluate pediatric surgical outcomes of these children in a tertiary center in Turkey
Design: A retrospective study is reported
Setting: Patients in present study were treated in atertiary hospital
Subjects: Pediatric Syrian refugees
Intervention: Surgery
Main Outcome Measure: Syrian refugees who were operated at the Pediatric Surgery Department of our hospital between June 2014 and November 2017 were evaluated retrospectively. Demographic data, diagnosis, and treatment were recorded.
Results: We operated twenty male and eight female patients under general anesthesia. 8 (%28.6) of them had newborn pathologies, 5 (%17.9) had inguinal pathology, 3 (%10.8) had tumor, 3 (%10.8) had urological disorders, 5 (%17.9) had gastrointestinal pathology, 1 (%3.5) had lymphangioma, 1 (%3.5) had nux diaphragmatic hernia, 1 (%3.5) had bronchoscopy for evaluating tracheoesophageal fistula, and 1 (%3.5) was operated due to trauma. Patients died due to trauma and mutiple congenital anomalies. Others were treated succesfully.
Conclusions: Wars and natural disaster effects humans and especially children. They have to leave their countries and move to neighbouring countries. By this study we wanted to draw attention and rise awareness on this emergency. Like the pediatric surgeons in the border, all the pediatric surgeons in our country will continue to do their best with regard to these children.
EnglishSyrian refugee, Children, SurgeryIntroduction
Wars affects soldiers and also elders, women and children. Since the war in Syria began in March 2011 Turkey is hosting 2,967,149 Syrian Refugees and 44.7 % of them are under age of 18[1] .Emerging situations like health, education, basic needs, protection, and social activity facilities is being provided by The Republic of Turkey[2]. Thousands of seriously injured Syrians were brought to Turkey for emergency operations and intensive care[2]. More than a million patient consultations for Syrian refugees were registered in out patient settings [2] . Although Konya is not a Sryian neighborhood province there is a great refugee movement and survey. In present study we aimed to evaluate the demographic and clinical characteristics of Syrian refugees to a pediatric surgery department of a tertiary care hospital.
Material and Methods
The study protocol was approved by the Selcuk University Medical Faculty Ethics Committee (2017/21-06/12/2017). The records of Syrian children those operated between June 2014 and October 2017 in Pediatric Surgery Department were retrospectively analyzed. Demographic data, diagnosis, and treatment were recorded. All patients had preoperative routine blood tests. If needed they had urine analysis, urinary ultrasonography, plain abdominal X-ray, computerized tomography, and magnetic resonance imaging. They received antibiotic prophylaxis excluding inguinal pathologies. All operations were performed under general anesthesia. Newborn patients were treated in newborn intensive care unit, some others in intensive care unit, and also in reanimation unit. After discharge some of the patients did not come back for follow up.
Results
Twenty male and eight female patients were operated under general anesthesia. 8 (%28.6) of them had newborn pathologies, including anal atresia, corpus callosum hypoplasia, meningomyelocele, hydrocephalus, feeding intolerance, diaphragmatic hernia, gastric perforation, patent omphalomesenteric duct, meconium pseudocyst, again diaphragmatic hernia, and necrotizing enterocolitis . Divided colostomy, stamm gastrostomy, primary repair of diaphragmatic hernia, partiel gastric resection, resection ileo-ileal anastomosisi,, loop ieostomy, intestinal resection with divided jejunostomy, and primary repair with mesh was performed respectively. 5 (%17.9) had inguinal pathology as inguinal hernia (three of them), bilateral hydrocele, and incarcerated inguinal hernia. High ligation and hydrocelectomy was performed. 3 (%10.8) had tumor including Wilms tumor, abdominal rhabdomyosarkoma, and b cell lymphoma. Total-partiel excision, loop ileostomy, and chemoteraphy was applied. 3 (%10.8) had urological disorders like ureteropelvic junction obstruction, bilateral vesicoureteral reflux due to posterior uretral valv with chronic renal failure, and left vesicoureteral reflux. Anderson Hynes pyeloplasty, Mitrofanoff procedure and subureteral transurethral injection (STING) were performed. 5 (%17.9) had gastrointestinal pathology, including dysphagia and malnutrition due to cerebral palsy, hematemesis, feeding intolarence due to cardiomyopathy and pulmonary hypertension, feeding intolarence due to coanal atresia, and rupture of hepatic hydatid cyst. Stamm gastrostomy, gastroscopy, laparascopic gastrostomy, Stamm gastrostomy, and unroofing was performed respectively. Bleomycin injection was performed to lomber lymphangioma. Recurrence diaphragmatic hernia received patch repair. Splenectomy was pereformed to multitrauma patient. Bonchoscopy was performed to a patient that had aspiration pneumonia with tracheoesophageal fistula suspicion (Table 1). Those who had multitrauma and mutiple congenital anomalies were died. Others were treated succesfully and some of them are being treated by pediatric oncology and pediatric gastroenterology department.
Discussion
Immigration due to wars is a serious problem that causes complex problems and affects human life. Women and children are the most aggrieved group. Turkey is a neighbour country to Syria and wounded refugees are being treated especially in border cities [3]. Although Konya is not a Syrian neighborhood province there is a great refugee movement and survey as other cities in our country. This is the first study that evaluates immigrant children from Syria with pediatric surgical diseases.
There are several reports evaluating Syrian refugees. Heart disease in Syrian refugee children were reported by Al-Ammouri et al [4] .Late presentation and diagnosis, high rate of complications, suboptimal living conditions, lack of funding and high mortality rates were the major challenges of refugees in their study.
Newborns in present study had not any prenatal diagnosis. Clinical characteristics and pregnancy outcomes of Syrian refugees were reported by Erenel et al [5] . They showed that 41.3 % of Syrian patients did not receive antenatal care. Their findings support our results. One patient with multiple congenital anomaly including anal atresia and corpus callosum hypoplasia was died in our study. We do not have any knowledge about wheter parents of these children has exposure to chemical weapons. It was used in August 2013 as known [6] .
Turkish Government Ministry of Health has mended free healthcare for Syrian refugees. Pediatric surgical outpatients like inguinal hernia, hydrocele are being treated in State hospitals and not allowed to tertial centers. This explains the low number of patients with inguinal pathologies in our study.
In tumor group chemical weapon effects was seen in a patient from Aleppo with b cell lymphoma. Another one who had Wilms tumor had chemical waste doubt in drinking water. Although we are not sure we think that chemical weapons was used or being used in Syrian war.
Late presentation and diagnosis was the major challenge in patient with bilateral vesicoureteral reflux due to posterior uretral valv with chronic renal failure. Patients with gastrointestinal pathology, lomber lymphangioma, and recurrence diaphragmatic hernia had a successful treatment. Trauma was due to traffic accident in present study.
Injuried patients in Syria were transferred to emergency department of hospitals in border cities in Turkey so there is not any injuried patient such gunshot wounds, and burn in our study [7] . Differently from present study Çelikel et al evaluated demographical data and injury characteristics of Syrian children who were wounded in Syria Civil War and died while being treated in Turkey [8] . Children mostly died of head and neck injuries predominantly caused by bombing attacks and autopsies of them revealed fatal intracranial hemorrhages and parenchymal injuries in their study. Similarly patients with cranial gunshot wounds in the Syrian civil war were analysed by Aras et al [9] but only 8.6% of them were pediatric patients. The orphan children of Syria are at high risk of developing mental health disorders due to traumatic experiences, adjustment difficulties, and loss [10]. For reducing the morbidity and mortality associated with mental illness in this population, mental health interventions were offered[10]. Similarly the prevalence of post-traumatic stress disorders in adult Syrian refugees living in camps in Lebnon was determinated. Refugees from Aleppo had significantly more post-traumatic stress disorders than those coming from Homes [11] .
Birth characteristics of Syrian refugees and Turkish citizens in Turkey was evaluated and cesarean delivery number, median neonatal birth weight, and gestational diabetes was significantly higher in Turkish citizens [12].
As reemerging infections measles, poliomyelitis, leishmaniasis, and multidrug-resistant tuberculosis were most frequently seen in Syrian refugees [13] . Multidrug-resistant gram-negative bacterial infections were seen with high incidence in gunshot or surgical wounds.
Limitation of this study may include a retrospective design and low number of patients. Despite these limitations present study is the first to investigate pediatric surgical patients among Syrian refugees. The international community has to be aware of this and assist Turkey’s efforts to provide adequate health care to Syrian refugees.
Conclusions
Wars and natural disaster effects humans and especially children. They have to leave their countries and move to neighbouring countries. By this study we wanted to draw attention and rise awareness on this emergency.
ACKNOWLEDGMENT
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.
There is no conflict of interest.
Englishhttp://ijcrr.com/abstract.php?article_id=2436http://ijcrr.com/article_html.php?did=2436[1] Syria Regional Refugee Response. Turkey,Inter-agency Information Sharing Portal, 2017. Accessed at April 5, 2017 at http://data.unhcr.org/syrianrefugees/country.php?id=224
[2] Döner P, Ozkara A, Kahveci R. Syrian refugees in Turkey: numbers and emotions. Lancet 2013;31;382(9894):764.
[3] Akkucuk S, Aydogan A, Yetim I, Ugur M, Oruc C, Kilic E, Paltaci I, Kaplan A, Temiz M. Surgical outcomes of a civil war in a neighbouring country. J R Army Med Corps 2016;162(4):256-60.
[4] Al-Ammouri I, Ayoub F. Heart Disease in Syrian Refugee Children: Experience at Jordan University Hospital. Ann Glob Health 2016;82(2):300-6.
[5] Erenel H, Aydogan Mathyk B, Sal V, Ayhan I, Karatas S, Koc Bebek A. Clinical characteristics and pregnancy outcomes of Syrian refugees: a case-control study in a tertiary care hospital in Istanbul, Turkey. Arch Gynecol Obstet 2017;295(1):45-50.
[6] Rosman Y, Eisenkraft A, Milk N, Shiyovich A, Ophir N, Shrot S, Kreiss Y, Kassirer M. Lessons learned from the Syrian sarin attack: evaluation of aclinical syndrome through social media. Ann Intern Med 2014;6;160(9):644-8.
[7] Karaku? A, Yengil E, Akkücük S, Cevik C, Zeren C, Uruc V. The reflection of the Syrian civil war on the emergency department and assessment of hospital costs. Ulus Travma Acil Cerrahi Derg 2013;19(5):429-33.
[8] Çelikel A, Karbeyaz K, Kararslan B, Arslan MM, Zeren C. Childhood casualties during civil war: Syrian experience. J Forensic Leg Med 2015;34:1-4.
[9] Aras M, Alta? M, Yilmaz A, Serarslan Y, Yilmaz N, Yengil E, Urfali B. Being a neighbor to Syria: a retrospective analysis of patients brought to our clinic for cranial gunshot wounds in the Syrian civil war. Clin Neurol Neurosurg 2014;125:222-8.
[10] Saltaji H, Al-Nuaimi S. Do not forget the orphan children of Syria. Lancet 2016;20;387
(10020):745-6.
[11] Kazour F, Zahreddine NR, Maragel MG, Almustafa MA, Soufia M, Haddad R, Richa S. Post-traumatic stress disorder in a sample of Syrian refugees in Lebanon. Compr Psychiatry 2017;72:41-47.
[12] Demirci H, Yildirim Topak N, Ocakoglu G, Karakulak Gomleksiz M, Ustunyurt E, Ulku Turker A. Birth characteristics of Syrian refugees and Turkish citizens in Turkey in 2015. Int J Gynaecol Obstet 2017;137(1):63-66.
[13] Doganay M, Demiraslan H. Refugees of the Syrian Civil War: Impact on Reemerging Infections, Health Services, and Biosecurity in Turkey. Health Secur 2016;14(4):220-5.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241104EnglishN2018February17HealthcareCorrelation of High Sensitivity C-Reactive Protein and Carotid Intimal Medial Thickness in Patients with Ischemic Stroke
English2528Virendra AtamEnglish Arpit GuptaEnglish Sciddarth KoonwarEnglish Manoj KumarEnglish Isha AtamEnglishBackground: Stroke is defined as an acute neurological deficit lasting more than 24 hours and caused by cerebrovascular etiology. It is further subdivided into ischemic stroke (caused by vascular occlusion or stenosis) and hemorrhagic stroke (caused by vascular rupture, resulting in intra parenchymal and/or subarachnoid hemorrhage).
Aim: Our study was designed to study the levels of High sensitivity C reactive protein (HsCRP), which is a marker for chronic inflammation, in patients with ischemic stroke due to large vessel atherosclerosis and correlate it with carotid intimal medial thickness.
Methodology: This study was done in Department of Medicine and Department of neurology in KGMU, Lucknow, between August 2016 to July 2017, and 100 patients with ischemic stroke presenting within 72 hours of onset, who met the inclusion and exclusion criteria. HsCRP was evaluated and CIMT was subsequently measured.
Result: HsCRP is significantly increased in patients with ischemic stroke. The carotid intimal medial thickness which is a proven marker for large artery atherosclerosis is also increased in patients with ischemic stroke and it is also significantly correlated with the levels of HsCRP. The levels of HsCRP is elevated more in patients with Diabetes Mellitus and Hypertension.
Conclusion: HsCRP levels are increased in patients of ischemic stroke suggesting that it could be used as a marker for the prediction of the ischemic stroke when combined with CIMT, together these two could predict the ischemic stroke.
EnglishHigh sensitivity C reactive protein, Subarachnoid hemorrhage, Carotid artery, Ischemic strokeINTRODUCTION
Stroke is defined as an acute neurological deficit lasting more than 24 hours and caused by cerebrovascular etiology. It is further subdivided into ischemic stroke (caused by vascular occlusion or stenosis) and hemorrhagic stroke (caused by vascular rupture, resulting in intra parenchymal and/or subarachnoid hemorrhage).[1]
Progressive atheromatous plaque in the carotid artery usually at the bifurcation results in gradual narrowing of the carotid artery. This process can be symptomatic but may lead to ischemic stroke or transient ischemic attack from embolization, thrombosis, orhemodynamic compromise. To measure the extent of atherosclerotic disease we measure Carotid Intimal medial thickness, which is a proven marker for the atherosclerotic large vessel disease.
High sensitivity C reactive protein is a marker of inflammation has gained importance in the recent times as a pro-inflammatory marker. Various studies have shown that HsCRP could be used as an early marker of atherosclerosis. [2]
MATERIALS AND METHODS
Our study was designed to study the levels of High sensitivity C reactive protein (HsCRP), in patients with ischemic stroke due to large vessel atherosclerosis and correlate it with carotid intimal medial thickness. This study was done in Department of Medicine and Department of neurology in KGMU, Lucknow. This study was conducted in between August 2016 to July 2017, and 100 patients with ischemic stroke presenting within 72 hours of onset, who met the inclusion and exclusion criteria.
A standardized questionnaire was given that includes Name, Age, Sex or any family h/o diabetes or hypertension. Any concurrent history of hypertension, thyroid, or Diabetes mellitus was asked. All participants were asked to give informed written consent after explaining the study. The study was approved by the Ethical committee, KGMU, Lucknow. After making the diagnosis of ischemic stroke the patients were subjected to blood investigations for which approximately 5 ml venous blood sample was drawn and HsCRP levels were analyzed in those samples along with complete blood picture, S. Urea, S creatinine. Along with that if the patient wasn’t in the fasting state, then sample for fasting lipid profile was also drawn after 8 hours of fasting.
RESULTS
Statistical analysis was done by the mean, median, standard deviation and Student t-test and the significance was analyzed by the "p-value".
The mean age of the study population was 60.98±7.35. The Male-female ratio was 2.81.
The mean values of HsCRP and CIMT were increased in patients with ischemic stroke and are significantly correlated with each other. The factors which are not significant are Hb and HDL.
DISCUSSION
HsCRP which is a marker of chronic inflammation is significantly increased in patients with ischemic stroke. The carotid intimal medial thickness which is a proven marker for large artery atherosclerosis is also increased in patients with ischemic stroke and it is also significantly correlated with the levels of HsCRP. The levels of HsCRP is elevated more in patients with Diabetes Mellitus and Hypertension. As compared to the levels in patients without hypertension or diabetes mellitus, the patients having both or either one of them has increased levels. Moreover, the patients having uncontrolled Diabetes Mellitus i.e. HbA1C > 9.0 are having even more levels. The levels of HsCRP are not significantly correlated with HDL and Hb.
The results were in concordance with the following studies, Dibyaratna Patgiri1 et al [3] hsCRP is an acute phase reactant whose concentration rises in stroke as well as in those at risk. The rise may be identified even before the appearance of risk factors. Hence, hsCRP may be useful as a predictive and diagnostic marker in stroke. Liu et al [4]. We found that higher hs-CRP concentrations were associated with a higher risk of IS, particularly for non-fatal stroke, male and hypertensive subjects. In contrast, we did not observe significant associations between hs-CRP and ICH/ SAH
CONCLUSION
HsCRP levels are increased in patientswith ischemic stroke suggesting that it could be used as a marker for the prediction of the ischemic stroke when combined with CIMT, together these two could predict the ischemic stroke. As we had a small sample size, more studies need to be done to predict the role of HsCRP as a marker of ischemic stroke.
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.
SOURCE OF FUNDING: NIL
CONFLICT OF INTEREST: NIL
Englishhttp://ijcrr.com/abstract.php?article_id=2437http://ijcrr.com/article_html.php?did=2437
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Patgiri D. Serum hsCRP: A Novel Marker for Prediction of Cerebrovascular Accidents (Stroke). JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH. 2014
Liu Y, Wang J, Zhang L, Wang C, Wu J, Zhou Y et al. Relationship between C - Reactive Protein and Stroke: A Large Prospective Community Based Study. PLoS ONE. 2014;9(9):e107017.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241104EnglishN2018February17HealthcareIndications & Yield of Colonoscopy - A Retrospective Study at Chennai Medical College Hospital & Research Centre - Irungalur, a Rural Tertiary Care Centre in South India
English2933S. PadmaEnglish R. MuruganEnglishColonoscopy is the one of the most important investigation to be done for patients presenting with symptoms of colonic diseases. The clinical presentation of lower GI tract diseases varies in different communities. The yield of colonoscopy also varies from place to place and the yield also depends on the various indications. Aim of the Study: To know the indications for colonoscopy in patients with symptoms of lower GI tract diseases and also to assess the yield of colonoscopy in various indications.
Materials and Methods: A retrospective study of patients who underwent colonoscopy from November 2014 to October 2016 at CMCH & RC was done. Data were collected from endoscopy register and analysed.
Results: A total of 513 patients who registered for colonoscopy were evaluated. Male: female ratio was 341:172. Among those 506 patients (98.6%) tolerated the procedure. Caecum could be reached for 91.3% of the patients. Most common indication was bleeding per rectum 25.49%, clinical suspicion of Irritable Bowel Syndrome (IBS) 17.7%, Constipation 15.2%.
The findings were normal study in 36.56%, haemorrhoids: 30.8%, polyp colon: 9.2%, Inflammatory Bowel Disease: 6.52%, carcinoma: 4.74%. Polypectomy was done in 10 cases. Overall yield of colonoscopy was 63.5%.
Conclusion: Colonoscopy is an effective procedure for diagnosing lower GI symptoms. The yield of colonoscopy is high in patients with symptoms of bleeding per rectum, carcinoma colon, anaemia, Ileocaecal kochs..
EnglishColonoscopy, Bleeding per rectum, Yield of colonoscopy
INTRODUCTION
Colonoscopy is the main investigative procedure in patients with suspected lower GI tract diseases. Suspicion of colonic diseases arise when the patients having symptoms such as anaemia, diarrhoea, constipation, abdominal pain, bleeding per rectum, features of malignancy like weight loss, loss of appetite, altered bowel habits7. The current practice is to perform colonoscopy for all the patients who present with symptoms of lower GI tract diseases and it is the better first line investigation1. Colonoscopy is useful to know the exact site of lesion, to confirm the diagnosis by biopsy, or removal of suspected cancerous lesions in polyps2. There are still some controversies regarding open access endoscopic service versus a strict criteria for doing the procedure3,4,5. Selection of the patients for colonoscopy based on symptoms is important, because the colonoscopy helps to detect the malignant lesions as well helps to treat the benign lesions also. Data has been reported from various studies documenting the indications and the yield of colonoscopy in various symptoms of colonic disease6,7. Only few studies are reported regarding the evaluation of indications & the yield of colonoscopy in South India.
The aim of the study is to know the indications of colonoscopy in various symptoms of colonic disease and assess the yield of colonoscopy in these indications in our hospital, a tertiary care centre, in rural part of South India.
MATERIALS AND METHODS
It is a retrospective study of the available data from the colonoscopy procedures performed by the medical gastroenterologist at Medical Gastroenterology Department Chennai Medical College Hospital and Research Centre, Irungalur, Tiruchirapalli, Tamilnadu, South India. Data from November 2014 to October 2016 was reviewed.
Patients with any of these symptoms of (Table.2)
Bleeding per rectum
Clinical suspicion of Irritable Bowel Syndrome
Constipation
Chronic diarrhoea
Anaemia
Abdominal pain
Clinical suspicion of carcinoma colon
Right Iliac Fossa mass & Right Iliac Fossa pain
were included. Patients who attended the Gastroenterology outpatient department, as well as cases referred from the wards were scrutinised by the Gastroenterologist and selected for colonoscopy. Colonoscopy was done after proper bowel preparation. Colonoscopy was done without sedation. Biopsies were taken by the Gastroenterologists discretion. Diagnostic yield was regarded as positive for each of the indication, if the lesion found could account for the symptoms of the patient. Data analysis includes all the cases posted for colonoscopy, including the cases where the colonoscopy not reached up to caecum.
RESULTS
Total of 513 cases selected for colonoscopy.506 cases had undergone colonoscopy. The number of males and females were 66.4% and 33.62% respectively .Age and sex distribution shown in Table.1.
The caecum and terminal ileum was reached in 462 cases(91.3%).The commonest indications for colonoscopy were bleeding per rectum 129 cases(25.49%), and other indications were clinically suspected Irritable Bowel Syndrome (IBS)90 cases(17.79%), constipation 77 cases (15.22%), chronic diarrhoea 39cases(7.71%), clinically suspected IleoCaecal Kochs 35 cases(6.92%),anal fissures 24 cases (4.74%),anaemia 23 cases(4.55%),fistula in ano 17 (3.36%), abdominal pain 12cases(2.37%), clinically suspected colon cancer 11 cases (2.17%),Right Iliac fossa pain & mass 8 cases(1.58%), and surveillance scopy (which includes colonoscopy done for Inflammatory Bowel Disease, melena, Alcoholic Liver Disease, Hepatomegaly, Portal Hypertension, Recto-Vaginal fistula, etc.(Table.2).
Colonoscopic findings were, Normal study in 185 cases(36.56%), haemorrhoids in 156 cases (30.8%), polyp colon 47 cases(9.29%), Inflammatory Bowel Disease (Chrons -9 &ulcerative colitis-24) in 33 cases (6.52%),carcinoma colon in 24 cases(4.74%), kochs lesion in 12 cases(2.37%), proctitis in 9 cases(1.78%), diverticular disease in 6 cases (1.19%),solitary rectal ulcer in 5 cases(0.99%), non specific ulcers rectum in 4 cases(0.79%), pancolitis in 4 cases(0.79%), & others (caecal teleangectasia, porta hypertensive colopathy, pseudomembranous colitis, pin worm infestation, Gastro-Jejunocolic fistula, extraneous compression etc.) in 21 cases(4.15%) (Table.3).
Out of 47 polyps diagnosed by colonoscopy, 15polyps were dimunitive,8 were sessile,20 were Englishhttp://ijcrr.com/abstract.php?article_id=2438http://ijcrr.com/article_html.php?did=2438
Lindsay DC, Freeman JG, Cobden I, should colonoscopy be the first investigation for colonic disease?, BMJ 1988;296:167-169.
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Endoscopic selection committee of British Society of Gastroenterology. Future requirements for colonoscopy in Britain. Gut 1987;28: 772-775.
Wayne JD, Bashkoff E. Total colonoscopy, is it always possible (abstract). Gastrointest Endosc 1991:37:264.
Md Abu Sayeed, Rabiul Islam, Dilruba Siraji, Md Gofranul Hoque, A Q M Mohsen.Colonoscopy: A study of findings in 332 patients. JMCTA 2007;18(2):28-31.
Berkowitz I, Kaplan M. Indications for colonoscopy, An analysis based on indication and diagnostic yield S Afr.Med. J 1993;83: 245-248.
Anders Lassen, Anders Kilander, and Per Ove stotz Diagnostic Yield of colonoscopy based on symptoms Scandinavian journal of Gastroenterology 2008;43:356=362.
Abdulfatai Bamidele Olokoba, Olusegun Ayodeji Obateru, Mathew Olumuyiwa Boju Woye, Samud Adegboyega olatoke. indications and findings at colonoscopy in Illorin Nigeria Niger Med J 2013 Mar-Apr;54(2):111-114.
Mohammed A. Al Shamali, Maher Kalaoui, Fuad Hasan, Abdulkareem Khajah, Iqbal Siddiqe, Basil Al-Nakeeb colonoscopy : Evaluating Indications and Diagnostic Yield Annals of Saudi Medicine, Vol 21.Nos 5-6 2001.
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William D.Chey,Borko Nojkov, Joel H. Rubenstein, Richard R. Dobhan, Joel K. Greenson, Brooks D. Cash. The Yield of colonoscopy in patients with non constipated Irritable bowel syndrome: Results from prospective, controlled U.S trial. Am J Gastroenterol.2010 April;105(4):859-865.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241104EnglishN2018February17HealthcareClinical and Molecular Studies on Thalassemia
English3439Syed Raju AliEnglish Sanjida Sakhawat SintheeEnglish Md. Rafiad IslamEnglish A.S.M. SarwarEnglishThalassemia is a genetic disorder in blood, occurs due to abnormal formation or absent of globin peptide chains of hemoglobin. There are mainly α-globin chains and β-globin chains remain in hemoglobin. When any chain becomes abnormal or dysfunctional then it turns into thalassemia. Defected globin chains are unable to form functional red blood cells, as a result the patients with thalassemia suffer from sever lack of red blood cells as well as available oxygen. The main causes of globin genes disturbance are due to genetic alterations, mainly point mutations. The locations of α-globin genes are at chromosome 16 and β-globin genes are at chromosome 11. β-thalassemia can be divided into three categories, β-thalassemia minor, if one gene is defected; β-thalassemia intermedia, when both β-genes are defected but not at severe level and some chains are functional; and β-thalassemia major, when both globin genes get mutated and globin chains become fully dysfunctional and the patients evolve most of the traits which are responsible for β-thalassemia. Though thalassemia is spread all over the world but every place is not epidemic. Turkey, South Asia, Mediterranean sea area, Iran and some other countries are consider as thalassemia belt. The frequency of thalassemic patients is high at the prevalence zone of malaria because it is considered that thalassemia is against
of malaria. The treatments of thalassemia are very complex, expensive and time consuming. However, blood transfusion is more efficient treatment of thalassemia than others. Besides, bone marrow transplantation and gene therapy are the next generation therapies also under consideration.
EnglishThalassemia, Anemia, Globin chains, Hemoglobin, Blood transfusion, Bone marrow transplantationINTRODUCTION
Disease means feeling some disorder or abnormality in the body, caused by different ways like infection, poison, venom, accident, exposures, radiation and genetically from parents to offspring. Some diseases are connected with blood, very sensitive and normally incurable thalassemia is one of them. Thalassemia is an inherited disorder, one type of hemoglobinopathy and causes by abnormal hemoglobin chains. As a result patients suffer from severe lack of functional red blood cells (RBCs). Though the disease thalassemia has been originated more than 6,000 years ago but in 1925, Dr. Thomas Cooley and his colleagues described the disease for the first time (1). The word thalassemia has come from two Greek words ‘Thalassae’ means ‘Blood’ and ‘Hamia’ means ‘Sea’ and collectively thalassemia means ‘Sea in the Blood’ as a reference of its prevalence in Mediterranean sea area (2). However, decreased amount of RBCs leads to anemia; as a consequence the oxygen-carrying capacity in blood is reduced. Anemia also destructs of erythroblast in the bone marrow, erythrocytes in the peripheral blood and causes ineffective erythropoiesis (3,4). The proper medication of thalassemia of has not been established yet.
Causes of thalassemia
It is considered that various changes in alpha and beta globin genes are mainly responsible for respective thalassemia. More than 200 mutations (more specifically, point mutations) alter the amino acids compositions, later, turn into abnormal globin peptide chains as a result the shape of hemoglobin becomes changed (5,6). Moreover, inappropriate mRNA splicing, imprecise protein folding also can generate thalassemia at any stage of life. Furthermore, if one or more globin genes become dysfunctional or mutated then at least there is a chance for a person to be a carrier of thalassemia (Table-1).
Thalassemia prevents malaria
In 1945, J.B.S Haldane observed that the frequency of thalassemia is high at the prevalence areas of malaria. Nevertheless, at those belts the thalassemic carriers were surviving more than non-thalassemic persons (7). Haldane hypothesized that the mutations in globin genes were somehow prevented the deadly case of malaria though the mechanism was not clear. That protection was randomly and the parasites of malaria could not complete their life cycle in abnormal red blood cell.
Transmission probability of thalassemia from parents to children
When both parents are healthy means do not have any mutation or defect in globin genes then there is almost no chance to transmission of thalassemia from parents to children. If one of parents is either affected or carrier, then there is a chance for children of being thalassemia carrers. However, when both of parents are carriers then according to the first law of mendel there are 25% chance for a child to be totally healthy, 50% chance to be a carrier and 25% chance to be a patient of thalassemia (Figure-1).
Epidemic zone of thalassemia
The prevalent area of this disorder is known as Thalassaemic Belt. Iran is a high prevalent zone of thalassemia. Alpha thalassemia commonly found in the South Asia and in Southern part of China. However, Beta thalassemia is widely spread in the world commonly found in the Mediterranean sea area, the Middle East, the mainly the Indian subcontinent, Russia and Northern part of China (5,7,19). Previously thalassemia was known as one of the most common inhered Hemolytic Anemia in South East Asia (20,21).
Types of thalassemias
Thalassemias are heterogeneous group of Mandelian disorders, which are characterized by the abnormal synthesis of α or β-globin chain of hemoglobin. Thalassemia also can be classified according to the modicum in the globin chain formation. There are four hemoglobin chains which are divided under two main types are Alpha (α) chains and Beta (β) chains. There are also some auxiliary chains associated with alpha and beta chains are known as gamma (γ), delta (δ), zeta (ζ), epsilon (?) (20). These auxiliary chains are also responsible for thalassemia. There are four genes which responsible for formation of α-globin chains and two genes for β-globin chains. When one or more genes related with α-globin chains become defective or mutated then it causes α-thalassemia. Same as, defective genes for β-globin chains are responsible for β-thalassemia.
1. Alpha thalassemia
Alpha thalassemia is a genetically autosomal recessive defect caused by decrease production or total absence of alpha globin peptides due to mutation in associated genes. Mainly deletions of nucleotides occur in one or more of four alpha globin genes. The respective genes of alpha globin are present in chromosome number 16. The normal feature of α-globin gene is indicated as αα and its genotype is indicated as αα/ αα. When mutation occurs in one or both globin genes then it is mentioned as “_ α” or “_ _” respectively. These also represent the most common forms of α-thalassemia. It is more common in South Asia than any other zone of the world (22).
Types of α–thalassemia
Clinically, both forms of deletional and nondeletional α-thalassemia can be broadly classified into four categories depending on the number of functional α-globin genes.
Type-1: When four genes are mutated then following category is known as Haemoglobin (Hb) Bart’s hydrops or α-thalassemia major (_ _ /_ _) (22,23).
Type-2: When there is inheritance of just one functional α-globin gene out of four genes (_ _/ _ α) then it is known as Hb H disease or α-thalassemia intermedia. Patients with Hb H due to nondeletional types show chronic haemolytic anaemia of severity than with deletional type (23,24).
Type-3: If two genes of α-globin are infected or mutated in cis or trans position so the talassaemia is called α-thalassemia trait or α-thalassemia minor, results in heterozygousity for α0 thalassemia (_ _/ αα) and homozygosity for α+ thalassemia (_α /_ α) (23).
Type-4: When three genes of α-globin chain are functional and only one gene is defected or dysfunctional (_ α/ αα) then it syndromes as α-thalassemia silent carriers and exhibit no clinical abnormality (23). (Note: Here ‘_’ indicates mutation in the α-globin gene)
2. Beta thalassemia
In general, most of the thalassemia is descendent from parents to children as autosomal recessive traits. Beta (β) thalassemia is originated by a group of genetic disorders of β-globin genes, present in chromosome number 11. Mutations in β-globin genes lead to either decreased amount or completely absent of β-globin polypeptide which results abnormal hemoglobin (Hb) in red blood cell (RBC) consequently turns into Anemia (25).
Symptoms of β-thalassemia
Phenotypically β-thalassemia is known by several signs and syndromes. If a patient carries these symptoms, then a physician preliminary can determine that the patient may have β-thalassemia. These are: anemia variable severity, dark urine, enlarged abdomen, liver, spleen, feeding problems (infant), susceptibility to infection, jaundice and so on (26).
Types of beta thalassemia
There are three main classes of beta-thalassemia based on disease acuity, β-thalassemia minor, intermedia and major.
i) Beta-thalassemia minor
If a single gene of β-globin chains becomes mutated of dysfunctional any how then thalassemia minor originated silently. The patients of minor β-thalassemia may not expose any symptom during the disease except occasional reduced anemia and sometimes patients may require blood transfusion. It may be inherited when both parents carry a single mutated gene of β-globin and risk at every child will remain under 25% risk of homozygous β-thalassemia (26,27).
ii) Beta-thalassemia intermedia
Beta-thalassemia intermedia is the middle phase/condition according to the severity of thalassemia disorder. Here, one or both β-globin genes may be mutated but the β-globin chains will not be totally present or absent and after a certain time it turns into β-thalassemia major. The patients of β-thalassemia intermedia generally suffer from defects in different bones, deformities of face, osteoporosis, ulcer in legs, increased thrombosis, stroke, pulmonary embolism and so on (26,28). Moreover, iron overload in intestine and hypogonadism effect are other alarming concerns. The patients require frequent blood transfusion and regular medication (29).
iii) Beta-thalassemia major
Βeta thalassemia major occurs when both β-globin genes become mutated or fully unable to function; as a result β-globin chains remain absent in hemoglobin. If the patients of β-thalassemia major remain poorly transfused or untreated then the clinical features of β-thalassemia major are evolved. A patient who is suffering from severe β-thalassemia major, usually bears a lot of physical and morphological changes in various organs of his/her body. Mainly size and shape of liver and spleen become abnormal, deformities in the femurs, typical craniofacial changes in the skull, depression of bridge in the nose, some changes in the teeth placement also can be found among the patients (28). The patients need regular blood transfusion or successful bone marrow transplantation and regular observation by experience physicians and staffs.
TREATMENTS FOR THALASSEMIA
The patients are affected with thalassemia, considered ‘Half-Related Quality Of Life (HRQOL). The complete medication or curing has not been established against thalassemia. However, there are some supporting treatments which are referred and applied to the affected patients to reduce the severity of the disease. The most potential treatments are:
i) Blood transfusion therapy
Regular blood transfusion is the most common treatment of thalassemia intermediated and major. The routine of blood transfusion and amount of blood depends on the severity of the disease; however, it may be once a month or two months or six months. The most concern of blood transfusion is the quality and homogeneity of donor blood (30). The blood must bears some criteria such as, donor and recipient blood group and rhesus must be same, diseases and contamination free, allergy free, pathogens screened, and blood components complying with standard guidelines by the National Blood Centre. In this case, nursing staffs must bear high experiences and the patients, receiving blood transfusion need regular quality care.
ii) Bone marrow transplantation (BMT)
Blood is produced in bone marrow which contents some hematopoietic stem cells having a capacity to form different blood cell components. If the bone marrow of a healthy donor can transplant to a thalassemic patients properly then there is a chance to recovery normal RBCs production by the patient in vivo. The first successful BMT of β-thalassemia was in 1982 (31). A successful BMT therapy can lead to a success of β-thalassemia free survival significantly but the main challenge of BMT is adjustment of donor bone marrow with recipient. In general, our body system either reject any foreign elements directly of makes a antigen antibody reaction. In the case of BMT, it is subjected to finding a donor with an identical Major Histocompatibility Complex (MHC). Homologous linage is another important issue, as donors healthy parent, sibling and near relative are better choice (26,32).
iii) Hydroxyurea therapy
Lack of functional globin chains can be back up by enhancing γ-globin chains synthesis. However, the increased number of γ-globin chains reduce α and/or β-globin chains imbalance; potentially, γ-globin leads to progress RBCs. Hydroxyurea is a pharmacologic agent that increases γ-globin production and boost up fetal hemoglobin (HbF) (33). So it is considered as a alternative therapy for patients, suffering from β-thalassemia. The considerable advantage of increased expression of γ-globin gene is that it regulates the production of excess α-chain (34).
iv) Gene therapy
The gene therapy has been a next generation concept to cure thalassemia, though the success rate is not significant till now. It focused on utilizing retroviral vectors to insert desire globin genes into the target cell, so that the genes become capable to integrate with host cell genome precisely. The expectation of gene therapy is to avoid abnormal gene expression or silencing but long term normal gene expression orderly. Nevertheless, to be an effective and realistic therapeutic approach gene needs to meet the following criteria: a) donor and recipient should have lineage specificity; b) the therapeutic vector should exhibit stability; c) gene of interest must have respective regulatory elements; d) proper trans-gene expression and precise localization at sustainable levels; e) the therapeutic process must be safe and contamination free and so forth (35).
DISCUSSION
The diseases which are not linked with permanent genetic changes are fully curable by proper medication, care and exercise. But the diseases are descendent from parents to offspring genetically are not easy to think to cure properly. Thalassemia is an inherited autosomal recessive disorder; it passes from generation to generation by vertical gene transformation. It is not possible to remove the disease from the patients permanently. However, the disease can be controlled by some managements and regular practices.
To prevent thalassemia there is another option at prenatal stage. The parents should have definite diagnosis and appropriate counseling on their health condition. Everyone should check him/herself that either he/she is a thalassemia carrier or not. If both of couple are carriers then they need counseling regarding their chance of having an affected child. There are some genetic markers which can differentiate among affected patients, carriers and unaffected healthy.
Nevertheless, besides blood transfusion it is essential to develop next generation novel drugs for the patients who are suffering from thalassemia and its side effects. Artificial hemoglobin or RBCs production and successful combination with blood stream may be a breakthrough in the treatments of thalassemia. Moreover, chelating agent preparation is also important which can capture free iron and reduce iron overload in the blood of the patients.
The patients who do not get proper and sufficient treatment can suffer from several complications, such as increased size of spleen, heart failure, frequently clot formation inside blood vessels, high susceptibility microbial infection growth failure, endocrine dysfunction, delayed sexual maturity and so on.
CONCLUSION
Thalassemia is a very serious inherited disorder present among hundreds of thousands of people. It starts from beginning of the life and the frequency of the disease can be observed among infants and babies because the patients do not exist longer. Though it is considered that several mutations are the main causes of thalassemia but most of the cases it descendents from ancestor to new progeny. Affected or carrier parents may give birth a affect baby or a carrier. It is a matter of sorrow that no proper treatment has been developed yet to cure thalassemia fully, it can control only for some times. Though there are some treatments existing but not free from side effects or limitations, moreover, the treatments are very expensive and time consuming. It is matter of hope that thousand of scholars and scientists are trying to remove the disease by inventing novel drugs. Gene therapy, bone marrow transplantation and induced pluripotent stem therapy are also going on besides blood transfusion. Prenatal diagnosis and counseling can lessen the frequency of affected new born babies. To make worldwide awareness about thalassemia the World Health Organization (WHO) has declared 8th May as international thalassemia day since 1994.
ACKNOWLEDGEMENTS
The authors would like to sincerely acknowledge to the scholars whose valuable articles helped to write this review article; specially grateful to Mr. Md. Sakhawat Hossain for his excellent support and also grateful to Mr. Md. Arif Khan and Mr. Mohammad Uzzal Hossain whose suggestions were valuable to write the article.
ABBREVIATIONS
1. A: Adenine
2. C: Cytosine
3: G: Guanine
4: T: Thymine
Englishhttp://ijcrr.com/abstract.php?article_id=2439http://ijcrr.com/article_html.php?did=2439
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241104EnglishN2018February17HealthcareSelf Medication Problem in Egypt: A Review of Current and Future Perspective
English4045Khaled KasimEnglish Haytham HassanEnglishSelf-medication is a common practice in developing countries, including Egypt, but little is known about its epidemiology as well as the future plan needed to overcome this problem. This future perspective article aimed to describe the current situation of this problem in Egypt and the prospective vision of the author about this problem and the future plan needed for its prevention and control. Egyptian literatures in English language about self medication from 1995 onwards were searched through a web-based medical database during September, 2015 and articles concerned with this issue was retrieved and reviewed. The reviewed literatures, although sparse, showed a considerable high prevalence of medication abuse among Egyptian population in the recent years which was as high as 86.4% in certain Egyptian governorate. Moreover, there has been lack of studies about other epidemiologic aspects of this problem in terms of its distribution and determinants, its health and economic impacts, and its prevention and control strategies. The present article pays the attention of public health personnel, university and medical researchers to carry out more studies and to increase awareness of general population, students, senior physicians, pharmacists, and organizations about this serious public health problem. In addition, the author presented his prospective view to combat this problem through short and long-term preventive and control plan.
EnglishAbuse, Egypt, Intervention, Medications, Misuse, PreventionIntroduction
Self-medication is defined as the use of medications without consulting a doctor regarding indication, dose and duration of treatment (1). Self medication represents an aspect of self-care behavior in which the person does by himself to establish and maintain health, preventing and dealing with diseases (2). The public health importance of self-medication increased when in 1980s World Health Organization (WHO) approved switching of some medications to non prescription status to be sold over-the-counter (OTC) without any prescription in order to reduce the burden on health care professionals (2,3). Subsequently, patients can bypass the health care system and purchased most of medications from private pharmacies without prescription (4).
In Egypt, as in many Middle East countries, medications can easily be obtained over the counter and this is represented a serious public health problem in these countries. The prevalence of medication abuse was progressively increased in Egypt during the last two decades. An earlier study on drug utilization among children in Alexandria in 1995 reported that 21.1% of purchased medications were not prescribed (5). One year later, the prevalence was 72% in a cross sectional study including 25 private pharmacies in Alexandria city (6). Much more recently, in a community-based survey in the same city, however, the prevalence of medication abuse was increased to be as high as 86.4%; the most commonly used drugs were analgesics (96.7%), and cough and cold preparations (81.9%), while antibiotics abuse was 53.9% (7). In Cairo, a cross-sectional study of antibiotic dispensing was carried out to describe the pattern of antibiotics dispensing in 36 pharmacies in greater Cairo. They found that 23.3% of the recorded antibiotics were dispensed upon pharmacist’s recommendation and in the studied pharmacies and 13% upon patient request (13). Antipyretic misuse was also reported in a recent hospital-based study El-Shataby hospital, Alexandria city, where 140 out of the studied 200 women (70%) reported that they gave un-prescribed antipyretics for their children under 5 years complaining of fever, and common cold (9). Most common reasons towards self medication practice in the above mentioned studies was to avoid long waiting periods in hospitals, minor illness, and reduce cost to save money.
Up till now, however, there is no legislation or restrictions on self medication, particularly for antibiotics that may lead to the emergence and spread of antibiotic resistance of different types of pathogenic bacteria with a consequent failure of antibiotic therapy and higher mortality and morbidity and prolonged hospital stay (10,11). The literature showed shortcoming of the Egyptian studies concerned with health and economic impacts of self medication, and in particular antibiotics misuse.
This study aimed to review the current situation of self medication problem among Egyptian population in order to depict a prospective vision about this problem with the purpose to develop a future plan to overcome this serious public health problem.
Methods
Studies about medication abuse were reviewed from several electronic databases, such as PubMed, Scopus, and Google Scholar. Egyptian articles published in English language from 1995 onwards and concerned with all health related aspects of this problem were retrieved and reviewed. The search was done during September, 2015. The search terms used in searching process was "Medication", "Self medication", "Antibiotics", "Abuse", "Misuse", "Overuse", "Antipyretics", "Vitamins", "Bacterial resistance", "Antimicrobial resistance", "Prevalence", "Determinants", "Impacts", Surveillance", "Prevention" and "Intervention". The word “Egypt” and "Egyptian" has been added to all terms used in the searching process, and reference lists of relevant articles and reports were checked. Visiting World Health Organization (WHO), Center of Disease Control (CDC), and ministry of health and population (MOHP), Pharmacy Syndicate websites were also done during searching process.
Epidemiology of medication abuse problem in Egypt
The articles retrieved and reviewed from Egyptian literature concerning medication abuse were relatively few (10 studies) and are presented in table 1 (5-9, 12-16). Four of these studies were published as early as during the last years of 20th century (5,6,12,15) and 6 articles were published during the period from 2009 to 2015 (7-9, 13,14,16). Of these studies, there have been three studies involved private pharmacies (6,8,13), three studies were hospital-based (5,9,14), two studies among university students (12,16), one study was outpatient clinic-based (15), and one study was community-based (7). Also, the published articles were found to be conducted in three Egyptian cities; five in Alexandria (5-9), four in Cairo (13-16), and one in Assuit city in Upper Egypt (12).
With the exception of one study (14) which studied only the prevalence of self medications, all other studies were studied the prevalence of self medications and some related factors of its practice. However, none of these studies have discussed the impacts of self medication in terms of antimicrobial resistance and economic impacts. Furthermore, no study has discussed the surveillance and strategies needed to combat this important public health problem, and most of these studies were concerned only with knowledge, attitude and practice of the studied subjects towards medication abuse.
Prevalence and determinants studies
Before 21th century, and according to the results of published studies during this period, the prevalence of medication abuse among Egyptian population was ranged from 21.1% to 72% (5,6,15). Among university students, medication abuse was found to be 66.1% in a sample of Assuit university students (12). The abused medicines in these studies include analgesics, antipyretics, antibiotics, cough sedatives and medications for diarrheal diseases.
There has been a gap of knowledge about the prevalence of medication abuse in the Egyptian literature during the period from 1998 to 2008. Thereafter, the prevalence of self medications showed wide variations with the highest prevalence was found in a recent community-based survey including 1100 adults in Alexandria city, where the prevalence of medication abuse was 86.4%. Among these subjects, the most commonly used drugs were analgesics (96.7%), and cough and cold preparations (81.9%), while antibiotics abuse was found in only 53.9% of the studied subjects (7). The lowest prevalence, however, was reported a cross-sectional study of antibiotic dispensing was carried out to describe the pattern of antibiotics dispensing in 36 pharmacies in Greater Cairo. They found that 23.3% of the recorded antibiotics were dispensed upon pharmacist’s recommendation and 13% upon patient request in the studied pharmacies (8), with overall self medication prevalence was 81.1%.
A high prevalence of self medication was also reported in a recent university study conducted on a random sample of 330 medical students from Ain Shams University (16). In that study, the overall prevalence of self medication among the studied students was 55.2%, and it was 58.8%, 54.4% and 87.2% for antibiotic, vitamins and analgesics, respectively. A significant higher rate of analgesic (62.7%) and vitamins (91.5%) misuse were also found among the studied female students (16). For other medications abuse, the prevalence of antipyretic misuse was high among women attending El-Shataby and El-Ramal children hospitals, Alexandria city. Out of the studied 200 women, there have been 140 women (70%) reported that they gave un-prescribed antipyretics for their children under 5 years complaining of fever, and common cold (9).With the exception of only one study (14), all other studies have reported some reasons of self medications. The most common reasons towards self medication practice cited in the above mentioned studies was to avoid long waiting periods in hospitals and/or clinics, minor illness, and reduce cost to save money, clients claimed that they knew the treatment from a previous prescription, had confidence in the pharmacist, and recommendation from the pharmacist. Other reported factors were related to level of education, and lack of knowledge and health education about the dangerous effects of medications without physician prescription. However, these factors were presented in proportions and no further analyses were done to get the exact risk of these factors on the practice of medication abuse among the studied subjects. Other factors related to accessibility and affordability of health services, public and environmental and lifestyle factors, however, were not discussed in the previous studies and have to be considered by the researchers in the upcoming studies.
Impacts of self medication
The impacts of medication abuse have been globally restricted to the impacts of antibiotics misuse on the microbial resistance and its associated health and economic effects. In Egypt this issue has been reported in only one study (17). This study has reported a high resistance rate to antimicrobial agents in surgery and intensive care units in Cairo university hospitals, and attributed this to the bad hospital hygiene and misuse of antibiotics. In that study, the highest resistance rate was shown by Staphylococcus Aureus (23.8%), Pseudomonas (14.9%) and Escherichia coli (10.5%).
For other impacts of medication abuse; such as economic impacts, The Egyptian literature showed no studies about this issue. Only one study calculated the mean cost of drugs per encounter which was LE 7.29 (8). Of course, this finding was not actually representing the meaning of economic impacts as result of health related problems (higher morbidity and mortality and prolonged hospital stay) encountered in medication abuse, particularly with antibiotics misuse.
Antibiotics abuse is known to be associated with bacterial resistance, and the United States has reported at least 2 million people become infected with bacteria that are resistant to antibiotics and at least 23,000 people die each year as a direct result of these infections (18). The Institute of Medicine has estimated the annual cost of infections caused by antibiotic-resistant bacteria to be US $4 to $5 billion, and the misuse of antibiotics increases antibiotic resistance infections and costs the US health care system over $20 billion each year (19).
Future perspective of upcoming studies about self medication in Egypt
From the epidemiologic points of view, the Egyptian literature about self medication was sparse, and the published studies showed several limitations. Of these limitations, the studies were restricted to only three cities in Egypt; Cairo, Alexandria, and Assuit, and accordingly, their results did not reflect the exact magnitude of this problem among Egyptian population. Also, the included small sample size found in some studies in terms of; included pharmacies, hospitals, health care workers as well as general population, and the vagueness about the sampling size and techniques in other studies might threaten the representativeness of the samples and the potential of selection bias. According to the last human resources for health in Egypt, published in 2011 by MOHP in collaboration with WHO, the number of licensed pharmacies was 139,479 in all sectors, the number of pharmacists in public sector was 15,457 and the number of physicians and nursing personnel in all sectors was 223,203 and 280,561 respectively (20). Moreover, the study population, hospitals and pharmacies included in these studies were only from urban communities. No data about self medications were found for rural communities which represent 50.9% of the Egyptian population, according to the World Bank data in 2014 (21).
Many risk factors which are known to influence this problem were not examined in the published Egyptian population, and the studied factors were presented in simple proportions with no calculation of the exact risks was done in almost all studies. Finally, there has been a great lack in studies concerned with the economic and health impacts of medication abuse and there were very few studies investigated bacterial resistance associated with antibiotics misuse which represent the most important misuse in the self medication issue, not only in Egypt but also worldwide.
Understanding the epidemiologic aspects of any public health problem in terms of its dynamic (prevalence), distribution, and determinants, represents the cornerstone in its prevention and control. Accordingly, the first step in dealing with this problem in the future is to conduct a well designed large national study through the Ministry of Health and Population (MOHP) to know the exact magnitude of the problem all over the country. As such studies need a big fund and the only institution in Egypt capable of funding such large national study is the MOHP, its role is mandatory. Also, universities in different Egyptian governorates, particularly medical faculties, have to carry its responsibility to search such problem in its governorate using a large well designed stratified multistage sample including primary health care centers and pharmacies (private and governmental) in urban and rural areas, different sectors of population, and physicians from different hospitals in the studied governorate. Also, collaboration of different medical departments such as community medicine, microbiology, may be of value in studying the bacterial resistance resulted from antibiotics misuse. Economists from faculties of commerce and economy have to be invited to participate in studies concerned with the economic aspects of this serious public health problem.
Prevention and control
In Egypt, the prevention and control studies about medication abuse were lacking and there was no clear protocol for surveillance and intervention of this problem in terms of prevention and control. On the other hand, however, Several Western studies have investigated the intervention strategies against medication abuse, although most of these studies have stressed on planning of surveillance and intervention protocols to reduce antibiotic misuse and its impacts (22-25). These protocols included health education campaigns; professional education as well as public awareness campaigns.
The best intervention protocol should relay on discovering the most influencing factors associated with this problem, patients’ knowledge and behavior, professionals’ knowledge and routines, and the organization of care (26). It is pertinent here to note that epidemiologic studies have to play an important role in choosing the suitable intervention program; through descriptive and analytic studies of all problem aspects, and to evaluate the effect of the chosen program later on.
The future perspective of prevention and control strategies for medication abuse has to go though two parallel plans; short-term and long-term plans. The short-term plan will be dependent on the role of physicians, pharmacists and other governmental and nongovernmental organizations in the community. The aim of this plan is to increase awareness of the public towards the hazards of self medication and its adverse health and economic impacts through well designed and effective short messages delivered though mass media, as well as primary health care centers, pharmacies and hospitals. There must also be proper legislations and regulations to limit the sale of medication without prescription. Moreover, the role of pharmacist is essential in this short-term plan as a communicator, a quality drug supplier, and as a trainer and supervisor. The establishment of the new clinical pharmacy program in some faculties of pharmacy in Egypt may help to graduate pharmacists with proper knowledge and skills to perform such functions necessary to reduce the problem of self medication among population.
The long-term plan should stress on the current situation of the magnitude of this problem and its influencing factors in the Egyptian community. This step could be carried out through conducting a large national study as previously mentioned. According to the results of this proposed national study, the policy makers will have a clear view to design intervention strategies to be applied all over the country. The strategies have to include:
Students: Introducing curriculum courses about this problem for university students including medical and paramedical students. Also, educational training program about the hazards of self medication should be tailored for preparatory and secondary school students
Physicians: Training courses about this problem through the continuing medical education programs.
Pharmacists: The pharmacist must be encouraged to participate in continuing professional development activities such as continuing medical education programs. The pharmacist is often assisted by nonpharmacist staff and those must follow pharmacy educational and training courses.
General population: Increasing their awareness about this issue through different methods of mass media. As mothers, one of the most important population sectors, appeared to have a great impact on the success of any prevention and control programs, special care should be given to them through well designed health education courses delivered in Maternal Child Health (MCH) care units distributed all over Egypt.
Introducing a monitoring and surveillance unit in both MOHP and pharmacists syndicate. Monitoring has to include the advertisements of medicines both in print and electronic media, particularly for vitamins, tonics and herbal medicines.
Expanding health insurance coverage to involve all Egyptian population.
Enhancing the role of family medicine, family physicians and clinical and community pharmacists.
Establishing Pharmaceutical Supreme Council with its aim: To review and refine overthe-counter (OTC) in Egyptian pharmaceutical constitution, rationalization of drug utilization, and to put the new policies and legislations that suits the magnitude and impacts of self medication problem in Egypt at the present and future time.
Redistributing the Budget of health research projects provided by Egyptian MOHP to include those projects proposed to probe this public health problem in its different health and economic aspects.
Conclusions
Medication abuse is a serious public health problem worldwide, particularly in developing countries. Although sparse, Egyptian literature showed a considerable high prevalence of self medication, particularly for antibiotics, analgesics and vitamins. On the other hand, however, there is great lack of studies regarding other epidemiologic aspects of this problem. Furthermore, no surveillance and intervention studies were found in the reviewed Egyptian literature.
The prospective vision should include the conduction of a large national study all over the country to get sound and accurate epidemiologic data about all aspects of this problem. The proposed prevention and control measures should go in two parallel plans; short-term and long-term plans. The short-term plan should stress on increasing awareness of the public, and developing proper legislation and regulations.
The long-term plan should be primarily based on the conduction of national large study to help policy makers to apply the intervention strategies and policies suitable for Egypt and according to the contributing factors of this problem. The long-term plan has to include measures to refine over-the-counter, enhance monitoring and surveillance systems, including self medication problem in the curriculum of health sciences faculties, encourage the researchers to carry out more studies about this problem in different Egyptian governorates, expand the health insurance coverage, enhance the role of family medicine, and provide more funds for self medication researches.
Englishhttp://ijcrr.com/abstract.php?article_id=2440http://ijcrr.com/article_html.php?did=2440
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El-Nimr NA, Wahdan IM, Wahdan AM, Kotb RE. Self-medication with drugs and complementary and alternative medicines in Alexandria, Egypt: prevalence, patterns and determinants. East Mediterr Health J 2015;21(4):256-265.
Sallam SA, Khallafallah NM, Ibrahim UK, Okasha AO. Pharmacoepidemiological study of self medication in adults attending pharmacies in Alexandria in Egypt. East Mediterr Health J 2009; 15:683-691.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241104EnglishN2018February17HealthcarePrevalence of Risk Factors for Diabetes Among Construction Workers in Majmaah City, Saudi Arabia
English5560Mohammad Shakil AhmadEnglishBackground: Considering the fact that diabetes is one of the most prevalent non – communicable diseases in the world today, secondary prevention can at best prolong life of those affected by it. But arguably it has been proved time and again that primary prevention will always lead to a better quality of life. Risk factors have been the major factors studied worldwide to prevent diabetes and due to a high rate of migration of people around the world it should be considered as an essential tool to diagnose the risk of diabetes among migrants.
Purpose: The aim of the study was to assess the risk factors that play a significant role in causing diabetes among construction workers.
Methods: The risk factors data was collected from 120 (150) construction workers (response rate=80%) staying in two residential compounds. The workers were asked to fill in a pre – tested, structured and close-ended questionnaire to evaluate the risk factors. In addition, we measured the BP and BMI by using weight scale, measuring tape, and mercury sphygmomanometer.
Results: The results showed that construction workers had an acceptable quality of life but the risk factors were also present that could pose a threat in future to the development of diabetes mellitus. 95.5 % ate all types of food without any consideration. 21.7 % of them were above the normal weight. 62.5 % were sleeping less than 7 hours, which increased the stress level.
Conclusions: Construction workers have good quality of life in Saudi Arabia. However, prevalence of modifiable and nonmodifiable risk factors for developing DM is considerable. Primary preventive measures need to be inculcated to reduce it to a level where it ceases to be a public health problem.
EnglishExpatriates, Asians, Risk factors, Diabetes mellitus, Saudi ArabiaIntroduction
Diabetes mellitus is a chronic metabolic disorder, which has affected all part of the world, and its prevalence is still increasing. The people living with diabetes are vulnerable to various complications both long term and short term.
According to WHO more than one in three adults worldwide has diabetes – a condition that causes around half of all deaths from stroke and heart disease. It has also published that that 347 million people worldwide have diabetes out of which more than 80% of people with diabetes live in low- and middle-income countries with a grim projection that diabetes death will double between 2005 and 2030.2. It is important to note that diabetes is a multifactorial disorder, which is common in genetically susceptible individuals who are, exposed to environmental risk factors especially those who are employed in stressful and difficult environment condition.
Saudi Arabia is one of the largest labor markets in the world with 11 million foreign workers from more than 100 countries work in different sectors and fields. Saudi Arabia is committed to achieve the milestone of Vision 2030 and all efforts are being aimed at making labor market more attractive to foreign workers.
With the globalization of oil and gas industry Saudi Arabia has become an important work destination for many expatriate workers from various countries. Among expatriate workers, common health problems include alcoholism and respiratory problems caused by sand and dust in the air – a situation exacerbated by continuous construction work in most states.
There is lot of evidence available from Multiple studies in the past that there is a much higher prevalence of cardiovascular diseases risk factors among expatriates living in a foreign country compared to their own country of origin. There has been mention of few studies in the gulf region about workers health problems like urinary tract infections, hepatitis E infections, accidents and injuries etc. but very rarely any studies have covered health problems like diabetes mellitus among the expatriate workers.
Contributing to the above factors it has been determined that working in shift may itself be an independent risk factor for sleeping quality, diabetes and hypertension even in retired workers. Applicable intervention strategies are needed for prevention of sleep loss, diabetes, and hypertension for shift workers.
With this occupational and environmental background we felt there is a need to look into the risk factors for non – communicable diseases especially diabetes mellitus among apparently healthy non – Saudi construction workers and assess their health behavior and habits that can determine their chances of having the disease in the future.
Research Problem and Motivation:
This was a baseline pilot study to find out the association of risk factors for diabetes and hypertension among the immigrants workers and their knowledge and attitude toward its prevention in Majmaah, KSA.
Research Methodology:
It was a cross – sectional study of the prevalence of risk factors among the expatriate construction workers for diabetes and hypertension. It consists of two parts:
An interview based pre – tested close-ended questionnaire administered to the participants and the responses entered by the interviewee.
An anthropometric assessment to measure BMI and recording the blood pressure in an ambulatory position.
There were six residential compounds of construction companies in Majmaah where the expatriate workers were residing. Cluster sampling method was used to select two residential compounds for the study. Since this is a baseline study to find out the prevalence of risk factors for diabetes and hypertension among expatriate workers, a complete enumeration method was used to include all the resident workers (150) in the study who were residing in the selected residential compounds.
Total duration of the study was 6 months. The data collection took around 2 months to complete as planned.
Training was given to the data collectors on conducting the survey. A language translator was present during the survey to resolve any issue of communication gap between the investigators and the participants.
The data collected with the aid of:
A pre – tested, structured and close ended questionnaire was administered by the investigators to the study participants.
A human electric weighing scale calibrated to the nearest 0.5 kgs used for taking weight.
A measuring tape – each 1cm 10 line 5line mean 1\2 cm was used for measuring the height of the participants to calculate the BMI
A blood pressure instrument – calibrated to the nearest 0.5 mm of Hg used to take the blood pressure in the sitting position.
Data analysis was done using SPSS version 20.0 for assessing the qualitative data.
Ethical Considerations
Participation consent from the workers was taken in the beginning of the study. They were briefed about the advantages to them as well as to the community due to their participation. All information kept purely confidential and to be used only for the purpose of statistical analysis.
Limitations
Due to difference in the mother tongue of the participants and the interview a slight probability of communication bias cannot be ruled out.
Inclusion and exclusion criteria
All the workers who are not citizens of Kingdom of Saudi Arabia were included in the study.
Any study participants who voluntarily refused to participate in the study were excluded.
Results:
A total of 120 expatriates (70.6%) participated out of a study sample of 170 residing in the residential compounds of a construction company in Majmaah, KSA. Most of the participants are native of Philippines, India and Pakistan. (Fig - 1)
The mean age of the participants was 35.25+8.78 years. Most of them are married (76.7%) but have left their family behind in their native countries. Even though majority of them are carpenters, there are 16 different occupations that the workers are involved in. Most of the workers come from a poor background (46.9%) but almost 36.7% have finished their education till the secondary school while only 10% are illiterate (Table – 1) (Table – 3)
An analysis of the modifiable and non-modifiable risk factors was done from the data collected and it was found that most of them are at risk of diabetes and hypertension.
It was found that 28.3% of the study populations were more than 40 years old and at an increased risk though the family history for the presence of diabetes and hypertension was not significant.
An analysis of the dietary habit showed that even though almost all of them prefer to have homemade food, the regular intake of fruits and vegetables is abysmally low at 4.2%. The dietary habit as shown in (Table – 2)
Looking into the lifestyle preferences of the study participants it was found that 69.2% did exercises like brisk walking on a regular basis while the rest either were irregular or didn’t do any at all. (Table – 4)
Majority of them were either tea or coffee drinkers (92.5%) while more than half (58.3%) consumed aerated drinks on a regular basis. About 12.5% had a history of alcohol consumption in the past. It was also found that more than 22% of the participants smoke on a regular basis. (Fig – 2) The average duration of sleep for most of the participants (62.5%) was less than the recommended minimum of 7 hours per day for keeping good health. (Table – 3)
On calculating the basal metabolic index (BMI) it was found that more than 21% were in the overweight and obese category. (Fig. 3) Even the waist circumference (mean 90.27+9.5 cm) among the 42.5% participants was more than the recommended 90 cm.35These are indicative of at risk population for diabetes and hypertension.
The measurement of blood pressure showed that more than 26.5% of the participants were having a high normal systolic reading (120 – 139 mm Hg) while 19.2% recorded more than 140 mm of Hg. Similarly, 33.3% had a diastolic blood pressure reading of more than 90 mm of Hg. A sizeable number of participants (19.2%) had a high normal diastolic reading between 80 – 89 mm of Hg. This is based on the classification given by the Joint National Committee; USA.36
Discussion:
Analysis of the data shows that on average the expatriates have a good quality of life during their stay in Saudi Arabia with easy access to basic amenities like food, clothing and proper accommodation. Furthermore, since they don’t find the local food acceptable, they prepare the food themselves when they are back from work. This study has shown that there is a significant proportion of expatriates who have non-modifiable and modifiable risk factors for diabetes and hypertension.
The results have shown that more than 28.3% of the study population was aged more than 40 years which according to other studies37 is one of the non – modifiable risk factors for developing diabetes and hypertension. The total number of participants with a positive family history was not significant which was in contrast to other studies38, 39, 40that showed a positive correlation between family history and the risk of getting diabetes and hypertension.
Lots of literatures have discussed the harmful effects of smoking and significantly its association with developing cardiovascular diseases among chronic smokers. Thus, there is documentation of a direct causal association between smoking and diabetes41, 42 and this study showed that more than 22.5% of the participants were smokers.
Dietary habit has significantly contributed single handedly to lifestyle diseases both in developed and developing countries. In our study we found that 95.8% of participant ate all types of food while very few took fruits and vegetables in substantial amount for health benefits. Similar studies have indicated that most of the people who consumed non – vegetarian food are at increased risk of diabetes and hypertension.43, 44
The prevalence of overweight among the participants was 20% and around 1.7% was found to be obese. Many studies45 have cited a direct association between obesity and non-communicable diseases like diabetes and hypertension. Our study showed that there was little awareness among the expatriate workers regarding obesity being a risk factor for diabetes and hypertension. A significant number of participants (42.5%) had waist circumference above 90 cm which is a risk factor for cardiovascular diseases as given by the WHO.46
An assessment of the frequency of doing physical activity among the expatriates showed that around 30.8% were not exercising even for a minimum of 3 days a week as suggested by the WHO47 to maintain a healthy lifestyle. This showed that they were at increased risk of developing chronic health disorders as supported by similar articles showing this association48
In study done in Guangzhou, China the prevalence estimate of self-reported NCDs was 16.0%. Hypertension and diabetes were reported as the most important NCDs. Of those who responded, 6.8% reported having more than 2 chronic conditions. Since 2002, the prevalence of hypertension has decreased by 13.3%. Awareness, treatment, and control of hypertension and diabetes were improved. The estimated prevalence of current smoking decreased, and the prevalence of former smoking increased from 2002. However, the prevalence of overweight and obesity, especially central obesity, increased.49
In a study done in Arab world in 2010, the burden of Disease Study 2010, the burden of non-communicable diseases (cardiovascular disease, cancer, chronic lung diseases, and diabetes) in the Arab world has increased, with variations between countries of different income levels. Behavioral risk factors, including tobacco use, unhealthy diets, and physical inactivity are prevalent, and obesity in adults and children has reached an alarming level. Despite epidemiological evidence, the policy response to non-communicable diseases has been weak.50
Conclusion:
The magnitude of risk factors for chronic non-communicable diseases is quite high in the study population. Appropriate preventive measure should be taken to control and prevent risk factors that increase the prevalence of HTN and DM.
Recommendation:
To reduce the prevalence of non-communicable diseases among expatriates working in an alien environment, preventive measures that need to be in place are:
Regular medical checkup for the workers especially who have risk factors.
Health promotion programs for the workers.
Promote balanced healthy diet with regular exercise.
Educational programs about the HTN and DM.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241104EnglishN2018February17HealthcareAquatic Phyto-Biodiversity of Bargi Dam Catchment Area at Jabalpur, Madhya Pradesh: An Appraisal
English4654Dharmendra Kumar ParteEnglish S. D. UpadhyayaEnglish R. P. MishraEnglish C. P. RahangdaleEnglish Sajad Ahmad MirEnglish Anu MishraEnglishAim: The study was conducted on Bargi Dam catchment area at Jabalpur district of Madhya Pradesh with the objective of Determining “The Aquatic species Floristic Composition Diversity and the Vegetation Structure of the Aquatic Plants Communities in the Bargi Dam Catchment Area”.
Methodology: Random sampling method was used to collect the vegetation data according to 36 plots of per quadrates 10m x10m size.
Results: A total of 119 species belonging to 79 genera and 39 families were recorded during the survey in which emergent 61%, marshy land 21%, free floating 9%, rooted floating 1%, submerged 8% aquatic plants were identified from the Bargi Dam catchment area.
EnglishWetland, Catchment, Floristic composition, Aquatic plantsINTRODUCTION
Aquatic ecosystems play an important role in human life. The aquatic reservoirs, tanks, dams, and ponds are used mostly for fishing, agriculture, irrigation, and other domestic purposes. Ponds are playing a very good role in rain harvesting, storage of water and regulation of ground water level. Wetland is among the most productive ecosystems in the world12. Several works have been done on the aquatic macrophytes and phytosociology in different freshwater bodies of India Biswas8 Subramanyam (1962). And Bhat, and Yousuf, (2007) , Billore and Vyas (1981), Mishra (1974), Unni,(1971), Dhote,(2007), Siraj et al (2011), Maheshwari,(1960) , Choudhary and Upadhyay (2009) and Anand et al.,(2012), undertook the taxonomic study of aquatic Plants ecosystems.
In India the first comprehensive work on the wetland flora was produced by Biswas and Calder, (1984). Aquatic plants are key components for the well-functioning of wetland ecosystem for biological productivity, supporting diverse community of ecosystem by providing lots of goods and services.
STUDY AREA
The entire study area around Bargi Dam (22044’7.5” to 22058’58.35” N latitude and 79053’52” E to 8007’13”) is spread to about 279.23 sq km along the Bargi Dam Catchment area Bargi to Chutka on both sides, covering three districts of Madhya Pradesh State i.e. Jabalpur, Mandla and Seoni, Fig.1 Total six range via Ghansour, Sikara, Bargi, Barela, Bijadandi, and Kalpi were surveyed for Aquatic plants species and identification. Range wise altitudinal variation is given in Table-1. Such a variation in the altitude of study area provides a wide diversity of landscape and aquatic habitat.
MATERIAL AND METHODS
In The present study consisted of the monthly field observations, collection and identification of the different plant species accruing in Bargi Dam catchment area from 2014-2017. Qualitative and quantitative analysis of aquatic plants, and documentation were done following the methodology of Mishra (1974).The collected specimens were pressed and herbarium were prepared following Jain and Rao, (1977). All specimens were deposited in the department of Plant Physiology J.N.K.V.V. Jabalpur The aquatic plants identification and nomenclature of the plants species were done in this paper based on available floras (The flora of Madhya Pradesh (Auther) and “Aquatic and wetland Plants of India” (Cooke,1901-1908).
CALCULATIONS WERE DONE USING FOLLOWING FORMULAE.
Total number of individuals of the species
Density (D) = ----------------------------------------------------
Total number of quadrats studied
Total number of quadrats in which species has occurred
Frequency (F) = -------------------------------------------------------------------------- X 100
Total number of quadrats studied
Total number of individuals of the species
Abundance = ------------------------------------------------------------------
Total number of quadrats in which the species occurs
No. of individuals of the species
Relative Density = ------------------------------------------------ X 100
Total no. of individuals of all species
No. of quadrats of occurrence of the individual species
Relative Frequency = --------------------------------------------------------------------- X 100
Total no. of quadrats of occurrence of all species
Total abundance of individuals species
Relative Abundance = ---------------------------------------------------- X 100
Total abundance of all species
(IVI) I Importance Value Index = Relative Density + Relative Frequency + Relative Abundance SIMPSON'S DIVERSITY INDICES
The term 'Simpson's Diversity Index' can actually refer to any one of 3 closely related indices.
Simpson's Index (D) measures the probability that two individuals randomly selected from a sample will belong to the same species (or some category other than species). There are two versions of the formula for calculating D. Either is acceptable, but be consistent.
where,
n = the total number of organisms of a particular species
N = the total number of organisms of all species
DISCUSSION
In this study, a total of 119 species, including Submerged, rooted floating, marshy land, free floating, and emergent aquatic plants, were recorded, (Fig.2)
Core Zone-1 - Overall diversity based on IVI in core zone was 300.00, and top ten species which have high IVI in core zone comprised of Vallisneria spiralis (6.31). Typha anguistata Bory and Chaub. (5.48), Alternanthera philoxeroides (Mart.) Griseb (5.54), Spilanthus ciliata H.B.K (5.26). Glossostigma diandra(L.) K, (5.00). Striga angustifolia (D.Don.) S.(4.75). Azolla filiculoides (4.57) Paspalidium punctatus (Burm.f.) (4.56) .And Rumex dentatus L. sp. Klotzschianus (Meisn.) Rchb , (4.56) , Fimbristylis dichotoma (L.) Vahl. (4.37). Table-01
Buffer Zone II - Overall diversity based on IVI in Buffer-1 zone was 193.49 and top ten species having high IVI diversity in Buffer-01 zone were Cyperus exalatus Retz (6.45). Vallisneria spiralis (6.43), Ammania auriculata Willd (4.68), Alternanthera philoxeroides(Mart.)Griseb (4.55). Cyperus pumilus L.(4.46). Ammania baccifera L.(4.08), Ceratophyllum demersum L. (4.07), Rotala serpillifolia (Roth.)Bremeck (3.92), Eleocharis atropurpurea (Retz.) J.(3.92), Fimbristylis falcata (Vahl) Kunth (3.78). Table-02
Buffer Zone III - Overall diversity (IVI) in Buffer-02 zone was 104.92 and top ten species with high IVI in this zone were Alternanthera sessilis (L.) R.Br. ex DC. (5.30). Eriocaulon duthiei Hook (4.87). Ischaemum rugosum Salisb (4.60) Aeschynomene indica L. (3.95). Cyperus digitatus Roxb. (3.95), Spilanthus ciliata H.B.K. (3.92), Ammania auriculata Willd (3.70), Typha anguistata Bory and Chaub (3.65). Marsilea quadrifolia L (3.53).and Cyperus exalatus Retz. (3.53) table no.01,02, and 03. Table-03
Conclusion
This study provides the comprehensive knowledge about the plant genera isolated from the studied region, my research also help the researchers to know about the valuable species that were documented as per the rules of plant nomenclature. A total of 119 species belonging to 79 genera and 39 families were recorded during the survey in which emergent 61%, marshy land 21%, free floating 9%, rooted floating 1%, submerged 8% aquatic plants were identified from the Bargi Dam catchment area.
Acknowledgements
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.
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